Abortion is becoming more common in primary care clinics : Shots

It’s a typical Tuesday at Seven Hills Family Medicine in Richmond, Va. The team — which consists of Dr. Stephanie Arnold, registered nurse Caci Young and several medical assistants — huddles to prepare for the day.

Arnold, a primary care physician, runs through the schedule. The 9 a.m. telemed appointment is for chronic condition management. At 10 a.m. there’s a diabetes follow-up. The 11 a.m. appointment is to go over lab results for potential sleep apnea, then there are appointments for knee pain and one for ADHD results review. The schedulers fit in a walk-in patient who has a suspected yeast infection.

And then, at 1 p.m., a patient who took the bus from Tennessee is scheduled for an abortion.

“It’s a little bit of everything, which is very typical of family medicine,” Arnold says. The patient from Tennessee is one of three abortion procedures Arnold will do today at this clinic, where abortion is “just in the mix,” Arnold says.

In lieu of standalone clinics offering abortions, or telehealth appointments where patients get abortion medication by mail, family doctors are offering an abortion option in a familiar setting.

This trend of primary care integrating medication or procedural abortions, usually in early pregnancy, is growing in states where abortion is legal. While there is little data on how common this is becoming, NPR heard from primary care doctors across the country who said they are expanding their practices to provide abortion care.

“There’s no reason for this care to be siloed,” says Arnold, who is very public about her offerings, which include abortions up to 12 weeks of pregnancy and gender-affirming care. “I don’t feel like it’s any different than my management of diabetes or chronic pain or endometriosis — this is just a routine part of my day.”

More demand for training

Elizabeth Janiak of Harvard Medical School co-leads a program called ExPAND that trains primary care providers on abortion. In May, she published a paper in the journal Contraception documenting the rising demand among primary care physicians seeking abortion care training, a phenomenon she observed after Roe v. Wade was overturned.

Janiak estimates a very small portion of family medicine doctors in the U.S. perform abortions in their practice. She points out that even 5% of the country’s 250,000 primary care doctors is a significant number. “So we’re talking thousands and thousands of providers,” she says. Since nearly 40% of U.S. counties have no OB-GYN, Janiak says, primary care doctors can fill gaps in reproductive health care.

Michigan, Colorado, California, too

In Michigan, Dr. Allison Ruff says “when Dobbs happened, I personally felt really engaged.” She’s an associate professor at the University of Michigan and an internist, a speciality that does primary care with a focus on medically complicated adults.

Right after the decision, it was unclear whether access to abortion would be banned in Michigan. So she started reading and talking to experts about what providing abortion entailed, and what she learned surprised her.

“The medications used for abortion are safer than a lot of the medicines we use every day for other things — that was really shocking to me,” she says. “As far as riskiness goes, it’s pretty small potatoes compared to some other things we learn in clinical practice every day.”

Ruff wrote a paper in November in a medical journal calling for more abortion training resources for doctors in her specialty.

“You can’t just send your patient out to the abyss and say, ‘Go talk to someone else, go to Planned Parenthood and get this handled,’” Ruff says. “No, we as general internists are able to provide that spectrum of care.”

In California, Dr. Sheila Attaie, a family physician in Sacramento, took advantage of that wave of interest and enthusiasm to expand access to abortion where she works.

“Everyone was emboldened after Dobbs in the blue states, and I have used that,” says Attaie, a fellow with Physicians for Reproductive Health. After advocating for years that her clinic fully integrate abortion, she says, administrators finally agreed after the Supreme Court overturned Roe v. Wade.

NPR heard similar stories from primary care doctors around the country, including in Minnesota and Pennsylvania. The doctors’ enthusiasm also came at a time when some blue states were making abortion access easier by getting rid of hurdles like waiting periods.

Integrating abortion into primary care is another way to increase access. Attaie says now, when patients find out they are pregnant, she can counsel them on all their options.

“Some folks end up scheduling for a medication abortion and some folks schedule for an initial prenatal visit — both of them happen in the same clinic at the same time, which is really great,” she says.

Normalize the care, but some keep it ‘hush-hush’

But while Dr. Stephanie Arnold in Virginia advertises her abortion services on her website, talks to the press and is very public, most other primary care providers are being quiet about it.

After Attaie’s clinic integrated abortions, she says she was told by administrators that “we weren’t allowed to advertise that we do it because we don’t want that attention” — attention that could come with protesters or threats from people who oppose abortion. Since it’s not mentioned on the website, the main way patients discover abortion is offered is during doctor’s appointments, often when discussing birth control or sexual health.

Attaie says she understands, but also finds the secrecy frustrating. “If we are hush-hush about all these things, how do we normalize them as health care?” she asks. “If we act in fear, how do we expect anything to be changed?”

Dr. Ben Smith, who practices family medicine in Fort Collins, Colo., can relate. And while limits on advertising may keep the number of abortions performed in his primary care clinic low — he estimates they do one to two per month — it can help free up appointments at abortion clinics nearby. That’s especially helpful in a state like Colorado, which has become a destination for people traveling from states with abortion bans.

“Every abortion that we do in primary care becomes a space for a more nationally facing organization [to] accommodate someone who is traveling from Texas, from Florida,” he says.

Pushback from anti-abortion groups

Anti-abortion rights activists oppose exactly what these physicians are trying to do: normalize abortion care. Dr. Christina Francis, an OB-GYN in Indiana who runs the American Association of Pro-life OB-GYNs, says abortion is nothing like managing a chronic condition like diabetes.

“Chemical abortion drugs end the life of my fetal patient, so that in and of itself makes it different from a diabetes drug,” she says. “But also, the complications related to a diabetes drug are not going to require an expertise that’s outside of the skill set of a family medicine physician to manage.”

Francis maintains that family medicine physicians aren’t qualified to provide abortion, which she opposes. “I’m not saying that family medicine physicians are not good physicians, they certainly are, but their training is not the same as OB-GYNs in these kinds of things,” she says. In her view, abortion is not part of essential health care for women. Her organization sued the federal government to try and remove abortion medication from the market, but the Supreme Court dismissed that challenge earlier this month.

Dr. Stephanie Arnold in Virginia pushes back on the idea that primary care doctors aren’t qualified to manage abortions. She points to a bulletin from the American College of OB-GYNs that says any clinician who can screen patients for eligibility can safely prescribe medication abortion, as long as they themselves can provide or refer patients for follow-up care — usually a uterine evacuation — as needed. The American Academy of Family Physicians also says it “supports access to comprehensive pregnancy and reproductive health services, including but not limited to abortion.”

Arnold says abortion has been separated from other kinds of care for political reasons, not for medical reasons. “It’s just important to me to fight back against that stigma,” she says.

A history of isolation and stigma

There have long been family doctors who provided abortion and advocated for access, but it hasn’t caught on like this before, according to Mary Ziegler, a historian at the University of California, Davis who’s written extensively on the history of abortion.

Before Roe v. Wade, abortions generally happened at hospitals, she explains, but even then, not all hospitals offered them, often for religious reasons, making access across the country very uneven.

In the 1970s, abortion rights groups began focusing on the opening of freestanding abortion clinics. “On the one hand, obviously, those clinics did expand access in a lot of parts of the country. On the other hand,” Ziegler says, “they physically and symbolically isolated abortion from other health services and made them easier to stigmatize.”

That isolation also made it easier for abortion clinics to be protested and lent credence to the idea that abortion was different from other forms of health care. For years, a key anti-abortion strategy was to target those clinics with regulations — known as TRAP laws, which stands for “targeted restrictions on abortion providers.” Those laws, for instance, mandate a certain width of hallways or that all doctors have admitting privileges at hospitals. TRAP laws made it hard or even impossible for clinics to operate, says Ziegler.

There have been advances that make abortion especially simple and safe, like abortion medication. But Ziegler says abortion in early pregnancy, which is when the vast majority of abortions happen, has never been medically complicated.

“What’s changed is more the willingness of primary care providers to integrate it into their practice, not their ability,” says Ziegler. “It’s about the stigma changing.”

Back in Richmond, a successful patient experience

At Seven Hills Family Medicine, the staff ready the procedure room for the abortion patients. It’s the same room where mole removals, IUD placements and biopsies happen. They use the nitrous oxide, also known as laughing gas, for pain relief, and Arnold will use a hand-held SofTouch device to perform the abortions.

This is just what Arnold envisioned when she set up the practice soon after the Dobbs decision. The 37-year-old doctor, who eschews a white coat and favors brightly patterned jumpsuits, changes into scrubs before the procedures.

Liz Johnson, who was one of Arnold’s primary care patients, had a medication abortion here in October 2022. Years before, she had an abortion at a specialty clinic and found it a little perfunctory. “It can feel very impersonal and fast and procedural,” she says, reflecting back on the differences between that day and her day in Arnold’s office.

She says she liked that the doctor, and staff knew her and her medical history. They checked in with her afterward to see how she was doing.

“I really appreciated the personal touch,” says Johnson, “being available and being able to text to check in.” She says the experience was so smooth she can hardly remember the details.

For Arnold, this is the way it should be.

And as a family medicine physician, this is how she wants people to understand her and her specialty. Those opposed to abortion call providers “abortionists” — that’s the word used by Supreme Court Justice Samuel Alito in the decision that overturned Roe v. Wade. Arnold says that term is used to “dehumanize” providers.

“I’m not some evil person who wants to harm people,” she says. “I am a mom and a family doctor, and I happen to provide abortion care.

“I’m a real doctor taking care of all kinds of real doctor things.”