It Is Time to Integrate Abortion Into Primary Care?

Susan Yanow, MSW | Disclosures
Am J Public Health. 2013;103(1):14-16. (Medscape)

   The Roe v Wade decision made safe abortion available but did not change the reality that more than 1 million women face an unwanted pregnancy every year. Forty years after Roe v Wade, the procedure is not accessible to many US women.
   The politics of abortion have led to a plethora of laws that create enormous barriers to abortion access, particularly for young, rural, and low-income women. Family medicine physicians and advanced practice clinicians are qualified to provide abortion care.
   To realize the promise of Roe v Wade, first-trimester abortion must be integrated into primary care and public health professionals and advocatesmust work to remove barriers to the provision of abortion within primary care settings.
   The 1973 Roe v Wade decision removed many legal obstacles to abortion and was a public health watershed. The availability of safe abortion services led to dramatically decreased rates of maternal morbidity and mortality in the United States, as in most countries that have removed legal impediments to abortion care.
   According to the most recent available data, approximately 1.2 million women obtain safe, legal abortions from skilled clinicians in the United States every year. The political debate over abortion has largely ignored the public health fact that the Roe v Wade decision did not create or change the need for abortion; legalization simply made abortion safe. Maternal death from unsafe abortion in the United States became a negligible statistic after 1973. Abortion is now one of the safest medical procedures available; only 0.3% of abortion patients experience a complication that requires hospitalization.
   Unwanted pregnancy continues to be a reality of women's lives. One in three women in the United States will seek an abortion before she is aged 45 years. For these women, restrictive laws driven by ideology, not science, are undermining the promise of Roe v Wade in many parts of the country. State restrictions—including waiting periods, parental consent requirements for minors, lack of insurance coverage or Medicaid coverage for abortion, and expensive and unnecessary building requirements for facilities that provide abortions—create almost insurmountable barriers to access, especially for rural, young, and low-income women. There are ever-increasing restrictions passed at the state and federal levels, and antiabortion activists have directed a relentless campaign of violence and harassment at clinics and clinicians who provide the service. Many medical residencies lack training opportunities, leading to a lack of skilled abortion providers. The cumulative result of these regulations, the harassment, and the lack of training is a shrinking number of sites that offer abortion services.
   Specialized abortion clinics performed 70% of all abortions in 2008, yet the hostile political climate those opposed to abortion have created is forcing the numbers of these clinics to decline every year. The number of abortion providers has declined dramatically, from 2908 in 1982 to 1787 in 2005. Eighty-seven percent of all US counties lacked an abortion provider in 2008; 35% of US women live in those counties.Abortion services are concentrated in cities.Almost all nonmetropolitan counties (which is 97% of all US counties) lack an abortion provider. In eight states (Arkansas, Idaho, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, and Wyoming) there are abortion clinics in only one city in the entire state. The result of the shortage of providers is that although abortion is one of the most common medical procedures performed in the United States, in many areas of the country women must travel for hours and deal with long delays to get the reproductive health care they need.
   Primary care clinicians provide personalized continuous preventative health care to patients throughout their reproductive years. Physician assistants, nurse midwives, and nurse practitioners (collectively, advanced practice clinicians, or APCs) and family physicians provide the majority of wellwoman care to patients throughout the country. The skills needed to provide abortions—including the ability to assess gestational age, provide counseling, provide medications, perform manual or electric vacuum aspiration, and conduct postabortion follow-up—are in the scope of practice of primary clinicians. Many primary care clinicians who specialize in women's health have specialized training. They perform suturing, colposcopy, intrauterine device insertions, endometrial biopsy, and gynecological care; and prescribe medications for family planning. These skills are comparable to those required to perform a firsttrimester abortion.
   The provision of first-trimester abortion care is clearly within the scope of practice of primary care clinicians. In fact, since 1973 physician assistants have provided abortions in Montana and Vermont. Beginning in the early 1990s, advocates and professional groups came together to begin state-by-state advocacy to clarify the laws and scope of practice issues and promote the involvement of APCs in abortion care. APCs have been legally recognized as competent to substitute for physicians in the performance of many tasks.Several studies have compared complication rates and patient satisfaction between abortions physicians provide and those APCs provide. These studies consistently show that APCs with the requisite skills, training, and experience are fully competent to provide medical and firsttrimester surgical abortions safely. As a result of state-bystate advocacy, APCs are now providing medication abortion in 18 states. APCs provide aspiration abortions in Montana, New Hampshire, Oregon, and Vermont.
   Additionally, APCs are providing aspiration abortion in California through a five-year demonstration project (Health Workforce Pilot Project No. 171) under the auspices of the University of California, San Francisco. Nurse practitioners, certified nurse midwives, and physician assistants have been trained to provide first-trimester aspiration abortion, and the project is being carefully evaluated. To date, 41 APCs at sites across California have been trained through the project. Nearly 8000 patients have received abortion care from these trained nurse practitioners, certified nurse midwives, and physician assistants. The project has conducted a study to compare the outcomes of these early abortions that APCs performed to a comparable number that physicians performed. The data show similar rates of high patient satisfaction and low complications in both groups
   Nurse practitioners, certified nurse midwives, and physician assistants have been increasing their commitment to abortion care, and there has also been remarkable advocacy among family medicine physicians. Several organizations (e.g., the Reproductive Health Access Project and the Center for Reproductive Health Education in Family Medicine [RHEDI]) have worked to increase training in abortion procedures in family medicine residency programs and to increase advocacy among family medicine professional organizations. Family physicians currently provide abortions at many of the freestanding clinics around the United States. Studies have shown that abortion care that family doctors provide have low rates of complication and that many patients would prefer to get their abortion from their family physician.
   As more primary care clinicians are being trained and expressing interest in providing abortions, new technologies are making it possible for women to diagnose and end their pregnancies earlier. Inexpensive and accurate pregnancy tests now allow many women to determine whether they are pregnant within two weeks after unprotected intercourse. Advances in ultrasound have made it possible to confirm a pregnancy very early on. These advances have contributed to women in the first trimester coming in earlier to end an unwanted pregnancy. Eighty-eight percent of women who have abortions get the procedure in the first 12 weeks of pregnancy, and 61.8% of women have their abortion before the ninth week. All these women could be treated in a primary care setting.
   Yet most of the primary care clinicians who currently provide abortions do so at freestanding abortion sites.Too often when a patient seeks an abortion from her primary care clinician at her medical home, she is referred to another health care provider,even though trained family medicine doctors, nurse practitioners, certified nurse midwives, and physician assistants can provide first-trimester abortions. Although there are certainly primary care clinicians who do not want to provide abortions to their patients, many qualified and trained clinicians are willing but unable to offer this care because of burdensome, politically motivated restrictions that are not derived from science, public health considerations, or good medicine.
   Family medicine practices and physicians and community health centers are key health access points for low-income and rural women. Community health centers are the medical and health care home for more than 20 million people nationally, and community health center patients are disproportionately low income, uninsured or publicly insured, and minority. If abortion care were available in these centers and in family medicine practices, more women would be able to end their unwanted pregnancies without having to travel hundreds of miles or face delays that push them into getting abortions later in their pregnancy.
   Unfortunately, most federally qualified community health centers do not offer abortion services because of the Hyde Amendment, a legislative provision barring the use of federal funds to pay for abortions. Additionally, many of the federally qualified community health centers rely on malpractice coverage from the federal government, which does not cover abortion care. Family doctors who want to provide early abortion care in their practices must purchase extremely expensive obstetrical coverage, even though many other procedures routinely performed in family medicine have a higher complication rate than do first-trimester abortion procedures. APCs face other barriers; in many states, APCs are prevented from providing abortions or are limited to providing only medication abortion because of laws promoted by those who seek to restrict abortion access and because of resistance to expanding the scope of APCs' practice to include abortion care. The World Health Organization recently issued technical and policy guidelines for safe abortion worldwide. The guidelines state,

"Both vacuum aspiration and medical abortion can be provided at the primary care level on an outpatient basis and do not require advanced technical knowledge or skills, expensive equipment such as ultrasound, or a full complement of hospital staff (e.g., anaesthesiologist)."

   The United States needs to step up to the World Health Organization standard. Health care reform has identified the importance of promoting high-quality, continuous, accessible, and cost-effective care in primary care settings. It is time for the promise of legal abortion to be available to every woman in the United States, rural or urban, low-income or middle class. Public health professionals and advocates must work together to find strategies to expand access to abortion by removing restrictions on the primary care clinicians who are trained and willing to provide the service. Forty years after Roe v Wade, it is time to integrate first-trimester abortion into primary care.