though public debate about abortion has been intense since Roe vs Wade,3 very little is known about why individual rural physicians do or do not incorporate.
Abortions in Rural Idaho: Physicians' Attitudes and Practices RogerA. Rosenblatt, MD, MPH, Rick Mattis, and L. Gary Hart, PhD
Introduction Abortions are virtually unavailable in rural America. Although first-trimester abortions are a constitutionally protected medical procedure, 94% of nonmetropolitan counties in the United States have no legal medical provider willing to provide abortion services.' Consequently, most rural women must travel significant distances to find a provider willing to perform abortions, a barrier that effectively denies this service to many.2 Why are rural physicians unwilling to provide abortions, and what steps can be taken to improve the availability of this procedure in small communities? Even though public debate about abortion has been intense since Roe vs Wade,3 very little is known about why individual rural physicians do or do not incorporate termination of pregnancy into their practice repertoire. This study explores the issue by surveying all potential abortion providers within rural Idaho, a conservative western state with the second lowest abortion rate in the country.4
Methods This investigation surveyed all general and family physicians, obstetriciangynecologists, and general surgeons in rural Idaho, identified from a roster maintained by the Idaho Medical Association of all active physicians in the state. Rural physicians were defined as allopathic and osteopathic physicians working in nonmetropolitan counties and in communities of fewer than 20 000 people. A survey instrument was sent to all 251 physicians who met the eligibility criteria for the study, with a second mailing sent to nonrespondents. The survey included questions about the physician's training and certification, range of obstetric and reproductive health services provided now and in the past, and attitudes toward abortions and the potential use of RU-486 (mifepristone). Thirtynine potential respondents were eliminated because the surveys were nondeliverable or the physicians were not currently practicing in a rural community in one of the three specialties of
interest. Of the 212 in-scope physicians who received the mailing, 138 (65%) responded. Sociodemographic characteristics of Idaho communities were obtained from the 1990 census. Characteristics of hospitals in those communities were derived from the 1993 American Hospital Association Guide to the Health Care Field.
Results Survey results revealed that 86% of the rural Idaho physicians were family physicians, of whom 72% were residency trained and 80% were board certified. Ninety-one percent of the respondents were male, and the average physician had been in practice for 15 years. The typical rural community in which these physicians practiced was a town of between 2500 and 5000 people, with an 18-bed hospital 56 miles from the nearest urban area. Rural Idaho family physicians and obstetrician--gynecologists provide a wide range of women's health services, including obstetrics and reproductive health (Table 1). Most of these physicians are active in obstetrics, and it is the rare family physician or obstetrician who does not provide basic family planning services. The family physicians provide a broad range of relatively complex surgical services as well, with roughly half of the respondents performing cesarean sections and tubal ligations, and a majority doing vasectomies, endometrial biopsies, and dilation and curettage. General surgeons, by contrast, are less likely to perform gynecological surgical procedures than either family physicians or obstetrician-
gynecologists. The broad repertoire of surgical skills among the family physicians suggests that most have the technical experThe authors are with the WAMI Rural Health Research Center, Department of Family Medicine, University of Washington School of Medicine, Seattle. Requests for reprints should be sent to Roger A. Rosenblatt, MD, MPH, University of Washington, Department of Family Medicine, Box 355304, Seattle, WA 98195-5304. This paper was accepted May 9, 1995.
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TABLE 1 -Women's Health Services Provided by Rural Idaho Physicians, by Physician Specialty, 1994 Physician Specialty
Service
% Family Physicians (n = 114)
% ObstetricianGynecologists (n = 9)
% General Surgeons (n = 15)
65
100
0
61
61 49
100 100
0 15
58 48
98 87 87 71 67 49 50 46 27 2
100 100 89 0 89 100 89 89 44 33
29 31 79 14 50 14 7 7 0
61 80 82 68 63 52 49 45 26 3.6
0
22
0
1.5
100 83 69
100 89 100
79 50 48
98 80 69
42
89
21
43
Obstetric services Routine prenatal care Routine deliveries Cesarean sections Family planning services
Oral contraceptives Diaphragm Depoprovera Vasectomy Norplant Tubal ligation Intrauterine device Morning-after pill Cervical cap 1 st trimester abortion 2nd trimester abortion Other women's health services Pap smear Endometrial biopsy Dilation and curettage Colposcopy
90-
7
% Total (n = 138)
86
86 7
80
70-:~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Peraonal
Moral Objections
Local Community Opposition
B Family
Phyaiciana (n = 114)
Servce Already Available within Reasonable Distance
*
lncreaaed
Lack of Training
Obstetrician-Gynecologista
Malpractice Insurance
(n = 9)
2 General
Medical
Partnera' Opposition
Surgeona (n = 15)
Note. Respondents could indicate more than one reason.
FIGURE 1-Rural Idaho physicians' reasons for not performing abortions, by physician specialty, 1994.
tise to perform first-trimester abortions, yet only 2 of the 114 family physicians
surveyed perform this procedure. According to data corroborated by the Idaho Department of Health Services, only 4 of 1424 American Journal of Public Health
the 44 communities served by the respondents to this survey have local abortion services. The most important reason family physicians gave for not performing abortions was their personal moral or
religious objection (82%), followed closely by local community opposition to the procedure (77%) (Figure 1). Younger, residency-trained physicians were more likely to have personal moral objections than their older colleagues. Despite their personal objections, however, 65% of the respondents morally opposed to abortion were willing to refer patients requesting abortions to another provider. The average travel distance from these communities to the nearest abortion provider is about 85 miles. Although surgical abortions are currently almost unavailable in rural areas, a substantial proportion of the respondents said they might consider using alternative methods to terminate pregnancy. Twentysix percent indicated that they would definitely prescribe RU-486 if it became available; an additional 35% were uncertain. Older physicians and those without residency training or board certification were more receptive to the use of RU-486 than residency-trained physicians who had been in practice for less than 5 years. However, very few physicians with strong moral objections to abortion said they would be willing to entertain the use of RU-486 (5%).5
Discussion Abortion is one of the safest, most efficacious, and most controversial medical procedures, with important personal and public health benefits.6 Unintended or unwanted pregnancies often have devastating effects on mothers and the infants they bear,7 and states that publicly fund abortions show evidence of substantially lower rates of teenage pregnancy and low-birthweight births. Yet access to abortions is shrinking in the United States, particularly in rural areas.8'9 This study of a conservative rural state shows that many rural physicians are unwilling to perform abortions because of their own moral objection to the procedure or because of local community opposition.5'10 Rural communities often have conservative political and religious views, and this study suggests that rural physicians often share the beliefs of their patients. About half the physicians in our study who are morally opposed to abortions will not refer their patients to another provider for this procedure. The development of less intrusive methods for the termination of pregnancy offers considerable promise for improving local access in rural areas.11-14 More than one quarter of the respondents indicated that they would prescribe RU-486 if it October 1995, Vol. 85, No. 10
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became available, a proportion similar to the results in another study.15 It is interesting to note that almost half the respondents already prescribe the morning-after pill; it may be that they see RU-486 as an extension of family planning techniques with which they are already comfortable. One major advantage of RU-486 in a rural community is increased anonymity and privacy.16 Although a small proportion of pregnancies terminated with RU486 will subsequently require a surgical evacuation,17 this is a procedure that is already within the repertoire of most rural physicians. If patients are able to secure safe medical abortifacients from pharmacies outside of their local communities18-or if these drugs are available within the outpatient medical setting19the termination becomes a private decision between the doctor and the patient, less susceptible to external pressures. O
Acknowledgment This study was funded by the Office of Rural Health Policy, grant #CSR 000007-03-0, Health Resources and Services Administration, US Public Health Service.
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