Early Abortion in Family Medicine: Clinical Outcomes

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

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.

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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

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.

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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

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