Health

How Primary Care Doctors Could Fix Abortion Access

As barriers to abortion increase, more primary care providers can—and should—offer the abortion pill.

by Garnet Henderson
May 31 2019, 11:00am

Bill Greenblatt / Getty Images

The vast majority of abortions in the United States happen in the first trimester, and most now happen before 8 weeks' gestation. At that point, an abortion either involves medication that can be taken safely at home, or is an in-clinic procedure lasting less than 10 minutes. Abortion is common, safe, and fast. So why can’t you get an early abortion from your primary care provider, just like you would any number of other routine procedures?

The most apparent answer is that, in many states, abortion is so heavily regulated that primary care doctors would have to seek special licensure and comply with medically unnecessary facility requirements in order to offer abortions—even if they were merely dispensing pills. An estimated 1 percent of US abortions are performed in physicians' offices; the procedure has been effectively siloed in abortion clinics.

The authors of a recent opinion in the New England Journal of Medicine (NEJM) argue that primary care providers must get more involved in abortion care for precisely this reason—the fact that a highly restrictive landscape has shuttered hundreds of abortion clinics nationwide. The need for this change becomes more pressing as state lawmakers launch direct challenges to Roe v. Wade and states with pro-choice laws may see more out-of-state patients.

Jessica Beaman, a primary care doctor and assistant professor of medicine at the University of California, San Francisco, points out that primary care providers play a critical role in supporting underserved patients in both rural and urban settings. Many are already providing some level of reproductive healthcare for their patients, like birth control counseling and STI testing.

“I wanted to bring this out into the public sphere to think about the role that [primary care doctors] can play in expanding access to abortion care for our patients,” said Beaman, who co-authored the NEJM opinion along with Dean Schillinger, chief of the UCSF division of general internal medicine at San Francisco General Hospital.

Beaman and Schillinger were especially concerned about abortion access in light of the Trump administration’s drastic changes to Title X, the country's only federally funded family planning program. Title X grants help clinics provide comprehensive family planning and sexual health services to low-income women, the majority of whom are young women of color, and the program has enjoyed broad, bipartisan support since its introduction in 1970. Title X providers have long been required to provide comprehensive, non-directive counseling on contraception and pregnancy options, including information about parenting, adoption, and abortion—and to make referrals for abortion if that's what the patient wanted.


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The most extreme of the Trump administration’s attempted changes to the Title X program is a so-called “gag rule” that would prevent Title X providers from even talking about abortion—let alone making any referrals—which could further limit abortion access for people who already face the most significant barriers.

This provision was recently blocked by a federal judge, but other changes to the program have resulted in $1.7 million in Title X grants being awarded to Obria, a network of anti-choice pregnancy centers that does not offer comprehensive contraception options or abortion referrals. Given President Trump’s recent inflammatory and inaccurate claims about abortion, it is expected that the administration will appeal to have its Title X gag rule upheld.

Beaman and Schillinger cite these changes to Title X in their article and specifically advocate for primary care doctors to offer medication abortion because it could be integrated into their practices with relative ease. One in four U.S. women will have an abortion by age 45, and major complications occur in less than 1 percent of procedures. Abortion is safer than many common dental procedures, tonsillectomy, colonoscopy, and far safer than childbirth, according to a landmark study released in 2018 by the National Academies of Sciences, Engineering, and Medicine.

Medication abortion doesn't require additional medical training beyond what primary care providers already have (as opposed to aspiration abortion, the other common first-trimester abortion procedure). Safely prescribing medication—including screening patients for any contraindications, counseling them about their options, and looking out for medication interactions—are typical responsibilities for primary care physicians. “These are things we are already doing on a regular basis and fits really well into the patient-centered model of care, which has already been integrated into our medical education for decades,” Beaman said.

Getting more general practitioners to provide abortion is a conversation that’s been happening for decades. For other advocates who have long argued that abortion care shouldn't be cordoned off in clinics, this conversation is welcome but frustrating. Monica McLemore, assistant professor of Family Health Care Nursing at UCSF, wrote on Twitter after the NEJM report was released: “Too bad we enshrined abortion care in clinics. It’s good that we innovated care but now hard to argue abortion is healthcare. I wish we’d invested in a primary care initiative a decade ago.”

“I was glad to see them write that opinion. What bothered me is that it feels like that recognition is late to the party. We tried to have this conversation back in 2000,” McLemore told VICE. After medication abortion became available in the U.S. following FDA approval in 2000, there was a movement to integrate abortion into primary care, with mixed results, she explained.

A key barrier to integrating abortion into primary care is that, in rural areas, primary care is largely provided by advanced practice clinicians (APCs) like nurse practitioners, nurse midwives, and physician assistants, McLemore said. Meanwhile, 34 states mandate that only physicians can provide abortions, despite evidence that APCs can safely perform first-trimester abortions. In a surprising series of events, a federal judge in Virginia recently ruled that the state’s physician-only law was unconstitutional in a summary judgement, but then reversed his own ruling, saying instead that the case should proceed to trial. The trial in this case, which challenges several abortion restrictions in Virginia, began on May 20.

Another significant barrier to offering abortions in primary care is the fact that mifepristone, one of the drugs used in medication abortion, is regulated under the FDA’s Risk Evaluation and Mitigation Strategy (REMS). This means that prescriptions for mifepristone cannot be filled in a regular pharmacy and providers must go through a special registration process and have to stock the drug in their office or clinic. Experts have long called for mifepristone to be removed from REMS, and the American Civil Liberties Union is currently challenging the restrictions in a case in Hawaii.

“The unfortunate reality around mifepristone is that it’s heavily regulated in a way that very dangerous drugs are regulated. This is a black-box label like chemotherapeutic agents or other very harmful drugs,” McLemore said.

And there are other barriers still to expanding access, including a set of laws in 24 states requiring that abortion providers adhere to arbitrary rules regarding things like corridor width and size of procedure rooms (neither of which have a measurable impact on patient outcomes). Despite a 2016 Supreme Court case that blocked some of these most onerous Targeted Regulation of Abortion Provider (TRAP) laws, many remain. In 18 states, these rules even apply to facilities where only medication abortion is offered.

The Whole Woman’s Health Alliance is challenging the restrictions in the Virginia case as well as other restrictions in Texas and Indiana. Amy Hagstrom Miller, the founder and CEO of Whole Woman’s Health, pointed out that, in Virginia, any provider—including family doctors and nurse practitioners—who does more than five abortions per month has to have their facility licensed as an abortion clinic. “This triggers things like inspections, which are targeted to abortion providers and do nothing to advance health, but do require administrative overhead,” she said.

McLemore said that some of the responsibility for filling gaps in care while abortion clinics continue to face onerous restrictions should lie with facilities that already meet these physical requirements, like hospitals. “Only about 4 percent of abortions happen in hospitals,” she said. “I don’t think anybody is holding hospitals and other institutions accountable. What are surgery centers and hospitals prepared to do, to cover what primary care might not be able to absorb?”

“I think it will take clinical and institutional leadership to think about better-integrating abortion system-wide,” Beaman said. This should start, she said, with physician training.

Many medical students have little to no exposure to abortion. Most family medicine programs lack abortion training, and even a third of OB/GYN residency programs fail to train doctors to perform abortions. “Students need to understand this is an inherent part of taking care of people,” McLemore said. In addition to removing mifepristone from REMS and allowing nurse practitioners and other APCs to provide early abortions, she adds that professional organizations should offer continuing education training for physicians and APCs to learn how to perform abortions.

Though medication abortion is the easiest option to integrate into primary care, McLemore points out that some people will still want or need other abortion procedures—medication abortion is only approved for use up to 10 weeks' gestation. “We need to have a whole host of options available, consistent with bodily autonomy,” she said.

Miller began her career working in an integrated family medicine practice that offered abortion, and later managed an OB/GYN clinic that provided abortion services. Though she's a proponent of integrating abortion into primary care and a variety of medical settings, she points out that there's value in the specific expertise of abortion clinic staff and providers.

“One of the points of pride in our abortion facilities is that we do have a specialty, one that I would want to make sure is carried forward,” Miller said. “Abortion has a cultural context, and for some people, a spiritual context. These ideas about parenting or not parenting, and sex, come to the fore when somebody faces an unplanned pregnancy. We take a holistic approach, and use the opportunity to talk about stigma and shame. To practice informed consent, and help people make choices with good information, I would love to see that integrated and upheld.”

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