Convincing new providers to offer medical abortion: what will it take?

tion (FDA) approved Mifeprex (mifepristone), commonly known as the “abortion pill,” an article in the Los Angeles Times1 predicted a bleak future for the drug in the United States. The reporter had contacted 53 clinics in California and found that fewer than half offered medical abortion to their patients. Reasons commonly cited for not offering the service included cost, the need for training and the obligation of instituting new procedures for counseling and follow-up care. Several providers also seemed to believe that medical abortion was inherently less reliable or acceptable than traditional surgical methods. One year later, the headlines of two articles presented starkly contrasting assessments of mifepristone’s acceptability: An article in the Washington Post2 was headlined “Abortion Pill Sales Rising, Firm Says,” whereas a piece in the New York Times3 read “Abortion Pill Slow to Win Users Among Women and Their Doctors.” The Post story drew from press releases by Danco Laboratories, the manufacturer and distributor of mifepristone in the United States. Meanwhile, the Times article relied on conversations with providers already performing abortions, who compared the costs and time involved in doing medical abortions with those of the already established surgical procedures. Not surprisingly, the providers interviewed stated that most doctors would probably decline to offer or promote medical abortion for their patients because it was a time-consuming and expensive service, particularly compared with surgical abortion. Continuing to rely on the perspectives of abortion providers to predict the fate of medical abortion in the United States is problematic. First, these providers, precisely because of their familiarity with an alternative technique, must overcome biases and, in some cases, preconceived notions about a new option. In fact, a review of the experience of medical abortion in France, Great Britain and Sweden concluded that “it can take a decade or longer for mifepristone to be fully recognized and integrated as a method of abortion,” and “provider knowledge and acceptance” are key factors.4 Second, focusing solely on the concerns of providers fails to recognize the influence of the other major actors in the public introduction of any new technology—namely, the consumers. Finally, these stories give short shrift to potential providers’ underlying hesitations about incorporating a new option in their practices. In early 2001, shortly after medical abortion using mifepristone became available in the United States, the Reproductive Health Technologies Project, a national advocacy organization based in Washington, DC, undertook a survey of women’s health care providers in California. The project sought to understand what potential providers would require to begin offering this method:5 What would it take to make the provision of this drug a benefit instead of a liability? Between February and May 2001, the project interviewed 20 providers working in community clinics, university-based medical centers, health maintenance organizations (HMOs), feminist clinics, student health centers and independent medical practices. All provided primary care services to women, 18 were physicians (although only one was an obstetrician-gynecologist) and none were abortion providers. Given the controversial nature of abortion, gaining access to the respondents was surprisingly easy, and their willingness to talk was unexpected. All those approached agreed to participate, spent more than an hour in the interview, and expressed an interest in receiving more information about the regimen and how to incorporate it in their clinical practices. The perspectives of the persons we interviewed—their concerns, expectations and interest in medical abortion—provide insight into what it will take to get providers to begin offering the method.