Medical Abortion in Family Practice: A Newsmaker Interview With Linda Prine, MD

Ursula Snyder, PhD

August 11, 2003

Aug. 11, 2003 — Editor's Note: A retrospective case series of 236 medical abortions in four family practice community health centers in Manhattan and the Bronx was conducted between November 2001 and June 2002. There was only one true medication failure, requiring a suction procedure. The failure rate of the protocol under the care of family physicians was 0.4%. The rate of success achieved was higher than in clinical trials, and there were few complications. The study — the first published trial to focus on the outcomes of medical abortion in a family practice setting — shows that provision of medical abortion by family physicians is safe, effective, and feasible.

To discuss the implications of the study findings, Medscape's Ursula Snyder, PhD, interviewed Linda Prine, MD, the lead author of the study, which was published in the Journal of the American Board of Family Practice. Dr. Prine is affiliated with the Beth Israel Residency in Urban Family Practice in New York City.

Medscape: Some physicians have said that after describing the protocol as approved by the U.S. Food and Drug Administration, their patients were put off and most decided to have a surgical abortion. You did not use the FDA-approved regimen in your study. Could you describe the regimen you used and protocol you followed and why?

Dr. Prine: The protocol we used came from the multicenter Abortion Rights Mobilization (ARM) trials, which tested mifepristone in a number of settings with thousands of participants. The investigators followed a protocol that used only 200 mg of mifepristone instead of the 600 mg called for in the FDA regimen. The lower dose produced fewer side effects and was as effective as the higher dose. The ARM protocol also used vaginal misoprostol at 800 µg instead of the 400 oral µg recommended by the FDA, which resulted in greater efficacy compared with the FDA protocol. Further, the ARM trial protocol allowed the women to administer the misoprostol at home between 24 and 72 hours after the mifepristone, so it allowed for added flexibility and one less office visit. So these things — increased efficacy and increased convenience and tolerability for patients — dictated our choice to use this evidence-based regimen.

Medscape: The results of your study are impressive: 99.2% of the women successfully completed a medical abortion, and there was only one medication failure. You also had a high rate of patient return for follow-up. How does this compare with specialty clinics? Do you think there were unique aspects of your study population that contributed to this high compliance?

Dr. Prine: At abortion clinics the traditional return rate for follow-up appointments is between 50% and 75%, whereas in primary — that is, continuity-care — clinics, our patients just keep coming back to us. Even if they don't come back at the exact time they were supposed to, they do come back eventually. In a family practice setting, patients of all ages come to us for a wide array of reasons. We had a 75% compliance [rate] with the scheduled follow-up visit, but we ultimately saw more than 90% on follow-up, because eventually patients came back for some other primary care concern (often with an ill family member). Follow-up varies according to the setting: in primary care you are going to see your patients again.

Medscape: Your failure rate was 0.4%. How does this compare with other studies?

Dr. Prine: Part of the reason there's a wide range of failure has to do with how quick the provider is to do a suction procedure — or how quick the patient is to request one. The patients who came to our clinic knew that we did not have a facility to do suction procedures on our premises at the time. These women had sought us out to begin with because what they wanted was a medical abortion. They didn't want to have a surgical procedure done. So they were more willing to tolerate bleeding for a little bit longer, for example. We did not find a need beyond the single continuing pregnancy to do a suction. At specialty clinics, patients often come back to get a sonogram, and until the providers get used to looking at sonograms and become comfortable with findings showing heterogeneous material in the uterus, they initially are more quick to do a suction procedure, which in many cases would probably be unnecessary. There is a learning curve, and studies have been published about this learning curve for providers in abortion clinics. Most family practice settings, on the other hand, would have to refer a patient elsewhere for a suction procedure. I think this, as well as the patient self-selection, contributes to a lower rate of intervention.

Medscape: Is this also in part because family practice physicians are more comfortable with expectant management of abortion?

Dr. Prine: Family doctors often recommend expectant management of miscarriage. Medical abortion is essentially the same thing — that is, expectant management of an induced miscarriage. It is something that most family doctors would be comfortable with once they get the hang of it.

Medscape: Could you discuss the need for pre- and postabortion sonography? Not all family practice offices have sonography equipment, which is very expensive. Is it an FDA regulation that they have this equipment?

Dr. Prine: It is not an FDA regulation that providers have sonography equipment. Further, it is not an FDA requirement to do pre- and postabortion sonography. We have developed clear indications for doing sonography, so we don't do it on every patient. Two of our sites did not have sonography equipment, so the physicians sent the women for a sonogram if it was needed. When it was not indicated, we followed the patients with quantitative HCG [testing] before and after the abortion. In my experience, after the medical abortion, the history is sufficient. The patient tells you that she cramped and bled and that she no longer feels pregnant. Then you know it has been successful. I think that as we get more and more comfortable with the process we will stop doing so much sonography at follow up, and may even be willing to stop testing for HCG.

Medscape: Could you describe any complications and how they were managed?

Dr. Prine: We had one medication failure, so that woman needed a suction to end the pregnancy. But we had no known complications. We did have a patient who got a suction procedure when she went to an emergency room. We weren't able to get access to that ER record so we had to include her in our failure rate, but we don't know if she really had a problem that needed a suction, or if she was simply seen by inexperienced physicians who didn't know how to manage her symptoms.

Medscape: The comments in your article suggest that you believe family practices are appropriate settings for abortions to be offered. Could you elaborate on this?

Dr. Prine: A family practice is really a perfect setting for women to access reproductive healthcare because they are getting all the rest of their primary care there. The woman often comes to the practice because her mother first brought her there, or she comes there with her children. In the case of medical abortion, it's a private affair just between the woman and her doctor or nurse practitioner. I found it rewarding to be the doctor who helps a woman through a crisis like this and allows her to make her own decision. It means a lot to many women to be seen in a place where they are known and treated with respect, and no one outside the exam room knows why they are there. It allows a woman to come to the other side feeling supported in her decision by someone whose opinion matters to her — her own physician.

Many patients reported to me previous difficulties with getting abortions. The appreciation of patients who come to us is beyond anything else I've experienced as a doctor. They are just so overwhelmed. They want so much to be responsible women and have their children when they can really take care of them. Often when women are seeking an abortion it's not considered by their family or partner to be an acceptable choice. In family practice, we can appreciate that that is what they are dealing with and support them in that decision so that it becomes an affirming process. Sometimes, because we often know the family, we can help them come together around this choice. These are women who want to postpone their childbearing until the infant they already have gets a little older, or until they can make enough of a living to support a child, or until they have a partner whom they think will help them to raise a family. Whatever the issue is, it is rewarding to be able to allow them that right to have their children when they really want them.

Medscape: This is no doubt an important experience for residents to see at the beginning of their career.

Dr. Prine: Absolutely. Two of the sites in our study were residency-training programs. In a sense, residents are also near the beginning of their childbearing years, so they can understand and relate to the situation of wanting to access reproductive healthcare in a secure and supportive setting. We found that our female residents especially have been excited to participate and get trained. In other programs where this training is not available, residents have begun to ask for it. Their stance is that the full range of educational options should be available to them. Just as they may not practice circumcisions when they are finished with residency, they do have the training available to them. They are asking for medical abortion training to be available to them so that they will be equipped to practice it if they choose.

Medscape: What factors do you believe limit the wider availability of medical abortion?

Dr. Prine: A range of efforts have been made by various states to intimidate doctors so that they won't offer medical abortion — from government reporting regulations to bureaucratic obstacles. Opposition from colleagues who are anti-choice can also be an influence. There is a lot to go up against even to just offer the abortion pill. I think what ends up winning over the doctors and the staff is the patients who appreciate the service so much. In our practice after some of us began offering the pill patients would tell the staff how much they appreciated the service, and the staff would tell the other providers how much the patients were appreciating it. Sometimes I would manage the process for my colleagues, and the patient would go back to them saying that the medical abortion was so much better than her other options. With time, it becomes something that doctors want to offer and they begin to see past the obstacles.

Medscape: You and your colleagues have also addressed this by developing an innovative approach to integrating medical abortion into family practice residency program. Could you summarize the core features of the approach? In particular, how did you address reservations and concerns about medical abortion?

Dr. Prine: The article in [the July/August issue of] Family Medicine describes the process we used to start up medical abortion services. First, we did a staff attitudes survey to see where our colleagues and nursing staff and clerical staff stood on offering the service. And they were nervous about offering abortions. Some of the responses on the questionnaires showed that they were worried about violence against our health center. They were afraid of being identified as being an abortion clinic; they were afraid that there might be patients whose significant other would become upset if they found out that their partner had come to the center to get a medical abortion. We had a consultation about security matters, and we instituted something we called "universal precautions for security measures," because in any practice there are many situations that can arise where you have an angry patient or an angry family member. Abortion care is just one of many reasons people can get upset in your waiting room. We take care of patients who have all kinds of stressful life experiences, and some exhibit that stress in our waiting room.

The security measures made the staff feel more comfortable all around because they did address wider concerns about staff and patient safety and security in the workplace. In the two years that we have been offering abortions we haven't had any trouble at all with our patients who came in for abortions or their partners, but we continue to have the same issues arise with some of our other patients and now we're better equipped to deal with it, so it was a real benefit for the practice to do this kind of security evaluation.

Another thing we found in our staff survey was that the people who were most opposed to offering medical abortion at our practice were also the ones with the least self-reported knowledge. So we did educational workshops to address the knowledge deficit. Subsequent staff surveys we've done have shown much less opposition. Now, there could be many reasons for this: it could be staff turnover, it could be that once we started doing abortions that people realized that nothing bad was going to happen. Anyway, attitudes have shifted over time, and as we do repeated surveys on attitudes we find our colleagues and staff are much more supportive now of offering abortion than they were when we first started.

We also conducted what we call "values clarification workshops" to let everyone get their feelings out about abortion and to promote an attitude of professionalism that says, "We're here to take care of patients, not judge them" and, "Whatever our patients' health needs are, we are interested in facilitating their care and not deciding for them what their life choices should be." These workshops helped us move people along to separate professional conduct from personal feelings.

Medscape: What would you say to family practice physicians who are considering whether or not to offer medical abortion?

Dr. Prine: I would basically say, it is safe, effective, and your patients will absolutely appreciate having this option from you. It's interesting how quickly [the news media] covered the downside. When the pill first came out, the press was full of all this scary misinformation about how the pill was going to cause excess bleeding, how women were going to be running off to emergency rooms all the time, how dangerous it was. This really intimidated doctors. Even I was nervous to offer medical abortion in the beginning. I was calling my patients, I was checking on them all the time, and after 10 and 20 and 30 abortions that went so smoothly, I started to realize that this was all hype. We did not have any emergencies for hemorrhaging, and as more and more studies come out it's obvious that these acute emergencies are extraordinarily rare.

The surprise to me was that the process was as predictable and uneventful as it was. Patient after patient came in and got the medication, and I'd have an occasional phone call mostly for the pain with the cramping or to confirm some instructions, and they would come back, and it worked. And that was my experience over and over again. It was this experience that was so different from what the press was stressing that led me to go back and look at my data and publish this retrospective study with my colleagues [in the Journal of the American Board of Family Practice]. I realized that medical abortion was something that any primary care physician could manage. Two of us who wrote the paper also happen to be surgical abortion providers, so we were the backup. Patients were to come to us at Planned Parenthood and get a procedure if necessary, but it wasn't. I thought that this was really important for doctors to know — it's not a scary, risky process at all, probably safer than a suction abortion because there is no risk of perforation or infection from the instruments.

When women come to me for a medical abortion, they get the abortion, and they also get contraception, before they even leave the office, that same day. In family medicine, we have greater access to our patients to facilitate contraception because they come to us with their children, with other family members or for sick visits. This gives us the opportunity to ask if they are happy with their method or if they need refills. In addition, one of the things we have done is to increase our colleagues' awareness about providing emergency contraception. It's not enough to just provide abortion services; it has to go hand in hand with preventing the need for abortion. We felt it important to educate all the physicians in the practice about the usefulness of proactive prescribing of emergency contraception. We prescribe it not only at "check-up" appointments, but also at sick visits for totally unrelated problems. We also take part in the "EC" hotline, where we call in prescriptions for women who need emergency contraception. And we teach our residents to prescribe emergency contraception proactively as well for women of reproductive age. We teach them to routinely ask about birth control, and if a woman is not on a high-efficacy method of birth control, we encourage the residents to give her a prescription for emergency contraception that can be filled in advance.

Also, looking at the needs of a whole family, one realizes the importance of bringing children into the family when they are wanted. For me, I know that having children has been the most life transforming event I have experienced, the most challenging, and even, at times, the most difficult. Having children is a decision to be taken very, very seriously. So I tell family doctors that this is what we are empowering women to do — to take that decision seriously. It is hard enough to raise and care for children under the best of circumstances, much less when a woman or her family is really ill prepared. Women who think this through deserve respect, no matter what the outcome of their decision.

Medscape: Do patients ever leave your practice when they hear you are offering abortions?

Not that any of them have ever told me, and I have had many discussions, even with patients who are against it. Meanwhile, many have come to me for a medical abortion and then said they want to continue with me as their family doctor. It was like this in the early days of the AIDS crisis. Some doctors refused to take care of people with HIV and gave as an excuse that they were worried about what their other patients would think. I think that is a false issue. I can understand being worried about violence if you practice in certain communities. I don't buy the "my patients will leave me" argument, though. What if their patients told them not to take care of patients of other races or religion? One needs to follow one's own conscience about what is right.

Medscape: Where can primary care physicians get instruction on how to use this pill and all of the other information they might need to use it?

Dr. Prine: There are several Web sites: the National Abortion Federation has medical information and educational CD-roms can be ordered from them (https://www.prochoice.org). The grant-funded project I work on, The Access Project, has a Web site (https://www.theaccessproject.org) that is directed toward family practitioners and includes the "evidence-based protocol," consent forms, chart review checklists, workshop outlines, and links to other useful information. The Center for Reproductive Health Research and Policy produced an excellent guide: "Early Medical Abortion: Issues for Practice" (https://www.reprohealth.ucsf.edu).

Fam Med. 2003;35(7):469-471
J Am Board Fam Pract. 2003;16(4):000-000

Reviewed by Gary D. Vogin, MD

 

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