National Partnership for Women & Families

Monthly Women's Health Research Review

Study explores factors influencing women's communication with OB-GYNs on abortion decisions

Summary of "Factors shaping women's pre-abortion communication with their regular gynecologic care providers," Chor et al., Women's Health Issues, April 20, 2016.

"The disparity between abortion prevalence and the number of providers offering this service reflects the current separation of abortion services from other aspects of reproductive health care in the United States," according to Julie Chor of the Department of Obstetrics and Gynecology at the University of Chicago and colleagues. The researchers cited several prior studies, such as a survey of 1,800 practicing OB-GYNs that found "while 97% of respondents had met with patients seeking abortions, 14% actually provided the service"; a study showing that "[n]early one-third of [U.S.] women will have an abortion by age 45"; and a study showing that U.S. physicians' offices provide only 1 percent of abortions.

According to the researchers, "The impact of this separation on the patient-provider relationship is understudied." They pointed to additional research showing that "many women did not perceive their trusted providers to be a resource for nonjudgmental support in abortion decision making," even though "the vast majority of OB/GYNS report a willingness to help women obtain an abortion even if they have personal objections to abortion."

For their study, the researchers aimed "[t]o elicit a deeper understanding of women's perspectives of the role that regular gynecologic providers play in abortion decision making" by "qualitatively explor[ing] women's experiences with patient-provider communication before obtaining their abortion at a dedicated abortion clinic."

Methods

The researchers conducted a sub-analysis of a larger study examining how doula support affects women's experiences obtaining abortion care in the first trimester.

The researchers gathered data from a clinic "within a large, public safety net hospital that serves a predominantly low-income population" in a state with "relatively few abortion restrictions." According to the researchers, eligible study participants were at least 18 years old, had an abortion at no more than 13 6/7 weeks of pregnancy, spoke English and were able to understand the study and give informed consent. Participants were interviewed by phone within two weeks of receiving abortion care.

The researchers focused on participants' "responses to the questions: 'Do you have a doctor you see regularly for gynecological care, such as for contraception, talking about plans for pregnancy, other female health related issues? Did you speak with him/her about your decision to have an abortion?'" According to the researchers, their analysis "present[ed] salient themes regarding women's discussions with gynecologic care providers, including 1) reasons for not discussing abortion, 2) reasons for discussing abortion, and 3) factors contributing to the expectation that gynecologic care providers do not provide abortions."

Results

The final sample included 30 women. Twenty-four of the respondents had a regular gynecologic provider, and only eight of those women "communicated with their provider before their abortion," the researchers wrote.

In terms of demographic information, the researchers found that the participants' median age was 25 and that most were black (96.7 percent), single (80 percent) and had had at least one previous pregnancy. The researchers also found that half of the participants had at least two children and 19 of the 30 women had previously had at least one abortion.

Reasons for not discussing termination

The researchers found that "[a]mong the women who had a regular gynecologic provider but did not speak to their provider, the most salient themes regarding not discussing abortion decision making" included:

  • "[P]erceiving that the discussion would not be beneficial";
  • "[E]xpecting that gynecologic care providers do not perform abortions";
  • "[A]nticipating or experiencing logistical barriers"; and
  • "[W]orrying about disrupting the patient-provider relationship."

The researchers found that most respondents "expressed confidence in their decision to terminate the pregnancy," noting that it was common for women to report that "they had nothing to discuss with their provider, because they were already resolved in their decision." Further, women "viewed the ability to diagnose their own pregnancy to mean that they did not need to see a provider," the researchers wrote. They stated that such responses from participants underscore that pregnant women "have the ability to both diagnose and decide a course of management without medical advice."

The researchers found that some women had concerns that discussing abortion with their provider "would be intrusive or potentially deleterious," with some expressing "concerns that the provider might attempt to change their minds."

According to the researchers, "Women largely perceived that abortion was not within their regular gynecologic care provider's scope of practice." The researchers explained that such an outlook "was often shaped by past experiences with an institution or specific provider's practices and values." They wrote that some of the women had worked with their providers for pregnancy care or other reproductive health care, but "had never encountered abortion services at their provider's clinical setting," while multiple women "understood that abortion care was provided by a separate group of providers and not by their regular provider." Nonetheless, "many women stated they would have liked their regular provider to perform the procedure."

The researchers noted that some women had providers at religiously affiliated institutions, so they did not request abortion care in anticipation that they would be rejected, while some declined to disclose their abortion care at all to providers affiliated with these institutions. According to the researchers, several "women did not schedule an appointment with their provider to avoid delaying the procedure," with many "fearing that such appointments would not be timely."

The researchers also found that "some women were hesitant to discuss their decision with their regular gynecologic care provider, expecting their provider to pass judgment or express disappointment." A few of the respondents "with long-standing relationships wanted to protect their provider from emotional involvement in their decision," according to the researchers.

Reasons for discussing abortion

The researchers found that "[o]f the eight women who spoke with their gynecologic care provider, most had no reservations about disclosing their decision." However, according to the researchers, "fewer than one-half sought an appointment specifically to discuss the abortion or receive abortion-related care." Rather, they found that "most conversations occurred because the pregnancy was diagnosed or came up in discussion during previously scheduled appointments."

Among women who discussed their decision with their providers, women said their providers "were generally supportive of their decisions," the researchers wrote. They found that while "few participants recalled receiving ... counseling [on their pregnancy options] from their provider, four women reported receiving referrals for abortion-related clinical or financial services."

Barriers to women accessing regular gynecologic care

The researchers also explored the experiences of six women who were not able to discuss their abortion decision because they did not have a regular gynecologic provider. According to the researchers, some of these women reported receiving care at a community clinic without a primary OB-GYN relationship, while others cited "lapses in insurance as a reason for not having a gynecologic care provider."

The researchers noted that multiple women who previously had a regular provider "regretted not having the opportunity" to discuss their decision with them.

Discussion

The study findings showing that women were resolute about their abortion decision and did not seek out consultations with their regular gynecologic care provider "reflect the fact that, for many women, scheduling an appointment to seek guidance about abortion is unnecessary," the researchers wrote.

The researchers also pointed to the finding that "[w]omen largely believed that their regular gynecologic care provider would not provide abortion-related care." The researchers explained that many "women did not seek abortion-related counseling or care" because their providers worked at religious institutions, and because "only 14% of OB/GYNS perform abortions" overall. "However, this finding also signifies that some women do not view their regular gynecologic provider even as a resource for abortion-related counseling," the researchers wrote, adding, "A gap, therefore, exists between this perception and the reality that the vast majority of OB/GYNS are willing to provide abortion counseling and referrals, even if they morally disagree with abortion." According to the researchers, "These findings underscore the need for gynecologic care providers to take greater care to convey their openness to discussing abortion with their patients."

The researchers outlined the reasons participants gave for deciding not to discuss their abortion decision with their regular provider, particularly the desire to protect "the provider from involvement in the decision." The researchers wrote that women's desire "to protect their physician from their abortion decision may indicat[e] that these women are projecting their discomfort with this decision" or could reflect providers' expressed discomfort with the procedure. According to the researchers, patients' "discomfort in speaking to providers about abortion and apprehension about being judged for their decision illustrates the intrusion of abortion stigma into the patient-provider relationship." They wrote that such discomfort reflects the "'prevalence paradox' -- despite the high prevalence of abortion, women who have abortions anticipate stigmatization and subsequently choose not to disclose their abortions," which "in turn, results in the perception that abortion is uncommon and perpetuates discrimination."

The authors said that the study showed that women "primarily sought and successfully obtained abortion care independent of their regular gynecologic provider," which suggests that "seeking counsel from their regular provider may not afford a significant benefit." However, noting that "some participants voiced concerns about speaking to their regular gynecologic provider about their abortion decision," the researchers wrote that "gynecologic providers may not be adequately conveying to women that they can be trusted to provide nonjudgmental guidance and care for the full spectrum of women's reproductive health experiences." The researchers noted that providers' failure to ensure patients feel comfortable discussing all reproductive health issues "risk[s] undermining the exchange of important health information and the provision of optimal reproductive health care." They concluded, "Therefore, gynecologic providers should seek to normalize discussions of abortion during routine gynecologic visits to ensure that, when faced with such decisions, women who so desire feel that they can turn to their provider for guidance in abortion decision making."