For abortion care, physicians may need to step aside to support patients

I have come to think that people who provide abortion care are models of the ideal health care provider.

Practicing this stigmatized work requires them to be nonjudgmental, ask open-ended questions and let patients take the lead. In the face of a building wave of restrictions against abortion, I’ve seen providers move heaven and earth to get people care — staying past closing time and finding lawyers, childcare, lodging, and funding for costs. They’ve had to become experts in deciphering policy, legal decisions and health care financing just to provide patients a service they need.

These providers persevere despite the stress of protests, being stalked, and threats of violence that would make many people throw up their hands and quit. As Texas has mostly banned abortion, with other states ready to follow, and as the Supreme Court prepares to take up a challenge to the very heart of Roe v. Wade, figuring out how to best serve people who need abortion care is as urgent as ever.

It’s time for clinicians to recognize that the future of abortion care may not have clinicians at its center.

People have been ending their own pregnancies without the help of clinicians for millennia. Even though Roe v. Wade legalized access to abortion care in the U.S. in 1973, many have still chosen to manage their own abortions. In 2000, when the FDA approved the combination of mifepristone and misoprostol for pregnancy termination, self-management of abortion in the first trimester has become even more safe and effective. Access to mifepristone and misoprostol has revolutionized how people imagine abortions outside the clinical setting, with images of dangerous back alleys replaced by internet searches for medications that are safer than over-the-counter medications like aspirin.

Studies show that most people can accurately determine if they are eligible for a medication abortion, including how far along they are in their pregnancies. The medication combination is safe and effective whether a person takes the pills after a physician hands them over or when they obtain and take the pills on their own. People who choose to get the medication themselves can find hotlines and resources on the internet. We’re just beginning to see the potential of medication abortion to revolutionize access.

But to fully realize it, clinicians must relinquish their role as gatekeepers.

Some people will continue to want the in-person, supportive experience that abortion providers pride themselves on giving — someone to hold their hand, to offer emotional support, or to have the reassurance of an ultrasound showing there is definitely a pregnancy inside the uterus. Others prefer to end their pregnancy in the privacy of their own homes.

Some people have described that managing the experience on their own gives them the space they need to emotionally process the pregnancy loss with whomever they choose, and not strangers. Some feel that this is more natural, a form of menstrual regulation. Others have been traumatized by the health care system in the past. They could be undocumented and afraid of encountering law enforcement. Or, they might not want to face angry protesters or may not be able to leave a house they share with an abusive partner. Some individuals’ homes are in states that have made it difficult, if not impossible, to take time off work and pay for childcare, transportation, and lodging to get to a clinic hundreds of miles away.

No matter the reason, clinicians need to trust that people know their own bodies and their own situations better than we do. We must support them whether they want an abortion in a clinic, to manage their abortion on their own without any clinician’s involvement, or anything in between.

The realities of Covid-19 greased the wheels for clinicians to become more comfortable with de-medicalizing abortion. I interviewed physicians who made significant changes to their medication abortion protocols in response to the pandemic, eliminating ultrasounds and unnecessary tests and follow-up visits so their patients could more easily access care. The desire to limit contact during the pandemic gave them the nudge they needed to follow the scientific evidence that blood tests, ultrasounds, and physical exams before and after taking the medications are not needed for the majority of people terminating a pregnancy with mifepristone and misoprostol.

The clinics that offered this streamlined model saw an increase in demand for medication abortion. After that experience, many of these physicians became more supportive of people managing their own abortions. Seeing how well it worked when they let go of some control made them comfortable with the idea of putting more power in the hands of their patients.

The physicians I spoke to had to do difficult internal work to confront their discomfort about people managing abortions without their assistance. A Washington state physician explained that after our first conversation about self-managed abortion she did her “own work around understanding the barriers that we’re putting up and the concerns that we have. Over the past year or so, I’ve done more reading and paid attention to this more. And so now I’m feeling like just supportive and interested in helping people on their journey.”

Clinicians who provide abortion care must ultimately rethink where we fit in the 21st century landscape. This means following the evidence and trusting people to know what they need and helping them get it. It means removing unnecessary barriers in our own practices that make getting an abortion in a clinic harder. It means providing patients medical information without judgment if they say they want or need to manage their own abortions. It means educating people about the safety of medication abortion and fighting any attempt to criminalize those who make reasonable decisions to take abortion pills with their chosen support system.

By doing that, we help normalize this safe, essential care. We recognize people’s expertise about their own bodies. We demonstrate that we trust people to manage their own reproductive choices in safe and effective ways. To continue our leadership as clinicians who put our patients first, sometimes we need to step aside.

Jennifer Karlin is a physician and an assistant professor of family and community medicine at the University of California, Davis.