The Supreme Court struck down constitutional protections for abortion and several states immediately banned essential care used by approximately one in four Americans who can get pregnant. As many people in the health professions have said, these bans will undermine bodily autonomy, criminalize a wide range of pregnancy outcomes, and limit personal and professional life millions of Americans. They will also undoubtedly increase pregnancy-related morbidity and mortality.
As educators and physicians who perform abortions, we believe that this vital health service should not be limited to abortion clinics and obstetrics and gynecology practices. They are already overloaded in our changing legal landscape. America urgently needs to expand and diversify its abortion care workforce, and primary care providers are key to that expansion. Family doctors, internists, pediatricians, nurse practitioners and certified midwives care for pregnant women. They can, and do, safely and effectively provide both medications and procedural abortions in their offices, but only 3 percent family physicians provide abortion care.
For reasons of health equity, many more primary care clinicians should step in to provide abortion services that are well within their scope of practice. Many people prefer to access abortion and other sexual and reproductive health services through their primary care physicians, who are usually their first and main source of health care. Additionally, providing abortions in the primary care setting reduces stigma and improves continuity with other health care services. This too increases access to abortion.
Access is a key issue here. Abortion rights have been eroded for decades by restrictive state laws, federal funding bans, conservative courts, and structural inequalities rooted in racism, misogyny, and xenophobia. Low-income, rural, black, aboriginal and immigrant communities are and will be even more disproportionately harmed by forced birth and criminalization miscarriage and self-managed abortion. Overzealous prosecutors are already charging people who abort (or even miscarry) with crimes.
Although telehealth and self-managed medical abortion can reduce some of the harm caused by abortion bans, many pregnant women will not be able to access these services, whether for lack of funds, internet access or a secure mailing address. Additionally, 19 states currently prohibit the provision of telemedicine abortions, and some patients will not be medically eligible for remote services. This will aggravate reproductive injustices and inequalities, continuing to sow mistrust among the marginalized.
In states where abortion ends up being completely banned, primary care practices will face many of the same legal and financial risks as dedicated abortion facilities. Yet primary care clinicians can play a pivotal role in helping to meet the increased demand that is already overwhelming abortion clinics in sanctuary and border states. The rural and peri-urban areas of the States already bear the brunt of the shortage of abortion providerssomething that is likely to rise sharply if deer is overturned. These are often areas where primary care clinicians are the sole suppliers health care, including sexual and reproductive health. Patients in rural areas are often already at a disadvantage when trying to access health care, including abortion, as most abortion providers are concentrated in large cities, which requires patients to manage transportation, housing, childcare and lost wages. Primary care abortion service providers could significantly reduce these burdens, as many of these clinicians will be located much closer to restricted states.
Expanding the primary care abortion workforce is not without challenges. Abortion providers tend to be clustered around academic medical centers that are often located in urban areas and states with fewer abortion restrictions. Abortion care personnel, like general medical personnel, has a severe lack of racial/ethnic diversity. Such diversity is key to building trust, improving health outcomes and reducing health disparities, issues that will be compounded by new restrictions on abortion and sexual and reproductive health care.
However, there is good evidence that change is possible, particularly within family medicine. When family medicine residents train to programs that include abortion education as part of routine education, their the abortion rate increases dramatically after graduation, to 29%. And, while the underrepresentation of Black, Indigenous, and Latino clinicians is rooted in the deeply racist evolution of America’s medical professions, this underrepresentation is less severe in family medicine given their call for concerted efforts to increase recruitment and retention of underrepresented groups. Research shows that primary care clinicians, especially those who are underrepresented, are more likely to work in underserved and marginalized communities already the hardest hit by abortion bans, many of whom are communities of color. A growing body of research indicates that racial/ethnic minorities have better overall experiences with like-minded clinicianswhich will be especially important for patients fleeing abusive and unjust state laws.
To support the increased supply of abortions among primary care clinicians, we propose the following actions:
Develop and fund abortion education in primary care to establish the necessary infrastructure (clinics, training sites, and residency programs) to form future clinicians, especially in border regions of less restricted states, such as southern Illinois, western Pennsylvania, western and eastern Maryland, and eastern Washington. states considering protections for the right to abortion and clinicians should also invest in the renewal of this vital medical staff.
Remove institutional barriers that limit telemedicine, the prescription of abortive drugs, and elective education, as well as restrict licensure and malpractice insurance. We need to ensure that professional certifications, such as the new family planning complex subspecialty, include non-gynaecologists and advanced practice clinicians, and that more restrictive states do not limit the abortion offer to sub-specialists.
- Implement policies to diversify and strengthen the abortion care workforce in communities most affected by criminalization. This means expanding primary care with intentional efforts to increase recruitment, retention, and mentorship of those underrepresented in medicine. It is also collaborating with abortion fund and listen and work with reproductive justice organizations. We also need to seek out and hear the perspectives of people on the ground in restricted states.
We know that the abortion access crisis and reproductive injustice predate the fall of deer decades, if not centuries, and that it will take many more decades to reverse current and past damage. We need to support broader human rights movements that include, but are not limited to abortion rights. We must defend the rights of all, including ALL pregnant women. Ultimately, expanding primary care abortion provision is only part of the broader coalition fight that is needed to ensure that all pregnant women in the United States can access sexual and reproductive health care that is inclusive, equitable and just.
This is an opinion and analytical article, and the opinions expressed by the author or authors are not necessarily those of American scientist.