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Guttmacher: Ob-Gyn residents who intend to provide abortion services often don’t

Rachel

Huh. Not what I’d have expected. How do we address this? Is it, as the piece suggests, with training on contract negotiation and conflict management? I don’t dislike the idea, I’m sure it’s helpful, but it leaves me… eh. When you’re the new hire, the applicant, the one just out of school breaking into an established practice, how much power do you have to change the established policies? Maybe I’m just too cynical, but…

Opposition to abortion within the health care community—rather than fear of public harassment —is a major factor preventing new physicians from becoming abortion providers, according to “Obstacles to the Integration of Abortion into Obstetrics and Gynecology Practice,” by Lori Freedman et al., of the University of California, San Francisco.

The authors conducted in-depth interviews with 30 obstetrician-gynecologists who had graduated 5–10 years earlier from residency programs that included abortion training. They found that although 18 had planned to offer elective abortions after their residency, only three were actually doing so. The majority reported that they were unable to provide abortions because of the formal and informal policies restricting abortion provision imposed by their private group practices, employers and hospitals. While some of these restrictions had been made explicit when the physicians interviewed for a job, others had become apparent only after the doctors had joined a practice or institution. A few physicians had attempted to moonlight as abortion providers while working in settings that prohibited abortion provision, but found that they were prohibited from offering abortion services outside the practice as well. Respondents indicated that the strain abortion provision might put on their relationships with superiors and coworkers was also a deterrent.

11 thoughts on Guttmacher: Ob-Gyn residents who intend to provide abortion services often don’t

  2. You’re not too cynical. This is a systemic problem, and systemic problems need to be addressed by changing the . . . (wait for it) . . . system. Giving individuals who, as you point out, are not in positions of power specific skills may help but only on rare occasions.

  3. I’m an aspiring OB/GYN (read: premed undergrad) and this is exactly what I fear. I really want to open a clinic with a full range of reproductive services for all people in a rural community. But the pressure I’ve heard about from established medical practices regarding abortion services is “that’s what they do in those clinics.” Many doctors consider abortion dirty health care. They segregate abortion services to clinics (thank god there are clinics!) but it’s a systemic problem that discourages young OB/GYNs from integrating it into regular care at their offices.

    Not to mention when you go to a clinic that provides abortion you’re surrounded by bullet proof glass and a series of heavy automatically locked doors. They have to be like a medieval castle to protect staff and patients. That would intimidate anyone from baiting the violent anti-choice wing-nuts to come around.

    I’ve found Medical Students for Choice really helpful in organizing and combating this problem.

    http://ms4c.org/

  4. It worries me that abortion has to be segregated from other forms of reproductive health. People who want abortions, may benefit from other reproductive health services at soem point, and people who now need other reproductive services, may need/want an abortion at some point. In my opinion, reproductive health is best provided if it’s integrated. Indeed, I agree that it’s a systemic problem that doctors have to resort to segregated abortion clinics if they really want to provide abortions, and then they can no longer provide comprehensive reproductive health care (or not at abortion clinics in the Netherlands at least).

  5. Thank you for this information! I’m a med school applicant and I am seriously considering OB/GYN as my eventual field (the other choice being child psychiatry… I’m into controversial fields I guess) and the main reason for that is that I want to provide abortions. It’s been my one of my big dreams since I was a teenager, actually. If I do end up in OB/GYN, I will be sure to ask explicitly whether I will be allowed to perform abortions when I look for jobs. These internal barriers are something I wouldn’t otherwise even think to ask about.

  6. I’m not a healthcare provider, but I am a patient. I have nobidea if my OB/GYN provides abortions, and I’ve never thought to ask. Mostly since most of the time I’ve been their patient, I’ve been pregnant or actively trying to become so!

    But next time I go in, I’ll ask. PAtients are (theoretically) more mobile than new doctors, and there are more of us.

  7. “People who want abortions, may benefit from other reproductive health services at soem point”

    I’d say that’s pretty much the rule with abortion patients. If you’re in for a medically-indicated abortion, odds are good that you’re either going to need contraceptive services and follow-up care to avoid another potentially dangerous pregnancy or want active and thorough prenatal care during your next pregnancy if you’re trying to carry to term. If you’re in for an elective abortion, odds are good that you’re going to want to explore your options for preventing another unwanted pregnancy and, depending on the method that failed, perhaps pursue STD testing.

  8. As an O&G registrar in the UK, I’d say that part of this problem may be the peculiarities of the system in the US. In the UK abortion for social reasons on the NHS is typically provided by general gynaecologists; although some units, to avoid staffing problems with trainee turnover, do employ staff grades to specifically cover the clinic and the STOP list. Whilst this provides a good service for the women attending the clinic and ensures that last minute clinic cancellations for lack of non-objecting staff does not take place, it removes the chance for routine training in abortion by trainees. You have to ask to get the chance to go to these clinics.

    However, caring for MTOPs for fetal anomaly takes place as part of the routine labour ward ward in all the units I’ve worked with.

  9. I’m the author of the study above. I’ve enjoyed reading this discussion and glad to see people are interested in the findings. Rose, you make a good point, the US is a special case and the UK has done things differently allowing for more integration of abortion services. Drew Halfmann studies the differences in US and UK policy development around abortion– he has an article out that is quite interesting. My article above is part of a larger sociological ethnography, the book comes out next month. It goes more deeply into the systemic issues, larger structural context, and some interesting individual stories. I hope some of you will respond to that as well.

  10. I’m so glad to see this issue being talked about! I wrote my undergraduate thesis on chronic shortage of abortion providers in the US, focusing specifically on the systemic and individualized roadblocks at each step of the way that prevent aspiring doctors from becoming providers. A lot of scholarship is out there talking about how there’s a lack of training at the med school and residency levels, but only recently have I seen more talk about what’s being called the “gap” between those who get trained and intend to provide but never actually do. I’m thrilled to see that this has been explored in this new piece, and I wish it had been around when I was writing my thesis! Lori Freedman – I can’t wait to read your book when it comes out!

    In addition to the logistical restrictions that are often in place by a physician’s employer, some of the other factors contributing to the gap that I wrote about in my thesis included: a lack of desire to perform abortions full-time, as the procedure itself is fairly simple and potentially even boring from a physician’s POV; fear of being harassed by anti-choicers, or more frequently, fear of having their children get harassed; learning that they don’t find abortion work rewarding in the rushed clinic setting where doctors rarely get to talk to the patients; the relatively low pay that abortion providers get for their work coupled with additional malpractice insurance; not having a professional mentor who provides the service; working in a city or other location with another provider around (the need isn’t seen as urgent anymore); and on and on. As has already been mentioned, one of the ways to make abortion provision more appealing to doctors (and, IMO, safer and more comfortable for patients) is to have this care well-integrated into medical practice so that physicians aren’t forced to pick and choose.

  11. This is a random and uneducated question but are medication abortions more integrated than surgical ones? Would an OB/GYN working in one of these environments which discouraged offering abortions still be able to prescribe and oversee the use of the abortion pill?

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