Abstract
Background
Many physicians who provide abortion care report feeling marginalized within medicine. Because abortion care can require consultation with many types of physicians, physician opinions of providers may have implications for quality of care. However, no measure of physicians’ attitudes about abortion-providing colleagues currently exists.
Methods
We developed a 24-item pool to measure perceptions of the motivations, competence, and standing within the medical profession of physicians who provide abortion care. We administered the survey to a sample of 1,640 faculty physicians at a Midwestern teaching hospital. We used Stata SE/14.0 for all analyses.
Results
Our response rate was 34% (n = 560), comparable with other studies of physicians. Exploratory factor analysis resulted in a three-factor solution: opinion, motivations, and competence. The scale demonstrated good internal consistency. Attitudes were largely favorable: 84% of participants agreed that abortion providers provide necessary care for women and 81% felt that abortion providers contribute positively to society. Compared with those who felt abortion should be illegal in all circumstances, attitudes were more favorable among those who felt that abortion should be legal. We observed an inverse relationship between religious attendance and attitudes. Participants with children held more favorable attitudes compared with those without children.
Conclusions
The Attitudes About Abortion-Providing Physicians Scale captures physicians' perceptions of their abortion-providing colleagues along three important dimensions: opinion, motivations, and competence. This sample of physicians held generally favorable views of their colleagues who provide abortion care.
Over the last several years, scholars have increased their attention on abortion stigma, including how abortion providers experience and manage this stigma. Stigma was first defined by sociologist Erving Goffman in 1963, as an attribute that is “deeply discrediting,” which moves someone from being seen as a “whole, usual” person to a “damaged, discounted one” (
Goffman, 1963
, p. 3). In other words, the individual becomes marked by their stigmatized attribute in the eyes of others. Abortion stigma is defined as a “negative attribute ascribed to women who seek termination of pregnancy that marks them, internally or externally, as inferior to ideals of womanhood” (Kumar et al., 2009
). Later, other researchers expanded this definition to include anyone associated with abortion, including parents or family of women who receive abortion care, pro-choice advocates, and care providers (Norris et al., 2011
). For abortion providers, stigma can manifest in many social realms: abortion providers may experience internalized guilt or shame as a result of their work, difficulty disclosing their work to others, strained relationships with other medical colleagues and marginalization within broader medicine, restrictive legislation targeting their practice, and, in some cases, harassment and violence (Harris et al., 2013a
).Abortion stigma results in stereotypes of abortion providers as motivated only by money, morally deficient, unskilled, and therefore dangerous to patients, and these stereotypes are often leveraged by opponents of abortion to pass restrictive abortion laws (
Harris et al., 2013b
). Between 2011 and 2017, state legislators passed more than 400 laws restricting access to abortion in the United States, accounting for 34% of all the abortion regulations enacted since Roe v Wade was decided in 1973 (Guttmacher Institute, 2018b
). These laws, and some of the media coverage that accompanies them, often rely on stigmatizing stereotypes of abortion providers as unsafe and incompetent (Guttmacher Institute
Policy trends in the states, 2017.
Policy trends in the states, 2017.
https://www.guttmacher.org/article/2018/01/policy-trends-states-2017
Date: 2018
Date accessed: July 27, 2018
Britton et al., 2017
, Harris et al., 2013a
). For example, Michigan passed HB5711 in 2012, which required abortion care centers to be licensed as surgical centers and largely banned private insurance coverage for abortion care, among numerous other restrictions. When the bill passed, its supporters argued that the restrictions would bring “long overdue regulation of the abortion industry” and were necessary to remedy “abortion clinic abuses,” such as abortions being performed in “dirty and unlicensed facilities” despite a lack of evidence to support these claims (Gray, 2012
, - Gray K.
Sides gear up for battle as Michigan lawmakers weigh abortion changes. Detroit Free Press.
www.freep.com/article/20120612/NEWS06/120612078/Michigan-abortion-proposed-bills
Date: 2012
Date accessed: August 10, 2019
Harris et al., 2013a
, Rendon, 2012
). Although many of the most restrictive laws have been challenged in the courts, these legal challenges typically highlight the well-documented safety of abortion, cite a need to maintain women's access to clinics, and describe the ways such laws delay services and increase the cost of an abortion (- Rendon B.
Michigan House Bill 5711, Pub. L. No. 5711.
www.legislature.mi.gov/%28S%28ztuhvymsegjdntihubtocn45%29%29/mileg.aspx?page=getobject&objectname=2012-HB-5711
Date: 2012
Date accessed: August 10, 2019
Guttmacher Institute, 2018a
; Guttmacher Institute
Targeted Regulation of Abortion Providers (TRAP) Laws.
Targeted Regulation of Abortion Providers (TRAP) Laws.
www.guttmacher.org/print/evidence-you-can-use/targeted-regulation-abortion-providers-trap-laws
Date: 2018
Date accessed: January 21, 2019
National Academies of Sciences, 2018
). Rarely, if ever, do they directly address, or attempt to correct, negative stereotypes of providers—allowing these stereotypes to influence lawmakers and become encoded into law and policy.Beyond regulating how abortion services take place, these laws influence the professional environments in which abortion providers work (
Britton et al., 2017
). In other words, stigma influences how abortion providers experience their work and has potential impacts on patient care. Indeed, prior research on abortion providers shows that many providers feel judged and looked down upon, not just in public policy and opinion, but by their medical colleagues as well. Some providers feel that their colleagues assume them to be “hacks” or unskilled physicians. They also feel that clinical complications of abortion are given extra scrutiny, and demand a defense of abortion itself, in addition to the specific clinical care provided (Harris et al., 2011b
). One study of abortion providers found that just over one-half of providers (53%) feel marginalized within medicine (Martin et al., 2014
). In another study, 39% of abortion providers reported that other health workers looked down on them and 23% felt that colleagues questioned their professional skills (Martin et al., 2018
). This marginalization and isolation may also be a result of the physical separation of abortion services from other clinical care, given that most abortion care is provided at free-standing outpatient clinics. Hospitals are estimated to provide only 4% of all U.S. abortions (Jones and Jerman, 2017
).There are several reasons to address the stigma that physicians who provide abortion care experience within health care. Physician opinions of abortion-providing colleagues have implications not just for the psychosocial well-being of those providers, but for quality of patient care. For example, stigma may make it more difficult to get consultations in clinically complicated patients who are seeking an abortion. Stigma may create a reluctance to—or difficulty in—transferring patients in the event of a complication, and it may factor into referring physicians' counseling of patients considering abortion; for example, they might exaggerate the risks. Stigma may also impact students and trainees who are deciding whether or not to include abortion in their training and future practice, contributing to ongoing human resource shortages in abortion care (
Freedman, 2010
, Freedman et al., 2010
). Although we have evidence that abortion providers have had stigmatizing experiences at work, very little is known about the opinions that physicians actually hold about their abortion-providing colleagues. To assess this, we developed a new scale to assess physicians’ attitudes about physicians who provide abortion care.Methods
The Attitudes About Abortion-Providing Physicians Scale (AAAPPS) was developed as part of a larger survey assessing physician attitudes about abortion and abortion providers within a university hospital system. This health system acts as the place of last resort for patients seeking abortion care in the face of a wide range of serious maternal and fetal health conditions. As a result, physicians across many health system departments may encounter women seeking abortion-related care and may interact with abortion-providing physicians within the hospital system or from free-standing clinics across the state. The survey included questions assessing knowledge of the health system's role in providing abortion care in the region, attitudes about abortion and physicians who provide abortion services, respondents' willingness to participate in abortion care, and attitudes and knowledge of legislative restrictions on abortion care.
Item Pool Development
We developed survey items after reviewing the literature on abortion provider stigma, including negative (“unskilled and dangerous”) and positive (“heroes”) stereotypes of abortion providers. Additionally, we conducted a secondary analysis of previous qualitative data collected on abortion providers who participated in a series of interventions known as the Providers Share Workshop, where participants reflect on the experience of working in abortion care (
Debbink et al., 2016
, Harris et al., 2011a
, Harris et al., 2011b
; Harris et al., 2013a
). Themes that emerged included perceived medical marginalization from their colleagues; feeling that, when complications occur, they receive greater scrutiny; and negative judgment of the skill and competence of physicians who worked at free-standing abortion clinics. We developed survey items addressing providers’ motivations, skills and competencies, and their professional standing. Once we had created an initial item pool we asked several experts and colleagues to review it. This group included family planning physicians and researchers engaged in abortion work, as well as several who were not involved in abortion care. We deliberately engaged colleagues who were known to the study team to hold a range of views on abortion (based on prior conversations and interactions) to review the survey items.This process produced a 24-item pool. Seventeen items were Likert scale questions, with answer choices that included strongly disagree, disagree, neither agree nor disagree, agree, and strongly agree. Example items included “Abortion providers make a positive contribution to society” and “Talented physicians usually do not become abortion providers.” For the remaining seven items, we asked respondents to compare abortion providers to “most other physicians” with the answer choices of less, equal, or more. Examples included, “Compared to most other physicians, abortion providers are _______ competent physicians” and “Compared to most other physicians, abortion providers are _______ motivated by their conscience to do their work.” One question specifically instructed respondents to consider abortion providers who work in free-standing clinics. Otherwise, the survey made no distinction between abortion providers who worked within the hospital setting, free-standing clinics, or both.
Participant Recruitment
We recruited physicians at a Midwestern teaching hospital, in a range of clinical departments: internal medicine and subspecialties, family medicine, emergency medicine, obstetrics and gynecology, surgery and subspecialties, anesthesiology, radiology, pathology, pediatrics and subspecialties, and psychiatry. We chose these departments because physicians in these areas may be involved in referrals for abortion care, or in pre-abortion or post-abortion management of patients. We set a target of 500 participants, which
Comrey and Lee, 1992
suggest is a “very good” sample for factor analysis, and in our case more than doubles the typical ratio of 10 participants per scale item.Because abortion can be a polarizing topic, before sending recruitment emails, we reached out to hospital department chairs to inform them that study was happening and to give them the chance to voice any concerns about their department's participation. No department chairs raised objections. We sent recruitment emails to all 1,640 physicians in the departments listed. If we had a 30% response rate, which is a typical rate when surveying physicians, we would meet our target sample size of 500. E-mails included a description of the study and a link to the online survey. To be eligible for participation, participants needed to be actively engaged in clinical practice. Participants were entered into a lottery to win one of ten $100 Visa gift cards. The survey was open for 14 days and we sent two reminder emails during that period. As all survey responses were anonymous, this study was deemed exempt from institutional review board oversight by University of Michigan's Institutional Review Board–Med.
Data Analysis
We used exploratory factor analysis to reduce the number of items and explore the subscale structure of the measure. Reliability was assessed using Cronbach's alpha.
Before proceeding with our multivariable regression modeling, we confirmed there was no multicollinearity between our independent variables and covariates. We ran a series of regression models, entering variables in blocks beginning with the effects of our independent variables (attitudes on legality and viewing it as an important part of women's freedom), for the full scale and each subscale. Next, we looked at associations between potential demographic covariates, including gender, age, parenting status, religious affiliation and attendance, medical specialty, and abortion referral history. We included parenting status because we view abortion as part of providing comprehensive reproductive health care and hypothesized that there might be a relationship between being a parent and having a more positive attitude about abortion providers. Given the framing of abortion as a religious and moral issue in the US, we hypothesized that there might be a relationship between attitudes regarding abortion providers and participants' religiosity. We present the full models which are adjusted for demographics. Data were analyzed using Stata/SE 14 (
StataCorp, 2017
).Results
Sample Characteristics
Five hundred sixty faculty physicians completed the survey (34% response rate); this is typical for an online survey of physicians, and adequate for testing the number of items in our pool (Table 1). Approximately equal numbers of women and men completed the survey. Most participants were married, had children, and were 45 years or older. The majority of the sample had completed their training more than 10 years ago. Thirty-one respondents reported that they are abortion providers and were thus eliminated from all of the analyses.
Table 1Demographic Characteristics
| Sample Characteristics | N | % |
|---|---|---|
| Gender | ||
| Male | 261 | 47 |
| Female | 270 | 48 |
| Not reported | 29 | 5 |
| Race/ethnicity | ||
| African-American or Black | 15 | 3 |
| White, non-Hispanic | 429 | 77 |
| Asian | 59 | 11 |
| Hispanic or Latina/Latino | 18 | 3 |
| Arab or Middle Eastern | 7 | 1 |
| Pacific Islander | 1 | 0.2 |
| Another | 9 | 2 |
| Prefer not to answer | 29 | 5 |
| Relationship status | ||
| Single/in a relationship/divorced/widowed | 59 | 11 |
| Married | 490 | 88 |
| Is a parent | ||
| Yes | 457 | 82 |
| No | 85 | 15 |
| Age (years) | ||
| 25–34 | 61 | 11 |
| 35–44 | 191 | 34 |
| 45–54 | 135 | 24 |
| 55–64 | 121 | 22 |
| ≥65 | 45 | 8 |
| Not reported | 7 | 1 |
| Specialty | ||
| Internal medicine–general | 76 | 14 |
| Internal medicine–subspecialty | 131 | 23 |
| Surgery–general | 9 | 2 |
| Surgery–subspecialty | 17 | 3 |
| Emergency medicine | 18 | 3 |
| Pediatrics | 74 | 13 |
| Pediatrics–subspecialty | 16 | 3 |
| Family medicine | 48 | 9 |
| Obstetrics and gynecology | 48 | 9 |
| Radiology | 23 | 4 |
| Anesthesiology | 48 | 9 |
| Pathology | 23 | 4 |
| Psychiatry | 23 | 4 |
| Other | 3 | <1 |
| Currently abortion provider | ||
| Yes | 31 | 6 |
| No | 529 | 94 |
| Years since completed training | ||
| <1 | 31 | 6 |
| 1–5 | 109 | 20 |
| 6–10 | 89 | 16 |
| 11–15 | 63 | 11 |
| 15–20 | 85 | 15 |
| ≥20 | 180 | 32 |
| Religious affiliation | ||
| Roman Catholic | 101 | 18 |
| Protestant | 116 | 21 |
| Muslim | 9 | 2 |
| Evangelical Christian | 19 | 3 |
| Jewish | 70 | 13 |
| Buddhist | 6 | 1 |
| Atheist | 60 | 11 |
| Agnostic | 39 | 7 |
| No religious affiliation | 101 | 18 |
| Another | 38 | 7 |
| Prefer not to say | 23 | 4 |
| Importance of religious beliefs | ||
| Very important | 90 | 16 |
| Somewhat important | 136 | 24 |
| Not important | 192 | 34 |
| Not applicable | 133 | 24 |
Knowledge About Abortion Services Within the Health System
Seventy-two percent of respondents were aware that abortion services were provided within their health system. Fewer than one-half of survey respondents felt they knew who to contact if they needed to refer a patient for an abortion. Approximately one-third of physicians—mostly obstetrician-gynecologists, anesthesiologists, and family medicine physicians—reported that they had treated patients who presented with a complication after an abortion. Thirty percent of respondents had previously referred a patient to a free-standing reproductive health clinic (e.g., Planned Parenthood), with few referring for abortion care within the hospital system.
Opinions About Abortion Providers
The survey respondents held favorable opinions about abortion providers' competency and motivations (Table 2). The majority of the sample agreed that abortion caregivers provided necessary care for women and that abortion providers make a positive contribution to society. A small percentage reported being suspicious of abortion providers’ motivations and thought that providers should be ashamed of their work. Most respondents said they would provide a consultation to an abortion provider. In the comparative skill and motivation questions, the sample responded that abortion providers are equally competent physicians, equally technically skilled, and equally well-trained to do the work they do.
Table 2Summary Statistics of the Attitudes About Abortion Providers Items
| Items | Strongly Disagree (%) | Disagree (%) | Neither Agree/Disagree (%) | Agree (%) | Strongly Agree (%) |
|---|---|---|---|---|---|
| Abortion providers are currently well-integrated into medical communities. | 9.5 | 36.3 | 32.9 | 17.0 | 4.3 |
| Abortion providers provide necessary care for women. | 5.4 | 3.9 | 5.7 | 15.0 | 70.0 |
| Abortion providers make a positive contribution to society. | 6.8 | 4.6 | 7.5 | 22.5 | 58.6 |
| If my child became a physician, I would be proud if they offered abortion services. | 12.3 | 3.8 | 20.4 | 21.1 | 42.4 |
| Abortion providers are heroes. | 13.1 | 6.6 | 38.9 | 18.9 | 22.5 |
| I would be happy to help if an abortion provider calls me for consultation about a mutual patient seeking abortion care. | 5.0 | 2.0 | 8.1 | 24.8 | 60.1 |
| I would be happy to help if an abortion provider calls me for consultation about a patient that I do not know who is seeking abortion care. | 5.8 | 8.1 | 13.7 | 29.4 | 43.0 |
| I do not wish to play a consultant role in the care of any woman seeking abortion care. | 49.3 | 28.5 | 11.1 | 5.2 | 5.9 |
| I worry that if I refer a patient for an abortion, she will receive substandard care. | 28.0 | 36.0 | 24.5 | 9.0 | 2.5 |
| Talented physicians usually do not become abortion providers. | 50.9 | 25.9 | 16.4 | 4.8 | 2.0 |
| I am suspicious of the motivations of abortion providers. | 60.9 | 24.2 | 9.2 | 3.4 | 2.3 |
| I think that abortion providers should be ashamed of their work. | 75.2 | 9.9 | 7.2 | 3.9 | 3.8 |
| Abortion providers who work in free-standing clinics (e.g. Planned Parenthood) are generally unskilled physicians. | 55.0 | 28.1 | 14.5 | 1.6 | 0.8 |
| Complications from abortion receive more scrutiny than complications in other medical care (e.g. at M&M conferences, in the media, etc.). | 6.3 | 11.5 | 35.5 | 28.9 | 17.8 |
| I am more likely to forgive a medical error by a general surgeon than by a physician who performs abortions. | 48.3 | 31.7 | 15.0 | 3.90 | 1.1 |
| I see more complications from abortion than I would expect if it is as safe as data suggest. | 39.6 | 20.6 | 37.8 | 1.6 | 0.4 |
| My sense is that complications from abortion are more common than those from miscarriage treatment. | 35.2 | 30.3 | 30.9 | 3.4 | 0.2 |
| Less (%) | Equally (%) | More (%) | |||
| Compared with other doctors, abortion providers… | |||||
| care _______ deeply for their patients. | 4.1 | 80.0 | 15.9 | ||
| are _______ concerned for their patients' safety. | 3.1 | 84.0 | 12.9 | ||
| are ______ motivated by their conscience to do their work. | 3.8 | 68.3 | 27.9 | ||
| are ______ motivated by money. | 41.3 | 54.0 | 4.7 | ||
| Compared with other doctors, abortion providers… | |||||
| are _____ competent physicians. | 3.1 | 96.0 | 0.9 | ||
| are ______ technically skilled. | 2.2 | 95.3 | 2.5 | ||
| are ______ well-trained to do the work they do. | 2.5 | 94.2 | 3.3 |
Factor Analysis and Scale Development
We conducted exploratory principal factor analysis on the 24-item pool. The Kaiser-Meyer-Olkin test results were 0.93, indicating that our sample was adequate for factor analysis. To determine the final factor solution, we compared the traditional Kaiser-Guttman method of retaining factors with eigenvalues of greater than 1 and Horn's parallel analysis. Both methods suggested a three-factor solution, which we rotated to obtain interpretable factors using varimax (orthogonal) rotation. We eliminated items with factor loadings below 0.40 and items that loaded on more than one factor. The final factor structure retained 20 items (Table 3).
Table 3Abortion Provider Stigma Scale Factor Analysis Results
| Factors | Factor Loadings |
|---|---|
| Factor 1 (13 items): Opinions | |
| Abortion providers provide necessary care for women. | 0.86 |
| Abortion providers make a positive contribution to society. | 0.89 |
| If my child became a physician, I would be proud if they offered abortion services. | 0.82 |
| Abortion providers are heroes. | 0.75 |
| I would be happy to help if an abortion provider calls me for consultation about a mutual patient seeking abortion care. | 0.83 |
| I would be happy to help if an abortion provider calls me for consultation about a patient that I do not know who is seeking abortion care. | 0.72 |
| I do not wish to play a consultant role in the care of any woman seeking abortion care. | −0.69 |
| I am suspicious of the motivations of abortion providers. | −0.76 |
| I think that abortion providers should be ashamed of their work. | −0.82 |
| Abortion providers who work in free-standing clinics (e.g., Planned Parenthood) are generally unskilled physicians. | −0.60 |
| I am more likely to forgive a medical error by a general surgeon than by a physician who performs abortions. | −0.58 |
| I see more complications from abortion than I would expect if it is as safe as data suggest. | −0.52 |
| My sense is that complications from abortion are more common than those from miscarriage treatment. | −0.56 |
| Cronbach's α Opinions = 0.95 | |
| Factor 2 (4 items): Motivations (Response options = more, equally, less) | |
| Compared with most other doctors, abortion providers… | |
| care _______ deeply for their patients. | 0.70 |
| are _______ concerned for their patients' safety. | 0.70 |
| are ______ motivated by their conscience to do their work. | 0.60 |
| are ______ motivated by money. | −0.47 |
| Cronbach's α motivations = 0.81 | |
| Factor 3 (3 items): Competence (Response options = more, equally, less) | |
| Compared with most other doctors, abortion providers… | |
| are _____ competent physicians. | 0.68 |
| are ______ technically skilled. | 0.63 |
| are ______ well-trained to do the work they do. | 0.54 |
| Cronbach's α = competence 0.80 | |
| Cronbach's α = AAAPPS total 0.94 | |
| Items not retained | |
| Abortion providers are currently well-integrated into medical communities. | |
| I worry that if I refer a patient for an abortion, she will receive substandard care. | |
| Talented physicians usually do not become abortion providers. | |
| Complications from abortion receive more scrutiny than complications in other medical care (e.g. at M&M conferences, in the media, etc.). |
Factor loadings represent rotated factor structure, using varimax rotation.
The first factor, “opinions,” included 13 items consisting of both positive (e.g., “Abortion providers provide necessary care for women”) and negative (e.g., “I think that abortion providers should be ashamed of their work”) attitudes about abortion providers. We called the second factor “motivations” as it included four of the seven items that compare abortion provider motivations to those of other physicians. Factor three, “competence,” included three items comparing skills of abortion providers to those of other physicians.
Scoring Subscales
All subscales were scored so that higher sums of individual subscale items reflect more positive attitudes. The first six items of the opinion subscale were scored as: strongly disagree (1), disagree (2), neither agree nor disagree (3), agree (4), and strongly agree (5). The remaining seven opinion subscale items were reverse coded. The four motivations and three competence subscale items were scored as: less (0), equally (1), or more (2), except for one item, “Compared to other physicians, abortion providers are ____ motivated by money,” which was reverse-coded. Therefore, for these two subscales, mean subscale scores less than one indicate negative attitudes and scores over one indicates more positive attitudes toward abortion providers, compared with other physicians. Aggregated total scores range from 13 to 79.
We tested whether respondents regarded abortion providers as similar to most other physicians in motivations or competence. The mean of the motivations subscale (4.8 ± 1.5) was higher than 4.0 (t = 12.9; p < .001), indicating more positive views of abortion providers' motivations. There were no statistically significant differences assessing abortion providers’ competence compared with other physicians.
Subscale Reliability and Validity
The scale demonstrated good internal consistency, with Cronbach alphas between 0.80 and 0.95 (Table 3). We used pairwise correlations to investigate whether the factors could be treated as individual subscales that could stand on their own. Subscales were only moderately to weakly correlated with each other (coefficients ranged from 0.5 to 0.3). These results, along with the internal consistency findings, confirm that each factor can function as an independent subscale.
We ran multivariable regression models to investigate the relationship between the total scale and each subscale to two statements on general abortion attitudes (Table 4). We used these statements: “I believe abortion should be… [Answer choices–illegal in all cases, illegal in most circumstances with some exceptions, legal in most circumstances with some exceptions, or legal in all circumstances]” and “I believe that abortion access is an important part of women's equality/freedom.” Each regression model was adjusted for gender, age, medical specialty, prior abortion referral practices, religious affiliation, and religious services attendance. We observed a statistically significant inverse relationship between religious attendance and attitudes for both the total scale and the opinions subscale. Participants with children and participants who had previously referred a patient for an abortion were positively associated with more favorable attitudes, for both the total scale and opinions subscale.
Table 4Multivariate Regression Models: Assessing Concurrent and Divergent Validity of AAAPPS and Subscales
| Variables | Model 1 AAAPP Full Scale | Model 2 Opinion Subscale | Model 3 Motivation Subscale | Model 4 Competence Subscale |
|---|---|---|---|---|
| Gender | ||||
| Male | −0.1 | 0.2 | 0.1 | 0.0 |
| Female | (ref) | (ref) | (ref) | (ref) |
| Age (years) | ||||
| 25-34 | (ref) | (ref) | (ref) | (ref) |
| 35-44 | −0.6 | −0.1 | −0.2 | 0.0 |
| 45-54 | 0.2 | 0.7 | −0.3 | 0.0 |
| 55-64 | −0.3 | −0.3 | 0.0 | 0.1 |
| ≥65 | −2.5 | −1.8 | −0.5 | 0.1 |
| Race/ethnicity | ||||
| White, non-Hispanic | (ref) | (ref) | (ref) | (ref) |
| Black | −2.8 | −1.5 | −1.0 | −0.2 |
| Hispanic | −3.0 | −2.5 | −0.2 | 0.0 |
| Asian | 1.3 | 1.3 | 0.1 | 0.0 |
| Arab | −4.9 | −4.2 | −0.2 | 0.0 |
| Pacific Islander | −3.5 | −2.0 | −1.2 | −0.1 |
| Other | −1.1 | −0.9 | −0.2 | −0.2 |
| Relationship status | ||||
| Married | (ref) | (ref) | (ref) | (ref) |
| Single, not in a relationship | −2.0 | −2.2 | 0.1 | 0.1 |
| In a relationship | 0.4 | 0.3 | 0.1 | 0.0 |
| Separated/divorced | 1.0 | 1.1 | 0.4 | −0.2 |
| Widowed | −3.0 | −3.6 | 0.1 | 0.2 |
| Is a parent | ||||
| No | (ref) | (ref) | (ref) | (ref) |
| Yes | 2.5 | 1.9 | 0.3 | 0.2 |
| Prefer not to answer | −3.3 | −4.2 | 0.6 | 0.4 |
| Has referred patient for abortion | ||||
| No | (ref) | (ref) | (ref) | (ref) |
| Yes | 2.1 | 2.2 | 0.2 | 0.0 |
| Medical specialty | ||||
| Internal medicine–general | (ref) | (ref) | (ref) | (ref) |
| Internal medicine–subspecialty | 0.5 | 0.5 | 0.2 | −0.2 |
| Surgery–general | −4.0 | −3.6 | 0.1 | −0.4 |
| Surgery–subspecialty | −2.1 | −0.6 | −0.4 | −0.3 |
| Emergency medicine | −0.9 | −0.8 | 0.1 | 0.0 |
| Pediatrics | 1.4 | 1.3 | 0.1 | −0.1 |
| Family medicine | 0.9 | 0.2 | 0.5 | 0.2 |
| Obstetrics and gynecology (excludes abortion providers) | 3.4 | 2.5 | 1.0 | −0.1 |
| Radiology | −1.6 | −1.4 | −0.2 | −0.2 |
| Anesthesiology | −0.7 | −1.3 | 0.1 | −0.1 |
| Pathology | −2.1 | −1.3 | −0.3 | −0.1 |
| Psychiatry | 1.5 | 1.8 | 0.1 | −0.2 |
| Pediatric subspecialty | −1.1 | −1.3 | 0.6 | −0.2 |
| Other | 2.5 | 2.4 | 0.2 | 0.0 |
| Abortion provider | 4.1 | 2.5 | 1.3 | 0.1 |
| Years since completed medical training | ||||
| <1 | 1.5 | 2.0 | −0.3 | 0.1 |
| 1-5 | 1.6 | 1.7 | 0.2 | 0.1 |
| 6-10 | 1.9 | 1.8 | 0.3 | 0.0 |
| 11-15 | −0.6 | −0.6 | 0.1 | 0.1 |
| 15-20 | 0.4 | 0.4 | 0.2 | 0.0 |
| <20 | (ref) | (ref) | (ref) | (ref) |
| Religious affiliation | ||||
| Protestant | (ref) | (ref) | (ref) | (ref) |
| Roman Catholic | 0.8 | 1.0 | −0.2 | 0.0 |
| Evangelical Christian | 3.7 | 1.9 | 0.7 | 0.4 |
| Jewish | 1.1 | 1.5 | −0.4 | −0.1 |
| Buddhist | 5.0 | 4.5 | 0.7 | 0.0 |
| Muslim | −2.8 | −3.0 | −0.5 | 0.2 |
| Atheist | 1.4 | 1.6 | −0.4 | −0.2 |
| Agnostic | −0.7 | 0.0 | −0.6 | −0.3 |
| Other | −0.3 | −1.2 | −0.2 | 0.3 |
| No religious affiliation | −0.5 | −0.1 | −0.3 | −0.1 |
| Prefer not to answer | 0.9 | 0.8 | −0.3 | −0.1 |
| Multiple religions | −0.1 | −0.1 | −0.2 | −0.2 |
| Religious services attendance | ||||
| Never | (ref) | (ref) | (ref) | (ref) |
| Once a year or less | −1.2 | −1.4 | 0.1 | 0.0 |
| Several times a year | −2.4 | −2.5 | −0.1 | 0.0 |
| Once a month | −3.3 | −3.5 | −0.2 | −0.1 |
| 2–3 times a month | −3.7 | −3.8 | −0.3 | 0.0 |
| Weekly | −4.8 | −4.0 | −0.6 | −0.1 |
| More than once a week | −2.5 | −1.3 | −0.7 | −0.2 |
| Not applicable | 1.5 | 0.8 | 0.9 | 0.2 |
| I believe abortion should be… | ||||
| Illegal in all circumstances | (ref) | (ref) | (ref) | (ref) |
| Illegal in most circumstances | 8.8 | 7.3 | 0.7 | 0.3 |
| Legal in most circumstances | 15.5 | 13.6 | 0.9 | 0.2 |
| Legal in all circumstances | 18.3 | 16.1 | 1.2 | 0.2 |
| I believe that abortion access is an important part of women's equality/freedom | ||||
| Disagree | (ref) | (ref) | (ref) | (ref) |
| Neither agree nor disagree | 6.9 | 5.6 | 0.6 | 0.5 |
| Agree | 15.0 | 13.7 | 1.1 | 0.6 |
| Constant | 32.4 | 27.3 | 2.8 | 2.2 |
| No. observations | 433 | 442 | 450 | 452 |
| R2 | 0.7 | 0.7 | 0.3 | 0.2 |
| F for change in R2 | 17.2 | 18.1 | 3.5 | 2.0 |
∗ p < .05.
† p < .01.
‡ p < .001.
The relationships between the subscales and our two validity items were in the expected directions, where greater support for abortion was positively associated with more favorable attitudes about providers, supplying evidence of criterion validity. Endorsing the idea that abortion should remain legal was a significant positive predictor of the total attitudes scale and the opinions subscale. Agreeing that abortion is important for women's equality was a significant positive predictor for the total scale and all three subscales. There was no significant relationship between opinions on the legality of abortion and the competence subscale.
Discussion
The AAAPPS captures physicians' attitudes about their abortion-providing colleagues along three important dimensions: opinions, motivations, and competence. Despite cultural stereotypes commonly perpetuated by anti-abortion activists of abortion providers as technically and morally deficient, attitudes in this sample were largely favorable. We found that a majority of the physicians surveyed view abortion providers' work as necessary care for women and agree that abortion providers make a positive contribution to society. We investigated whether physician colleagues perceive abortion providers as regular, legitimate physicians. While a small percentage (6%–7%) of respondents felt suspicious of abortion providers’ motivations or believed that talented physicians do not become abortion providers, the majority of the sample regarded abortion providers as equally competent and similarly motivated as other physicians. Almost 40% of the sample felt that abortion providers were less motivated by money than other physicians.
Our preliminary psychometric testing of the AAAPP scale provided evidence that it is a reliable and valid tool for measuring physicians' attitudes toward abortion providers. The AAAPPS demonstrated good reliability with high internal consistency. We provided evidence of criterion validity using two items assessing abortion opinions.
In previous studies abortion providers have described their experiences of medical marginalization, including feeling judged and looked down on (
Harris et al., 2011a
, Harris et al., 2011b
; Martin et al., 2014
). Somewhat surprisingly, the two items that came directly from abortion providers' self-reports of medical marginalization (“Abortion providers are well-integrated into medical communities” and “Complications from abortion receive more scrutiny than complications in other medical care [e.g., at M&M conferences, in the media, etc.])” failed to load in the factor analysis and we dropped them from the final opinion subscale. One explanation of this is that the factor structure identified direct personal opinions, whereas issues of judgment of complications and lack of integration of providers may be issues of perceived stigma on abortion providers' parts—meaning it is based more on the perceptions of others’ opinions or practices. In addition to holding favorable opinions about abortion providers, as well as their competence and motivations, the majority of our sample were willing to assist in patient consultations and very few worried that patient referrals for abortion care would result in substandard care. Our data suggest that there may be a disconnect between the perceptions of abortion providers and the reported attitudes of their non-abortion providing physician colleagues.There are several key limitations to this study. First, the response rate was low, at 34%. However, this rate is consistent with other web-based surveys of physicians, a group known to be difficult to recruit for research studies (
Cunningham et al., 2015
). Data were collected at a single health care system and therefore are not nationally representative. Physicians are also not the only health care workers who might interact with abortion providers in their community, and it will be important for future studies to survey nurses, among other clinical care providers.Implications for Practice and/or Policy
We envision several ways that this scale may be useful in future settings: as a tool for understanding institutional climate for abortion; as a way of identifying nonproviding abortion physician allies who can be mobilized to serve as potential advocates; as a way to identify and mobilize partners in caring for women with significant underlying medical problems before or after abortion; and to begin conversations about identifying and reducing institutional abortion stigma.
For health systems that want to make abortion care accessible to their patients, our survey data suggest that they may want to investigate the current knowledge level of their workforce. Even at this site, a teaching hospital located in a liberal town with an active family planning training program, more than 25% of the physicians surveyed did not know abortion services were offered at the hospital and 46% felt that abortion providers are not well-integrated into the medical community. Addressing the knowledge gap and building stronger connections between physicians who provide abortion care and other health care providers could help to facilitate women's access to care. In particular, women with complex medical histories seeking abortion often need to have that care coordinated by multiple medical specialists and are the patients most likely to receive their abortion care in a hospital setting. Knowing that abortion services are available within the health system would be a first step in building connections between these departments and could improve patient care. This tool could then be used as part of the process of building coalitions and putting policies in place that better coordinate and manage the care of these patients.
Finally, the physicians in our study recognize that their abortion-providing colleagues are competent, well-trained physicians. They may represent an important set of voices to mobilize when abortion restrictions based on negative stereotypes are being debated at the state and national levels. This may represent an untapped potential pool of abortion advocates to oppose restrictive laws that are based on negative stereotypes of abortion providers. Efforts to recognize the advocate role physicians can play in resisting policy that adversely affects women's health have been growing. Two physician professional organizations, the American Medical Association and American Congress of Obstetrician Gynecologists, came out against restrictive abortion laws in an amicus brief filed as part of the Whole Women's Health v Hellerstedt Supreme Court case (
American Medical Association and American Congress of Obstetrician Gynecologists, 2013
). Others are calling for advocacy training to be included in residency programs (American Medical Association and American Congress of Obstetrician Gynecologists
ACOG & AMA Brief for Whole Woman’s Health vs. Hellerstedt. 13-51008.
ACOG & AMA Brief for Whole Woman’s Health vs. Hellerstedt. 13-51008.
https://www.acog.org/∼/media/News%20Releases/20131220Release.pdf
Date: 2013
Date accessed: August 10, 2019
Aksel et al., 2017
).Conclusions
We developed the AAAPPS to assess physicians’ perceptions of their abortion-providing colleagues along three dimensions: opinion, motivations, and competence. Despite antiabortion stereotypes of providers as technically and morally deficient, attitudes in this sample were largely favorable. Our findings suggest that the scale can be a useful tool for understanding institutional climates toward abortion.
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Biography
Lisa A. Martin, PhD, is an Associate Professor of Women's and Gender Studies and Health & Human Services at the University of Michigan Dearborn. Her research applies an interdisciplinary approach to the social, political, and individual-level factors that influence abortion stigma.
Meghan Seewald, MA, has research interests that include the experience of stigma among health care providers, with an emphasis in both qualitative and quantitative analysis.
Lisa H. Harris, MD, PhD, is Professor, Obstetrics and Gynecology and Women's Studies, University of Michigan (UM), a clinical obstetrician-gynecologist, and cultural historian. Her research interests include historical, social, and political influences that work with biomedical factors to inform health care policies.
Timothy R.B. Johnson, MD, MA, has authored more than 250 articles, chapters, and books. He has served on editorial boards, study sections, professional committees, societies, and boards. He is an elected member of the Institute of Medicine of the National Academy of Science.
Article info
Publication history
Published online: October 23, 2019
Accepted:
September 19,
2019
Received in revised form:
September 12,
2019
Received:
February 1,
2019
Footnotes
Supported in part by a research grant from the Society of Family Planning. Beyond this acknowledgement of funding, authors do not have any conflicts to disclose.
Identification
Copyright
© 2019 Jacobs Institute of Women's Health. Published by Elsevier Inc.
