The impact of provider restrictions on abortion-related outcomes: a synthesis of legal and health evidence

Abstract

Many components of abortion care in early pregnancy can safely be provided on an outpatient basis by mid-level providers or by pregnant people themselves. Yet, some states impose non-evidence-based provider restrictions, understood as legal or regulatory restrictions on who may provide or manage all or some aspects of abortion care. These restrictions are inconsistent with the World Health Organization’s support for the optimization of the roles of various health workers, and do not usually reflect evidence-based determinations of who can provide abortion. As a matter of international human rights law, states should ensure that the regulation of abortion is evidence-based and proportionate, and disproportionate impacts must be remedied. Furthermore, states are obliged take steps to ensure women do not have to undergo unsafe abortion, to reduce maternal morbidity and mortality, and to effectively protect women and girls from the physical and mental risks associated with unsafe abortion. States must revise their laws to ensure this. Where laws restrict those with the training and competence to provide from participating in abortion care, they are prima facie arbitrary and disproportionate and thus in need of reform. This review, developed by experts in reproductive health, law, policy, and human rights, examined the impact of provider restrictions on people seeking abortion, and medical professionals. The evidence from this review suggests that provider restrictions have negative implications for access to quality abortion, contributing inter alia to delays and recourse to unsafe abortion. A human rights-based approach to abortion regulation would require the removal of overly restrictive provider restrictions. The review provides evidence that speaks to possible routes for regulatory reform by expanding the health workforce involved in abortion-related care, as well as expanding health workers' roles, both of which could improve timely access to first trimester surgical and medical abortion, reduce costs, save time, and reduce the need for travel.

Abortion providers in the United States: expanding beyond obstetrics and gynecology

“…Many APCs are already present in rural areas and serve underserved populations and are well practiced in family planning services. 3 There are data from 2001 citing significant FM physicians’ involvement in abortion care, 4 and an organization named Reproductive Health Education in Family Medicine (RHEDI) was founded in 2004 to advocate for abortion care as atpdel component of FM. 5 Ultimately, expanding the types of providers that are getting trained and providing abortions is crucial for ensuring access to and meeting the needs of people seeking abortions.…”

A narrative review of challenges related to healthcare worker rights, roles and responsibilities in the provision of sexual and reproductive services in health facilities

“…Several studies explored how laws and policies interfered in clinical decision-making, thus conflicting with providers’ ethical and legal obligations to ensure patient access to information and services 27 28. For example, state laws in the USA prohibited health providers working in publicly funded clinics from counselling or referring patients for abortion,29 thereby limiting patient care and communication,30 and ‘creating conflicts between professional values and legal obligations’ 31–33. Similarly, a case study on Zambia described how a law requiring that three physicians sign a form affirming a patient’s need for an abortion undermined the judgement of the primary doctor as well as the entitlements of the patient in question 34.…”

The WHO abortion care guideline: Law and policy—Past, present, and future

“…In Recommendation 21, the WHO recommends “against regulation on who can provide and manage abortion that is inconsistent with WHO guidance”, which overall seeks to expand networks of care by focusing on task‐based skills and competencies rather than on health professional authorization 9 . The reviewed evidence from seven studies in four countries supports the view that expanding scopes of practice improves access to quality care, specifically by shifting components of care away from physicians and increasing the number of care providers 27 . This causal pathway of impact relates to Recommendation 22, where the WHO recommends “that access to and continuity of comprehensive abortion care be protected against barriers created by conscientious objection” 9 .…”

“…9 The reviewed evidence from seven studies in four countries supports the view that expanding scopes of practice improves access to quality care, specifically by shifting components of care away from physicians and increasing the number of care providers. 27 This causal pathway of impact relates to Recommendation 22, where the WHO recommends "that access to and continuity of comprehensive abortion care be protected against barriers created by conscientious objection". 9 Rather than the direct regulation of conscientious objection, the recommendation focuses on the organization of the health system to protect against barriers to care, and one regulatory means of such protection is to increase the numbers of care providers.…”