Abortion Access and Opportunity in Rural Communities: A survey of clinicians

Transcription

1 Abortion Access and Opportunity in Rural Communities: A survey of clinicians August 2009

2 Melanie Zurek Executive Director Rural communities present somewhat of an unknown for the reproductive health community. This is especially true in the case of rural abortion care, where the needs of both healthcare providers and women are still couched in question marks. When the Abortion Access Project first moved forward to catalyze the integration of early abortion services into rural healthcare on behalf of women in these communities, we did so in the face of many questions. This report reflects the information we have gathered in beginning this work. While it is only the beginning of the knowledge I hope will be gained through the work of our research colleagues and AAP s on-the-ground rural project team, it deepens our understanding of the disparities in access rural women face and how these disparities persist. This survey was a catalyst for AAP s work I hope that it will likewise motivate you as colleagues and supporters to expand access to abortion for rural women. All the best, Melanie Zurek Abortion Access Project, Inc. P.O. Box Cambridge, MA tel fax Abortion Access Project

3 Introduction Abortion is one of the most common procedures performed in the U.S. Despite the tremendous need for abortion care, women in rural communities face many obstacles when accessing needed care. National data confirm that 97% of non-metropolitan counties do not have access to abortion services. 1 Beyond such aggregate statistics, there is very little published information on the availability of abortion care in rural communities and women s experience accessing this care. A 1995 study of rural physicians attitudes and practices in Idaho revealed that less than 4% of respondents currently provided abortion care, but 26% were interested in medication abortion (at that time not available). 2 A 1999 study of abortion services in rural Washington state compared data on pregnancy and abortion a decade apart, noting an increase in both travel and gestational ages of rural women seeking abortion care. 3 These findings from two different states provide evidence that the nationwide decline in abortion providers is jeopardizing rural women s access to abortion. 4 In recognition of the gap in abortion services, the Abortion Access Project (AAP) launched the Rural Abortion Provider Initiative in This initiative is currently the only national project specifically aimed at developing rural abortion providers. The project operates in seven states: Colorado, Iowa, Maine, Washington, West Virginia, Wisconsin, and Wyoming. To expand available information on rural abortion access and support the Provider Initiative, AAP collaborated with partners in selected states to conduct a multi-state survey of rural healthcare providers in The survey effort captured regions in five of the seven Rural Abortion Provider Initiative states (excluding Washington and Wisconsin). The survey had five aims: (1) identify existing abortion providers not known to AAP; (2) identify potential providers to train in abortion care; (3) understand the perceptions of physicians and advanced practice clinicians (APCs) regarding the need for abortion care; (4) ascertain health facilities need for referral information; and (5) compare and contrast abortion access with the availability of other reproductive health care services for women. This report discusses the results of the multi-state survey, which have been used to guide AAP s efforts with clinicians and other stakeholders. Most directly, the survey results have helped structure the resources, support and training that AAP offers to rural clinicians. In addition, the results provide a foundation for discussing rural women s access to abortion with reproductive health providers and rural health audiences. Our findings also expand available information on rural access to abortion care as a component of comprehensive reproductive health services.

4 Methods Instrument The AAPs Rural Abortion Provider Initiative project team designed the brief 10-item paper-and-pencil questionnaire (appendix 1). Nine questions used a multiple choice format that allowed respondents to select all answers that apply (where appropriate), and one question invited an open-ended response. The questionnaire was identical in all five states, with one exception. Surveys sent out in Maine included a slight adaptation to the response options for the question regarding respondents referral practices (question #9), which read, If medical and/or surgical [abortion] is not offered at your site, where are patients seeking those services referred? Check all that apply. In the Maine survey, the response options substituted Family planning health center (name of city) for Planned Parenthood health center (name of city). This small change was implemented to make the survey inclusive of independent reproductive health clinics in Maine. Sample AAP Field Consultants distributed the questionnaires by mail to 2,345 selected recipients in five AAP project states engaging in Rural Abortion Provider Initiative activities. Consultants followed up in about six weeks with a second round of surveys in each state, sent to recipients who had not yet responded. Designated recipients were generally limited to the clinician categories allowed to provide abortion services within the state s legal and regulatory environment. Sample selection therefore varied somewhat from state to state, both in the types of clinicians targeted and the geographic scope (see Table 1). Table 1. Description of Multi-state Survey Sample State Clinician Type Geographic Scope Colorado MDs and DOs South-central mountain region and eastern plains region Iowa MDs and DOs Statewide Maine Family medicine MDs, DOs, CNMs, and PAs West Virginia MDs and DOs Statewide Wyoming Primary care and ER physicians Washington and Aroostook Counties Statewide Analysis In addition to descriptive statistics, the data was analyzed through frequencies and cross-tabulation using SPSS.

5 Colorado Surveys were sent exclusively to physicians (MDs and DOs) because Colorado law prohibits the provision of abortion care by other qualified clinicians. The survey targeted 402 physicians in the south-central mountain region and eastern plains region, representing the rural regions not included in a 2006 survey of abortion access in Colorado jointly conducted by AAP and Planned Parenthood of the Rocky Mountains. (The 2006 survey used a substantially different survey instrument that precludes direct comparison of results.) Clinicians were identified through the Colorado Board of Medical Examiners list of Active Physician Licenses and Colorado Medical Providers Directory. Iowa Surveys were exclusively sent to physicians (MDs and DOs) in recognition that Iowa s legal and regulatory environment discourages the provision of abortion care by other qualified clinicians. The survey targeted physicians throughout the state, excluding those who fell within a 50 miles radius of known providers. Clinicians were identified through the State Board of Medicine and a total of 408 surveys were distributed. Maine A total of 148 surveys were sent to physicians (MDs and DOs), certified nursemidwives (CNMs), physician assistants (PAs), and nurse practitioners (NPs) practicing family medicine in Washington and Aroostook Counties (on the eastern and northern edges of the state, respectively). Clinicians were identified through the Maine Board of Licensure in Medicine (MDs and PAs), State Board of Nursing (NPs, CNMs), and the Board of Osteopathic Medicine (DOs). West Virginia Surveys were sent to physicians only (MDs and DOs), given that West Virginia s legal and regulatory environment is ambiguous about the provision of abortion care by other qualified clinicians. All 1,201 physicians in the state were included in the initial distribution of surveys. A second round of surveys was sent specifically to 427 physicians within zip codes that are approximately 50 miles from a known abortion provider and have a population under 25,000. Physicians were identified through the State Board of Medicine and the State Board of Osteopathic Medicine. Wyoming Surveys were sent to all 186 primary care and emergency room physicians listed in the 2008 Wyoming Board of Medicine Physician Directory, excluding those solicited in a previous statewide survey using a different instrument in Primary care physician categories included osteopathy, family medicine, family practice residence, general practice, gynecology, internal medicine, obstetrics, obstetrics and gynecology, and pediatrics.

6 Results A total of 162 individuals responded to our survey. The distribution of respondents across the five participating state is displayed in Figure1. Figure 1: Overall respondents by state Wyoming 8% West Virginia 22% Colorado 30% Colorado Iowa Maine West Virginia Wyoming Maine 11% Iowa 29% Table 2 includes a breakdown of the number of surveys distributed, the number of completed surveys and the response rate by state and across all five states. The overall response rate for the survey was 6.9%. Response rates were somewhat higher (11%) in the first three states (Colorado, Iowa, and Maine) than in West Virginia and Wyoming (3% and 7%, respectively). Because a greater number of surveys were distributed in the first round of administration in West Virginia, the pool of potential respondents was significantly larger in that state. Table 2: Surveys distributed and response rate Surveys distributed Number of respondents Response rate Colorado % Iowa % Maine % West Virginia % Wyoming % Total %

7 Respondent Background The questionnaire included items about respondents professional training, specialty and practice location. As expected, given the legal and regulatory environment for abortion service provision in most states, most respondents (91%) were physicians (Table 3). Almost three-quarters of the total sample (72%) reported an MD degree, and 19% reported a DO degree. In Maine, however, over half (53%) of respondents were NPs and only 35% of clinicians reported an MD degree. Wyoming and West Virginia had proportionally more DOs than the other states. Respondents medical specialty reflects the sampling strategies used in each state (Table 4). About three-fourths (76%) of the total sample worked in family medicine and internal medicine specialties. Because emergency medicine was targeted in Wyoming, nearly half of respondents in that state were emergency medicine specialists. A number of respondents reported practicing in more than one type of practice setting. Across the five states, group practice (33%) and private practice (32%) settings were the most frequently reported practice locations. In Wyoming and Colorado, however, proportionately more respondents worked in hospital settings (54% and 38%, respectively). In Maine, 35% of respondents reported working in a location defined as other, possibly indicating confusion with offered categories. Table 3. Professional training reported by respondents (N=157) MD DO NP CNM Other Colorado Iowa Maine West Virginia Wyoming Total 72% (113) 19% (30) 7% (11) 2% (2) 1% (1) Table 4. Medical specialties reported by respondents (N=162)* Internal Emergency Family Pediatrics Ob-Gyn Other Medicine Medicine Medicine Colorado Iowa Maine West Virginia Wyoming Total 8% (12) 9% (14) 68% (108) 4% (7) 11% (18) 3% (4) * Percentages do not add up to 100% because respondents could check more than one specialty. Table 5. Practice setting(s) reported by respondents (N=162)* Private Practice Women s Health Clinic Educational Institution Group Practice Community Health Center * Percentages do not add up to 100% because respondents could check more than one practice setting. Hospital Colorado 16) Iowa Maine West Virginia Wyoming Total 32% (51) 2% (3) 1% (2) 33% (53) 16% (25) 19% (31) 13% (21) Other

8 Services Offered To learn about the specific types of reproductive health services provided by rural clinicians, the questionnaire listed a wide range of services and asked respondents to indicate whether or not they currently provided each service (Table 6). Patterns of service provision were similar across the states, with a few exceptions (likely due to the fact that the survey targeted different specialties in different states). Across states, the most frequently reported services included pap smears (83%) and contraceptive services (74%). Twice as many clinicians reported providing hormonal contraception (78%) as compared with surgical or other contraceptive methods (29-45%). Respondents in Wyoming were less likely to provide contraceptive and pap smear services than respondents in other states. In three states (Colorado, Maine, Wyoming), two-thirds to three-fourths of respondents reported offering emergency c-section. In this multi-state sample of 162 healthcare providers, only two clinicians in the state of Colorado (1% of total) reported providing induced abortion services (Table 6). No respondents in the other four states offered abortion services, although substantial proportions reported providing services requiring compatible skill sets to those used in abortion care (e.g., cervical dilation, uterine evacuation). Moreover, across the five states only a fifth of respondents (19%) reported using aspiration for early pregnancy loss management (EPLM), an average that masks even lower levels of aspiration for EPLM (8-9%) in West Virginia and Wyoming (as compared with 41% in Maine). A somewhat higher percentage of respondents (29%) reported using medication for EPLM, although this was again lower in West Virginia.

9 Table 6. Reproductive health services offered by rural clinicians Colorado Iowa Maine West Virginia Wyoming Total %(N) %(N) %(N) %(N) %(N) %(N) Prenatal care 45 (22) 62 (29) 47 (8) 69 (24) 62 (8) 57 (91) Deliveries 35 (17) 34 (16) 53 (9) 29 (10) 39 (5) 35 (57) C-section 29 (14) 32 (15) 35 (6) 20 (7) 39 (5) 29 (47) Emergency c-section 69 (34) 53 (25) 88 (15) 47 (17) 85 (11) 63 (102) Contraceptive services 71 (35) 66 (31) 94 (16) 86 (30) 54 (7) 74 (119) Hormonal contraception 84 (41) 64 (30) 94 (16) 89 (31) 54 (7) 78 (125) IUD 57 (28) 43 (20) 59 (10) 29 (10) 39 (5) 45 (73) Tubal ligation 29 (14) 38 (18) 35 (6) 23 (8) 39 (5) 32 (51) Vasectomy 39 (19) 43 (20) 18 (3) 3 (1) 33 (4) 29 (47) Pap smears 86 (42) 75 (35) 94 (16) 94 (33) 54 (7) 83 (133) Endometrial biopsies 59 (29) 53 (25) 65 (11) 40 (14) 46 (6) 53 (85) Colposcopies 47 (23) 43 (20) 35 (6) 34 (12) 39 (5) 41 (66) 33 (16) 30 (14) 41 (7) 11 (4) 39 (5) 29 (46) 20 (10) 21 (10) 41 (7) 9 (3) 8 (1) 19 (31) 4 (2) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) 4 (2) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) Obstetric services Contraceptive services Other gynecological services Pregnancy loss/abortion services Early pregnancy loss management Medication Early pregnancy loss management Aspiration Induced abortion Medication Induced abortion Aspiration

10 Perceived Patient Need The survey included a series of questions that asked respondents to rate as low, medium, or high their patients need for four types of reproductive health services: contraception, obstetrics, abortion, and other reproductive health services. As shown in Figure 2, over twothirds of respondents (70-80%) perceived their patients need for contraceptive services, obstetrical services, and other services to be medium or high. For abortion, however, the proportions were inverse, with most respondents (67%) perceiving patient need for abortion services as low. The pattern of lower perceived need for abortion services as compared to other categories of reproductive health services was evident in each of the five states, as shown in Table 7. However, providers in Colorado and Maine were less inclined to characterize the need for abortion services as low (50%) than clinicians in the other three states (69-84%). Figure 2. Clinician perceptions of patient need for reproductive health services Table 7. Clinician perceptions of patient need for reproductive health services, by state Low Medium High N Colorado Contraception 26% 23% 51% (43) Obstetrics 36% 36% 29% (42) Abortion 50% 21% 29% (42) Other 26% 30% 44% (43) Iowa Contraception 28% 44% 28% (43) Obstetrics 29% 45% 26% (42) Abortion 84% 14% 2% (43) Other 20% 66% 15% (41) Maine Contraception 19% 31% 50% (16) Obstetrics 19% 56% 25% (16) Abortion 50% 44% 6% (16) Other 19% 44% 38% (16) West Virginia Contraception 12% 29% 59% (34) Obstetrics 22% 44% 33% (36) Abortion 74% 19% 7% (31) Other 3% 46% 51% (35) Wyoming Contraception 39% 31% 31% (13) Obstetrics 46% 31% 23% (13) Abortion 69% 15% 15% (13) Other 50% 33% 17% (12)

11 Perceptions about Patient Travel to Obtain Services For each of the four categories of reproductive health services, the survey asked respondents to estimate the distance patients would be required to travel to obtain the services if not provided by the respondent (see Table 8). Respondents perceived contraceptive services as being the most accessible, with nearly all respondents reporting that their patients would have to travel fewer than 50 miles to obtain such services. On average, most respondents (76%) also perceived obstetrical care as being accessible within a 50-mile radius, although this was true for only half of the respondents in Colorado. As shown in Table 7, clinicians perceptions regarding access to abortion care were quite different. Compared to other types of reproductive healthcare services, only a fourth (26%) of the sample perceived abortion as being accessible within 50 miles. In the five states combined, roughly half of all clinicians reported that patients would need to travel over 100 miles to obtain abortion care. Half of the Wyoming clinicians and a quarter of clinicians in Colorado estimated that patients would need to travel over 150 miles to obtain abortion care. Table 8. Perceptions about patient travel to obtain services Colorado Iowa Maine West Virginia Wyoming Total % (N) % (N) % (N) % (N) % (N) % (N) Contraceptive services Less than 50 miles 82 (14) 95 (19) 83 (5) 100 (21) 100 (7) 93 (66) 50 to 99 miles 18 (3) 5 (1) 17 (1) 0 (0) 0 (0) 7 (5) 100 to 149 miles 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 150 or over 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Obstetrical care Less than 50 miles 50 (15) 75 (21) 67 (6) 100 (28) 100 (8) 76 (78) 50 to 99 miles 33 (10) 25 (7) 11 (1) 0 (0) 0 (0) 18 (18) 100 to 149 miles 10 (3) 0 (0) 11 (1) 0 (0) 0 (0) 4 (4) 150 or over 7 (2) 0 (0) 11 (1) 0 (0) 0 (0) 3 (3) Abortion care Less than 50 miles 18 (7) 24 (9) 13 (2) 50 (16) 20 (2) 27 (36) 50 to 99 miles 28 (11) 40 (15) 13 (2) 28 (9) 20 (2) 29 (39) 100 to 149 miles 30 (12) 32 (12) 31 (5) 22 (7) 10 (1) 27 (37) 150 or over 25 (10) 5 (2) 44 (7) 0 (0) 50 (5) 18 (24) Other reproductive healthcare Less than 50 miles 523 (10) 90 (17) 71 (5) 96 (26) 100 (7) 82 (65) 50 to 99 miles 42 (8) 10 (2) 29 (2) 4 (1) 0 (0) 17 (13) 100 to 149 miles 5 (1) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 150 or over 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

12 Perceived Need Interest in Training The survey assessed respondents interest in providing medication abortion, aspiration abortion and early pregnancy loss management, if training and support were offered (see Table 8). Across states, respondents displayed greater interest (as assessed by yes and maybe responses) in offering EPLM services (49%), either aspiration or medication, than in providing abortion services. Levels of interest in EPLM were higher in Wyoming (64%), Maine (40%), and Colorado (35%) than in the other two states. Potential interest ( yes or maybe ) in medication abortion training was higher (34%) than interest in aspiration abortion (13%). At the individual state level, over one-fourth (27%) of clinicians in Colorado and Maine expressed definite interest ( yes ) in learning to provide medication abortion, as compared with relatively few respondents in Iowa (5%) and West Virginia (9%) and none in Wyoming. Few clinicians reported any interest in receiving training and support to provide aspiration abortion, and these were limited to the two states of Colorado (12%) and Iowa (3%). Table 9. Respondent interest in provision of abortion care and early pregnancy loss management Colorado Iowa Maine West Virginia Wyoming Total % (N) % (N) % (N) % (N) % (N) % (N) Medication abortion Yes 27 (11) 5 (2) 27 (4) 9 (3) 0 (0) 14 (20) Maybe 22 (9) 3 (1) 33 (5) 26 (9) 30 (4) 20 (28) No 51 (21) 92 (35) 40 (6) 66 (23) 69 (9) 66 (94) Aspiration abortion Yes 12 (5) 3 (1) 0 (0) 0 (0) 0 (0) 4 (6) Maybe 15 (6) 0 (0) 8 (1) 12 (4) 0 (0) 8 (11) No 73 (30) 97 (36) 92 (11) 88 (29) 100 (12) 87 (118) EPLM Yes 35 (14) 26 (8) 40 (4) 7 (2) 64 (7) 28 (35) Maybe 28 (11) 3 (1) 10 (1) 40 (12) 0 (0) 21 (25) No 38 (15) 71 (22) 50 (5) 53 (16) 37 (4) 51 (62)

13 To identify factors associated with greater interest in abortion care and EPLM, we conducted a series of cross-tabulation analyses. Table 10 examines interest in abortion care by professional background, specialty and practice location. To determine statistically significant differences, we ran Chi-square tests and examined cell-adjusted residuals. (Because of the relatively small number of responses in some of the categories that comprise the denominator, percentages should be interpreted with caution.) We found two significant differences when looking at medical specialty and interest in the three types of services (medication abortion, aspiration abortion, and EPLM). First, Ob/Gyns were significantly more likely to express interest in EPLM (70%) as compared with other specialties (25-30%) (X 2 =9.1, p<.05). Second, family medicine practitioners were more likely to say maybe to EPLM (28%) than other specialties (X 2 =8.392, p<.05), suggesting that family medicine s interest could be cultivated with additional support. Table 10. Interest in abortion care and EPLM by professional background (percentage) Medication Abortion Aspiration Abortion EPLM Yes Maybe No Yes Maybe No Yes Maybe No Profession MD (n=99) DO (n=28) NP (n=10) CNM (n=2) Specialty Internal medicine (n=9) ER medicine (n=11) Family medicine (n=95) Pediatrics (n=7) Ob/Gyn (n=17) Other (n=3) Practice location Private practice (n=47) PP or women s health (n=3) Group practice (n=51) Community health ctr. (n=23) Hospital (n=29) Other (n=13)

14 Additional analyses considered whether providing other reproductive health services or procedures makes a clinician more (or less) likely to be interested in providing abortion care or EPLM (Table 11). We found statistically significant differences related to EPLM but not to abortion care. Clinicians who reported providing prenatal care, doing c-sections, managing deliveries, inserting IUDs, performing endometrial biopsies or providing colposcopies were more likely to express interest in providing EPLM if training and support were available than those who did not provide such services. Specifically, respondents who provided prenatal care were more than twice as likely as those not providing prenatal care (46% vs. 18%) to report that they would consider training for and providing EPLM (X 2 =11.8, p<.05). Similar patterns were found for clinicians providing c-sections (52% vs. 22%) (X 2 =9.9, p<.05), inserting IUDs (42% vs. 19%) (X 2 =9.58, p<.05), doing endometrial biopsy (42% vs. 15%) (X 2 =11.3, p<.05), and doing colposcopies (48% vs. 17%) (X 2 =11.36, p<.05). Table 11. Interest in abortion care and EPLM services by current services provided Medication Abortion Aspiration Abortion EPLM Services currently provided Yes Maybe No Yes Maybe No Yes Maybe No Prenatal care (n=64) Deliveries (n=53) C sections (n=41) Contraception (n=111) Hormonal contraceptives (n=116) IUD (n=68) Tubal ligation (n=45) Vasectomy (n=42) Emergency C-section (n=77) Pap smears (n=104) Endometrial biopsy (n=76) Colposcopy (n=46)

15 Table 12 relates clinicians interest in offering abortion and EPLM services to perceptions of the need for abortion, perceptions of the distances women travel, and experiences with abortion referrals. Not surprisingly, interest in all three types of services (medication and aspiration abortion and EPLM) was significantly related to perceptions regarding the need for such services. First, a higher percentage of clinicians who perceived the need for abortion as being medium or high reported interest in medication abortion, compared to those who perceived the need to be low (X 2 =21.9, p<.01). Second, clinicians who perceived a low need for abortion services were more likely to express disinterest in providing aspiration abortion (93%) than those who perceived a high need for abortion services (67%) (X 2= 9.9, p<.05). Finally, respondents who perceived a high need for abortion were less likely to say no to providing EPLM services compared with those who perceived the need for abortion to be low (X 2 =15.1, p<.01). Perceptions of how far women had to travel to obtain abortion care showed no relationship to interest in providing abortion services or EPLM. In the analysis of referral patterns, however, clinicians who referred to an out-of-town Ob/Gyn were more likely to consider providing medication abortion (X 2 =11.0, p<.01) and aspiration abortion (X 2 =8.1, p<.01) than those not making referrals to out-of-town Ob/Gyns. Table 12. Interest in abortion care and EPLM by perceptions of need for abortion, perceptions of distances traveled, and referral experiences Medication Abortion Aspiration Abortion EPLM Yes Maybe No Yes Maybe No Yes Maybe No Perceived need for abortion High (n=18) Medium (n=27) Low (n=90) How far do women travel? Less than 50 miles (n=35) to 99 miles (n=37) to 149 miles (n=35) miles or more (n=22) Where do you refer? Local Ob/Gyn (n=9) Out-of-town Ob/Gyn (n=41) Out-of-town hospital (n=29) PP/women s health (n=70)

16 Referrals For clinicians whose practice sites did not offer medical and/or surgical abortion, the survey asked them to specify where they refer patients seeking abortion services (see Table 13). Although referral practices vary somewhat from state to state, the survey responses reflect a general reliance on the Planned Parenthood brand to connect women with services. In all five states, sizable proportions of respondents (40%-57%) made referrals to Planned Parenthood (or a comparable women s health center). In Colorado and Maine, nearly half of the respondents also reported making referrals to out-of-town Ob/Gyns. In examining clinicians responses and comparing the referrals to actual known providers of abortion care, we noted that respondents did not always provide accurate referrals. In some cases, respondents referrals caused patients to travel greater distances than necessary to receive abortion care, or respondents directed patients to family planning service providers who do not offer abortion services. Table 13. Referrals for patients seeking abortion services Colorado Iowa Maine West Virginia Wyoming Total Local ob/gyn 0 (0) 12 (5) 0 (0) 9 (3) 10 (1) 6 (9) Local hospital 2 (1) 2 (1) 0 (0) 0 (0) 0 (0) 1 (2) Out-of-town ob/gyn 45 (22) 12 (5) 47 (8) 24 (8) 20 (2) 29 (45) Out-of-town hospital 12 (6) 28 (13) 18 (3) 21 (7) 30 (3) 21 (32) PP/ women's clinic 57 (28) 45 (21) 53 (9) 42 (14) 40 (4) 49 (76) Other 8 (4) 4 (2) 24 (4) 13 (4) 10 (1) 10 (15) No referral 6 (3) 6 (3) 6 (1) 16 (5) 0 (0) 8 (12) Obstacles The only open-ended question in the survey asked respondents to describe the obstacles, if any, [that they] are aware of to providing abortion at [their] practice site. The responses clustered into five barrier categories (Table 13): (1) personal belief, (2) negative community response, (3) training and logistics, (4) no interest or not consistent with specialty, and (5) no demand or need. In the case of the third and fourth obstacles, respondents who conveyed a general willingness to provide services but identified specific challenges were placed in the training/logistics category, while those conveying specialty-related reasons and no specific challenges fell into the no interest/not consistent with specialty category. Among the categories developed, concerns about negative community response and practical or logistical concerns were the most frequently noted obstacles to providing abortion. The logistical concerns included challenges related to practicing in rural settings (e.g., ensuring access to hospital facilities in the event of complications), as well as broader challenges not unique to rural clinicians (e.g., staff resistance, liability insurance). Some concerns reflected gaps in knowledge about abortion care, such as concerns about pharmacists involvement in procuring Mifepristone (the medication must be order directly from the manufacturer by a physician, according to unique and restrictive FDA protocols), or the belief that abortion care should be provided solely by ob-gyn specialists. Respondents also listed personal beliefs as a barrier.

17 Obstacle Category # Illustrative Examples Personal belief 13 Negative community response 24 Training/logistics 23 No interest/not consistent with specialty 12 No demand/need 4 The OB providers in my practice believe all life is of value and do not kill innocent life. I pray you dry up and go away. Why do you choose death over life? Personal preference. We are adamantly opposed to abortion. Abortion is helpful to the mother but it kills the baby. Extreme negative community reaction -- not worth the grief! Possible loss of income. An extremely conservative political environment in a small (2,500 person) town. Very small community would lead to perception of loss of privacy. Local hospital would not support us. In-office set-up and liability. Lack of training, lack of decision, comfort to provide services. Staff resistance, lack of gyn backup. Closest hospital is 35 miles away if any complications. Having pharmacies supply RU-486 or Plan B. Adequate nursing and emergency staff not available in event of complications. I would rather have local ob/gyn office provide this service so that family physicians can continue taking care of other problems in this underserved community. Call partners are opposed and will refuse to share call if abortion services are provided; also concern for loss of revenue Do not have ultrasound on-site, do not have lab on-site. No [obstacles], but it s not my specialty at all. Internal medicine practice; our range in our office is years old. I have not seen any patients asking for this service - they must be going elsewhere.

18 Discussion Our five-state survey of 162 rural physicians and advanced practice clinicians highlights a number of factors contributing to rural women s difficulty in accessing abortion services. In the entire sample, only two providers in the state of Colorado reported actually providing abortion services. A majority of respondents perceived their patients need for abortion services to be low, and most expressed minimal interest in learning to provide either aspiration or medication abortion services, even with proper training and support. In the following paragraphs, we consider these findings in greater detail. Medical Specialty Family medicine was by far the most common specialty among survey respondents (68% of total), notable given that non-ob-gyn providers are noted as a growing subset among abortion providers. 5 When combined with respondents noting an internal medicine specialty, primary care or general practice clinicians made up three-fourths (76%) of the total sample. These sample characteristics correspond to known trends in rural healthcare delivery, with primary care specialties comprising the majority of physicians in non-metropolitan areas. 6 In comparison, only a third of physicians in metropolitan areas practice primary care. Additionally, only 3% of non-metropolitan patients visit ob-gyn specialists, as compared with 9% of metropolitan patients. 7 Need for Services Clinicians perceptions of patient need for abortion services raise a number of questions. Although one in three women will have an abortion by the age of 45 8, most respondents (67%) perceived a low need for abortion services, while classifying women s need for contraceptive services, obstetrical services, and other reproductive health services as medium or high. Comparing perceived need for abortion care by state, most respondents from Iowa (84%), West Virginia (74%) and Wyoming (69%) rated the need for abortion as low, whereas only half of the clinicians in Colorado and Maine perceived a low need for abortion care. Although the basis for state differences in perceptions about abortion need is unclear, our findings point to the importance of considering the state context when developing strategies to engage clinicians in abortion care. Several factors make it difficult to interpret clinicians responses regarding the need for abortion services. Because the survey did not provide measures to assess need (e.g., number of requests for abortion care, number of women of reproductive age), low need may have been conceptualized by respondents in different ways. For example, low need might mean that the respondent s patients: do not experience unintended

19 pregnancy; would not seek abortion services in the event of an unintended pregnancy; or are hesitant to approach clinicians for abortion care, either because of expressed disapproval of abortion by the clinicians or because of a lack of expressed support for all reproductive options around pregnancy. In settings where there is adequate availability of abortion services, it is also possible that patients needs are already being met. Without a clearly articulated demand for services, it may be difficult for providers to accurately assess need for abortion. Nonetheless, it appears that clinicians perceptions about patient need for abortion services are set apart from their perceptions about other reproductive health services. Personal knowledge and beliefs may be a factor driving some clinicians perceptions about the different types of services. For example, anti-choice sentiments may have caused some providers to select the low need category for abortion care but not for other services, reflecting their belief that no woman needs an abortion. Lack of information about abortion could also be a factor, given that the majority of medical education programs do not include content on abortion care. Services Offered Our survey results indicate that most rural providers offer some basic reproductive health services, including hormonal contraceptive services and pap smears. Services that require more specific skill sets and equipment, such as colposcopies and IUD insertions, appear to be less widely available. Abortion care, offered by only 1% of respondents, was essentially absent from our respondents menu of services. The technical skills involved in early abortion care using aspiration, such as cervical dilation and uterine evacuation, are similar to those needed for pregnancy loss management. However, whereas 19% of respondents reported providing aspiration pregnancy loss management and 29% provided early pregnancy loss management (EPLM) using medication, these technical skills are not being used for early abortion care. Informal analysis by state-based consultants further suggests that some clinicians may have understood medication management of EPLM as the administration of pain medication, not the use of misoprostol or Mifepristone. Patient Travel and Referrals Roughly half of clinicians estimated that patients traveled 100 or more miles for abortion care. However, clinicians assessment of the travel required to obtain abortion services may not always be accurate. Informal analysis by state-based consultants suggests that some clinicians may make inappropriate referrals, referring patients to distant clinics despite the availability of closer services, or referring patients to clinics that do not provide abortion care at all. A third (32%) of respondents noted an interest in receiving more information about referrals, reflecting an opportunity to educate clinicians about appropriate referral sources.

20 Training Although providers may be missing some opportunities to make appropriate referrals, our survey responses also clearly indicate that there is a lack of community-based abortion providers in these rural states and regions. One of the survey s primary goals was to identify and engage providers interested in receiving training in abortion care. As evidenced by yes or maybe responses, our findings highlight the fact that there is more potential interest in medication abortion training than in aspiration abortion training (34% vs. 13%). However, interest in both types of abortion training also varies notably by state, with providers in Colorado and Maine showing the most pronounced interest. Nearly half of Colorado respondents reported either a definite (27%) or possible (22%) interest in medication abortion training, and over a fourth were willing to either be trained (12%) or to consider training (15%) for aspiration abortion services. In Maine, respondents also showed significant interest in medication abortion (27% yes and 33% maybe ), but no clinicians responded yes to training opportunities in aspiration abortion and only one Maine provider responded with maybe. Few or no respondents in the other three states reported any definite interest ( yes ) in receiving training and support to provide medication abortion services. However, roughly a fourth of clinicians in West Virginia and Wyoming answered maybe, suggesting that there may be room to cultivate interest in medication abortion in these two states. Interest in learning to provide aspiration abortion services was minimal or nonexistent in these three states. In all five states, clinicians reported greater interest in early pregnancy loss management training than in abortion care training. In Wyoming, almost two-thirds (64%) of respondents stated that they would be interested in EPLM training ( yes ), and roughly half of respondents in Colorado, Maine, and West Virginia expressed definite or possible interest ( yes or maybe ). Because of its political and clinical connections to elective abortion care, outpatient uterine evacuation management of early miscarriage has not been taught to the majority of physicians. Decades of research on uterine evacuation, generated through experience with elective abortion, has been excluded from clinical instruction on miscarriage management because of stigma associated with elective abortion. Given that approximately 12 to 24 percent of pregnancies end in miscarriage before the first 20 weeks of gestation 9, this omission affects many women s ability to receive timely and appropriate care from their primary care providers. This gap in the healthcare delivery system also affects abortion care: it limits the system s ability to respond to both self-induced and incomplete abortion. Training clinicians in modern methods of managing miscarriage may result in more accessible, patient-centered care for women experiencing early pregnancy loss and a stronger system of back-up for early elective abortion. Our analysis of characteristics associated with interest in abortion and EPLM training revealed some noteworthy trends with regard to EPLM. Likely predictors of interest in

21 EPLM training included ob/gyn specialty and experience with other reproductive health procedures (including c-sections, IUD insertions, endometrial biopsies, and colposcopies). Family medicine specialists were more likely to indicate possible interest in EPLM training than other types of specialists, suggesting that this group of providers may be primed to receive support and encouragement. Perhaps unsurprisingly, clinicians who estimated a medium or high need for abortion care among their patient populations were more likely to report interest in medication abortion training, and were less likely to say no to training in aspiration abortion. Clinicians who ranked women s abortion needs as higher were also more likely to express possible interest in EPLM training and less likely to refuse EPLM training. Although our cross-sectional survey design precludes establishing causality, our findings suggest that clinicians who understand their patients needs may be more likely to consider stepping up to meet those needs, including the need for miscarriage management and abortion care. Obstacles Respondents highlighted negative community response as a key obstacle to providing abortion care. Building a network of support for abortion providers and offering providers one-on-one support are strategies that may partially address this obstacle; however, community backlash (and possibly violence) is a legitimate concern. Respondents also identified personal beliefs as a key obstacle. Although all health professionals have a duty to provide patients with the care that they need, no matter their personal beliefs, this can present a challenge for healthcare providers whose personal beliefs strongly conflict with their patients needs. 10 When personal beliefs preclude offering abortion care, emphasizing the importance of a quality referral practice is critical. The logistical and training barriers noted by respondents are more amenable to intervention and provide a key opportunity for future work. Technical support from AAP field consultants and others can address many of these logistical and technical obstacles, as well as the application of established strategies that can address barriers related to liability, surgical back-up, or staff resistance. Limitations Our low response rate and the survey s focus on the sensitive topic of abortion point to the possibility that our respondents were a self-selecting group, rather than a representative sample. Our survey intentionally elicited clinicians perceptions of patients reproductive healthcare needs and travel to receive care. Although provider perceptions do not necessarily reflect patients actual experiences, the findings concerning provider hesitation and lack of interest in providing abortion care highlight future areas to target for invention. Because the sample selection process was different in each state, our ability to draw nationally relevant conclusions from the aggregate data is limited. Moreover, response patterns varied considerably among the five states. Our findings suggest that future interventions in this group of states with active AAP involvement should be tailored to each state s particular context and that more research designed to reflect a national scope is needed.

22 Conclusion The results of our multi-state survey of rural healthcare providers provide an immediate springboard for training activities. Three states (Colorado, Iowa, and Maine) already have used the survey results to conduct state-level training. In addition, the survey represents a step towards filling in the information gap around abortion access in rural communities. The finding that abortion care is segregated from other reproductive health services is not unexpected. Rural clinician s responses to questions about perceived patient need, services currently offered, and travel to obtain abortion services suggest that abortion care is different from and does not enjoy the same availability as other reproductive health services. These results identified some solid opportunities for follow-up. Notably, the greater interest in medication abortion training as compared with aspiration abortion training highlights a key opportunity for expanding the number of clinicians trained in and providing abortion care. However, our findings also indicate that state-specific strategies are critical to successfully engage rural clinicians. Offering providers further information on abortion access in rural communities and enabling them to understand rural need for abortion care is essential to improve service delivery. However, as respondents feedback about obstacles to care suggested, abortion-related stigma can significantly distort providers interpretation of the need for services and women s preferences. Supporting the development of a network of informed community providers has the potential to address the need for services. It is possible to imagine that shift in the availability of abortion services in rural communities might reshape women s expectations around local abortion service, and thus the demand for abortion. The current absence of a provider base in rural communities also makes it vital to pursue a secondary provider education strategy to improve women s abortion access through appropriate referrals. Those with rural women s access to abortion in mind must continue to seek answers to outstanding questions as we partner with rural clinicians: How can we situate abortion care within the context of rural healthcare delivery? How can we contain the negative impact of abortion-related stigma on women seeking care and providers who offer it? What support is needed to make abortion care feasible in rural primary care settings? AAP continues to explore these questions and possible solutions through its Rural Abortion Provider Initiative, which seeks new collaborations within the reproductive and rural healthcare communities and uses innovative and collaborative strategies to address this enduring gap in abortion access.

23 References 1. Jones R, Zolna M, Henshaw S, Finer L. Abortion in the United States: Incidence and Access to Services, Perspectives on Sexual and Reproductive Health 2008; 40(1): Rosenblatt R, Mattis R, Hart L. Abortions in Rural Idaho: Physicians Attitudes and Practices. American Journal of Public Health 1995; 85(10): Dobie S, Hart G, Glusker A, Madigan D, Larson E, Rosenblatt R. Abortion Services in Rural Washington State, to : Availability and Outcomes. Family Planning Perspectives 1999; 31(5): Jones R, Zolna M, Henshaw S, Finer L. Abortion in the United States: Incidence and Access to Services, Perspectives on Sexual and Reproductive Health 2008; 40(1): Ibid 6. American Medical Association, Physician Characteristics and Distribution in the US, Chicago, IL: American Medical Association, National Ambulatory Medical Care Survey, Henshaw S, Finer L. The accessibility of abortion services in the United States, Perspectives on Sexual and Reproductive Health 2003; 35: Griebel C, Halvorsen J, Golemon T, Day A. Management of spontaneous abortion. American Family Physician Oct 1;72(7): American College of Obstetricians and Gynecologists Committee on Ethics. The limits of conscientious refusal in reproductive medicine; number 385: November 2007.