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Following a collaborative workshop at the 39th Annual Pregnancy Meeting, the Society for Maternal-Fetal Medicine Reproductive Health Advisory Group identified a need to assess the attitudes of maternal-fetal medicine subspecialists about abortion services and the available resources at the local and regional levels. The purpose of this study was to identify trends in attitudes, beliefs, and behaviors of practicing maternal-fetal medicine subspecialists in the United States regarding abortion. An online survey was distributed to associate and regular members of the Society for Maternal-Fetal Medicine to assess their personal training experience, abortion practice patterns, factors that influence their decision to provide abortion care, and their responses to a series of scenarios about high-risk maternal or fetal medical conditions. Frequencies were analyzed and univariable and multivariable analyses were conducted on the survey responses. Of the 2751 members contacted, 546 Society for Maternal-Fetal Medicine members completed all (448 of 546, 82.1%) or some (98 of 546, 17.9%) of the survey. More than 80% of the respondents reported availability of abortion services in their state, 70% reported availability at their primary institution, and 44% reported provision as part of their personal medical practice. Ease of referral to family planning subspecialists or other abortion providers, institutional restrictions, and the lack of training or continuing education were identified as the most significant factors contributing to the respondents’ limited scope of abortion services or lack of any abortion services offered. In the univariable analysis, exposure to formal family planning training programs, fewer years since the completion of residency, current practice setting not being religiously affiliated, and current state categorized as supportive by the Guttmacher Institute’s abortion policy landscape were factors associated with abortion provision (all P values <.01). After controlling for these factors in a multivariable regression, exposure to formal family planning training programs was no longer associated with current abortion provision (P=.20; adjusted odds ratio, 1.34; 95% confidence interval, 0.85–2.10), whereas a favorable state policy environment and fewer years since the completion of residency remained associated with abortion provision. The results of this survey suggest that factors at the individual, institutional, and state levels affect the provision of abortion care by maternal-fetal medicine subspecialists. The subspecialty of maternal-fetal medicine should be active in ensuring adequate training and education to create a community of maternal-fetal medicine physicians able to provide comprehensive reproductive healthcare services.
The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (SMFM) recognize abortion as an essential component of reproductive healthcare.
Although safe and effective, abortion is one of the most highly regulated medical procedures in the United States. Many legal, financial, and logistical barriers limit individuals from obtaining high-quality, timely abortion care.
Over the last 9 years, 479 abortion restrictions were enacted in 33 states; in 2020, 236 provisions were introduced to restrict abortion care across the country, and 27 of these provisions were enacted.
Reproductive services for women at high risk for maternal mortality: a report of the workshop of the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Fellowship in Family Planning, and the Society of Family Planning.
Although studies have found that MFM subspecialists discuss abortion in the setting of fetal anomalies identified during the midtrimester anatomic survey,
The Accreditation Council for Graduate Medical Education The American Board of Obstetrics and Gynecology, The American College of Obstetricians and Gynecologists.
The Maternal-Fetal Medicine milestone project,
2016
An enhanced understanding of the state of abortion training and practice among MFM physicians in the United States would help guide training and advocacy initiatives to increase equitable access to abortion care for high-risk individuals. The purpose of this study was to identify trends in the attitudes, beliefs, and behaviors of practicing MFM physicians in the United States regarding abortion practices through a survey sent to SMFM members. Within this document, the term “high risk” is used to describe an individual who, following an assessment of relevant medical and contextual factors, has an increased risk for experiencing pregnancy complications or maternal mortality if they become pregnant.
Reproductive services for women at high risk for maternal mortality: a report of the workshop of the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Fellowship in Family Planning, and the Society of Family Planning.
Reproductive services for women at high risk for maternal mortality: a report of the workshop of the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Fellowship in Family Planning, and the Society of Family Planning.
the SMFM Reproductive Health Advisory Group identified the goal of assessing the current abortion care resources available to MFM subspecialists. The group performed a literature review to identify survey tools that have been applied previously in similar studies.
The survey authors drafted questions that were disseminated to the advisory group for comment. Following incorporation of the suggested changes, a pilot test group completed the working draft of the survey and provided feedback aimed at enhancing the survey instrument.
The survey included questions to determine MFM physicians’ attitudes about abortion services and the resources available to them at the local and regional levels. Respondents provided demographic information and described their personal training experience. They subsequently received a set of questions to identify the factors that influence their provision of abortion care. They responded to a series of scenarios about high-risk maternal or fetal medical conditions and indicated whether they would provide abortion services or refer patients for abortion services in those specific cases. MFM providers who do not perform or refer patients for abortion services were asked about the contributing factors.
The survey population consisted of clinically active associate and regular members of SMFM and fellows enrolled in an MFM training program identified through the 2019 SMFM member database. Inclusion criteria included current enrollment in an MFM fellowship or current provision of clinical services as an MFM physician. Exclusion criteria included MFM physicians who are not currently providing clinical services. The survey was a web-based product hosted by Research Electronic Data Capture (REDCap) at the University of Texas Health Science Center at Houston, TX. REDCap is a secure, web-based application designed to support data capture for research studies.
The survey was distributed by SMFM through email and publicized via SMFM’s social media outlets and reminders at the 2020 Annual Pregnancy Meeting in Grapevine, TX. Five survey respondents were randomly selected to receive participation incentives.
We analyzed the frequencies of responses and conducted univariable and multivariable analyses of the responses using SPSS Statistics software for Windows, version 24.0 (IBM, Armonk, NY). We assessed the representativeness of the sample by comparing the demographic characteristics of survey respondents with that of the general membership of SMFM. The region of practice of the respondents was categorized as supportive, middle ground, or hostile using a scale modified from the Guttmacher Institute (Table 1).
A multivariable regression analysis included variables that were significant at a P value of <.10 in the univariable analyses. Statistical significance was defined as a 2-tailed alpha value of <.05. As a survey study of healthcare providers, this study received exempt status from the Institutional Review Board of the University of Texas Health Science Center at Houston, TX, (application reference HSC-MS-19-0750).
Table 1State policy landscape index
Policy landscape
States
Very hostile or hostile
Alabama, Arizona, Arkansas, Indiana, Kentucky, Louisiana, Mississippi, Missouri, Nebraska, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin
Leans hostile, middle ground, or leans supportive
Alaska, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Idaho, Illinois, Iowa, Kansas, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, Rhode Island, Vermont, Wyoming
Very supportive or supportive
California, Hawaii, Maine, New York, Oregon, Washington
Approximately 85% of MFM physicians nationwide are SMFM members. Of the 2912 associate and regular members of SMFM, 2751 were eligible for this study and received an email invitation to complete the Reproductive Health Services survey. Of these, 161 members were excluded because they either opted out of receiving email communications from SMFM or were not MFM physicians. In total, 587 responses were received, of which 14 were determined to be ineligible (not an MFM physician or not in active clinical practice) and were excluded. Of the remaining 573 respondents, 27 completed the initial screening question but did not answer the other survey questions and were also excluded. The final survey sample included 546 SMFM members who completed all (448 of 546, 82.1%) or some (98 of 546, 17.9%) of the survey, representing a response rate of 19.8% (Figure 1).
Figure 1Flow diagram for inclusion and exclusion of respondents
The demographic and geographic characteristics of survey respondents are displayed in Table 2. Most respondents were women (n=326; 59.7%), White (n=345; 63.2%), and reported a current, personal religious affiliation (n=293; 53.4%). The majority of respondents were fellowship-trained MFM attending physicians in active clinical practice (n=405; 74.2%), and about half (n=268; 49.1%) worked in academic medical centers. Diversity in age and career stage were represented among the survey participants. Respondents were from geographically diverse practice locations with balanced representation by US geographic regions. One-third of respondents (33.7%) currently practice in regions with a hostile abortion policy landscape. Demographic characteristics of the survey respondents (n=546) were compared with available SMFM membership data of all eligible respondents (n=2751). Compared with the general SMFM membership, survey respondents were more frequently female (59.7% vs 52.5%; P<.01) and within 5 years of completion of MFM fellowship training (27.7% vs 13.3%; P<.01). In addition, the distribution of geographic region of the clinical practices was significantly different between the survey respondents and the general SMFM membership (Northeast 22.2% vs 24.9%; Midwest 16.8% vs 19.2%; South 20.7% vs 32.4%; and West 22.3% vs 23.3%; P<.01). Data about the practice state were missing for 18% of respondents.
Table 2Demographics and characteristics of the Society for Maternal-Fetal Medicine member survey respondents
Overall, 271 of 463 respondents (58.5%) reported that their residency or fellowship training institution had a Ryan Residency Training Program, Complex Family Planning Fellowship, or both. These programs typically include abortion education and training during residency or an MFM fellowship. Respondents with exposure to these formal family planning training programs were significantly more likely to have received training and reported current competence in providing options counseling and performing abortions than those without family planning program exposure (Table 3). Specifically, respondents with exposure to family planning training programs were significantly more likely to report competence in abortion provision to the limit allowable by state law for all abortion methods. However, survey respondents reported less comfort in providing D&E to the limit allowable by state law (169 of 463, 36.5%) compared with dilation and curettage (D&C) (279 of 463, 64.1%) and induction termination (319/463, 68.9%), regardless of family planning training program exposure (P<.001 for both comparisons).
Table 3Training and perception of competency in family planning clinical services by exposure to formal family planning training programs
Survey participants received a series of questions regarding their current practice patterns and local and regional availability of abortion services. Data about the respondents’ understanding of the availability of abortion services at the state and local levels and their individual practice by indication and method are displayed in Table 4. For abortion, 83% of respondents reported availability in their state (excluding their primary medical facility), 70% reported availability at their primary institution, and 44% reported provision as part of their personal medical practice (including supervision of trainees). Abortion was more frequently performed by individual respondents and more frequently available at the respondent’s primary hospital center for the indications of “maternal life” and “life-limiting fetal anomalies” compared with other indications (P<.01). Individual provision of abortion differed significantly among respondents according to the regional policy climate. Overall, 69% of respondents in states with supportive policy climates reported abortion provision as part of their personal medical practice; in contrast, 52% of respondents in middle-ground states and 47% of respondents in hostile states included abortion provision at their medical practice (P<.01). Induction termination and D&C remained the most commonly utilized abortion techniques among survey respondents. Notably, 72% of respondents reported the availability of mifepristone at their primary hospital, and 56% reported use of mifepristone in their personal medical practice.
Table 4Reported availability of abortion at the state, local, and individual provider level by indication and method
Indication and method
State, n=453, n (%)
Primary hospital, n=382, n (%)
Personal medical practice, n=241, n (%)
Indication for abortion
Maternal life
392 (86.5)
368 (96.3)
234 (99.6)
Maternal physical health
381 (84.1)
303 (79.3)
187 (77.6)
Maternal mental health
342 (75.5)
243 (63.6)
138 (57.3)
Life-limiting fetal anomalies
399 (88.1)
348 (91.1)
227 (94.2)
Non–life-limiting fetal anomalies
372 (82.1)
268 (70.2)
165 (68.5)
Rape or incest
369 (81.5)
273 (71.5)
152 (63.1)
Other
374 (82.6)
237 (62.0)
106 (43.9)
Method of abortion
Mifepristone and misoprostol
375 (82.8)
278 (72.8)
135 (56.0)
Misoprostol only
315 (69.5)
263 (68.8)
139 (57.7)
Dilation and curettage
401 (88.5)
246 (64.4)
195 (80.1)
Dilation and evacuation
405 (89.4)
356 (93.2)
166 (68.6)
Induction termination
364 (80.4)
347 (90.8)
221 (91.7)
Unsure
41 (9.1)
10 (2.6)
—
Society for Maternal-Fetal Medicine. MFM subspecialist abortion survey. Am J Obstet Gynecol 2021.
Of the 244 respondents who provide abortion services at their clinical practice, 153 (62.7%) reported limiting the services they provide (by procedure type, gestational age, clinical indication, or another factor). Respondents who reported limiting the scope of their abortion services and those who reported not performing abortion ranked ease of referral to family planning subspecialists or other abortion providers, institutional restrictions, and the lack of training or continuing education as the most significant factors in their decision (Figure 2). Survey participants also cited state-level restrictions, logistics, and moral and religious considerations as other important factors impacting their provision of abortion services.
Participant responses to a series of scenarios about high-risk maternal or fetal medical conditions are displayed in Table 5. For both the fetal and maternal scenarios, advancing gestational age resulted in less frequent abortion counseling and provision and more frequent out-of-state referral. Overall, the respondents’ practice patterns were similar for cases with maternal vs fetal indications. Respondents indicated that the majority of individuals with indications for abortion at 20 weeks of gestation would receive care at their hospital by the MFM respondent or referral within the hospital center for fetal indications (345/475; 72.6%) and maternal indications (351/466; 75.3%; P=.35). Approximately 1 in 5 respondents indicated that abortion at 26 weeks of gestation for a fetal or maternal indication was available at their center, with 10.2% and 9.4% of respondents stating they would personally provide an abortion for a fetal or maternal indication, respectively. Although the number of respondents stating that they would not discuss abortion or refer a patient for abortion at 26 weeks of gestation in both scenarios was small, respondents were significantly more likely to omit discussing the option of abortion for maternal vs fetal indications at 26 weeks’ gestation (10.9% vs 5.9%; P=.005).
Table 5Reponses to fetal and maternal case scenarios
Responses
Fetal—trisomy 18 by CVS, n=475
Maternal—unrepaired tetralogy of Fallot with poorly controlled hypertension and stage III chronic kidney disease, n=466
Lastly, relationships between current abortion provision, exposure to family planning training programs, and other factors were evaluated using univariable and multivariable logistic regressions. In the univariable analysis, exposure to formal family planning training programs, fewer years since residency completion, current practice setting not being religiously affiliated, and current state categorized as supportive by the Guttmacher Institute’s abortion policy landscape were associated with abortion provision (all P<.01). After controlling for these factors in a multivariable regression, exposure to formal family planning training programs was no longer associated with current abortion provision (P=.20; adjusted odds ratio, 1.34; 95% confidence interval, 0.85–2.10), whereas a favorable state policy environment and fewer years from residency were associated with abortion provision (Figure 3).
Figure 3Current abortion provision and exposure to family planning training programs
The multivariable model included the following factors associated with current abortion provision that had a P value of <.10 in the univariable analysis: exposure to formal family planning training programs, <5 years since residency completion, religious affiliation of current practice setting, and state abortion policy landscape (Guttmacher Institute).
CI, confidence interval; OR, odds ratio.
Society for Maternal-Fetal Medicine. MFM subspecialist abortion survey. Am J Obstet Gynecol 2021.
This survey of practicing MFM physicians found that factors at the individual, institution, and state levels affect their provision of abortion care. Although the majority of respondents reported competence in options counseling related to pregnancy continuation or termination, less than half (244 of 546; 44.7%) provide abortion as part of their current medical practice. MFM physicians who completed postgraduate training at an institution with a family planning training program more frequently performed abortions in their practice, however, practice location but not exposure to abortion training was associated with current abortion provision. The ability of MFM physicians to provide or refer for abortion services for high-risk patients varied by geographic region and abortion policy landscape. The heterogeneity among respondents regarding the types of procedures, gestational age limits, indications, and personal practice patterns are consistent with other surveys
and highlight the complex relationship between provider, hospital, and state-level factors and abortion provision by MFM physicians.
Abortion for maternal vs fetal indications
By 26 weeks of gestation, MFM subspecialists were less willing to provide abortions for maternal indications than for fetal indications at their institution. However, abortion practice patterns were similar for fetal and maternal indications at earlier gestational ages in the clinical scenarios provided. Notably, at 26 weeks of gestation, 10% of MFM subspecialists replied that they would neither discuss nor refer for abortion for either maternal or fetal indications in the clinical scenarios provided. We speculate that there are several contributing factors to this finding. In the setting of a maternal indication for ending a pregnancy at 26 weeks of gestation, preterm delivery would typically be recommended rather than abortion because this gestational age is beyond the threshold of viability at most institutions. At and beyond 26 weeks of gestation, a good fetal outcome is likely with preterm delivery for maternal indications and subsequent neonatal care; therefore, this option is usually discussed rather than abortion. We cannot exclude the possibility that respondents interpreted “abortion” at 26 weeks of gestation as equivalent to a medically indicated preterm delivery. In addition, hospital policies may differ in terms of maternal and fetal indications for abortion, including palliative induction in cases of severe fetal anomalies. Differences may also exist in the confidence of MFM physicians in managing medical conditions in which pregnancy poses a risk but is not contraindicated. Previous surveys have demonstrated variation in counseling and management strategies by MFM physicians in the context of fetal indications,
Disparities in abortion training in maternal-fetal medicine fellowships
Although the majority of respondents reported receiving abortion training during postgraduate education, only one-third reported performing D&E in their current practice. One reason for this difference may be ease of referral to family planning subspecialists or other trained clinicians, which was reported by respondents as the most important factor in their decision about providing abortion. Lack of training was reported as another important factor. One mechanism to increase the number of MFM physicians trained in abortion care may be to leverage partnerships with institutions that have a Ryan Residency Training Program or Complex Family Planning Fellowship Program.
Currently, 64.8% of MFM fellowship sites also have a Ryan Residency Training Program and 27.5% also have a Complex Family Planning Fellowship.
Expanding D&E training opportunities for MFM fellows and clinicians may optimize care and increase the number of treatment options for people with severe pregnancy complications, particularly those who live in areas with no or limited access to family planning subspecialty care.
Reproductive services for women at high risk for maternal mortality: a report of the workshop of the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Fellowship in Family Planning, and the Society of Family Planning.
Regional training partnerships and national networks for elective training rotations during fellowship have been proposed as models to facilitate such training.
Regional disparities in abortion access for maternal-fetal medicine patients
Individual abortion provision by MFM physicians differed according to the policy landscape, with a higher proportion of MFM physicians practicing in states with a supportive legislative climate reporting abortion provision than those practicing in more hostile states. Although multiple factors contribute to this association, including the ability to refer cases to family planning colleagues and local institutional policies, the unequal geographic distribution of abortion clinics across the United States indicates reduced abortion access for high-risk patients with maternal or fetal indications for abortion.
Increasing high-risk patient access to the full range of reproductive health services, including abortion care, regardless of their location, is important in reducing the economic and regional disparities in obstetrical and gynecologic health outcomes.
Strengths of this study include the geographic diversity of respondents, which is generally representative of the SMFM membership. The anonymous format of this survey is also a strength. This study considered the attitudes of MFM subspecialists about abortion services for high-risk individuals and their competence in abortion provision. Previous surveys aimed at MFM subspecialists have assessed the barriers to provision of D&E,
compared their attitudes and practice patterns for second-trimester abortions indicated for abnormal pregnancies with those of trained family planning subspecialists,
all of which demonstrated heterogeneity in MFM physicians’ attitudes and practice patterns regarding abortion. A strength of this survey includes the breadth and depth of family planning topics assessed, from personal training experience and practice patterns to factors that influence the decisions to provide abortion care. Therefore, this survey provides novel, contemporary data regarding factors that affect the provision of abortion care by MFM subspecialists at the individual, institution, and state levels.
The study also has limitations. The 19.8% response rate raises the possibility of sampling bias. It is possible that because of the polarizing nature of the survey topic, respondents who do not provide reproductive health services chose not to respond to this survey. Our sample was younger and more often female than the SMFM population at large, all of which may have contributed bias to the responses. Previous studies of obstetrician-gynecologists suggest that younger age, female gender, and university faculty practice are associated with an increased likelihood to perform abortion services.
Therefore, it is possible that our results demonstrate greater access to abortion care and overestimate the provision of abortion care by MFM physicians than may actually exist in the broader MFM community. As with any quantitative surveys, respondents were limited in the amount of information they could provide in the questionnaire. Our survey sought to evaluate a wide variety of topics, which may have contributed to the large number of surveys that were not completed. Although care was taken in survey design, some detailed answers challenged the ability to perform aggregate analysis.
Future studies
Future studies may consider qualitative research to expand on the findings from this survey. Because of the important role MFM subspecialists may serve as abortion providers and facilitators, characterizing the reasons why some MFM physicians do not refer or provide abortion care may provide opportunities to engage these individuals, improve access for high-risk patients, and reduce pregnancy-related morbidity and mortality. Finally, this study largely investigated the perceptions of MFM physicians about the availability of abortion care. Determining the accuracy of these perceptions, particularly in states or hospital systems with more restrictive policies, may be important.
Conclusion
In the context of rising maternal mortality rates in the United States, the role of the MFM subspecialist as abortion provider and facilitator is critical for reducing maternal morbidity and mortality among high-risk patients. The results from this survey describe the attitudes and practice patterns of MFM physicians regarding abortion as an option for their patients and identifies areas of opportunity to develop comprehensive reproductive health services for high-risk individuals. Interdisciplinary collaboration and training for MFM physicians in contraception and abortion are critical for optimizing maternal outcomes and achieving health equity, but it is not sufficient. Institutional and state-level advocacy by MFM subspecialists about the importance of the availability of comprehensive reproductive health services, including abortion for high-risk patients, is needed to reduce the geographic and other inequities in care.
The results of this study suggest that abortion access for the MFM patient population is determined by geographic location and the abortion policy landscape. All patients deserve equitable access to pregnancy management options that allow them to optimize health outcomes in alignment with their own values and goals. For MFM patients with complicated maternal and fetal conditions, the ability to make decisions regarding pregnancy continuation in a nuanced medical discussion with their MFM physician is particularly critical. The subspecialty of MFM should be active in ensuring adequate training and education to create a community of MFM physicians able to provide comprehensive reproductive healthcare.
Reproductive services for women at high risk for maternal mortality: a report of the workshop of the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Fellowship in Family Planning, and the Society of Family Planning.
This survey and publication were supported by an anonymous grant.
All authors and committee members have filed a disclosure of interests delineating personal, professional, business, or other relevant financial or nonfinancial interests in relation to this publication. Any substantial conflicts of interest have been addressed through a process approved by the Society for Maternal-Fetal Medicine (SMFM) Board of Directors. SMFM has neither solicited nor accepted any commercial involvement in the specific content development of this publication.
This document has undergone an internal peer review through a multilevel committee process within SMFM. This review involves critique and feedback from the SMFM Publications and Document Review Committees and final approval by the SMFM Executive Committee. SMFM accepts sole responsibility for the document content. SMFM publications do not undergo editorial and peer review by the American Journal of Obstetrics & Gynecology. The SMFM Publications Committee reviews publications every 18 to 24 months and issues updates as needed. Further details regarding SMFM publications can be found at www.smfm.org/publications.
SMFM recognizes that obstetrical patients have diverse gender identities and is striving to use gender-inclusive language in all of its publications. SMFM will be using terms such as “pregnant person or persons” or “pregnant individual or individuals” instead of “pregnant woman or women” and will use the singular pronoun “they.” When describing study populations used in research, SMFM will use the gender terminology reported by the study investigators.
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