Why is abortion care usually delivered at specialized clinics? The answer has to do more with stigma and politics than medicine. Historically, this part of reproductive health care has been siloed.
MARY LOUISE KELLY, HOST:
In states where abortion is legal, some family doctors are offering their patients abortions in a familiar setting. Since the Supreme Court overturned Roe v. Wade, more and more primary care providers and clinics are providing abortion medication and procedures, especially in early pregnancy. As NPR’s Selena Simmons-Duffin reports, there’s a bit of a catch. Most are being very quiet about it, which makes it hard for patients to know it’s an option.
SELENA SIMMONS-DUFFIN, BYLINE: Imagine a young woman makes an appointment with her family doctor. She has some abdominal pain and some other symptoms she wants to get checked. Her doctor says…
SHEILA ATTAIE: Why don’t we just run a pregnancy test just to be sure? And it’s positive.
SIMMONS-DUFFIN: That’s doctor Sheila Attaie, a family doctor in Sacramento, Calif. After a pregnancy test comes back positive…
ATTAIE: Then you kind of, like, go through that, like, options counseling with them.
SIMMONS-DUFFIN: The options include continue the pregnancy and schedule a prenatal visit or end the pregnancy and get an abortion. Both are available right there in the same clinic.
ATTAIE: For some people, they know right away. For some people, I’ve seen them week after week to support them through whichever route they choose.
SIMMONS-DUFFIN: Attaie fought hard to fully integrate abortion into the clinic where she works. She says for a long time, clinic administrators weren’t convinced. Then Roe v. Wade was overturned in the Dobbs decision.
ATTAIE: I was like, listen. We need to do these things. And they were like, yes, you’re right. And, like, everyone was kind of, like, emboldened – right? – like, after Dobbs in the blue states.
SIMMONS-DUFFIN: In Fort Collins, Colo., family medicine doctor Ben Smith can relate.
BEN SMITH: There was an all-hands-on-deck mentality that happened after Dobbs where there was, you know, an incredible kind of surge of interest and willingness and a sense of capacity.
SIMMONS-DUFFIN: NPR heard similar stories from doctors in Michigan, Minnesota and Pennsylvania. Some of these states have also loosened regulations, like getting rid of waiting periods. In Smith’s primary care clinic, they don’t do many abortions – about one or two a month. But he says even that small number can make a difference since Colorado has become a destination for people traveling from states with abortion bans.
SMITH: Every abortion that we do in primary care becomes a space for a more nationally facing organization that can accommodate someone who is traveling from Texas, from Florida.
SIMMONS-DUFFIN: There isn’t a lot of data yet on exactly how many internal medicine or family medicine doctors are beginning to provide abortion in primary care, but there is some evidence that the trend is growing. A recent study found a surge in applications to programs that train primary care providers on abortion. Some have online resources. This training video shows a doctor talking with a patient about what plans they have for getting pregnant and using different kinds of birth control.
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UNIDENTIFIED ACTOR #1: (As character) I’m here for you to talk about any of the different options. And also, if you do get pregnant and you don’t want to continue the pregnancy, I have pills for that, too.
UNIDENTIFIED ACTOR #2: (As character) Great. Thank you.
UNIDENTIFIED ACTOR #1: (As character) No problem. OK. So let’s go back to talking about your diabetes.
SIMMONS-DUFFIN: There are barriers for clinics, including stigma and administrative hurdles, like the FDA’s rules for prescribing abortion pills, says Elizabeth Janiak. She’s a professor at Harvard Medical School who co-leads ExPAND, one of the training programs. She says those barriers help explain why the portion of primary care doctors offering abortion is quite small.
ELIZABETH JANIAK: But one thing that I think is really important to remember is that even if we were to be really conservative and say 5%, there are so many primary care doctors in this country. So we’re talking thousands and thousands of providers.
SIMMONS-DUFFIN: The federal government estimates there are more than 250,000 primary care physicians in the U.S. That’s more than six times the number of OB-GYNs. And Janiak points out nearly 40% of U.S. counties have no OB-GYNs, which means there are reproductive health gaps to fill. There have long been family doctors who provided abortion and advocated for access, but it hasn’t caught on like this before, says Mary Ziegler, a law professor at UC Davis who’s written extensively on the history of abortion. Back in the ’50s and ’60s, she says, abortions generally happened at hospitals. But not all hospitals offered them, often for religious reasons, and access across the country was uneven.
MARY ZIEGLER: So in the ’70s, abortion rights groups began focusing on the opening of free-standing abortion clinics.
SIMMONS-DUFFIN: On one hand, she says, the clinics did expand access.
ZIEGLER: On the other hand, they physically and symbolically isolated abortion from other health services and made them easier to stigmatize, made it easier for abortion clinics to be protested and, you know, made it easier to argue that abortion was very different from other forms of health care.
SIMMONS-DUFFIN: For years, a key anti-abortion strategy was to target those clinics with regulations known as trap laws that mandated a certain width of hallways or required doctors to have admitting privileges at hospitals, for instance. Here is Ziegler.
ZIEGLER: Trap laws, combined with the rise of clinic blockades and clinic protesting and even violence against abortion doctors, you know, led to a pretty precipitous decline in the number of physicians who were either trained to perform abortions or willing to perform abortions.
SIMMONS-DUFFIN: The fact that more and more doctors are signing up to train on integrating abortion into primary care is a sign that the stigma is changing, she says. Dr. Christina Francis, an OB-GYN in Indiana who runs the American Association of Pro-Life OB-GYNs, does not think the regulations that have separated abortion from other kinds of healthcare were just political.
CHRISTINA FRANCIS: In general, the abortion industry has been actually largely under-regulated, not regulated as stringently as hospitals.
SIMMONS-DUFFIN: She also says that family medicine doctors don’t have the specialized training that OB-GYNs do to provide reproductive healthcare, and that includes abortion, which she opposes.
FRANCIS: I’m not saying that family medicine physicians are not good physicians. They certainly are, but their training is not the same as OB-GYNs in these kinds of things.
SIMMONS-DUFFIN: She says the trend concerns her. She does not consider abortion essential healthcare for women. Many organized medical groups disagree with her. The American College of OB-GYNs says any clinician who can screen patients for eligibility can prescribe medication abortion safely as long as they themselves can provide or refer patients for follow-up care as needed, usually a uterine evacuation. From the patient perspective, Liz Johnson has had two different abortion experiences. She’s a graduate student in Pittsburgh getting her master’s in social work. Years ago, she had an abortion at a specialty clinic.
LIZ JOHNSON: It’s honestly – like, I think it can feel very, like, impersonal and fast and, like, procedural, like, da, da, da, da, da (ph), you know?
SIMMONS-DUFFIN: In October 2022, she had an abortion with her primary care doctor. She liked that her doctor already knew her and her medical history.
JOHNSON: I really appreciated, like, the personal touch of, like, being able to, like, text to check in and stuff like that. So it went really smoothly to the point I just can’t even, like, elaborate – like, no problems.
SIMMONS-DUFFIN: Johnson describes herself as an open book. More and more patients have been willing to speak publicly about their experiences with abortion. But that openness isn’t always present among the primary care clinics that have recently begun to provide abortions. In Sacramento, Dr. Sheila Attaie says after the clinic she works for started to provide abortion…
ATTAIE: We weren’t allowed to advertise that we do it because they don’t want that attention.
SIMMONS-DUFFIN: Attention that might come with protesters or threats from people who oppose abortion. Attaie says she gets it, but she also finds the secrecy frustrating.
ATTAIE: If we act in fear, how do we expect anything to be changed? If we, like, are hush-hush about all these things, how do we normalize them as health care?
SIMMONS-DUFFIN: Harvard’s Janiak says this may be evidence of the need for broader cultural change. But just because right now primary care providers don’t have abortion on their lists of services or on their websites doesn’t mean, she says, they’ll never get there. Selena Simmons-Duffin, NPR News.
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