Referral of women requesting abortion in Nebraska
Awarded 2014
Complex Family Planning Fellowship Research
Valerie French, MD
University of California, San Francisco

This study on abortion referral evaluated how patients navigate the medical system when they desire an abortion and how providers participate in that process. The study had two arms: 1) a patient arm assessing the influence of clinician referral on the time it took a woman to obtain an abortion, and 2) a provider arm that assessed the attitudes and practices of clinicians when patients request an abortion referral.
Influence of clinician referral on Nebraska women’s decision-to-abortion time
Objective: To assess the association of clinician referral with decision-to-abortion time.
Study design: We conducted a cross-sectional survey of women seeking abortion at all three Nebraska abortion clinics. We defined referral as direct (information for an abortion clinic), inappropriate (information for a clinic that does not provide abortions) or no referral. Women reported when they recognized their pregnancy, decided to seek abortion and contacted a clinician. The primary outcome – decision-to-abortion time – was time from certain decision to abortion. We used multivariate linear regression analysis, controlling for potential confounders.
Results: Participants (n=356) were a mean of 26.8±5.3years old, primarily white (62%), unmarried (88%) and urban (87%), with a mean gestational duration of 8(2/7)weeks (S.D.±20days). Forty-six percent (164) had contacted a clinician and 30% (104) had discussed abortion with one before their abortion. Of those, 30% received a direct referral, 6% received an inappropriate referral and 64% received no referral. Decision-to-abortion time did not vary by referral type [mean difference compared with direct referral: inappropriate referral, 1.1days, 95% confidence interval (CI) -13.4 to 15.6, p=.88; no referral, -0.4days, 95% CI -7.0 to 6.3]. The most common reasons cited for delay in obtaining an abortion were an inability to get an earlier appointment (105/263, 40%) and time needed to raise money to pay for the abortion (73/263, 28%).
Conclusion: While neither occurrence of referral nor type was associated with decision-to-abortion times, women in Nebraska continue to face barriers to timely abortion care.

“She’s on her own”: a thematic analysis of clinicians’ comments on abortion referral
Objective: The objective was to understand the motivations around and practices of abortion referral among women’s health providers.
Methods: We analyzed the written comments from a survey of Nebraska physicians and advanced-practice clinicians in family medicine and obstetrics-gynecology about their referral practices and opinions for a woman seeking an abortion. We analyzed clinician’s responses to open-ended questions on abortion referral thematically.
Results: Of the 496 completed surveys, 431 had comments available for analysis. We found four approaches to abortion referral: (a) facilitating a transfer of care, (b) providing the abortion clinic name or phone number, (c) no referral and (4) misleading referrals to clinicians or facilities that do not provide abortion care. Clinicians described many motivations for their manner of referral, including a fiduciary obligation to refer, empathy for the patient, respect for patient autonomy and the lack of need for referral. We found that abortion stigma impacts referral as clinicians explained that patients often desire additional privacy and clinicians themselves seek to avoid tension among their staff. Other clinicians would not provide an abortion referral, citing moral or religious objections or stating they did not know where to refer women seeking abortion. Some respondents would refer women to other providers for additional evaluation or counseling before an abortion, while others sought to dissuade the woman from obtaining an abortion.
Conclusions: While practices and motivations varied, few clinicians facilitated referral for abortion beyond verbally naming a clinic if an abortion referral was made at all.