Note: The following article provides interesting insights
about the phenomenon of the thinning ranks of abortion providers, and how
supporters of legal abortion view the problem and its possible solutions. It is
not written from a pro-life activist's perspective, but gives pro-life activists
very useful facts. For more information on how both sides in the abortion battle
acknowledge this phenomenon, ask for the booklet "Access" from Life Dynamics
Incorporated, PO Box 2226, Denton, TX 76202 (940-380-8700).
Graduate Education
Obstetrics and Gynecology Vol. 80, No.4, Oct 1992
CLINICIANS WHO PROVIDE ABORTIONS:
THE THINNING RANKS
David A. Grimes, MD
Access to abortion services in the United States has become increasingly
limited because of a decrease in rural hospital providers and a growing shortage
of clinicians willing to offer this service. As of 1988, 83% of United States
counties had no identified provider. The deficit in numbers of clinicians stems
from the current imbalance between incentives and disincentives. The single most
powerful incentive appears to be altruism. On the other hand, disincentives
include poor pay, frequent harassment, low prestige, sub-optimal working
conditions, and tedium. In 1990 a symposium on abortion provision was held,
sponsored by the National Abortion Federation and ACOG. Among the remedies
suggested by the attendees were increasing the integration of abortion training
into the mainstream of residency education, improving the pay and work
environments for clinicians, and where feasible expanding the capacity of
physician providers by using mid-level practitioners working under physician
supervision. (Obstet Gynecol 1992; 80: 719-23)
… We cannot fail to recognize that the performance of legal, elective
abortion is indeed essential to preserving women's health, therefore making it
an unavoidable responsibility of physicians and hospitals in rendering health
care. Unless they do take on this responsibility enthusiastically and
thoroughly, the unhappy and dangerous impact on the young women of our nation
will be incalculable.
E. W. Overstreet, 1971(1)
The legalization of abortion was a necessary but insufficient step toward the
provision of abortion services for women in the United States. As suggested by
Overstreet 2 decades ago, these services ultimately depend on the availability
of affordable clinicians who are both skilled and willing to provide abortions.
To the extent that such clinicians are not available, the public health promise
of legal abortion will go unfulfilled.
In recent years, access to abortion services has become increasingly limited,
because of both the dearth of facilities in rural America (2) and the growing
shortage of clinicians providing the service (3) (also O'Hara D. Abortion. MDs
who do them and those who won't. American Medical News, December 9, 1989;
Kolata G. Under pressure and stigma, more doctors shun abortion. New York
Times, January 8, 1990; Gorney C. Abortion in the heartland. The
Washington Post, October 2, 1990). In 83% of United States counties, in
which 31% of women of reproductive age live, there is no identified provider
(2). Some states, such as South Dakota, have but a single physician who performs
abortions. Thus, many South Dakota residents seeking abortions must travel long
distances, which both increases expense and compromises care should
complications develop. Access is a challenge in other rural states: In Wyoming,
more than half of women who obtained abortions in 1985 traveled to another state
for care (2).
Distance clearly matters in women's reproductive choices; in one rural state,
abortion rates were found to be inversely related to the distance to a provider
(4). Because of the worrisome public health implications of the growing shortage
of clinician providers, this article will review some incentives and
disincentives influencing professionals' involvement in this field and discuss
potential solutions to the problem.
Influx and Retention of Clinicians
Two factors govern the rate of recruitment and retention of clinicians
providing abortion services: training and incentives. Both appear to be
inadequate. The last published nationwide survey of resident physician training
in abortion (5) was conducted in 1985. Although the majority of residency
programs in obstetrics and gynecology offered training, the proportion had
declined 22% from the proportion in a survey conducted a decade earlier. A
survey conducted in 1991 revealed that the proportion of programs in which
first- and second-trimester abortion was routinely (as opposed to optionally)
taught had declined since 1985 (Mackay HT, personal communication, June 2,
1992).
Most abortions today take place in freestanding abortion clinics, not in
teaching hospitals (2). Hence, even in those hospitals where abortion training
is provided, the limited numbers of cases may compromise residents' ability to
develop sufficient surgical expertise. For example, only 10% of residency
programs reported that their residents collectively performed over ten abortions
per week (5). Others (2,6) have echoed this concern about numbers of hospital
abortions, noting that 45% of hospital providers in the United States perform
fewer than 30 procedures per year. Whereas ten abortions per week may provide an
adequate case load for surgical training, 30 per year is unlikely to be adequate
even for programs with few residents.
In programs that offer abortion training, the level of resident participation
is directly linked to the programs' expectations (5). Where training is expected
as a matter of course, the majority of residents participate. Where programs
make training an option, fewer elect to be involved.
Other thoughtful commentators in the early years of legal abortion made this
observation:
A serious problem that impedes (resident) physicians' enthusiasm for
abortion is lack of technical challenge and variety for those who perform
the procedure. They feel that abortions are boring and repetitive, are not a
necessary learning experience, add to their already heavy work load, and use
time they would rather spend taking care of a variety of more interesting
and challenging patients (6).
When already overworked, few residents will opt for additional elective work.
Moreover, few academic departments have faculty with both a deep commitment and
a busy practice of abortion to serve as role models and mentors for residents.
Hence, this "minor" surgery is relegated to low priority among the many
activities competing for residents' time.
Organizations concerned with the content of residency training have an
inconsistent approach to abortion. In its "Design for Resident Education in
Obstetrics and Gynecology,"(7) the Council on Resident Education in Obstetrics
and Gynecology states, "In order to provide adequate training in surgical
skills, a program must have a faculty proficient in the required skills and must
provide sufficient opportunity for individual instruction in each procedure
to all residents" (emphasis mine). Although D&C and laparoscopy are
specified, the document does not mention abortion.
The Council's "Educational Objectives for Residents in Obstetrics and
Gynecology'' (8) is more explicit. For example, one terminal objective is:
Given an 18-year-old woman, 9 weeks pregnant, who requests termination of
pregnancy, the resident should be able either to arrange contact with a facility
and personnel with skills and attitudes that permit them to respond to her
request or to provide education, counseling, support in decision making, and,
where indicated, carry out the surgical procedure.
The same approach is taken with a patient requesting a second-trimester
abortion (8).
The American Board of Obstetrics and Gynecology, Inc. certifies physicians as
having special competence in obstetrics and gynecology. Its written and oral
tests include abortion topics, and the Board requires candidates for the oral
examination to report their experience with abortion. Nevertheless, the Bulletin
(9) of the Board does not specify a requirement for expertise in abortion:
Residents should have acquired the capability to perform, independently,
major gynecologic operations, spontaneous and operative obstetric deliveries, to
manage the complications thereof and be capable of performing the essential
diagnostic procedures required of a consultant in obstetrics and gynecology.
"Minor" operations, such as abortion, are not mentioned.
Given adequate training in abortion and a large demand for those skills, what
motivates a clinician to provide the service? Three factors appear important:
altruism, esteem, and compensation (3). The desire to help women in need seems
to dominate. To the extent that benevolence prevails, physicians will be willing
to provide abortions. Two other motivations, glamour and high pay, no longer
exist in the provision of abortion; these problems are discussed later.
Efflux of Clinicians
Out-migration of clinicians providing abortions appears to be exceeding
in-migration for two reasons: natural attrition through retirement and premature
discontinuation due to dissatisfaction. The former problem has been termed the
"graying of the abortion provider" (3). Leaders in the field who were
instrumental in the repeal of restrictive laws are now approaching retirement
age. Many of these were motivated by having cared for patients who had been
injured or killed by illegal abortions. Clinicians younger than their early 40s
today may have never encountered such patients, and hence may lack the personal
commitment of older providers to ensure that these conditions do not recur. For
example, a recent survey of family physicians in Kansas (10) revealed that
physicians older than 40 years were more likely to support abortion rights than
were their younger colleagues; this pattern was observed for both sexes.
Harassment and intimidation may dissuade skilled clinicians from entering
this field or convince them to quit. Harassment of providers takes many forms,
ranging from picketing of homes and offices to obscene telephone calls to death
threats. On an organizational basis, this may translate into loss of hospital
privileges and close scrutiny by state licensing boards because of the supposed
"shadowy" nature of abortion practice (6). Abortion clinics have been the
targets of an epidemic of arsons and bombings; during 1984, 1% of all clinics in
the United States were attacked (11).
Performing abortions no longer pays well. Because the cost of abortion (and
the corresponding physician's fee) have not kept pace with inflation, both are
now well below market value. In 1972, a first-trimester abortion in a clinic in
New York city cost approximately $147; in 1989 dollars, that would translate
into about $588 (Henshaw SK, personal communication, October 25, 1990). However,
the average cost of such abortions in 1991 was below $300 (12). Thus, the true
cost of an abortion is about half that in the early 1970s (6, 13).
During this interval, physicians have been paid progressively less for
providing the same service. In 1973, physicians customarily received about $50
per case, the equivalent of about $190 today (Henshaw SK, personal
communication, October 25, 1990). In contrast, current fees usually range from
$30-50, with the largest private clinic provider in the nation paying $25 per
operation. Invited to work part time in an abortion clinic, one young
gynecologist replied, "I can generate as much income seeing office patients with
vaginitis as I can by doing abortions . . . and without the hassles." Poor
compensation for abortion services is a chronic problem in other countries as
well (14).
Working conditions for clinicians providing abortions are frequently
unsatisfying. For clinicians who have spent years honing their diagnostic
skills, abortion largely underutilizes their abilities and relegates them to the
role of a technician. As noted by Potts, "when the patient was a 'client' who
had decided on the prescription, this eliminated half the medical mythology and
demoted the doctor to technician or tradesman" (14). Both the evolution of new
clinic personnel (abortion counselors and nurse-practitioners) and the rapid
flow of patients in clinics have depersonalized the abortion experience, not for
the patient but for the clinician. For some, communication may be limited to a
brief discussion with the patient on the operating table before surgery.
Management protocols in clinics may regiment the practice of medicine. For
example, some physicians work part-time in clinics as independent contractors.
As such, they may have little input into protocols for patient management, thus
depriving them of their traditional autonomy in clinical decisions. Instead of
serving as the captain of the medical team, the physician may be only the "hired
help" for the day. Because of a perceived lack of medical control, some
physicians have been reluctant to work in abortion clinics (6).
Isolation can occur. Clinicians whose practice is limited to abortion
services may become estranged from the medical community. "In private practice
the attending is still judgmental, equating abortion with illicit sex or
hostility toward motherhood. His colleague who fulfills his obligation to
society under the new law is little better than yesterday's abortionist in his
eyes" (15).
The tedium of largely repetitive operations can be compounded by the
emotional stress surrounding unwanted pregnancies and families in crisis (16,
17). A practice limited to women with personal crises differs markedly from the
usual mix of patients in an obstetric and gynecologic practice. On the other
hand, some physicians find helping women to resolve personal crises especially
rewarding.
Potential Solutions
In response to the growing problem of insufficient numbers of clinicians
providing abortion, a symposium sponsored by the National Abortion Federation
and ACOG was held in 1990 to explore the problem and to recommend solutions (3).
The recommendations covered three general areas: improving the training of
resident physicians, removing disincentives to abortion provision, and exploring
the use of physician-supervised mid-level clinicians to perform abortions.
First, abortion must be integrated into the mainstream of residency training.
How this is done will necessarily depend on local settings. High-quality
abortion training can be offered within university residency programs, as occurs
at the University of North Carolina School of Medicine (3) and the University of
California-San Francisco School of Medicine (18). In these centers, highly
visible and well-respected faculty teach residents both first- and
second-trimester abortion. In some residencies, discussions about abortion are
included in seminars on medical ethics, which helps to integrate abortion into
the curriculum and to clarify residents' personal feelings about the issue.
Where insufficient patient volume or high costs of hospital-based care deter
such services, extramural training in freestanding clinics can be arranged, as
occurs at the University of Vermont School of Medicine (3). Professional
liability insurance coverage for residents training in extramural facilities can
pose problems. Precedents exist, however, for having training in extramural
sites covered under an umbrella policy for residents. Alternatively, abortion
clinics may carry insurance that will cover physicians working in the facility.
Of course, exemptions from training should be allowed for those opposed to
abortion on religious or ethical grounds. However, some residents decline not
because they are opposed to abortion but because this will lighten their work
load if no alternative duties are assigned. Others may opt out not because they
have a moral aversion to abortion but because they feel no moral obligation to
perform the procedure. Some residency programs may pressure residents to
participate in this "elective" activity by requiring them to arrange for their
own coverage if they choose not to perform abortions. In some cases, this
translates into extra nights of duty.
Second, current disincentives to involvement must be replaced by incentives.
Communities must curb the harassment of clinicians. Actions of local law
enforcement officials can make a difference: Vigorous prosecution and conviction
of perpetrators helped to counter the epidemic of anti-abortion violence across
the United States (11). Having one's telephone lines jammed, door locks glued
shut, and family threatened (Gorney C. The Washington Post, October 2,
1990) should not be part of the price of practicing medicine. Working conditions
for clinicians need upgrading. In addition, clinicians need to be granted more
authority and autonomy in freestanding clinics.
Paying clinicians appropriately for their services will likely overcome much
of the current reluctance. Few surgeons are willing to receive one-fourth today
what they did 20 years ago for performing the same operation. Inequitable
compensation for this service denigrates its value to the patient and to
society.
Third, the use of physicians other than obstetricians/ gynecologists and
non-physician providers should be pursued. For example, suction curettage is
well within the scope of practice of family physicians (10). Although the notion
of a paramedic provider of abortion is not new, (15, 19, 20) nontraditional
providers have recently established an enviable record of accomplishment. Some
states, eg, Montana and Vermont, allow mid-level clinicians under the
supervision of physicians to perform abortions (3). In Montana, a physician
assistant has been providing this service for over 12 years. In Vermont,
physician assistants have been documented to have first-trimester abortion
complication rates comparable to those of physicians (relative risk 0.9; 95%
confidence interval O.6-1.4; P = .61) (21). The requisite skills clearly
can be acquired by physician assistants, nurse-practitioners, and
nurse-midwives, if they desire to learn.
Abortion remains the most divisive social issue of our time. Despite strong
professional support for legal abortion (American College of Obstetricians and
Gynecologists. Abortion attitudes: Little change in 14 years. ACOG News Release,
August 28, 1985), there remains a "lack of enthusiasm and even opposition from
many gynecologists, who consider abortion a distasteful chore" (22).
Regrettably, many aspects of medicine are both distasteful and a chore; these
personal considerations, however, must never influence one's decision about
doing what is best for the patient. As noted 20 years ago, ". . . the medical
profession must be educated to the fact that abortion is no longer a favor to
bestow but, rather, an obligation to perform" (5). If we as a nation and as a
profession default on this obligation, the legacy of Roe v Wade will
become an empty promise in the years to come.
References
1. Overstreet EW. The role of the university hospital in solving the logistic
problems of legal abortion. Clin Obstet Gynecol 1971;14: 1243-7.
2. Henshaw SJ, VanVort J. Abortion services in the United States, 1987 and
1988. Fam Plann Perspect 1990;22:102-42.
3. National Abortion Federation. Who will provide abortions? Washington, DC:
National Abortion Federation, 1991:1-27.
4. Shelton J, Brann EA, Schulz KF. Abortion utilization: Does travel distance
matter? Fam Plann Perspect 1976; 8:260-2.
5. Darney PD, Landy U, MacPherson S, Sweet RL. Abortion training in U.S.
obstetrics and gynecology residency programs. Fam Plann Perspect 1987;19:158-62.
6. Hodgson JE, Ward RE. Provision and organization of abortion and
sterilization services in the United States. In: Hodgson JE, ed. Abortion and
sterilization: Medical and social aspects. New York: Grune and Stratton,
1981:519-41.
7. Council on Resident Education in Obstetrics and Gynecology. A design for
resident education in obstetrics and gynecology. Washington, DC: Council on
Resident Education in Obstetrics and Gynecology, 1986:10-2.
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objectives for residents in obstetrics and gynecology. 3rd ed. Washington, DC:
Council on Resident Education in Obstetrics and Gynecology, 1984:1-116.
9. American Board of Obstetrics and Gynecology, Inc. Bulletin for 1991.
Seattle, Washington: The American Board of Obstetrics and Gynecology, Inc.
1990:11-2.
10. Westfall JM, Kallail KJ, Walling AD. Abortion attitudes and practices of
family and general practice physicians. J Fam Pract 1991;33:47-51.
11. Grimes DA, Forrest JD, Kirkman AL, Radford B. An epidemic of antiabortion
violence in the United States. Am J Obstet Gynecol 1991;165:1263-8.
12. National Abortion Federation. Membership directory, 1991. Washington, DC:
National Abortion Federation, 1991:1-90.
13. Muller C. Abortion: Financial impact on the patient. Clin Obstet Gynecol
1971;14:1302-12.
14. Anonymous. A state-registered abortionist? Lancet 1975;ii:912-3.
15. Hall RE. The future of therapeutic abortions in the United States. Clin
Obstet Gynecol 1971;14:1149-53.
16. Rooks JP. Emotional issues for professionals. In: Berger GS, Brenner WE,
Keith LG, eds. Second trimester abortion. Perspectives after a decade of
experience. Boston: John Wright-PSG Inc. 1981:251-7.
17. Kaltreider NB. Psychological impact on patients and staff. In: Berger GS,
Brenner WE, Keith LG, eds. Second trimester abortion. Perspectives after a
decade of experience. Boston: John Wright-PSG Inc. 1981:239 49.
18. Darney PD. Training physicians in elective abortion technique in United
States. In: Landy U. Ratnam SS, eds. Prevention and treatment of contraceptive
failure. New York: Plenum Press, 1986:133 40.
19. Karman H. The paramedic abortionist. Clin Obstet Gynecol 1972;15:379-87.
20. Mattingly RF. The paramedic abortionist. Obstet Gynecol 1973; 41:929-30.
21. Freedman MA, Jillson DA, Coffin RR, Novick L.F. Comparison of
complication rates in first trimester abortions performed by physician
assistants and physicians. Am J Public Health 1986;76:550-4.
22. Paintin DB. Legal abortion in England and Wales. In: Porter R, O'Connor
M, eds. Abortion: Medical progress and social implications. London: Pitman,
1985:4-20.
Address reprint requests to: David A. Grimes, MD Women's Hospital, Room L1013
1240 North Mission Road Los Angeles, CA 90033
Received April 13, 1992. Received in revised form June 8, 1992. Accepted June
9, 1992.
Copyright 1992 by The American College of Obstetricians and Gynecologists.
