ANSIRH blog

I recently met with an inspiring group of family practitioners to talk about my new book, Willing and Unable: Doctors’ Constraints in Abortion Care. Although it’s a study of ob-gyns’ experiences after abortion training, these family medicine doctors could relate to the concerns of the book. They had all gone through the TEACH program: Training in Early Abortion for Comprehensive Healthcare. And most of the physicians I met at the TEACH meeting are engaged in the integration of abortion care into their practice on some level.

At the meeting, I read narratives from my book about the kinds of obstacles to abortion practice the ob-gyns faced. These included dramatic examples of intimidation by superiors in their practices and group policies that prohibit abortion, as well as the less dramatic, but just as effective barriers such as stigma, local practice culture, and economic disincentives. Taken together, I call these collective barriers within medicine the institutionalized buck-passing of abortion care to abortion clinics.

The book really spells out this problem on multiple levels: micro, meso, and macro. But what remain elusive are the solutions (surprise, surprise). And that is what people consistently ask me about.

So I thought I’d take this opportunity, in a liberating medium such as the blog, to conjecture a bit about solutions. Disclaimer: these are not findings. They are not observations. They are guesses. And as a researcher, I’m uncomfortable with guesses. But they have been recurring for the last three or four years as I’ve researched and written this book. Therefore, below I offer several ways to approach reducing the barriers to abortion practice within the medical profession. Some of these routes take longer than others.

Really slow change

Culture change—With the major successes of Ryan Residency Programs around the United States training ob-gyns in abortion care, there is a significant proportion of physicians who have become very familiar with abortion, even if they do not incorporate abortion care into their practice. These doctors fill the medical community more and more each year and can serve as ambassadors of good will between colleagues. They will make more informed and compassionate referrals for patients needing quality abortion care. I imagine that, over time, this will be a supportive influence for women needing abortions and those providing the care.

Time—a simplistic point, but one that holds a lot of truth, is somewhat reassuring, and is often heard in the realm of gay rights: Some of the biggest opponents who hold the most power will retire (or pass on). Their successors may not be as oppositional.

Gender shift—Women are increasingly filling the physician ranks, especially in primary and ob-gyn care. Statistically, women are more supportive of abortion. This will change things.

Patient infiltration—and by this I do not refer to actual patients. But rather patience. I did hear stories of physicians who went to work for conservative practices with strict abortion prohibitions, only to find that after a while they started to receive referrals for fetal anomaly terminations. Their colleagues were actually quite happy to have a known, skilled second trimester provider in the group to care for their patients. This not only helps meet those particular patients’ needs, but accomplishes some degree of culture change and openness around abortion practice that wasn’t there. I also interviewed a physician who recounted a story of when she asked her private practice group, in a very conservative area, whether they would consider offering medication abortion. Sure, she was massively shut down. But persistence might open that possibility up with time.

If this speed doesn’t satisfy, as I presume may be the case for many of you who are still reading. Here are other suggestions.

Medium-paced change

Intentional practice formation—taking things completely into your own hands, much like Ani Difranco did when she started her own record label, like-minded providers can team up (as they are doing in many cities around the United States) to create fresh new practice groups that make the inclusion of abortion a priority of the practice. This demands more energy and risk from new providers, but some of you probably think it is worth it. And there are family practice and ob-gyn organizations working to help you do this.

Selective employment—again, more professionally risky than many would like, doctors can turn down jobs that prohibit abortion practice—and explain why to their would-be employer. They can refuse to practice in Catholic-owned hospitals that routinely prohibit abortion, contraception, sterilization, and fertility care.

Lobby hospitals—many hospitals and surgery centers prohibit abortion, and not for religious ownership reasons. But, there may be room for change. Sometimes administrators are not at all opposed to abortion, and are instead concerned about how to manage conflict that may arise. They may worry about how to staff abortion procedures, who assists or cleans up, etc. Some hospitals have had success addressing the administrators’ fears head-on and making staffing plans proactively.

Pass the baton—physicians can support expanding the scope of practice of nurse practitioners, physician assistants, and certified nurse-midwives to include early abortion care. Some states are doing it. No need for a turf war here. These clinician trainees are proving themselves as competent as physician learners and may be able fill important service gaps.

Got more ideas?

I’d love to hear about them and I’d love to hear what aspects of this discussion need to be developed further. Abortion is never a simple issue, is it? Not for women having abortions. Not for professionals trying to provide them. Neither should it be for the analyst trying to come up with good answers on how to fix all the craziness therein! I look forward to you adding your two cents.