A qualitative study to assess abortion referral patterns among generalist Ob-Gyns and primary care providers
Awarded 2016
Complex Family Planning Fellowship Research
Allison Linton, MD
Northwestern University

For a woman seeking an abortion, an informed, timely, non-judgmental referral from a general clinician has the potential to expedite care and assist the woman in navigating a complicated and tumultuous landscape.  However, it is unclear from the currently available literature whether general practitioners have either the knowledge or willingness to make meaningful abortion referrals, and what barriers they perceive.  It is also unknown if the growing number of merging health care systems has an impact on how abortion referrals are made by general health practitioners, and whether practitioners access and utilize existing institutional family planning resources. 
With this background, we sought to describe current abortion referral patters and barriers to making these referrals among physicians and mid-level clinicians in the fields of general obstetrics and gynecology, general internal medicine, family practice, and general pediatrics within a large, newly merged academic health care system.  Practitioners were recruited from Northwestern Medicine (a newly-merged health care system encompassing 4 separate hospitals across Chicago and its northern and western suburbs), and the research team performed qualitative interviews.  Interviews focused on referral patters before and after inclusion in a merged health care system, attitudes concerning abortion referral provision, and perceived barriers to providing abortion referrals.  A total of 37 interviews were performed and transcribed.  The interview transcripts were then analyzed for themes related to the topic areas of interest.
Overall, clinicians in all fields and practice sites reported comfort in discussing abortion when counseling a pregnant patient on her options, and said they were willing to provide abortion referrals if requested.  However, despite being willing to provide these referrals, many felt ill equipped to do so and identified many barriers in the abortion referral process, including both knowledge deficits and systemic inefficiencies.  Abortion referrals were also seen as “different,” requiring more time and effort than referrals for other specialty services, and often viewed as more secretive or taboo.  Lastly, clinicians did not report a change in their referral patterns since inclusion in a merged health care system, and many clinicians were unaware of family planning services and resources available at partnering institutions. 
These findings suggest multiple opportunity points for family planning specialists and generalist practitioners to work together to improve the abortion referral process.  While prior studies have shown that some general clinicians do not provide referrals for abortion services, this study suggests that at least for a subset of this population, this may be secondary to a lack of knowledge and familiarity rather than an unwillingness to provide a referral.  Participants in this study were willing to provide referrals, but identified specific barriers that made these referrals more difficult or unfamiliar, and desired additional education and support.  By working to improve knowledge and decrease barriers, family planning providers and generalist clinicians may help to facilitate timely access to quality abortion services.
In addition, this study suggests that a merger alone is not enough to facilitate family planning care within a merged health care system.  Continuous outreach and education must occur to increase awareness of what services are available within a merged health care system.  Ideally, generalist practitioners should see family planning colleagues within their merged health care system as a resource for clinical care and services, but also general clinical support and information.