Self-Sourced Medication Abortion, Physician Authority, and the Contradictions of Abortion Care.

The growing acknowledgment of the phenomenon of individuals terminating their pregnancies by obtaining the medications necessary for an abortion-which this article refers to as "self-sourced medication abortion" (SSMA)-has shed light on the current contradictions in the world of abortion provision. This article offers a brief historical overview of the relationship between abortion provision and mainstream medicine, pointing to the factors that have led to the marginalization of abortion care. It then discusses interviews with 40 physicians who provide abortions about their perspectives on SSMA, and it explores how this group responds to the contradictions presented by SSMA. In doing so, it interrogates the changing meaning of "physician authority" among this subset of physicians. The authors suggest that these interviewees represent an emergent sensibility among this generation of abortion physicians, a sensibility strongly tied to a commitment to social justice.

COVID-19, health care, and abortion exceptionalism in the United States.

CONTEXT: Few qualitative findings have been published that explore and identify the challenges experienced by independent abortion providers during the COVID-19 pandemic in the United States (US). In this paper, we explore these themes while expanding the concept of "abortion exceptionalism" beyond its original legal meaning to address the impact of abortion stigma. METHODS: Twenty abortion providers from independent abortion clinics throughout the US South and Midwest participated in semi-structured interviews in June and July 2020. Interviews explored the challenges of providing abortion care in the wake of the COVID-19 pandemic and sought to identify how clinics strategized and amended their clinical practices to continue providing abortion care during this time. RESULTS: All providers we spoke to noted significant challenges to providing abortion care in the early days of COVID-19. In addition to experiencing the same concerns as other health care institutions, abortion clinics also faced additional, unique burdens that can only be attributed to the politics of abortion exceptionalism. Examples of this abortion exceptionalism include abrupt orders to close clinics, the need to rely on traveling physicians, legislature-imposed limits on telemedicine, heightened activities of protesters, and non-evidence-based regulation of medication abortion. CONCLUSION: Despite major challenges and differential treatment, independent abortion clinics in the US persevered to continue to provide abortion care throughout the COVID-19 pandemic.

Greasing the wheels: The impact of COVID-19 on US physician attitudes and practices regarding medication abortion.

OBJECTIVE: To explore US provider perspectives about self-sourced medication abortion and how their attitudes and clinic practices changed in the context of the COVID-19 pandemic. STUDY DESIGN: We conducted a multi-method study of survey and interview data. We performed 40 baseline interviews and surveys in spring 2019 and 36 follow-up surveys and ten interviews one year later. We compared pre- and post-Likert scale responses of provider views on the importance of different aspects of standard medication abortion assessment and evaluation (e.g., related to ultrasounds and blood-typing). We performed content analysis of the follow-up interviews using deductive-inductive analysis. RESULTS: Survey results revealed that clinics substantially changed their medication abortion protocols in response to COVID-19, with more than half increasing their gestational age limits and introducing telemedicine for follow-up of a medication abortion. Interview analysis suggested that physicians were more supportive of self-sourced medication abortion in response to changing clinic protocols that decreased in-clinic assessment and evaluation for medication abortion, and as a result of physicians' altered assessments of risk in the context of COVID-19. Having evidence already in place that supported these practice changes made the implementation of new protocols more efficient, while working in a state with restrictive abortion policies thwarted the flexibility of clinics to adapt to changes in standards of care. CONCLUSION: This exploratory study reveals that the COVID-19 pandemic has altered clinical assessment of risk and has shifted practice towards a less medicalized model. Further work to facilitate person-centered abortion information and care can build on initial modifications in response to the pandemic. IMPLICATIONS: COVID-19 has shifted clinician perception of risk and has catalyzed a change in clinical protocols for medication abortion. However, state laws and policies that regulate medication abortion limit physician ability to respond to changes in risk assessment.

COVID-19 and Independent Abortion Providers: Findings from a Rapid-Response Survey.

CONTEXT: The ways in which the COVID-19 pandemic has affected abortion providers and abortion care, and the strategies clinics are adopting to navigate the pandemic, have not been well documented. METHODS: In April-May 2020, representatives from 103 independent abortion clinics (i.e., those not affiliated with Planned Parenthood) completed a survey that included close-ended questions about how the pandemic, the public health response, and designations of abortion as a nonessential service had affected their clinic, as well as open-ended questions about the pandemic's impact. Analyses were primarily descriptive but included an exploration of regional variation. RESULTS: All U.S. regions were represented in the sample. At 51% of clinics, clinicians or staff had been unable to work because of the pandemic or public health responses. Temporary closures were more common among clinics in the South (35%) and Midwest (21%) than in the Northeast and West (5% each). More than half of clinics had canceled or postponed nonabortion services (e.g., general gynecologic care); cancelation or postponement of abortion services was less common (25-38%, depending on type) and again especially prevalent in the South and Midwest. Respondents reported the pandemic had had numerous effects on their clinics, including disrupting their workforce, clinic flow and work practices; increasing expenses; and reducing revenues. State laws (including designations of abortion as nonessential) had exacerbated these difficulties. CONCLUSIONS: Although independent abortion clinics have faced considerable challenges from the pandemic, most continued to provide abortion care. Despite this resiliency, additional support may be needed to ensure sustainability of these clinics.

Abortion Providers on Politically Engaging Patients.

BACKGROUND: For decades, abortion providers have lamented the lack of patients' voices in the abortion rights movement. Given the millions of women who have received abortions, the absence of this large constituency, providers assert, has been politically costly. Underlying this disappointment is a parallel question that reflects a philosophical divide among abortion providers: are attempts to politically engage abortion patients a desired or appropriate element of care? METHODS: We interviewed providers from 14 abortion clinics, representing a range of approaches to care, patient volume, and geographic locations. We transcribed and analyzed the interviews to identify themes related to whether, why, and how providers worked to politically engage their patients. RESULTS: We found that many respondents limited or avoided political engagement with patients, believing that such efforts interfered with patient care or comfort, were not a priority given limited time, and were not something in which patients were interested. Many participants were unclear as to what political work they could pursue as nonprofit facilities. In contrast, other providers believe political outreach helped patients to more fully understand their care experiences, could influence future patients' access to care, and was an important part of the way they cared for patients. CONCLUSIONS: These varying approaches reflect divergent ways of and reasons for engaging abortion patients politically. Future research should consider if the act of obtaining an abortion could be understood as low-level engagement with the abortion rights movement, particularly as abortion access is increasingly limited and patients might be considered potential activists.

What will become of reproductive issues in Trump's America?

The election of Donald Trump to the presidency came as a severe and unexpected shock to the already beleaguered pro-choice movement in the US. This article will review what the president-elect said during the campaign about abortion and what his administration is likely to do after his inauguration.

Commentary: abortion provider stigma and mainstream medicine.

This commentary describes the various manifestations of the stigmatization and marginalized status of abortion providers in relation to mainstream medicine. The article also addresses some of the current efforts to respond to this stigmatization.

The politicization of abortion and the evolution of abortion counseling.

The field of abortion counseling originated in the abortion rights movement of the 1970s. During its evolution to the present day, it has faced significant challenges, primarily arising from the increasing politicization and stigmatization of abortion since legalization. Abortion counseling has been affected not only by the imposition of antiabortion statutes, but also by the changing needs of patients who have come of age in a very different era than when this occupation was first developed. One major innovation--head and heart counseling--departs in significant ways from previous conventions of the field and illustrates the complex and changing political meanings of abortion and therefore the challenges to abortion providers in the years following Roe v Wade.

A descriptive analysis of abortion training in family medicine residency programs.

BACKGROUND AND OBJECTIVES: Access to abortion services in the United States is declining. While family physicians are well suited to provide this care, limited training in abortion occurs in family medicine residency programs. This study was designed to describe the structure of currently available training and the experience of residents participating in these programs. METHODS: E-mail questionnaires were sent to key faculty members and third-year residents in nine programs that have required abortion training. These faculty members and a sample of residents also completed semi-structured interviews. RESULTS: Residency programs varied in the amount of time dedicated to the procedural aspects of abortion training, ranging from 2 to 8 days, and also in non-procedural aspects of training such as values clarification and didactics. Themes that emerged from interviews with residents included the benefit of training with respect to technical skills and continuity of care. In addition, residents valued discussion of the emotional aspects of abortion care and issues relating to performing abortions after graduation from residency. CONCLUSIONS: While the details of the curricula vary, residents in programs with required abortion training generally felt positively about their experiences and felt that abortion was an appropriate procedure for family physicians to provide. Residents emphasized the importance of both non-procedural and technical aspects of training.

Integrating abortion training into family medicine residency programs.

BACKGROUND AND OBJECTIVES: Family physicians provide many office-based procedures in primary care settings. While first-trimester abortion is a procedure appropriate for and performed by family physicians, few residency programs offer routine training in this skill. This study explored the experience of residency programs that have initiated or are in the process of initiating required abortion training. METHODS: Faculty members responsible for abortion training curricula in identified programs completed questionnaires and semi-structured interviews. RESULTS: Faculty members from nine programs with required training and seven programs interested in initiating this training were included in the study. Factors that assisted in curriculum development included the support of family medicine and obstetrician-gynecologist faculty. Commonly encountered challenges included the need for dedicated resources, inter-specialty conflict, and limited access to training sites. CONCLUSIONS: Family medicine programs can be successful at developing required abortion training. Collaboration with colleagues inside and outside the family medicine department and with receptive training sites will benefit programs interested in such.

Advanced practice clinicians as abortion providers: current developments in the United States.

A hopeful note in the contemporary abortion environment in the United States is the expanding role of advanced practice clinicians--nurse practitioners, physician assistants and nurse-midwives--in first trimester abortion provision. A large percentage of primary health care in the U.S. is currently provided by these non-physicians but their involvement in abortion care is promising, especially in light of the shortage of physician providers. Two national symposia in 1990 and 1996 approved the expansion of early abortion care to non-physicians. As of January 2004, trained advanced practice clinicians were providing medical, and in some cases, early surgical abortion in 14 states. This has required not only medical training but also political organising to achieve the necessary legal and regulatory changes, state by state, by groups such as Clinicians for Choice and the Abortion Access Project, described here in examples in two states and the reflections of three advanced practice clinicians. Recent surveys in three states show a substantial interest among advanced practice clinicians in abortion training, leading to cautious optimism about the possibility of increased abortion access for women. Most encouraging, advanced practice clinicians, like their physician counterparts, show a level of passionate commitment to the work that is rare elsewhere in health care in the U.S. today.

Normalizing the exceptional: incorporating the "abortion pill" into mainstream medicine.

Mifepristone, also known as RU-486, and in the US known as "the French abortion pill", finally received FDA approval in the United States in September 2000. This paper discusses the steps now in process to integrate this drug into mainstream healthcare and the sociological implications of those efforts. Each of the steps that is normally taken to introduce a newly approved medication in the US context is rendered highly complex in the case of mifepristone--because of the unique circumstances of abortion in both American culture generally, and medical culture specifically. The story of RU-486/mifepristone, as it is currently unfolding, can be understood as one of attempting to "normalize the exceptional". After offering a brief historical overview of the protracted struggle for FDA approval of mifepristone in the US, this paper discusses the typical processes for integration of a newly approved medication into mainstream medicine and contrasts this process with the special challenges posed by a drug that is associated with abortion. We outline the challenges to implementation, including both external and internal obstacles. We compare the traditional role of a pharmaceutical company in drug diffusion and the circumstances of the company that produces mifepristone in the US. We discuss such external obstacles as the conflict between the FDA-approved regime and an evidence-based alternative; the necessity for physicians to order and dispense this drug; the ambiguity over the need for ultrasonography; and insurance reimbursement, malpractice, and other legal issues. Internal issues addressed include "turf issues" between medical specialties and between physicians and advanced practice clinicians as well as concerns over "cowboy medicine", and patient compliance. This paper concludes with an exploration of the sociological implications of this effort to "normalize the exceptional".