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A pilot survey of medical abortion knowledge and practices among obstetrician/gynecologists and family practitioners in Los Angeles County
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A pilot survey of medical abortion knowledge and practices among obstetrician/gynecologists and family practitioners in Los Angeles County
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Content
A PILOT SURVEY OF MEDICAL ABORTION KNOWLEDGE AND
PRACTICES AMONG OBSTETRICIAN/GYNECOLOGISTS AND FAMILY
PRACTITIONERS IN LOS ANGELES COUNTY
by
Caryn Ruth Dutton, M.D.
A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(APPLIED BIOSTATISTICS AND EPIDEMIOLOGY)
May 2003
Copyright 2003 Caryn Ruth Dutton, M.D.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
UMI Number: 1417919
INFORMATION TO USERS
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®
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UMI Microform 1417919
Copyright 2004 by ProQuest Information and Learning Company.
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UNIVERSITY O F SO U T H E R N CALIFORNIA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CALIFORNIA 8 0 0 0 7
Th is thesis, written by
Caryn Ruth Dutton M.D.
under the direction of hex. .Thesis Committee,
and approved by all its members, has been pre
sented to and accepted by the Dean of The
Graduate School, in partial fulfillment of the
requirements for the degree of
Master of Science
Date_ _
THESIS COMMITTEE
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ACKNOWLEDGEMENTS
I would first like to thank the Medical Women’s Faculty Research Fund at the
University o f Southern California Keck School of Medicine for the grant awarded
to support this research project.
I would also like to thank my thesis committee: Dr. Stan Azen, Dr. Denise Globe,
and Dr. Raquel Arias for their advice, support, and wisdom. Finally, this research
would not have been possible without the enthusiastic participation of the
physicians who responded to this survey.
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TABLE OF CONTENTS
Acknowledgements ii
List of Tables iv
Abstract v
Introduction
Chapter I: Medical Abortion: Practice and 1
Provision o f Services
Chapter II: Use of the Internet for Survey Distribution 12
and Data Collection
Methods 16
Results 19
Discussion 32
Bibliography ' 37
Appendix A: Survey Content and Appearance 43
Appendix B: Explanation of Domain Scores 55
iii
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TABLES
Table 1.
Demographics by Practice Specialty
Table 2.
Frequency Distributions for All Survey Questions
Table 3.
Mean Domain Scores by Practice Specialty
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ABSTRACT
This pilot survey was designed to evaluate initial results from an Internet-based
physician survey on current knowledge, beliefs, and practice regarding medical
abortion in Los Angeles County. Twelve physicians participated in the survey,
including seven Obstetrician/Gynecologists and five Family Practice physicians.
The findings from this limited pilot survey contrast previous similar surveys, with
physicians who do not currently provide abortion reporting that they do not
anticipate any future provision o f medical abortion. All o f the physicians
surveyed were supportive of a woman’s right to choose abortion. The participants
did not find that the Internet-based survey was easier than a standard mail survey,
though they all used a computer or the Internet daily in their practices. These
findings will guide development of future surveys and analysis directed at
elucidating barriers to medical abortion provision.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
INTRODUCTION
Chapter I: Medical Abortion: Practice and Provision of Services
Unintended pregnancy remains a significant public health problem in the United
States, despite advances in contraceptive technology and increasing birth control
options available to women. The 1995 National Survey o f Family Growth
reported that 49% o f all pregnancies in the previous year were unintended. And
of those unintended pregnancies, 51% ended in induced abortion.1 Unplanned or
unintended pregnancies often result from poor access to medical care. The
consequences of carrying an unintended pregnancy to term can be significant, and
include a variety o f health risks for the mother and infant, and long-term effects
on socioeconomic status and behavior that inevitably impact society as a whole.
Because o f these health risks, it is crucial to continue efforts to reduce unwanted
pregnancy through increased access to reproductive health care and with
improved methods of fertility regulation and birth control. Continued access to
legal abortion and the right of a woman to seek pregnancy termination also insure
a safe alternative to keeping an unwanted pregnancy. Historical data from the
U.S. and current data in many developing countries verify that as access to legal
abortion is restricted, the severity and frequency of complications related to illegal
abortion increase dramatically.3 And as concerns increase about uncontrolled
population growth around the world, it can be noted that “no society has achieved
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replacement level fertility without use of abortion.” 4 Contraceptives and even
surgical sterilization methods can fail, and abortion may be the only option for a
family or a woman hoping to plan their reproductive future. Therefore, despite
the personal, political and religious turmoil that is often associated with the
provision of abortion, it will continue to be a significant public health issue.
Abortion is currently one of the most common surgical procedures in the United
States, with an estimated 1.36 million procedures performed annually.5
Unfortunately, access to abortion has become increasingly limited over the past
few decades. This is primarily due to a shortage of qualified providers, and to a
huge geographic disparity in the location of providers. Based on data from 1995-
1996, 86% of all US counties and 95% of all rural US counties have no abortion
provider.5 In California, a survey conducted in 1998 and 1999 by the California
Hospital Abortion Access Project questioned all California general health care
facilities on access to abortion by having volunteers pose as pregnant women
seeking abortion care. In this manner, they obtained information on services
currently and realistically available to women in California. The survey found
that out of 362 hospitals, only 5% provide abortion services without imposing
significant restrictions. Over 72% (261/362) of hospitals did not provide any
abortion care.6
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For women in the U.S. and worldwide, the availability o f medical abortion, in
addition to surgical abortion, offers a safe and effective alternative for pregnancy
termination. The Food and Drug Administration (FDA) approved the first
marketed prescription drug for medical abortion in the U.S. on September 28,
2000.7 Mifepristone (Mifeprex tm ), formerly known as RU-486, has now been
available in this country for just over 2 years. The availability o f mifepristone in
the U.S. offers both patients and providers increased access, privacy, and choice
compared to the precedent of pregnancy termination only available as a surgical
procedure. An alternate medical regimen using methotrexate has also been used
to induce a medical abortion (though it is not FDA-approved for this indication).
Many women express a preference for medical abortion because o f the perceived
increase in control over the process, which women experience as similar to a
natural miscarriage.8 Medical abortion also offers an alternative that avoids the
inherent risks involved with surgical instrumentation o f the uterus and with
administration o f anesthesia.
As with any new health technology, there is a need for education, training, and
development of skilled providers before medical abortion will be available or
utilized on a large scale. And many questions remain to be fully answered: Will
there be an increase in the number of “abortion” providers now that medical
abortion is approved? Will physicians who have not previously provided surgical
abortion offer medical abortion to their patients? Will physicians whose beliefs
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have influenced their decision not to provide surgical abortion be more willing to
provide medical abortion? What barriers to provision o f medical abortion exist
that do not currently exist for surgical abortion? And how will physicians manage
the barriers that develop?9 Because abortion remains a controversial medical
practice, there are barriers to provision that are unique even compared to other
medical procedures.
One example o f a barrier exists at the first stage in the availability of
mifepristone— ordering the medication. The FDA specifically instructs that
providers obtain mifepristone from the manufacturer, rather than patients
obtaining it from a pharmacy, so that appropriate use can be insured. This results
in secure and confidential access on behalf of the prescriber, and ultimately for
the patient, but also limits overall access to medical abortion. For example, a
physician in a government-funded family planning clinic is unlikely to have a
mechanism for ordering and paying for a supply of mifepristone, because most
states limit the use of federal dollars for abortion services. Also, because no other
medications are similarly paid for and distributed by the physician, immediate
financing of the cost o f obtaining mifepristone will be difficult within fixed-
budget health systems.
With the recent approval of the medical abortion regimen, both physicians and
patients will be searching for information and for confirmation o f its usefulness.
4
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A meta-analysis including protocols similar to the FDA-approved regimen
concluded that medical abortion with mifepristone and misoprostol is 94-96%
effective in terminating pregnancies less than 7 weeks gestation without need for
surgical intervention.1 0 Despite this knowledge, providers are faced with
providing a service very different than a traditional surgical abortion, with
patients who will need specific instructions, education, and support during the
multi-day process. It is therefore difficult to predict the eventual practice of
medical abortion in the U.S., or to translate the experiences of research studies
into practical knowledge o f how medical abortion will be used and provided in
the medical community. Surveys performed prior to the FDA approval of
mifepristone can offer some insight.
The Kaiser Family Foundation has performed two provider surveys on the topic
of medical abortion; the first survey was published in September 1998, and the
second follow-up study was completed in 2001. The earlier o f the two, the
National Survey o f Health Care Providers on Medical Abortion,1 1 was a random-
sample telephone survey of 756 providers, including 305 Obstetrician-
Gynecologists (Ob/Gyns), 283 Family Practitioners (FPs), and 229 nurse
practitioners or physician assistants (NPs/PAs). At that time, few providers
reported being very familiar with mifepristone (5-14%), and even fewer reported
current use of methotrexate for medical abortion (7% o f Ob/Gyns, 4% o f FPs, 2%
of NPs/PAs). Traditional division of the specialties was apparent in the current
5
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performance o f surgical abortion (36% of Ob/Gyns, 3% of FPs, 2% ofNPs/PAs).
Despite these responses, 54% of Ob/Gyns, 45% of FPs, and 54% ofNPs/PAs said
they would be likely to prescribe mifepristone in the next year if it was approved.
This demonstrates a high interest in mifepristone, the agent used to initiate a
medical abortion, and also a huge potential for increasing the number o f providers
(especially outside of Ob/Gyn) performing abortion above the smaller numbers
who provided surgical abortion at that time.
The 1998 National Survey of Health Care Providers on Medical Abortion also
questioned providers on potential barriers to medical abortion practice, and nearly
half of all providers (41-48%) reported that their current practice or hospital
policy forbids surgical abortion. However, few providers cited institutional
barriers, community pressure, liability, or lack o f facilities or training as
significant factors in their decision not to provide medical abortion in the future.
The 2001 National Survey of Women’s Health Care Providers on Reproductive
Health: Views and Practices on Medical Abortion1 2 was also a national random-
sample telephone based survey o f 790 physicians (595 gynecologists and 195
family physicians). Since mifepristone was approved the previous fall (2000), a
much higher proportion of providers reported familiarity with mifepristone, and
confidence in its safety and efficacy. Only 6% o f Ob/Gyns and 1% of FPs
reported current practice of medical abortion, but higher numbers (16% of
6
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Ob/Gyns and 7% o f FPs) said they were very likely or somewhat likely to begin
prescribing mifepristone within the next year compared to the previous survey in
1998. In contrast to 1998, lower numbers o f providers reported that they
currently provide surgical abortion (27% Ob/Gyns and 1% of FPs). Common
reasons cited by Ob/Gyns for not providing medical abortion included lack of
demand from patients, concerns about protests or violence, no interest in offering
abortion services, and concern about office space, political and legal aspects, and
problems with knowledge or the regulations surrounding mifepristone. 70% of
FPs reported minimal demand from their patients, with the remaining concerns
similar to those o f Ob/Gyns.
Several similar studies have been published, but all were completed previous to
the approval o f mifepristone. Koenig et al. surveyed 772 health care professionals
by telephone (305 Ob/Gyns, 238 FPs and 229 NPs/PAs) in 1997.1 3 They also
found that higher numbers of providers would be likely or somewhat likely to
prescribe mifepristone (45-54%) than the number who currently provide surgical
abortion. O f those who did not provide surgical abortion at the time of the
survey, 35% of Ob/Gyns and about half of the FPs and NPs/PAs expressed
interest in providing medical abortion.
Similar results regarding providers’ interest were obtained by smaller regional
studies in California1 4 and Idaho.1 5 A separate survey o f the physician
7
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membership o f the Society for Adolescent Medicine reported that 42% would
prescribe mifepristone if approved, with strong support from the respondents for
provision by primary care physicians.1 6 Koenig et al. questioned a group of
Ob/Gyn and FP physicians, along with nurse practitioners and physician assistants
in 1997, and concluded that the providers most likely to be interested in providing
• 13
medical abortion were currently involved m provision o f surgical abortion.
Other studies have focused providers’ early experiences with medical abortion
provision either as part o f research studies, or with methotrexate medical
abortions. Interviews with physicians who were among the first to provide
medical abortion reported generally positive experiences, and specifically that
1 7
providing this new technology did not disrupt their usual office routine.
Feedback from physicians involved in the initial mifepristone trials in the US was
also positive, and the majority o f these physicians planned to provide medical
abortions following FDA approval.1 8 Descriptive research on providers o f
methotrexate-induced abortions identified several potential barriers to provision,
including the perceived costs of the procedure (with more frequent clinic visits
and higher utilization of staff for counseling), and the belief that it would be
unrealistic for those not currently providing surgical abortions to enter medical
abortion provision.1 9 Issues of adequate facilities or staffing were not thought to
be significant barriers to provision.
8
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There are also studies investigating the relationship between physicians’ attitudes
towards abortion and the provision o f (surgical) abortion, all completed prior to
the advent o f mifepristone. An analysis of survey responses from 539 family
practitioners in Kansas revealed that a larger majority of respondents believe that
abortion should be legal (78%) than classify them as pro-choice (56%). 2 0 Only
0.5% of the sample provided surgical abortion as part o f their medical practice. In
addition, physicians who self-identified as pro-choice were supportive o f some
limited indications for abortion. When asked to select from a list of
“circumstances” in which patients choose abortion, all o f the physicians indicated
more acceptance for reasons that were related to a medical condition such as
health o f the mother (83%) or a fetal anomaly (65%) compared to reasons that
were primarily related to the woman choice such as contraceptive failure (24%) or
20
a woman’s personal decision (55%).
This pilot study involves the design and validation o f a questionnaire on the topic
of medical abortion. The questionnaire is designed to be given to physicians, and
will investigate correlations between knowledge of medical abortion, attitudes and
beliefs towards abortion, physician specialty and other demographic variables
with the provision or intention to provide medical abortion. Respondents are also
questioned regarding perceived barriers to the practice o f medical abortion in their
communities. Both Obstetrician-Gynecologists and Family Practitioners were
9
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included among the respondents to assess practices and beliefs among those
clinicians most likely to provide reproductive health services for women.
In addition, this pilot study involves use o f the Internet as a survey tool to
facilitate response rates, data collection and data analysis. It is hoped that a larger
scale survey based on this initial work will provide valuable information
regarding potential areas for future research, education, and training.
Comparisons of practice patterns and barriers will also be performed relative to
specialty (Ob/Gyn or FP). Initial marketing o f mifepristone and education efforts
have been directed at Ob/Gyn physicians, therefore they should have greater
knowledge and experience with the regimen compared to FPs. Identifying areas
for improvement will ultimately assist with facilitating the integration of medical
abortion provision into routine women’s health services, and increasing access to
a vital public health need.
10
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Chapter II: Use of the Internet for Survey Distribution, Response, and
Collection of Data
Surveys have been widely utilized in medicine for collection o f cross-sectional
data, specifically data on subjective parameters such as behaviors and attitudes.
Research questions regarding disease prevalence and exposure to risk factors are
also ideally suited for questionnaires or surveys. The concept o f utilizing the
Internet for survey distribution, response, and collection o f data may revolutionize
survey research on specific populations. Internet-based survey techniques provide
advantages o f rapid response times, low expense, and convenience compared to
traditional mail or telephone surveys.2 1 In addition, the Internet improves the
efficiency o f survey research by reducing errors, facilitating data management,
and eliminating the need for data entry off paper forms. By programming HTML
or using a commercially available software package, one can also customize
surveys to include branching, skip patterns, and random presentation of the order
of responses.
Internet-based surveys have significant potential advantages over traditional
surveys in several specific situations:
- Need for geographic diversity o f respondents
11
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- Well-defined target audience that frequently uses email (i.e. registered
members o f a on-line medical society or service, medical students,
department chairs)
- For a target populations that are traditionally difficult to reach, including
11
adolescents, students, and drug-abusers
- For research on use o f the Internet or computers as a tool for the practice
of medicine
- For research on the prevalence o f rare diseases or unusual cases
Research that involves the collection of ideas, rather than hypothesis testing, is
also easily accomplished with Internet-based surveys. 2 1 Medical researchers
have only started to explore the utility of the Internet for survey research. Several
23
investigators have now published results from Internet-based surveys of patients
and also of providers.24'2 7
With the use of any new technology there are often drawbacks as well. For
example, reliance on the Internet alone for surveying a general population will
result in significant selection bias. The sample o f respondents with Internet
access will be younger, more highly educated, white, and have a higher
socioeconomic class, corresponding to the demographics o f those with access.
Currently in the U.S., approximately 85.4% of households with annual incomes
over $75,000 have Internet access, compared to 14.4-42.2% with access in
households with annual incomes less than $35,000.2 8 In addition, there are
12
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confidentiality issues and concerns about preventing multiple responses from the
same individual— some of which can be addressed by more complex
programming. Validity is also a concern: the replies obtained by asking a
question in person cannot be replicated by the anonymity of replying via the
Internet.2 1 Reliability may be questioned if the survey appears in different forms
depending on the connection speed, the browser software, and the appearance of
the survey on the display.
For these reasons, if scientific research is planned, development of a pilot survey
is a crucial step in Internet survey design. The assessment o f knowledge, beliefs
and experience with a recently introduced medical regimen or technique, such as
medical abortion, should be well suited to collection of data over the Internet.
Providers with access to the Internet are unlikely to have different knowledge or
beliefs relative to those without access, though younger physicians are likely to be
more experienced with use of computers and the Internet. Because the use of
medical abortion is likely still uncommon, an Internet-based survey can easily
collect information on common barriers or problems encountered by physicians in
practice. In contrast, using this survey technique would not be useful for
estimating the frequency o f medical abortion in the community, or geographic
access to medical abortion services.
13
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There are several potential models for Internet-based surveys, depending on the
target population, the programming experience o f the researcher, and the time
frame available. These include disk-by-mail, postal mailings o f a survey with an
option provided for responding over the Internet, email distribution o f the survey
with instructions on return, or email or postal mail distribution o f the URL
(universal record locator) for the specific survey to be completed. For this pilot
survey, respondents were either sent the URL for this survey by email, postal
mail, or were shown how to enter and retrieve the URL in person by the
investigator. These options were used to reduce costs related to the survey, to
facilitate feedback regarding technical difficulties, and to accommodate those
respondents with minimal experience with computers or the Internet.
14
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METHODS
Twelve physicians participated in this pilot survey: seven Obstetrician-
Gynecologists (Ob/Gyns) and five Family Practitioners (FPs). The protocol
allowed for up to 30 total physicians to be recruited. Participants were chosen by
convenience, though an effort was made to recruit from diverse areas of Los
Angeles County, and from diverse practice types. All Ob/Gyns were currently in
an active generalist practice, and not sub-specialists within their fields. The
Institutional Review Board at the University of Southern California Keck School
of Medicine approved the study protocol. Participants were guaranteed that their
responses would remain anonymous. An invitation to participate was made over
the phone, by mail or by Internet if an email address was available. A stipend of
$50 for participation was offered to each physician as an incentive and as
reimbursement for his or her time.
The questionnaire was designed and programmed in HTML using a commercial
software package (SurveySolutions for the Web, Perseus Development
Corporation, Braintree, MA). The USC Institute for Prevention Research’s
information specialists provided technical assistance to post the questionnaire to a
secure server using peri scripts provided by the Perseus software. Participants
were provided with the URL (universal record locator) address corresponding to
the first page of the survey, and each participant was assigned a unique access
code to identify him or her as a legitimate respondent to the questionnaire. (See
15
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Appendix A for reproductions of several html pages o f the online appearance of
this survey.) The survey was specifically designed to be easy to read and without
distracting graphics, however the commercial software program’s settings limited
control over the final appearance.
The 29-item questionnaire had the following seven sections, each corresponding
to a domain o f interest: 1) knowledge of medical abortion: familiarity with
mifepristone or methotrexate for medical abortion, and perceptions of safety and
effectiveness o f the medical abortion regimens (6 questions); 2) practice of
abortion: likely referral pattern for a patient requesting an abortion, and the
estimated number o f surgical abortions or medical abortions the physician has
performed in the previous six months (8 questions); 3) Patient interest and
demand for medical abortion (3 questions); 4) perceived barriers to provision of
medical abortion (1 multi-part question); 5) physician attitudes and beliefs
regarding abortion (3 questions); 6) familiarity with the Internet and computers (4
questions); and 7) demographic information: age, gender, years in practice, and
practice setting (4 questions).
Depending on the respondent’s answers, the survey was designed to skip certain
pre-designated questions. For example, if a physician reported that he or she did
not routinely perform abortions then they did not receive additional questions
regarding the number o f medical or surgical abortions performed in the last six
16
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months. This respondent would, however, then receive a question asking about
possible future provision of medical abortion. (See appendix A for a listing of the
individual questions, and the skip logic that was used to direct the respondents to
the next page of questions.)
Based on each individual respondent’s answers, the total number o f questions
presented ranged from 25 to 28 total items. Question types included “choose one
response,” “select all that apply,” open-ended, or likert scale design. The
software was set to require a response to each question except for the “select all
that apply” and open-ended question types.
Within several question domains, a scoring system was created to correspond to
the relevant attitudes or practices. (See Appendix B for details of scoring and
measurement scales used) These scores were developed for use in determining
associations between beliefs, practice, and demographics o f the respondents.
Data analysis was performed using SAS, version 8.0 (SAS Institute, Inc., Cary,
NC).
17
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RESULTS
Twelve physicians completed the pilot survey, and the demographics o f this
sample are provided in Table 1. All o f the physicians were less than 60 years of
age. The respondents were recruited to represent a variety of practice types.
Age distributions were similar between the two groups o f physicians.
Table 1. Demographics by Practice Specialty
Obstetrician/
Gynecologists
n= 7
Family
Practitioners
n= 5
Age group o f respondents
Less than 30 0 0
31-40 3 3
41-50 1 1
51-60 3 1
61-70 0 0
Over 70 0 0
Gender
Male 2 2
Female 5 3
Years in Practice
Less than 5 years 3 0
5 to 10 years 0 2
11 to 15 years 1 2
16 to 20 years 1 0
20 to 30 years 2 1
More than 30 years 0 0
Practice Type
Solo-practitioner 1 0
Single-specialty group 2 1
HMO 1 0
Privately-funded primary 0 1
care clinic
Government-funded 0 1
primary care clinic
Family Planning Clinic 1 0
Other 1 2
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Prior to interpretation o f the survey results, each question in the survey was
evaluated individually to determine the frequency of responses, and to determine
the validity of the question. Table 2 lists all o f the responses, shown listed by
specialty and by percentage o f total responses.
The first set o f six questions in the survey assessed providers’ familiarity, and
knowledge o f safety and efficacy of the two regimens for medical abortion:
mifepristone/misoprostol, and methotrexate/misoprostol. These identical
questions have been used in two similar surveys of providers focused on medical
abortion knowledge.11,12 The majority o f the physicians responding indicated
familiarity with the regimens, though less were as familiar with the methotrexate
regimen. All o f the physicians believed the regimens to be safe and effective.
The next questions address patient interest and demand for medical abortion. The
responses indicate that about half of the providers in each group had been
approached by their patients for information regarding medical abortion. The
number of patients requesting information or referral varied widely, and only 17%
of the physicians had knowingly provided follow-up care for women who had
previously had a medical abortion.
Following these questions, the survey focused on determining actual practice of
medical and surgical abortion. The respondents are then assigned to one o f three
19
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groups based on their response to actual provision of abortion (question 12):
group 1 is composed of providers who do not perform abortion; group 2 is
composed o f providers who have performed surgical but not medical abortion;
and group 3 is composed of physicians who have performed medical abortion.
These assignments also determined the next question seen by each respondent in
the survey. For this sample of respondents, group 1 was composed of five
physicians, group 2 had two physicians, and group 3 had five physicians. There
were some discrepancies apparent between the responses to questions 10, 12 and
13 among the family physicians surveyed. H alf o f all the providers surveyed
either did not have coverage or were unaware o f their coverage from their liability
insurer regarding medical abortion practice. Responses to question 14
demonstrated that patients are paying for their medical abortions through a variety
of funding sources, though only one of the providers surveyed recalled an incident
when the reimbursement dictated the type of abortion a patient received.
20
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Table 2. Frequency Distributions for All Survey Questions
Obstetrician/ Family Total
Gynecologists Practitioners
n= 7 n= 5
Knowledge of Medical A bortion Regimens
1. How familiar are you with the mifepristone medical abortion regimen?
Very familiar 3 (43%) 1 (20%) 4 (33%)
Somewhat familiar 4 (57%) 3 (60%) 7 (58%)
Not familiar at all 0 1 (20%) 1 (9%)
2. From what you know, is the mifepristone regimen
Very safe 7 (100%) 3 (60%) 10 (83%)
Somewhat safe 0 2 (40%) 2(17% )
Not safe at all 0 0 -
3. From what you know, is the mifepristone regimen
Very effective 7 (100%) 4 (80%) 11 (92%)
Somewhat 0 1 (20%) 1 (8%)
effective
Not effective at all 0 0
4. How familiar are you with the methotrexate medical abortion regimen?
Very familiar 3 (43%) 0 3 (25%)
Somewhat familiar 4 (57%) 5 (100%) 9 (75%)
Not familiar at all 0 0
5. From what you know, is the methotrexate regimen
Very safe 5 (71%) 2 (50%) 7 (64%)
Somewhat safe 2 (29%) 2 (50%) 4 (36%)
Not safe at all 0 0 [Missing 1
response]
6. From what you know,, is the methotrexate regimen
Very effective 4 (57%) 1 (25%) 5 (46%)
Somewhat 3 (43%) 3 (75%) 6 (64%)
effective
Not effective at all 0 0 [Missing 1
response]
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Table 2. (continued) Frequency Distributions for All Survey Questions
Obstetrician/ Family Total
Gynecologists Practitioners
n= 7 n= 5
Patient Interest in Medical Abortion
7. Have any o f your patients requested information about how to obtain a
medical abortion?
Yes 4 (57%) 3 (60%) 7 (58%)
No 3 (43%) 2 (40%) 5 (42%)
Don’t remember/ 0 0
_______ no opinion___________________________________________________
8. Approximately how many patients have requested this information in the
past six months?
Median (range) 10(0-250)___________ 1 (0-25)_________________
9. Have you met patients in your practice who have had a medical abortion
with a different provider?
Yes 1 (14%) 1 (20%) 2 (17%)
No 6 (86%) 4 (80%) 10(83%)
Don’t remember/ 0 0
_______ no opinion___________________________________________________
________________Physician Practice of Medical Abortion______________
10. If a patient requests an abortion for an early pregnancy...
a. I refer her to a doctor or clinic that provides medical abortion
always 3 (42%) 1 (20%) 4 (33%)
usually 0 1 (20%) 1 (8%)
sometimes 2 (29%) 0 2 (17%)
never 2 (29%) 3 (60%) 5 (42%)
b. I refer her for a surgical abortion
always 2 (29%) 2 (40%) 4 (33%)
usually 1 (14%) 2 (40%) 3 (25%)
sometimes 3 (43%) 1 (20%) 4 (33%)
never 1 (14%) 0 1 (9%)
c. I prescribe mifepristone and misoprostol for a medical abortion
always 2 (28.6%) 0 2 (16.7%)
usually 0 0 -
sometimes 0 0 -
never 5 (71.4%) 5 (100%) 10(83.3%)
22
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Table 2. (continued) Frequency Distributions for All Survey Questions
Obstetrician/ Family Total
Gynecologists Practitioners
n= 7 n= 5
10. If a patient requests an abortion for an early pregnancy... (continued)
d. I prescribe methotrexate and misoprostol for a medical abortion
always 0 0 -
usually 0 0 -
sometimes 3 (43%) 0 3 (25%)
never 4 (57%) 5 (100%) 9 (75%)
e. I perform a surgical abortion
always 0 0 -
usually 0 0 -
sometimes 6 (86%) 0 6 (50%)
never 1 (14 %) 5 (100%) 6 (50%)
f. I refer her for pregnancy counseling
always 0 2(40%) 2 (17%)
usually 0 1 (20%) 1 (8%)
sometimes 3 (43%) 2 (40%) 5 (42%)
never 4 (57%) 0 4 (33%)
11. Does your liability insurance cover you for medical abortion?
Yes, I have coverage 5 (72%) 1 (20%) 6 (50%)
No, I do not have 0 3 (60%) 3 (25%)
coverage
Don’t know/ no opinion 2 (28%) 1 (20%) 3 (25%)
12. Please select the most accurate description of your past or current practice
below:
I do not provide any
abortion services for my
patients
1 (14%) 4 (80%) 5 (42%)
I have only provided
surgical abortion for my
patients
2 (29%) 0 2 (17%)
I have only provided
medical abortion for my
patients
0 1 (20%) 1 (8%)
I provide both medical
and surgical abortion for
my patients
4 (57%) 0 4 (33%)
23
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Table 2. (continued) Frequency Distributions for All Survey Questions
Obstetrician/ Family Total
Gynecologists Practitioners
n=7 n=5
13. Please estimate how many medical abortions you perform every six months:
(Group 3 only responding to questions 13-15)
Number o f medical 15,100 0
abortions with
mifepristone (individual
responses listed)
Number o f medical 3,10 0
abortions with
methotrexate (individual
responses listed)
14. Who pays for the medical abortion procedure?
Patient (self-pay) 3 0
Private Insurance 2 0
HMO 1 0
Medi-Cal 2 0
Other 0 1
15. Have you had any patients who wanted a medical abortion, but were forced
to have a surgical abortion due to problems with reimbursement?
Yes 1 0
No 2 1
Don’t know/ no opinion 1 0
16. Please estimate how many surgical abortions you perform every six months:
(Groups 2 and 3 responding)
Number of surgical 15 0
abortions (median, (5-5000)
range)
24
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Table 2. (continued) Frequency Distributions for All Survey Questions
Obstetrician/
Gynecologists
n - 7
Family
Practitioners
n= 5
Total
Physician Beliefs and Attitudes Regarding Abortion
17. Should abortion be legal in the United States?
Yes 7 5 12 (100%)
No 0 0 -
Don’t know/ 0 0 -
no opinion
18. Under which circumstances do you believe abortion is an appropriate option
for a pregnant woman? (Please select as many answers as applicable)
To save the life o f the 7 5 12 (100%)
mother
If the pregnancy results 7 5 12 (100%)
from rape or incest
If there is a fetal anomaly 7 5 12 (100%)
If the woman chooses an 7 5 12 (100%)
abortion
If the woman is too young 7 5 12 (100%)
or too old
Contraceptive or 7 4 11 (92%)
sterilization failure
Undesired sex of fetus 7 4 11 (92%)
None of the above 0 0 -
19. The terms pro-choice and pro-life are often used to classify basic attitudes
towards abortion. In general, pro-choice refers to individuals who advocate that
abortion is a private matter involving a woman’s personal choice. Pro-life refers
to individuals who advocate that the primary issue is the right to life of the fetus.
Do you classify yourself as...
Pro-choice 7 5 12 (100%)
Pro-life 0 0 -
Neither-1 have an 0 0 -
alternate definition o f my
beliefs
Don’t know/ no opinion 0 0 -
25
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Table 2. (continued) Frequency Distributions for All Survey Questions
Obstetrician/ Family Total
Gynecologists Practitioners
n=7 n= 5
Physician Beliefs and Attitudes Regarding Medical Abortion
20. In the next year, how likely are you to start prescribing the mifepristone
regimen? (Groups 1 and 2 responding, n=7 total)
Very likely 0 0 -
Somewhat likely 0 0 -
Not likely at all 3 4 7 (100%)
No opinion/ don’t know 0 0 -
21. What are the main reasons you do not prescribe the mifepristone regimen
currently? (Groups 1 and 2 responding, n=7 total)
Personal moral objections 1 1 2 (29%)
Personal religious 0 1 1 (14%)
objections
Institutional barrier 1 1 2 (29%)
Lack of training 2 1 3 (43%)
Local community 1 0 1 (14%)
opposition
Fear of consequences on 0 1 1 (14%)
practice
Medical partners’ 0 0 0
opposition
Service already available 1 2 3 (43%)
within reasonable distance
Not familiar enough 1 1 2 (29%)
No demand 2 0 2 (29%)
Potential for 0 2 2 (29%)
complications
Unsafe drug 0 0 0
Inadequate physical 0 2 2 (29%)
resources (staff,
equipment)
Increased liability 0 3 3 (43%)
coverage
Risk of malpractice/legal 0 2 2 (29%)
problems
Other 1 2 3 (43%)
26
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Table 2. (continued) Frequency Distributions for All Survey Questions
Obstetrician/ Family Total
Gynecologists Practitioners
_______________________________ n-7 _____________n=5________________
22. Have any o f these factors prevented or impeded you from prescribing
mifepristone in the past? (Group 3 responding, n=5 total)
Personal moral objections 0 0 0
Personal religious 0 0 0
objections
Institutional barrier 2 1 3 (60%)
Lack o f training 1 0 1 (20%)
Local community 0 0 0
opposition
Fear of consequences on 0 0 0
practice
Medical partners’ 0 0 0
opposition
Service already available 0 0 0
within reasonable distance
Not familiar enough 0 1 1 (20%)
No demand 0 0 0
Potential for 0 0 0
complications
Unsafe drug 0 0 0
Inadequate physical 0 0 0
resources (staff,
equipment)
Difficulty obtaining or 2 0 2 (40%)
ordering mifepristone
Increased liability 0 0 0
coverage
Risk of malpractice/legal 0 0 0
problems
Other 1 0 1 (20%)
(reason not
given)
27
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Table 2. (continued) Frequency Distributions for All Survey Questions
Obstetrician/Gynecologists Family Total
n= 7 Practitioners
n= 5
Physician Familiarity With Computers/Internet
23. Please select the appropriate description o f your' use o f computers and the
Internet:
a. I use a computer daily in my practice.
always 6 (86%) 3 (25%) 9 (75%)
usually 0 2 (40% 2 (17%)
sometimes 0 0 0
never 1 (14%) 0 1 (8%)
b. I use the Internet or email daily in my practice.
always 6 (86%) 4 (80%) 10 (84%)
usually 0 1 (20%) 1 (8%)
sometimes 0 0 0
never 1 (14%) 0 1 (8%)
24. Please estimate how many years you have been using email and/or the
Internet
Less than 1 year 0 0 -
1-2 years 0 0 -
3-5 years 6 (86%) 3 (25%) 9 (75%)
More than 5 1 (14%) 2 (40%) 3 (25%)
years
25. Did you find this survey more difficult to complete than a standard mail
survey?
Yes 7 (100%) 5 (100%) 12 (100%)
No 0 0 -
Don’t know/no 0 0 -
opinion
Questions 17-19 asked all of the physicians to clarify their beliefs and attitudes
surrounding abortion, and were modeled after questions previously used by a
similar survey.2 0 All of the respondents participating in this survey had similar
beliefs on abortion, resulting in no apparent difference between specialties or
relative to other demographic factors for this convenience sample. Seven subjects
28
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answered question 20, which asks the physicians in groups 1 and 2 (those
currently not providing medical abortion) to anticipate possible future provision
of mifepristone for medical abortion. None o f these physicians intend to change
their practice o f medical abortion within the coming year.
Question 21 asked those physicians who provide medical abortion to identify
barriers that prevent or impede them from provision of mifepristone medical
abortion. Sixty percent o f the providers in this group cited “institutional barriers”
that interfere with the provision of medical abortion. Similarly, question 22 asked
the remaining physicians for the main reasons they currently do not provide
mifepristone medical abortions. The most common responses were “lack of
training,” “service already available within a reasonable distance,” and “increased
liability coverage.” Responses to “other” barriers preventing provision o f medical
abortion with mifepristone included: “Cost,” “Unable to provide surgical abortion
if meds fail,” and “I believe a best practice referral center model is most
appropriate.”
Responses to questions about familiarity and comfort with computers and the
Internet are listed at the end of Table 2. Despite the majority o f the physicians
reporting frequent use of computers and long-term familiarity, none of these
respondents thought that the Internet survey was easier than a standard mail
survey.
29
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Table 3. Mean Domain Scores by Practice Specialty
Obstetrician/
Gynecologists
Family
Practitioners
Domain I:
Knowledge of medical abortion 9.1 7.3
Domain II:
Perceived barriers to current
practice o f medical abortion
3.5* 5.0
Domain III:
Perceived barriers to initiating
practice of medical abortion
5.0 7.5
Domain IV:
Attitudes/beliefs regarding abortion 10.0 9.8
*two missing responses
Domain scores were calculated for four separate constructs (see Appendix B) and
are presented by specialty in Table 3. Comparison of these scores appears to
demonstrate that Ob/Gyns overall have a greater familiarity with the mifepristone
regimen, and have fewer perceived barriers to providing medical abortion.
Attitudes and beliefs among the physicians in this sample were similar, regardless
of specialty.
30
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DISCUSSION
This pilot study was designed to evaluate an internet-based physician survey on
the topic of medical abortion. Due to the limited number of respondents, the
survey did not allow for adequate statistical comparisons to be made between the
two physician specialties or between different demographic characteristics.
Ideally, a larger number of participants could test the validity of the individual
questions; from these initial responses, there were minimal differences in
knowledge, beliefs, and practice for many o f the items in this survey. The
descriptive results presented above are useful for guiding further design of a
similar physician survey.
On review o f the responses, the use o f domain scores to evaluate the designated
constructs of knowledge, attitudes, and perceived barriers appeared to be a useful
mechanism for summarizing the data. Though it was anticipated that using an
Internet-based commercial survey program would improve data collection and
accuracy, there still appeared to be inconsistencies in the intended data collection
and actual output. For example, question 22 had missing responses for two
individuals, despite an accurate number of responses to questions both prior to
and after this question in the intended survey sequence. Manual review of the
data did not clarify if this was a programming error or respondent error. Thus the
reliability of this survey can be challenged based on possible malfunction or
misinterpretation o f the software.
31
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The reliability o f the individual respondents’ interpretation o f certain questions is
also suspect, based on the discrepancies noted for questions 10-12 above. There
appeared to be one FP who stated that s/he provides medical abortion under one
question format, but does not provide medical abortion when asked in a different
format. This section of questions regarding “practice o f abortion” will need
editing and review prior to any future survey administration.
Despite the enthusiasm in the medical literature regarding use o f the Internet for
survey administration and data collection, all of the 12 respondents in this pilot
study indicated that a mail survey would be preferable to a web-based survey.
Therefore the next stage of survey design for this topic and physician sample
should be a traditional written response format, rather than continued use of the
web-based format.
Other investigators have also questioned the usefulness o f Internet-based survey
technology. For now, internet-based surveys may be best utilized for specific
situations and populations, especially when the research question involves use of
computers or the Internet. Wyatt, in an editorial accompanying a journal article
that utilized an Internet-based provider survey, warned against “introducing
further uncertainty into our current research methods” by adopting web surveys as
a routine technique for data collection.2 1 “The choice about whether to use the
32
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Web for a survey,” he states, “should not be driven by economics but by a
consideration o f the many alternative techniques.”2 1
The recruitment o f respondents for this survey was difficult, both due to the
survey topic, and the known limitations o f any physician survey due to demands
on their time. An attempt was made to contact physicians personally to increase
their interest in the subject, and also to recruit participants by referral from other
local physicians. However, many of the inquiries by phone, letter, or email were
not returned over the several month period of recruitment. Response rates for
physician surveys are notoriously low, and particularly for this pilot survey, the
difficulty in recruitment raises a question of non-response bias for the limited
results obtained. Some methods that have been suggested to improve response
rates include: 1) allowing physicians flexibility to choose the mode of interview
(i.e. phone, mail or Internet); 2) providing opportunities for the physicians to
express their opinions completely; and 3) improving the cost-benefit ratio for
participation.2 9 All of these tactics could be applied with a subsequent
administration of this survey, though the individual reimbursement of $50 for
participation is already quite high compared to the national standard for similar
provider surveys.
33
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Other studies have directly addressed the issue o f physician response rates based
on the format of the survey. Similar to the opinions o f the respondents in this
pilot survey, the perceived benefits of the use of the Internet have not been
supported by results. Several reports comparing physician response rates between
Internet and mail formats for the same survey found higher rates o f return for the
traditional mail format.24,30,3 1
Individuals with experience in the field of medical abortion who offered to review
this survey for content during development suggested some other changes that
might improve future survey administration on this topic. These included the
addition o f questions regarding any previous training the physician has received
in abortion or medical abortion to relate this to current practice or interest. One
survey of Ob/Gyns found that training during residency was significantly
associated with both the practice of abortion and with beliefs surrounding
abortion.3 2 Therefore, a similar investigation regarding this association in the
case of medical abortion would be useful in guiding training initiatives.
A second area for further investigation would involve the barrier o f the “cost” of
medical abortion, which was cited by several of the respondents as they gave
verbal feedback regarding this survey. Both the medication itself, and the
multiple visits required for adequate counseling, administration o f medications,
and for follow-up has made proving medical abortion prohibitive for at least one
34
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of the Ob/Gyn physicians who participated in this survey. At one clinic in Los
Angeles, a physician stated that the only way they have made the medical
abortion procedure affordable for patients is to use an evidence-based alternative
regimen with one-third the dose o f mifepristone (and one-third the cost.) Based
on these comments, it appears that the monetary incentive to provide medical
abortions is low.
In contrast to the results of previous studies regarding provider interest in medical
abortion, none of the physicians in this sample anticipated adding medical
abortion to their practice within the next year. This result may be related to the
limited sample size, or possibly to the barriers cited, including institutional
restraints, costs, and lack of training. If the survey is repeated, it may be useful to
allow physicians to rate which barriers are most influential or significant in their
decision regarding medical abortion provision, rather than assuming that the
number of barriers is related to their decision.
This research was designed as a pilot survey primarily for the purpose o f testing
the survey instrument, and also due to the cost considerations o f planning a larger
scale survey o f providers. The results presented are intended for use in guiding
further survey development, and for validation of a questionnaire to assess
medical abortion practice and beliefs. Similar studies o f providers have been
performed, but most were completed prior to the approval and introduction of
35
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mifepristone into the United States. The limited information obtained by this
pilot survey regarding the current practice o f medical abortion in Los Angeles
County is in some aspects contradictory to prior findings, especially regarding any
anticipated future provision of medical abortion. It may be that the only providers
who are interested, typically those who previously provided abortion, have
already added this service to their practice. However, further wide-scale research
is necessary to compare current practice with that predicted prior to the
introduction of mifepristone, and to accurately determine the common barriers
and needs of providers interested in providing medical abortion.
36
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Planning Perspectives, 31(1): 35-38.
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patterns in the treatment o f female urinary incontinence: a postal and
internet survey. Urology, 57(1): 45-48.
Koenig, J., Tapias, M., Hoff, T. and Stewart, F., 2000. Are US Health
Professionals Likely to Prescribe Mifepristone or Methotrexate? Journal of
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Lacher, D., Nelson, E., Bylsma, W. and Spena, R., 2000. Computer Use and
Needs of Internists: A Survey o f Members o f the American College of
Physicians-American Society o f Internal Medicine. Proceedings / AMIA
Annual Symposium: 453-456.
Lugo-Vicente, H., 2000. Profile o f Internet users: survey o f the surgical section of
the AAP. Boletin- Asociacion Medica de Puerto Rico, 92(4-8): 63-64.
Miller, N., Miller, D. and Koenigs, L.P., 1998. Attitudes of the Physician
Membership o f the Society for Adolescent Medicine Toward Medical
Abortion for Adolescents. Pediatrics, 101(5): 916 e4.
National Telecommunications and Information Administration, 2001. A Nation
Online: How Americans are Expanding their use o f the Internet. Available
at: http://www.ntia.doc.gov/ntiahome/dn/hhs/ChartH7.htm. Accessed June
18, 2002.
Potts, M., 1999. Foreward. In: M. Paul, E. Lichtenberg, L. Borgatta, D. Grimes
and P. Stubblefield (Editors), A Clinician's Guide to Medical and Surgical
Abortion. Churchill Livingstone, New York, pp. xi.
Raxiano, D., Jayadevappa, R., Valenzula, D., Weiner, M. and Lavizzo-Mourey,
R., 2001. E-mail versus conventional postal mail survey o f geriatric chiefs.
Gerontologist, 41(6): 799-804.
Rosenblatt, R., Mattis, R. and Hart, L., 1995. Abortions in Rural Idaho:
Physicians' Attitudes and Practices. American Journal o f Public Health,
85(10): 1423-1425.
Shanahan, M., Metheny, W., Star, J. and Piepert, J., 1999. Induced Abortion:
Physician Training and Practice Patterns. The Journal o f Reproductive
Medicine, 44: 428-432.
VanGeest, J. and Johnson, T., 2001. Methodologies for improving response rates
in mail surveys of physicians, The 129th Meeting o f the American Public
Health Association, Abstract #22745.
41
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Westfall, J., Kallail, K. and Walling, A., 1991. Abortion Attitudes and Practices
ofFam ily and General Practice Physicians. The Journal o f Family
Practice, 33(1): 47-51.
Winikoff, B., 1995. Acceptability of medical abortion. Family Planning
Perspectives, 27: 142-148, 185.
Wyatt, J., 2000. When to Use Web-based Surveys. Journal o f the American
Medical Informatics Association, 7(4): 426-430.
Zhang, Y., 1999. Using the Internet for Survey Research: A Case Study. Journal
of the American Society for Information Science, 51(1): 57-68.
42
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APPENDIX A
Survey Content and Appearance
This is a sample questionnaire with the actual questions that were used in the
pilot survey. Each physician read the introduction, agreement o f participation,
and instructions, but the titles (PARTI, PARTII, etc) and all other italics were
left out o f the final survey._______________________________________________
A Pilot Survey o f Medical Abortion Knowledge and Practices Among
Obstetrician/Gynecologists and Family Practitioners in Los Angeles County
INTRODUCTION
Thank you for participating. We hope to gain from this survey a better sense of
how physicians have met with the challenge of integrating medical abortion into
their practices, and what barriers exist to provision of medical abortion.
Even if you do not provide, are ambivalent, or do not believe abortions should be
performed (in all cases or in some cases,) please answer these questions as
completely as possible. Your identity will remain confidential; neither your name
nor any identifying characteristics will be revealed in publication, presentation, or
any other format. Any presentation of the data will only identify that the
physicians responding were Ob/Gyn or Family Practice physicians in Los Angeles
County. In addition, the data will be stored in a database that will not have any
additional information linking your responses to your name, contact
information/address, or location of practice. There are a total of 30 physicians
participating in this pilot survey: 15 Ob/Gyn and 15 Family Practice physicians.
The principal investigator, Caryn Dutton MD, will be the only individual with any
knowledge o f each participant’s identity, but will not be able to identify who
entered each response once the data has been collected. The database will be
secured with password-protection, so that no other individuals will have access to
the data.
43
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AGREEMENT OF PARTICIPATION
I ACKNOWLEDGE THAT I HAVE READ THE ABOVE STATEMENT
DESCRIBING THE PROCEDURES THAT WILL BE FOLLOWED TO KEEP
MY RESPONSES CONFIDENTIAL. I AGREE TO PARTICIPATE IN THE
FOLLOWING SURVEY, AND I UNDERSTAND THAT I MAY CONTACT
CARYN DUTTON, MD AT ANY TIME IN THE FUTURE IF I HAVE
QUESTIONS OR CONCERNS REGARDING THE USE OF THE DATA
COLLECTED BY THIS SURVEY.
□ IAGREE
□ I DO NOT AGREE, AND I CHOOSE NOT TO PARTICIPATE
IN THIS SURVEY
INSTRUCTIONS
Each page will contain one question. Use your cursor arrow to select the box next
to your answer or answers. If you make a mistake, you can click on the box again
to un-select that answer.
Once you have completed the question, use your cursor arrow to click on the box
labeled “NEXT” at the bottom right comer o f the page. If you want to go back to
a previous question, use your cursor arrow to select the box labeled “BACK” at
the bottom left comer o f the page.
At the end o f the survey, you will be asked to use your cursor arrow to select a
box labeled “SUBMIT.” Once you have selected this box, all your previous
answers are final and you cannot use the “BACK” option to correct them.
Once you have read and understood these instructions, please use your cursor
arrow to click on the box labeled “NEXT” at the bottom right comer of this page.
44
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PARTI: ASSESSMENT OF PHYSICIAN KNOWLEDGE OF MEDICAL
ABORTION
Since Fall of 2001, a new option has been available to women who desire
pregnancy termination o f gestations less than seven weeks- medical abortion with
mifepristone (commonly known as RU-486) and a prostaglandin, usually
misoprostol.
1. How familiar are you with the mifepristone medical abortion regimen?
□ Very familiar
□ Somewhat familiar
□ Not familiar at all
2. From what you know, is the mifepristone regimen
a Very safe
□ Somewhat safe
□ Not safe at all
3. From what you know, is the mifepristone regimen
□ Very effective
□ Somewhat effective
□ Not effective at all
The next questions pertain to an alternate medical abortion regimen which is a
combination of methotrexate and a prostaglandin.
4. How familiar are you with the methotrexate medical abortion regimen?
□ Very familiar
□ Somewhat familiar
□ Not familiar at all
5. From what you know, is the methotrexate regimen
□ Very safe
□ Somewhat safe
□ Not safe at all
6. From what you know, is the methotrexate regimen
□ Very effective
□ Somewhat effective
□ Not effective at all
45
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PART II: ASSESSMENT OF PATIENT INTEREST/DEMAND FOR MEDICAL
ABORTION
7. Have any o f your patients requested information about how to obtain a medical
abortion?
□ Yes
□ No
□ Don’t remember/no opinion
8. Approximately how many patients have requested this information in the past
6 months?
9. Have you met patients in your practice who have had a medical abortion with a
different provider?
□ Yes
□ No
□ Don’t remember/no opinion
46
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PART III: ASSESS PRACTICE OF MEDICAL ABORTION
10. Please indicate your practice (past or present) by checking the appropriate
response for each option (a - f.)
If a patient requests an abortion for an early pregnancy...
always usually sometimes never
(a) I refer her to a doctor or
clinic that provides medical
abortion.
(b) I refer her for a surgical
abortion.
(c) I prescribe mifepristone and
misoprostol for a medical
abortion.
(d) I prescribe methotrexate and
misoprostol for a medical
abortion.
(e) I perform a surgical abortion.
(f) I refer her for pregnancy
counseling.
□ O ther__________________
□ Don’t remember/no opinion
11. Does your liability insurance cover you for medical abortion?
□ Yes, I have coverage
□ No, I do not have coverage
□ No opinion/don’t know
12. Please select the most accurate description o f your past or current practice
below:
O I do not provide any abortion services for my patients
O I have only provided surgical abortion for my patients
O I have only provided medical abortion for my patients
O I have provided both medical and surgical abortions for my
patients
47
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(Based on responses to question 12, respondents will be split into three groups.
Group 1 is composed o f those physicians who do not perform medical or surgical
abortion. Group 2 is composed o f those physicians who have performed surgical
but not medical abortion. And Group 3 is composed o f physicians who have
performed medical abortion. The internet-based survey then directed each
respondent to the appropriate questions that follow.)
PART III: ASSESSMENT OF PRACTICE OF MEDICAL ABORTION, cont’ d
(Questions 13-15 fo r Group 3 only, Group 1 skips to question 17, and group 2
skips to question 16.)
13. Please estimate how many medical abortions you perform every six months:
number o f medical abortions with mifepristone____________
number of medical abortions with methotrexate
14. Who pays for the medical abortion procedure?
□ Patient (self-pay)
□ Private insurance
□ HMO
□ Medi-Cal
□ Other
15. Have you had any patients who wanted a medical abortion, but were forced to
have a surgical abortion due to problems with reimbursement by their insurer?
□ Yes
□ No
□ Don’t know/ no opinion
(Group 2 and Group 3)
16. Please estimate how many surgical abortions you perform every six months.
48
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PARTIV: ASSESSMENT OF ATTITUDES/BELIEFS ABOUT ABORTION,
MEDICAL ABORTION AND BARRIERS TO PROVISION OF MEDICAL
ABORTION
{All groups)
17. Should abortion be legal in the United States?
□ Yes
□ No
□ Don’t know/ no opinion
{All groups)
18. Under which circumstances do you believe abortion is an appropriate option
for a pregnant woman? (Please select as many answers as applicable)
□ To save the life of the mother
□ If the pregnancy results from rape or incest
□ If there is a fetal anomaly
□ If the woman chooses an abortion
□ If the woman is too young or too old
□ Contraceptive or sterilization failure
□ Undesired sex of fetus
□ None of the above
{All groups)
19. The terms pro-choice and pro-life are often used to classify basic attitudes
towards abortion. In general, pro-choice refers to individuals who advocate that
abortion is a private matter involving a woman’s personal choice. Pro-life refers
to individuals who advocate that the primary issue is the right to life of the fetus.
Do you classify yourself as...
□ Pro-choice
□ Pro-life
□ Neither-1 have an alternate definition of my beliefs
□ Don’t know/ no opinion
49
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PARTIV: ASSESSMENT OF ATTITUDES/BELIEFS ABOUT MEDICAL
ABORTION AND BARRIERS TO PROVISION OF MEDICAL ABORTION
cont’ d
{Groups 1 and 2 only)
20. In the next year, how likely are you to start prescribing the mifepristone
regimen?
□ Very likely
□ Somewhat likely
□ Not likely at all
□ No opinion/don’t know
(Groups 1 and 2 only)
21. What are the main reasons you do not prescribe the mifepristone regimen
currently?
(Please select as many answers as applicable)
□ Personal moral objections
□ Personal religious objections
□ Institutional barrier
□ Lack o f training
□ Local community opposition
□ Fear o f consequences on practice
□ Medical partners’ opposition
□ Service already available within reasonable distance
□ Not familiar enough
□ No demand
□ Potential for complications
□ Unsafe drug
□ Inadequate physical resources (staff, equipment)
□ Increased liability coverage
□ Risk o f malpractice/legal problems
□ Other
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
PARTIV: ASSESSMENT OF ATTITUDES/BELIEFS ABO UT MEDICAL
ABORTION AND BARRIERS TO PROVISION OF MEDICAL ABORTION,
cont’ d
{Group 3 only)
22. Have any of these factors prevented or impeded you from prescribing
mifepristone in the past year? (Please select as many answers as applicable)
□ Personal moral objections
□ Personal religious objections
□ Institutional barrier
□ Lack o f training
□ Local community opposition
□ Fear o f consequences on practice
□ Medical partners’ opposition
□ Service already available within reasonable distance
□ Not familiar enough
□ No demand
□ Potential for complications
□ Unsafe drug
□ Inadequate physical resources (staff, equipment)
□ Difficulty obtaining or ordering mifepristone
□ Increased liability coverage
□ Risk of malpractice/legal problems
□ Other
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{All groups continue remainder o f survey)
PART VI: ASSESSMENT OF FAMILIARITY WITH INTERNET
23. Please select the appropriate description of your use o f computers and the
internet:
always usually sometimes never
(a) I use a computer daily in my
practice
(b) I use the internet or e-mail
daily in my practice.
24. Please estimate how many years you have been using email and/or the
internet:
a. Less than 1 year
b. 1 -2 years
c. 3-5 years
d. More than 5 years
25. Did you find this survey more difficult to complete than a standard mail
survey?
□ Yes
□ No
□ Don’t know/no opinion
52
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PART VII: PHYSICIAN DEMOGRAPHICS
26. How old are you?
□ Less than 30
□ 3 1 - 4 0
□ 4 1 - 5 0
□ 5 1 - 6 0
□ 6 1 - 7 0
□ Over 70
Gender:
□ Male
□ Female
28. How many years have you been practicing medicine?
□ Less than 5 years
□ 5 - 1 0 years
□ 1 1 -1 5 years
□ 1 6 -2 0 years
□ 2 0 - 3 0 years
□ More than 30 years
29. Please select the single response that best describes your practice setting:
□ Solo practitioner
□ Single-specialty group
□ Multi-specialty group
□ HMO
□ Government-funded primary care clinic
□ Privately funded primary care clinic
□ Family planning clinic
Please use the cursor arrow to select the box in the bottom right comer labeled
“SUBMIT” once you have completed the survey.
Thank you again for your participation!
53
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This is a representation of the appearance of this survey when viewed using an
Internet browser (example shows layout o f questions 10 and 11 above):
Please indicate your practice (past or present) by checking the
appropriate response for each option listed below.
If a patient requests an abortion for an early pregnancy,
Always Usually Sometimes
I refer her to a doctor or clinic that
provides medical abortion
r r r
1 refer her for a surgical abortion
r r c
I prescribe mifepristone and
misoprostol for a medical abortion
r r
I prescribe methotrexate and
misoprostol for a medical abortion
c c r
I perform a surgical abortion
c
.T f.- '-'U
r
I refer her for pregnancy
counseling
c r
Don't remember/no opinion
r
i Other I
Does your liability insurance cover you for medical abortion?
C
Yes, I have coverage
No, I do not have coverage
No opinion/don't know
Next
N e w
r
r
r
r
Powered by Perseus SurveySolutions.
54
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APPENDIX B
Explanation of Domain Scores
Domain I
The “knowledge o f medical abortion” domain is a summary score o f familiarity,
safety and efficacy o f the mifepristone regimen of medical abortion. The
methotrexate knowledge was similar among all respondents, and was not
incorporated into this domain. Therefore this score reflects the providers’ use and
understanding o f mifepristone for medical abortion.
Domain I: Knowledge of Medical Abortion
Question Origin Responses Corresponding
score
1 KFF1 and KFF2 Very familiar 10
Somewhat familiar 5
Not familiar at all 0
2 KFF1 andKFF2 Very safe 10
Somewhat safe 5
Not safe at all 0
3 KFF1 andKFF2 Very effective 10
Somewhat effective 5
Not effective at all 0
KFF1 [Foundation, 1998 #35]
KFF2 [Foundation, 2001 #34]
Each individual’s summary score for Domain I was based on the mean score for
these three questions. A high score (range 0-10) corresponds to more accurate
and familiar knowledge of the mifepristone medical abortion regimen.
55
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Domain II:
The “perceived barriers to current practice of medical abortion” domain is a
summary score o f the total number o f barriers to provision o f medical abortion
identified by those physicians who currently provide medical abortion.
Domain II: Perceived barriers to current practice of medical abortion
Question Origin Responses Corresponding
score
22 KFF Personal moral objections Yes = 1 2
o
I I
o
SG Personal religious
objections
Yes - 1
o
I I
o
£
K F F Institutional barrier Y e s - 1
o
I I
o
£
KFF Lack of training Yes = 1
o
I I
%
ROS Local community
opposition
Y e s -1
o
I I
o
SG Fear of consequences on
practice
Yes - 1
o
I I
o
55
ROS Medical partners’
opposition
Yes - 1
o
I I
o
£
ROS Service already available
within reasonable
distance
Y e s - 1
o
I I
%
KFF Not familiar enough Y e s - 1
o
I I
o
£
SG No demand Y e s - 1
o
I I
o
£
KFF Potential for
complications
Y e s - 1 N o - 0
KFF Unsafe drug Yes - 1
o
I I
o
£
SG Inadequate physical
resources (staff,
equipment)
Y e s - 1
o
I I
o
£
SG Difficulty obtaining or
ordering mifepristone
Y e s - 1
o
I I
o
£
KFF, ROS Increased liability
coverage
Y e s - 1
o
I I
o
£
Risk of malpractice/legal
problems
Yes - 1
°
I I
o
£
Other Yes - 1 No = 0
KFF [Foundation, 1998 #35; Foundation, 2001 #34]
ROS [Rosenblatt, 1995 #10]
SG Self-generated
56
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The “perceived barriers to current practice” domain was calculated by totaling the
number o f barriers selected by each respondent (range 0-16). The summary score
(range 0-10) was assigned based on a scale as follows: five or more barriers, final
score was 10, three or four barriers, final score was 5; one or two barriers, final
score was 2; zero barriers, final score was 0.
57
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Domain III:
The “perceived barriers to initiating practice of medical abortion” domain is a
summary score o f the total number o f barriers to provision of medical abortion
identified by those physicians who do not currently provide medical abortion.
Domain III: Perceived barriers to initiating practice o f medical abortion
Question Origin Responses Corresponding
score
22 KFF Personal moral objections Yes =
o
I I
o
Z
SG Personal religious
objections
Yes = Z
o
I I
o
KFF Institutional barrier Yes = 3
o
I I
o
KFF Lack o f training Yes =
o
I I
o
£
ROS Local community
opposition
Yes = No = 0
SG Fear of consequences on
practice
Yes = No = 0
ROS Medical partners’
opposition
Yes =
j
< = >
i i !
©
Z
!
ROS Service already available
within reasonable
distance
Yes = Z
o
I I
o
KFF Not familiar enough Yes = z
o
I I
o
SG No demand Yes =
o
I I
o
z
KFF Potential for
complications
Yes =
o
I I
o
z
KFF Unsafe drug Yes =
o
I I
o
z
SG Inadequate physical
resources (staff,
equipment)
Yes =
o
I I
o
z
KFF, ROS Increased liability
coverage
Yes =
I I
o
Risk of malpractice/legal
problems
Yes -
I I
o
Other Yes =
o
I I
o
z
KFF [Foundation, 1998 #35; Foundation, 2001 #34]
ROS [Rosenblatt, 1995 #10]
SG Self-generated
58
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The “perceived barriers initiating practice” domain was calculated by totaling the
number o f barriers selected by each respondent (range 0-16). The summary score
(range 0-10) was assigned based on a scale as follows: with five or more barriers,
final score was 10, with three or four barriers, final score was 5; with one or two
barriers, final score was 2; with zero barriers, final score was 0.
Domain IV :
The ’’attitudes toward abortion” domain is a summary score o f respondent’s
attitudes towards the legality and appropriate clinical practice o f abortion as well
as his or her personal beliefs.
Domain IV: Attitudes toward abortion
Question Origin Responses Corresponding
score
16 WES Yes 10
No 0
Don’t know/no opinion -
17 WES To save the life o f the mother 10
If the pregnancy results from a rape 10
or incest
If there is a fetal anomaly 10
If the woman chooses an abortion 10
If the woman is too young or too old 10
Contraceptive or sterilization failure 10
None of the above 0
18 WES Pro-choice 10
Pro-life 0
Neither -
Don’t know/no opinion -
WES [Westfall, 1991 #11]
Respondents were not penalized for selecting “Don’t know/no opinion” or
“Neither.” If these responses were selected for questions 16,18, or both, then the
summary score did not include a contribution from that question. The sum of the
responses from all three questions, using a mean for all sections o f question 17,
was averaged to calculate the final summary score (range 0-10). A high score
(range 0-10) corresponds to full support o f abortion, while a low score
corresponds to either a personal beliefs against abortion or beliefs regarding the
restriction of abortion practice.
59
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
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Asset Metadata
Creator
Dutton, Caryn Ruth
(author)
Core Title
A pilot survey of medical abortion knowledge and practices among obstetrician/gynecologists and family practitioners in Los Angeles County
School
Graduate School
Degree
Master of Science
Degree Program
Applied Biostatistics and Epidemiology
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
biology, biostatistics,health sciences, obstetrics and gynecology,health sciences, public health,OAI-PMH Harvest
Language
English
Contributor
Digitized by ProQuest
(provenance)
Advisor
Azen, Stanley (
committee chair
), Arias, Raquel (
committee member
), Globe, Denise (
committee member
)
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c16-307844
Unique identifier
UC11327425
Identifier
1417919.pdf (filename),usctheses-c16-307844 (legacy record id)
Legacy Identifier
1417919.pdf
Dmrecord
307844
Document Type
Thesis
Rights
Dutton, Caryn Ruth
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...
Repository Name
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Repository Location
USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA
Tags
biology, biostatistics
health sciences, obstetrics and gynecology
health sciences, public health