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).
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.
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.
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.
8. Council on Resident Education in Obstetrics and Gynecology. Educational 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.