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March 23, 2022
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Few PCPs provide abortion services in US, but new care strategy may increase their role

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Primary care clinicians accounted for a small proportion of abortion providers in the United States in 2019, according to findings published in JAMA Internal Medicine.

However, researchers found that a screening strategy for medication abortion eligibility based on history alone was safe, effective and could help expand the abortion provider workforce.

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Strasser J, et al. JAMA Intern Med. 2022;doi:10.1001/jamainternmed.2022.0223.

“All abortion providers are important providers of an essential service that is becoming increasingly restricted,” Julia Strasser, DrPH, MPH, a senior research scientist at the George Washington University Milken Institute School of Public Health, told Healio.

“While many primary care providers have the clinical skills to provide abortion care, this study finds few that do provide this care,” she added. “Integrating abortion care into primary care would increase access to abortion.”

Julia Strasser
Julia Strasser

Abortion services by provider type

In a cross-sectional study, Strasser and colleagues identified clinicians who provided medication or procedural services for induced abortion or management of pregnancy loss in 2019. They used prejudicated medical claims from the private data company IQVIA to obtain full-year, month-level counts of these services.

In total, Strasser and colleagues examined services provided by 23,346 clinicians. Of these, 85% had medical claims for the management of pregnancy loss only, 6% had claims for induced abortions only and 9% had claims for both.

The researchers identified 3,550 abortion service clinicians and 22,001 clinicians who provided management of pregnancy loss. The majority of clinicians who provided management of pregnancy loss were OB/GYN physicians (86%). This service was also provided by emergency medicine clinicians (6%), other clinicians in OB/GYN (3%) and family medicine clinicians (2%), according to Strasser and colleagues. Overall, 99% of the clinicians who provided this service were physicians. The remaining 1% were advanced practice clinicians, including advance practice registered nurses (43%), nurse midwives (16%) and physician assistants (32%).

Among the clinicians who provided induced abortions, 88% were physicians and the remaining 12% were advanced practice clinicians. The researchers reported that OB/GYN physicians (72%) most often performed induced abortions in 2019. However, this service was also performed by family medicine physicians (9%), advanced practice registered nurses (8%), nurse midwives (3%) physician assistants (1%), emergency medicine clinicians (1%), internal medicine clinicians (1%) and pediatricians (0.6%).

“Because of coverage restrictions on abortion services, medical claims data provide an incomplete picture of the abortion clinician workforce,” Strasser and colleagues wrote.

Strasser said that primary care providers have an essential role in abortion care “as they are more likely to be located in rural and underserved areas, where access to care can present a challenge.”

“Primary care providers can also play a unique role with continuity of care if they can offer abortion services to their patients, rather than referring them to other providers,” she added.

Medication abortions

A separate retrospective cohort study, also published in JAMA Internal Medicine, found that screening for medication abortion eligibility by history alone was effective and safe for in-person dispensing or mailing of medications.

“Medication abortion has the potential to expand access to abortion care, especially as access to in-person abortion care becomes difficult or impossible due to state-level and other restrictions,” Strasser said.

Ushma D. Upadhyay, PhD, MPH, an associate professor in OB/GYN and reproductive sciences at the University of California, San Francisco, and colleagues assessed 3,779 patients in 34 states who obtained a medication abortion without a proabortion ultrasonography or pelvic examination between Feb. 1, 2020, and Jan. 41, 2021. The patients received care at 14 independent, Planned Parenthood, academic-affiliated and online-only clinics in the U.S. The main outcomes were effectiveness of the history-based screening strategy, which the researchers defined as a complete abortion after 200 g mifepristone and up to 1,600 g misoprostol without an additional intervention, as well as major abortion-related adverse events.

Among the study cohort, 23% were Black, 14.1% were “Latinx”/Hispanic and 42.9% were white. Latinx is used by the study authors as an alternative term for Latino or Latina.

For 69.5% of patients, it was the first time they used medication abortion. In total, 66.4% of medications were dispensed in person while the remaining 33.6% were mailed to patients. Upadhyay and colleagues analyzed follow-up data for 74.8% of abortions.

Overall, medication abortion was 94.8% effective (95% CI, 93.6-95.9), and the adjusted rate for a major abortion-related event was 0.54%, according to the researchers. Effectiveness was similar for medications dispensed in person (adjusted effectiveness rate = 95.4%; 95% CI, 94.1-96.7) or mailed (aER = 93.3%; 95% CI, 90.7-95.9).

“Given the high effectiveness and very low risks associated with omitting in-person tests and using history-based screening alone, no-test medication abortion can offer substantial benefits to clinicians and patients and is consistent with the principle of patient-centered care,” Upadhyay and colleagues wrote. “The use of history-based screening may appeal to primary care and other types of clinicians without access to ultrasonography technology or other tests. A shift toward history-based screening could expand the provision of abortion care to a variety of PCPs, including nurse practitioners and physicians in family medicine, adolescent medicine and internal medicine.”

In a related editorial, Jennifer Karlin, MD, PhD, an assistant professor of reproductive and perinatal health at the University of California, Davis Health Medical Center, and Jamila Perritt, MD, MPH, FACOG, the president and chief executive officer of Physicians for Reproductive Health, said that reducing abortion service limitations, such as in-person requirements, can increase the number of clinicians who provide abortions.

Many clinicians already support moving toward a model of abortion care that is “less medicalized,” according to Karlin and Perritt.

“Researchers, clinician providers of abortion services and experts are leading the way toward a less burdensome, evidence-based model of medication abortion care delivery,” they wrote. “Hopefully, regulators will also follow the evidence and prioritize our collective principles of quality health care delivery.”

References:

Karlin J, Perritt J. JAMA Intern Med. 2022;doi:10.1001/jamainternmed.2022.0216.

New study identifies small yet essential workforce providing abortions in the U.S. https://www.newswise.com/articles/new-study-identifies-small-yet-essential-workforce-providing-abortions-in-the-u-s. Published March 21, 2022. Accessed March 21, 2022.

Strasser J, et al. JAMA Intern Med. 2022;doi:10.1001/jamainternmed.2022.0223.

Upadhyay UD, et al. JAMA Intern Med. 2022;doi:10.1001/jamainternmed.2022.0217.