The Department of Health and Human Services published a final rule containing updated regulations for providers participating in the Title X family planning program. These regulations would limit patients’ ability to obtain abortion-related information, counseling, and services. The rule is scheduled to go into effect on May 3, 2019, pending the outcome of lawsuits filed in federal courts by more than 20 states seeking to block its implementation. The changes it would make to the Title X program represent the latest in a series of state and federal regulations restricting access to abortion that has been implemented over the past 5 years. We believe that this emerging reality creates an imperative for the broader primary care community to accelerate uptake and implementation of a feasible, safe, and effective innovation that can democratize access to these services: medication abortion.
The Title X program, enacted in 1970, was designed to ensure access to comprehensive contraceptive care and preventive reproductive health services, especially for low-income and uninsured people. Its overarching objective is to provide information to promote informed decision making and autonomy in family planning. Although Title X funding has never covered abortion services, the new rule would require that there be “clear financial and physical separation” between projects and programs funded by Title X and “facilities where abortion is a method of family planning.”1 Physical separation could be achieved by constructing separate entrances for the two spaces, for example. In addition, the rule would no longer require that Title X providers offer abortion counseling, and it would finalize the prohibition against using funds from the program to refer patients for abortion. The rule is clear that Title X providers cannot “refer for abortion (even) when requested by a client.”
What we find striking about this move is that a program never intended to cover abortion services is now being hijacked to restrict information about, and access to, abortion services for vulnerable populations. The new regulations would have a substantial effect on the 4 million people who are served by the 3858 currently extant Title X–funded clinics in the United States each year. Engaging primary care clinicians not affiliated with the Title X program in routinely offering medication abortion thus becomes critically important.
Each year in the United States, more than 600,000 pregnancies result in induced abortion; the majority of these abortions (roughly 90%) occur in the first trimester. Barriers to obtaining abortion services are increasing, and 90% of U.S. women live in a county without an abortion clinic. As of 2014, the United States had only 1671 facilities that provided abortions, but there are more than 200,000 practicing primary care physicians. Pregnant people who are unable to obtain a wanted abortion are more likely to live in households with incomes below the federal poverty level, to be unemployed, and to have fewer aspirational plans than those who are able to obtain abortion services. Legislation in Texas that created onerous requirements for abortion clinics — and was ultimately struck down by the Supreme Court in Whole Woman’s Health v. Hellerstedt — resulted in the closure of more than half the state’s clinics. The requirements increased the distance that residents needed to travel to reach the nearest abortion facility by an average of 51 miles.
Prior to the availability of mifepristone for medication abortion in the United States, nearly all first-trimester abortions were performed using vacuum aspiration, and referral to clinicians trained in surgical-abortion services was standard primary care practice. When the Food and Drug Administration (FDA) approved mifepristone in 2000, many abortion-rights supporters believed that more clinicians would offer medication abortion and access would greatly expand. In 2006, the percentage of first-trimester abortions in the United States that were medical was 10%; by 2015, the percentage of medical abortions was still only 24%. By contrast, in parts of Europe, such as France, the United Kingdom, and Scandinavia, such rates are between 60 and 90%.
What’s more, estimates suggest that only 1% of abortions in the United States are performed in physicians’ offices.2 Nearly all abortion services remain siloed in stand-alone clinics or particular specialties, such as obstetrics and gynecology. Barriers that may explain the lack of dissemination of medication abortion into primary care include misperceptions about the complexity and safety of dispensing mifepristone, lack of training opportunities, organizational policies prohibiting abortion, ambivalence or ethical or moral discomfort among providers, stringent FDA regulations that require both provider registration in a central database and in-clinic storage and direct dispensing of mifepristone to patients, and concerns for the safety of clinic patients and staff because of intimidation and threats of violence.4
Protocols for providing medication abortion are well aligned with the structure and functions of primary care. Mifepristone, a progesterone-receptor antagonist that aids in endometrial detachment of a pregnancy, is dispensed in the clinic as one 200-mg pill. Patients are then instructed to take 800 μg of misoprostol, a prostaglandin analog, at home, to induce uterine contractions. This regimen is effective in completing an abortion in 97 to 98% of cases. Medication abortions can be safely offered at up to 10 weeks’ gestation. Serious complications, such as hemorrhage or infection, occur in an estimated 0.23% of cases.5 Common effects of the medications (abdominal cramping and nausea) can be easily managed, and follow-up to ensure completion of the abortion can be performed safely and effectively in person or over the phone. The National Academies of Sciences, Engineering, and Medicine affirmed in a 2018 report that medication abortion lends itself to widespread integration into primary care since it doesn’t require procedural training or special equipment, the medications can be dispensed and patients can be monitored in an outpatient setting, and counseling skills can be acquired.
In order to integrate medication abortion into primary care, we believe that greater efforts should be made to educate primary care clinicians about this intervention. Information could be provided by means of didactics and workshops in residency training and continuing medical education courses. More personalized “academic detailing” could be delivered by regional experts or experienced peers. Health system leaders and health plans could support primary care practices by using readily available implementation tool kits that inform best practices and reduce barriers for integration of medication abortion services.
Given mounting regulations, many people who would formerly have been able to obtain comprehensive reproductive health care in Title X family planning clinics may be forced to seek care in other settings or carry an unwanted pregnancy to term. Many patients have expressed a strong desire to receive abortion services from their primary care providers. Primary care clinicians could be an important resource for providing care to people in need of reproductive health and abortion services, given their breadth of training and commitment to providing comprehensive care. Performing medication abortions requires clinical evaluation to confirm an intrauterine pregnancy, basic knowledge about the medications involved, comfort with providing patient-centered counseling, and leadership to champion the integration of new clinic protocols. Such tools are in keeping with those that primary care clinicians already use to optimize care for patients with a range of acute and chronic conditions.
Reproductive health care is a well-established component of primary care. Nearly every primary care clinician will care for women who become pregnant. We believe that updates to the Title X program that would restrict access to abortion-related information, counseling, and services create an imperative to shift away from regarding medication abortion as a niche technique toward considering it the standard of care for people seeking abortion services. Regardless of whether the final rule is ultimately allowed to stand, we believe that the evolving regulations that threaten to further restrict access to abortion in the United States mean the time has come for the primary care community to turn the promise offered by medication abortion into a reality.