Family Physicians' Barriers and Facilitators in Incorporating Medication Abortion

Group 1: Absence of Training and No Provision

Family physicians who did not receive abortion training and were not abortion providers discussed their lack of training as the most significant barrier to abortion provision. As one participant explained to us, “I myself do not [provide abortions], but that is… more of a reflection of lack of training. It is not by no means anything I am philosophically opposed to” (P32, West, Supportive).

Other participants agreed that while family physicians should provide abortions, the lack of universal training made them uncomfortable with prescribing MAB. For example, one physician working in a Southern state felt “completely uneducated on the approach.” As a result, she felt unable to prescribe the medication necessary for a medication abortion. As she explained to us: “I do not prescribe any medications that I do not understand” (P35, South, Hostile). Another physician emphasized the absence of training on abortion provision as a unique problem that family physicians face: I treat diabetes, I treat thyroid medication, why wouldn't I provide that service? … I think that the challenge is - is that unlike diabetes, which pretty much all family medicine physicians have like bought into and can agree like, okay, this is a chronic disease, we need to manage it, these are the typical ways we do it, abortion does not necessarily elicit that same universal approach (P30, West, Supportive).

The absence of training on medication abortion provision prevented this group from possessing the technical skills to provide abortions. Physicians in this group shared that their lack of exposure to abortion during training solidified for them the exclusion of abortion from family physicians' scope of practice. Furthermore, their lack of training resulted in this group of physicians not being exposed to or aware of the systemic barriers physicians face in integrating medication abortion into primary care.

These physicians, more than participants in other groups, mentioned how location – with subsequent state politics, hospital system restrictions, and poor community support—dissuades them from providing abortions.

I think it's just the region I live in… I mean if I lived in an area where it was routine to provide those services, it would be definitely different than living somewhere where, where you're not able to (P13, South, Hostile).

Group 2: Received Training but Do Not Provide

Family physicians who received abortion training but do not provide abortions primarily described external barriers that prevented or made it difficult to offer abortion in their clinical practice. Unlike the first group of physicians who lacked technical skills and knowledge around institutional barriers, the second group generally had more concrete knowledge of state and institutional restrictions preventing them from providing MAB. For example, one participant discussed how the state laws where she practiced restricted her ability to provide.

There are a ton of… ridiculous abortion restriction laws that happened. Like, you have to have a sign to a certain dimension in the waiting room…to be able to perform abortions…If I lived anywhere else that was more liberal and had better state laws, I would a hundred percent be doing this [providing abortions] (P15, Midwest, Hostile).

Another participant similarly focused on the legal barriers on abortion provision that made it impossible to provide abortion in her clinic: “The setting of my clinics is not an ambulatory - quote unquote, ambulatory surgical center. So, based on state laws… I would not be able to provide it in my family medicine clinic” (P85, Midwest, Hostile).

Many of the physicians in this group chose to work in Federally Qualified Health Centers (FQHCs). Due to federal restrictions such as the Hyde Amendment, that prevents federal funds from being used for abortion, these physicians felt a lack of administrative support to provide MAB. One physician we spoke with expressed her frustration with not being able to provide abortions at her FQHC, despite robust training during residency: The red tape to be able to provide abortions in an FQHC setting is just so enormous… Like why would they [clinic administration] do that when they could just send them to a Planned Parenthood? …[I]t's just become so normative that abortions occur at specialized clinics that a lot of administrators in the primary care world feel like there isn't a huge reason to get into the abortion business (P6, South, NA).

This group also brought up the logistic barriers imposed by the REMS criteria on mifepristone. As one participant lamented, “I would be doing it in a heartbeat if I could prescribe mifepristone, and my patient could pick it up at a commercial pharmacy, but she cannot because of the way it is regulated by the FDA” (P6, South, NA).

Although most physicians in this group were frustrated by not being able to provide, some felt that they did not need to provide abortion services because patients could access care at local reproductive health clinics. As one physician described: Part of why I haven't, like, tried really hard to integrate this into my practice is that I have somewhere to send the patients… [if that weren't true] that would be more motivating for me to push myself to do something that I'm not already doing (P26, West, Supportive).

Finally, a few participants in this group, including two thought leaders, had provided abortion care since residency but were not providing abortions at the time of the interview due to competing demands from their current leadership roles and other clinical responsibilities.

Group 3: Received Training and Provide Abortion Services

Most of the physicians who provided abortions (n = 10, 59%) in the study were not providing MAB in primary care settings, and many split their time working between primary care and reproductive health clinics to provide abortions.

As with group 2, some physicians worked at institutions with policies prohibiting abortion provision at their sites or in states with hostile abortion policies that made it more difficult to provide. For example, leadership at one participant's clinic created a policy prohibiting abortion care at their site after hiring her, knowing that she worked part-time at an abortion clinic. Another participant was hired by an academic Family Medicine department for her reproductive health expertise with the goal of expanding their abortion training for residents. After she joined faculty, the Obstetrics and Gynecology (OBGYN) department prevented her from providing abortion care and training.

Two participants who provided abortions in a reproductive health clinic felt like they were too junior to take on the process of getting their primary care clinics to provide MAB. One participant who previously lost a job because her primary care employer found out she was providing abortions at another clinic shared, “I would really need to establish myself there,” before she would be willing to try and integrate abortion care (P1, Midwest, Supportive). Another participant who had recently graduated from residency reflected on how residents never received training on how to navigate the barriers to integrate MAB in primary care.

Like in residency or in medical school there's a lot of just like, oh, learn to do this procedure…. But there's not a lot of training in what are the systemic barriers or issues that you would face if you were trying to actually do this procedure in your office (P9, West, Supportive).

Seven participants were providing abortions in primary care, of which 5 exclusively provided in primary care and 2 provided in primary care and reproductive health settings. Four of these participants joined practices where MAB was already integrated. One participant (P52) had almost integrated MAB into her primary care clinic at the time of the interview and confirmed afterward that she was providing MAB to patients. All participants who provided MAB in primary care settings were either based in the Northeast or West and none were providing abortions in states with hostile abortion restrictions.

Participants who successfully integrated MAB into primary care described facilitators that helped them to provide. Those who provided abortions in FQHCs shared how persistence and supportive administration contributed to their ability to provide in that setting.

It's something my organization is pretty deeply committed to. But places where there aren't big champions, I think those extra costs or those extra administrative hassles may not…the people that run other organizations may not see it as worthwhile (P10, Northeast, Supportive).

A thought leader who started working on MAB integration before mifepristone was even approved by the FDA, shared how she continued to provide MAB at her FQHC despite numerous barriers: There was always another barrier, another barrier. But, you know, by then, we were already offering abortions. We were offering the pills and the MVAs in the office. And, you know, that seemed like the right thing to do and it seemed like the right thing to advocate for (P88, Northeast, Supportive).

In addition to understanding the laws and policies around MAB provision, participants described the importance of having physicians who were committed to providing MAB and willing to overcome challenges.

Well, you really have to have a champion. You really have to have someone who's just gonna dig in and work at it and work at it and work at it (P88, Northeast, Supportive).

P52 lived in a rural town where abortion was difficult to access and described how her community inspired her to integrate MAB into her primary care clinic: [In] at least half of the hospital board meetings somebody stands up and talks about how important it is to have reproductive choice… a couple community members would even call the clinic manager and try to demand time to talk about how to implement this… It's [community advocacy that was] really key to having me finally pull it together and realize that whatever the risk is, I can't just keep ignoring my community's need and I need to do something (P52, West, Supportive).

P52 and P8, the only new career family physician in our sample who successfully integrated MAB into primary care, both initiated the process of integrating MAB by sharing their intentions with their colleagues. They discussed how not having seniority at an organization impacted their approach. P52 waited until she had been at the clinic for a few years to begin conversations around providing MAB, whereas P8 initiated the conversation earlier and got approval to provide MAB from OBGYN leadership.

In my first year or two here, I just didn't wanna buck the system… Because I knew it was going to alienate me from her [the clinic director]. And I wanted to establish that I'm competent and a go getter (P52, West, Supportive).

You know, I'm pretty new…I'm a small fish in a big, big pond. I'm not gonna make any waves. So, I took what they gave me, and I was like, all right, I'll do IUDs and endometrial biopsies and medication abortions, and I'll get to the rest later (P8, Northeast, Neutral).

P52 faced opposition from antiabortion leadership. Despite unsupportive leadership, P52 joined hospital committees to change the policy.

I finally had to create a policy and procedures for the addition of this service line… And I eventually clawed my way onto the medical executive committee for the hospital (P52, West, Supportive).

P52 partnered with advocacy organizations and worked with the Reproductive Health Access Project to address each barrier that came up. P8 leveraged his relationship with an OBGYN colleague who helped him expand his scope and eventually also provide aspiration abortions to his patients. When leadership changed at P52's institution, she moved forward with the policies and procedures she had been working on and started prescribing mifepristone to her patients.