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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Response to Leeman
Training for abortion care
Response to Greenberg
Response to Chavkin
Family Physicians provide abortions
More evidence that family physicians provide excellent abortion care
Attitudes of Patients to Abortion in Family Medicine
Safety of abortion in the outpatient setting
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Ian M. Bennett, Philadelphia, USA Physician, University of Pennsylvania, Margaret Baylson
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The comments that Dr. Leeman makes regarding training numbers are important ones. The competence of a provider is not necessarily reflected in a number but rather is a capacity that may be achieved before (or after) any stated number. We made the decision to have providers complete 150 aspiration abortions because they were training to be trainers themselves rather than just providing abortion care. We also were training for providers to go to 12 weeks completed gestational age which requires additional skills than earlier weeks of gestation. It is certainly true however that the number was ultimately arbitrary and should not be seen as a requirement. Given our excellent outcomes we seem to have achieved our goals but a much lower number may have resulted in equivalent results. We certainly support the concept of a competency based evaluation approach and we are eager to see the results of studies evaluating their associated outcomes. Thank you also for your suggested alternative approach to evaluating possible missed ectopic pregnancies using rapid repeat beta-HCG measurement. The shorter follow up for aspiration abortion would be of benefit to the overall delivery of care. This would not be directly applicable to medication abortion protocols due to the fact that the abortion itself does not occur on the day of the “procedure” visit, but rather over a period of a few days after. Competing interests: None declared |
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Larry Leeman, Albuquerque, USA Family Medicine; University of New Mexico
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The paper is an important contribution by demonstrating excellent outcomes in abortion care delivered by family medicine physicians and in a training context. We can hope that these excellent outcomes will facilitate increased access to abortion training by family medicine residents. This offers the potential to provide access to abortion care in the 85% of the counties in the United States that lack an abortion care provider The family medicine faculty received extensive training is abortion care with a requirement to have completed over 150 aspiration procedures. While the extensive procedural training is exemplary it may not be realistic for residents in either Family Medicine or Ob/Gyn in many educational settings. The increasing acceptance of expectant management or misoprostol as alternatives to uterine aspiration have greatly decreased the use of uterine aspiration. Ob/Gyn residents will likely have far lower uterine aspiration procedural numbers upon graduation than the faculty in this paper. We need to look at procedural evaluation criteria that are competency rather than number based. With regard to the "missed" ectopic pregnancies, I suggest modifying the protocol for the situation in which there is no gestational sac after uterine aspiration to avoid waiting a week for the hCG followup. One method would be obtain a quantitative hCG level at the time of the procedure and repeated in 12-24 hrs to demonstrate a decrease in hCG level of at least 20% c/w aspiration of an IUP rather than waiting a week (Seeber BE, Barnhart KT. Suspected ectopic pregnancy. Obstet Gynecol 2006; 07:399-43) Competing interests: None declared |
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Ian M. Bennett, Philadelphia, USA Physician
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We agree wholeheartedly that early abortion care fits very nicely within the context of family medicine. By providing more comprehensive reproductive health care we are able to provide preventive care services that cannot be as well delivered outside of the context of a medical home. The best example is our very high use of highly effective contraception (IUD and Implanon) post abortion which is not seen at sites that do not have continuity of care with their patients. More work is needed to show that it is really the continuity of care that matters but it sure feels like it does as we work with a woman/couple to consider what post abortion contraception steps will help her avoid ending up with another unintended pregnancy. This preventive care model is a perfect fit for a specialty that feels comfortable with pregnancy care, has a tradition of offering medical procedures, emphasizes prevention and behavior change, values continuity of care, and loathes abandoning patients just when they have a health crisis. Competing interests: None declared |
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Ian M. Bennett, Philadelphia, USA Physician
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We appreciate the positive comments and agree about the significance of the study findings. With regard to whether additional training is needed it is important to note that the providers carrying out the procedures (or in some cases supervising trainees) had extensive training in abortion care and it is important not to take away the lesson that only cervical dilation and ectopic pregnancy training is needed. It may be true however that additional attention to these topics would be useful for the providers studied. Additional training per se may not have the greatest benefit however when it comes to the missed ectopic pregnancies. Most of these cases involved not following established protocols. The providers were all well trained in this area. It may be that interventions that improve processes of care are needed rather than additional factual training. Even if we know what to do very well it is clear that care providers need systems in place to ensure that protocols are followed especially in the case of rare outvcomes like these. Competing interests: None declared |
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Wendy Chavkin, US MD,MPH Professor of Public Health and ObGyn Mailman School of Public Health, Columbia University
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This article is important and reassuring as it confirms that family physicians can safely and competently provide early abortions. This is important for their patients - to integrate abortion into their overall medical care and to spare them from having to deal with an unknown provider and institution at a sensitive moment. It is also significant as it widens access to abortion and does so within the context of comprehensive care over the lifespan. The authors discuss the two points where the family physicians observed here need further training - when dilation is difficult and diagnosis and follow up regarding ectopics. Given how problematic access to abortion has been in the US, safe and sensitive provision by family physicians represents an important contribution. Competing interests: None declared |
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Megan M Greenberg, New York, NY Program Assistant, RHEDI
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Bennett et al's article adds to the growing body of evidence that family physicians provide abortion care with equally positive outcomes as care provided at specialized abortion clinics. Abortion provided by family physicians in the family medicine office has added benefits for women who feel more comfortable seeing their usual doctor in their usual setting. Further, providing abortion in the family medicine home demonstrates that early abortion is simply one of the many services family physicians offer their patients. I commend AFM for publishing this important data, and look forward to more articles on this topic. Competing interests: None declared |
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Ian M. Bennett, Philadelphia, USA Physician, University of Pennsylvania
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We appreciate the supportive comments of Dr. Wu and agree that this is an important study showing the ability to provide abortion in Family Medicine sites without additional complications or difficulties managing expected complications. With regard to attitudes of patients to abortion care in family medicine settings several studies have been carried out which indicate that patients feel positively towards this care and even express a preference for care in that setting over a site outside primary care (see citations below). More work is clearly needed to extend the findings to broader populations - particularly in settings where there are few abortion providers and family physicians could make a great contribution to access. However, the initial work suggests that patients are favorably disposed to abortion in primary care. Rubin, S., & Gold, M. (2008). Women's perceptions of the family medicine clinic as a site for abortion access. Contraception, 78, 190-190. Rubin, S. E., Godfrey, E., & Gold, M. (2008). Patient attitudes toward early abortion services in the family medicine clinic. Journal of the American Board of Family Medicine, 21, 162-164. Competing interests: None declared |
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Justine P Wu, Princeton junction NJ Physician, UMDNJ-Robert Wood Johnson Medical School
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Bennett et al. publish an important observational study documenting the safety of both medication and aspiration abortion in the family medicine/outpatient setting. These data highlight the need for continued education of family medicine residents in early pregnancy options and abortion training. The next step is to document women's level of satisfaction and perspectives regarding accessing abortion services in primary care. Competing interests: None declared |
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