Abortion Policies in U.S. Teaching Hospitals

Abstract

OBJECTIVE: To evaluate the prevalence and features of policies regulating abortion in U.S. teaching hospitals. METHODS: In this mixed-methods study, we conducted a national survey of obstetrics and gynecology teaching hospitals (2015–2016) and qualitative interviews (2014 and 2017) with directors at obstetrics and gynecology residency programs. We asked participants about hospital regulations on abortion and their perceptions of the nature and enforcement of these policies. Interview analysis was conducted with a grounded theoretical approach and informed development of the survey. The prevalence of policies was described using survey data; differences in policy structures by region were analyzed using a series of logistic regression models. RESULTS: Directors from 169 of 231 eligible training programs responded to the survey (73%). Institutional policies limited abortion beyond state law in 57% of teaching hospitals, most commonly in the Midwest and South (odds ratio [OR] 4.3, P<.01 for Midwest; OR 4.0, P=.001 for South vs Northeast). Policies varied in form (written and unwritten) and restricted abortion based on the indication for the procedure and gestational age. Nonmedically indicated, or “elective” procedures were more commonly restricted (48% of sites reporting any policy and 25% prohibiting these abortions altogether) than medically indicated ones (28% of sites reporting any policy.) Policies were created by those with institutional power, including hospital leadership and obstetrics and gynecology department chairs, and were perceived to be motivated by personal beliefs and a desire to avoid controversy. Rules were commonly enforced by medical specialists, hospital ethics committees, and department chairs. Qualitative data highlighted the convoluted nuances of these policies, which often put clinicians at odds with their professional mandates. DISCUSSION: Reportedly driven by broader institutional interests, obstetrics and gynecology teaching hospital policies often restricted abortion beyond state law to the detriment of abortion access and training opportunities. Vague or unwritten abortion policies, although difficult to navigate, gave health care providers some agency and flexibility over their practices.

Interprofessional Abortion Opposition: A National Survey and Qualitative Interviews with Abortion Training Program Directors at U.S. Teaching Hospitals

“…Prior fi ndings from these study data demonstrated that a majority of teaching hospitals have institutional policies that regulate abortion on the basis of gestation and reason for needing the procedure, with abortions at later gestations or those considered "elective" being more severely regulated. 13 Similarly, in the current analyses, approximately half of respondents agreed that their colleagues resist abortion provision because of personal beliefs about acceptable gestational limits and reasons. This type of policing is in line with Kimport et al ' s notion of "stratifi ed legitimacy"; physicians make choices about which abortions to provide, for whom and for what reasons that refl ect society ' s judgments about women ' s reproductive behavior.…”

“…[4][5][6][7][8][9][10][11] Abortion in hospitals is highly regulated. [4][5][6]12,13 Published fi ndings based on data from the current study demonstrated that more than half of U.S. obstetrics-gynecology teaching hospitals have policies that limit abortion beyond the requirements of state law. 13 Similarly, a 2002-2003 national survey found that 34% of obstetrician-gynecologists practiced in a hospital that restricted abortion provision.…”

“…[4][5][6]12,13 Published fi ndings based on data from the current study demonstrated that more than half of U.S. obstetrics-gynecology teaching hospitals have policies that limit abortion beyond the requirements of state law. 13 Similarly, a 2002-2003 national survey found that 34% of obstetrician-gynecologists practiced in a hospital that restricted abortion provision. 12 Also, a qualitative study of obstetrician-gynecologists who had received abortion training and wanted to provide abortion care found that the majority were unable to off er abortion in their practice setting, including hospitals, because of formal and informal institutional policies.…”

“…Our previously published analyses showed that both formal and informal policies existed in the majority of teaching hospitals, typically restricting abortion on the basis of the reason for the abortion and gestation beyond what was required by state law. 13 The interviews highlighted the complex and often convoluted nature of these policies and their enforcement. The current study looks beyond institutional policies, examining the extent to which hospital colleagues oppose abortion care, how and why they do so, and how interprofessional opposition limits clinicians' ability to provide abortion in hospitals.…”

“…Data regarding formal and informal policies and policy enforcement have been reported elsewhere. 13 This article focuses on data from survey modules about interprofessional opposition and its implications for abortion provision.…”