Facilitating Abortion Services in Primary Care Settings After the Loss of Federal Protections

Introduction

Abortion restrictions rapidly increased following the United States (U.S.) Supreme Court’s case, Dobbs vs Jackson Women’s Health Organization (Dobbs), ending the federal protection of abortion rights in the U.S.¹ Restrictions are expected to worsen pregnancy-related morbidity, mortality, and disparities, which are already U.S. public health crises.^2–4

Community based primary care is well-positioned to address health disparities due to its accessibility and patient-centered approach.⁵ Prior studies have demonstrated patient preference for and satisfaction with receiving an abortion in primary care settings.^6–9 Furthermore, primary care-based abortion services have been shown to be both safe and effective.¹⁰ Despite the need, patient preference, and safety of abortion services in primary care, many clinicians face barriers that prevent them from incorporating these services into their practice.^11–13

The five state WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) region of the Northwestern U.S. is diverse in its abortion access following the Dobbs decision.¹⁴ Regional learning collaboratives, a method uniting peers and experts to drive practice change through focused, team-based learning, can support abortion care in primary care settings.^10,15,16 We sought to explore the interest and potential effort of a regional learning collaborative focused on supporting abortion access and care to patients of clinicians belonging to regional networks across the WWAMI territory.

Methods

The Won’t Go Back (WGB) initiative was launched in July 2022 to: 1) support the delivery of safe and legal abortion care to patients, and 2) assist primary care clinicians in their care of patients seeking this service across the WWAMI region. A needs assessment survey and clinician convenings were carried out to explore interest and opportunities for moving forward.

The survey assessed clinician demographics, reproductive health services offered and interest in a learning collaborative supporting abortion services in primary care. Survey items were created, then pretested through cognitive interviewing with five independent staff members. An initial anonymous section was followed by a second survey for those who indicated interest in participating in the WGB learning collaborative. Study data were collected and managed using REDCap (Research Electronic Data Capture) tools hosted at the Institute of Translational Health Sciences.^17,18 The survey was disseminated to three networks involved with primary care training, research or reproductive health services: 1) the Family Medicine Residency Network (FMRN), 2) the WWAMI Population Research Network (WPRN), and 3) Federal Title X recipient clinics in Washington State. Survey links were emailed to clinician representatives from the aforementioned clinics, with some clinics possibly having multiple representatives. Two reminder emails were sent two weeks apart. Data was collected from December 2022-February 2023. No incentives were provided.

Respondents to the learning collaborative section received an invitation to attend online Zoom convenings. Agenda items focused on introductions (location and context), family planning service status, and goals. A transcript of each convening was recorded, and verbal consent was obtained for transcript collection and data analysis. Two research members compiled field notes and transcripts to assess common themes and summarize convening results. These were reviewed by the larger team to reduce analysis bias and guide the creation of a primary care abortion learning collaborative. The University of Washington (UW) Institutional Review Board reviewed this study and determined that the effort had exempt status.

Results

Discussion

Our study provides novel insight into the variety and prevalence of reproductive health services offered across primary care clinics in the Northwestern U.S., clinician interest in starting/growing abortion services within their practice, barriers faced by interested clinicians and preferred support options for implementation of services. Training primary care clinicians in abortion services and creating a referral network of clinicians could potentially address identified needs.

Most clinicians (63%) offered EPL management, a highly transferable skill to early abortion care. Additionally, most clinicians expressed concern about their community’s access to abortion or miscarriage care, highlighting the fears experienced by those even in states with full legal protections, such as Washington. The most requested solution to clinician barriers from the survey was implementation support and a collaborative model to help clinicians integrate abortion services and share knowledge.

Key themes from the convenings highlighted barriers to incorporating abortion care into primary care, including restricted access to mifepristone, federal funding limitations, lack of organizational support, legal challenges, and staff with anti-abortion views. The most supported solution was an abortion learning collaborative offering webinars on protocols, counseling, telemedicine, staff values clarification, and logistics.

Our findings should be interpreted within the study’s limitations. The response rate (21%) is consistent with other clinician surveys but remains low, potentially reflecting response bias.^20,21 Convenings were limited to WPRN, FMRN, and Title X clinic respondents, with most responses from Washington; therefore, the results may not be generalizable across the region. This study aimed to explore interest in regional collaboration, not provide epidemiologic evidence of specific clinics. The exact number of clinics represented is unknown, but our focus was to assess individual views and protect anonymity. Therefore, the data reflects this goal.

As restrictions expand, increasing access to safe abortion care is a public health need. We found substantial interest in abortion care training and referral networks across our WWAMI region. This needs assessment helped to inform the development of and curriculum for a Project ECHO focused on increasing access to medication abortion in primary care, launched in September 2024. Additional research and reproductive health training programs are needed to address the abortion care access need across restricted and non-restricted states.