Even with Roe v. Wade still the law of the land, primary care doctors in the United States have difficulty prescribing U.S. federally approved abortion pills, a new study finds.
Getting in the way is a complex combination of state and federal regulations, insufficient training and institutional hurdles, researchers found when they surveyed dozens of doctors.
“As family physicians provide comprehensive medical care to individuals throughout their life course — including supporting their reproductive choices — they are prime individuals to provide medication abortion,” explained study lead author Dr. Na’amah Razon.
“We found a range of barriers that prevented family physicians from integrating medication abortion into their primary care practices,” said Razon, an assistant professor in the Department of Family and Community Medicine at the University of California, Davis.
It’s a landscape that will likely only gets worse, said Razon, whether or not Roe v. Wade is actually overturned, although a leaked draft from the U.S. Supreme Court indicates it will be.
“Given the recent movement toward restricting abortions in the United States, family physicians could face increasing barriers in providing medication abortion,” she noted.
The two-pill regimen consists of mifepristone and misoprostol. Planned Parenthood notes this noninvasive method is safe and 94%-96% effective. And the Guttmacher Institute says that the medicinal approach now accounts for more than half of all abortions in the United States.
Until December 2021, the U.S. Food and Drug Administration only allowed mifepristone to be administered in-person at a clinic, a hospital or under the direct supervision of a certified medical provider. Retail pharmacy pickup and mail orders were not allowed. The December FDA ruling did away with the in-person requirement, allowing telehealth consultation, though all the doctors in the current study were interviewed before that decision came down.
For the study, 48 U.S. primary care doctors were interviewed in 2019 and classified into one of three groups: those who did not provide abortions and had not been trained to do so (11 doctors); those who didn’t provide abortions, despite having received training (20 doctors), and those who had been trained and did provide abortion services (17 doctors).
Roughly two-thirds were not providing abortions at the time they were surveyed.
Those in the untrained/non-provider group said their lack of training was the main reason for not offering abortion care.
Such doctors variously said their lack of abortion care skills left them “uncomfortable,” unfamiliar with the medications involved, and/or unconvinced that abortion services truly falls within the realm of family medicine. They were also the most likely to point to their state’s anti-abortion political climate, a lack of community support, and a poor understanding of local hospital regulations as discouraging factors.
By contrast, those who didn’t provide abortion services despite their training generally said they understood all too well the wide range of primary care, clinic and hospital restrictions in place in their region.
This group also cited the federal Hyde Amendment as a red-tape barrier to providing care in their own practice and elsewhere. That law prevents any federal funds from being used for abortion.
In addition, the group highlighted the FDA’s REMS (Risk Evaluation and Mitigation Strategy) as another impediment. REMS is a drug safety protocol applied to certain medications. Since 2011, the FDA has applied REMS to mifepristone to restrict how, where and when it can be prescribed and obtained.
Among primary care doctors who were trained and currently providing abortion care, 60% said they didn’t offer abortion pill prescriptions as part of their family practice, but only at specialized reproductive health clinics.
Researchers also found that practitioners who offered abortion pill prescriptions in their primary care setting were located in either the Northeast or West; none resided in states with highly restrictive abortion laws in place.
Some also noted that the institutions and/or hospital ob-gyn departments with which they worked prohibited abortion services of any kind.
Several said that in order to make abortion pills available at a family practice or a specialized clinic it was necessary to have a “champion” on board willing to jump through the regulatory hoops involved.
Elisa Wells is co-founder and co-director of Plan C, an organization dedicated to ensuring unrestricted and non-stigmatized access to abortion pills. She expressed frustration with the status quo.
“The science about the absolute safety of medication abortion doesn’t support these added barriers to access,” Wells said. “Many primary care providers we have talked to are not in practices that allow them to do abortion, so that’s a huge hurdle,” even among those who are trained and willing.
Wells, who was not involved in the study, said that ensuring widespread abortion pill access will mean convincing the FDA to remove all REMS restrictions for mifepristone.
“Mifepristone is an extremely safe medication,” she noted, “and any licensed provider should be able to write a prescription for a patient who qualifies for it, and the patient should be able to fill that prescription at any pharmacy.”
The findings were published in the May-June issue of the Journal of the American Board of Family Medicine.
There’s more on abortion medication at Plan C.
SOURCES: Na’amah Razon, MD, PhD, assistant professor, Department of Family and Community Medicine, University of California, Davis, Sacramento; Elisa Wells, MPH, co-founder and co-director, Plan C; Journal of the American Board of Family Medicine, May-June 2022