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Obstetrics & Gynecology 1999;93:576-580
© 1999 by The American College of Obstetricians and Gynecologists
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ORIGINAL RESEARCH

Influence of Physician Attitudes on Willingness to Perform Abortion

ARYAN N. AIYER, MD, GEORGE RUIZ, MD, ALLEGRA STEINMAN, BA and GLORIA Y. F. HO, PhD

From the Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Bronx, New York.

Address reprint requests to: Gloria Y. F. Ho, PhD, Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Belfer Building 1312, Bronx, NY 10461, E-mail: ho{at}aecom.yu.edu


   Abstract
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Abstract
Materials and Methods
 Results
 Discussion
 References
 
Objective: To survey attitudes about abortion in a sample of physicians practicing in the Bronx, New York, identify factors associated with those attitudes, and investigate how attitudes about abortion influence willingness to do it.

Methods: A questionnaire mailed to obstetricians and gynecologists affiliated with a medical school in the Bronx elicited information on attitudes about abortion and the willingness to do it. Attitude scores were measured on a Likert scale ranging from 1 to 5, with 5 indicating a proponent attitude about abortion. The practice score ranged from 0 to 2, with 2 indicating proponent attitude about practicing abortion.

Results: The median attitude score was 3.8. Physicians were receptive to reasons for abortion that were medically indicated. A proponent attitude was found in non-Catholics and those who were trained in residency programs that required observing abortions. The median practice score was 1.2. The most important personal factors influencing a physician’s decision not to perform abortions included lack of proper training and ethical and religious beliefs. There was a significant positive correlation between the attitude score and practice score (r = .42, P < .001).

Conclusion: Personal beliefs and past experience with abortion are associated with attitudes about abortion that, besides competence doing them, influence physicians’ willingness to do them. Offering training in abortion might benefit physicians who are proponents and willing to perform abortions.

In recent years, the number of physicians who perform abortions has decreased.1 Many hospitals reduced the number of abortions allowed, or have stopped allowing elective abortions altogether.2 Fewer hospitals are performing abortions, so fewer residents are trained in the procedure, because most residency training is in a hospital. The decline in abortion providers might reflect diminishing availability of training in abortion procedures. Alternatively, attitudes about abortion might influence whether a physician decides to do them. This survey was conducted to identify factors associated with physician attitudes about abortion and to examine whether personal attitudes about abortion influence willingness to perform them, and physician preference between surgical or medical abortion.


   Materials and Methods
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Abstract
 Materials and Methods
Results
 Discussion
 References
 
The study protocol was approved by the institutional review board at the Albert Einstein College of Medicine. The study population for this survey consisted of resident and attending physicians, in the Department of Obstetrics and Gynecology at the Albert Einstein College of Medicine, who practiced in the Bronx. A six-page questionnaire was sent to each physician with a self-addressed, stamped, return envelope. Participants were guaranteed that their responses would remain anonymous. A brief presentation of the study was made during a departmental grand rounds meeting to encourage participation.

The questionnaire had the following six sections: 1) demographic information: gender, age, marital status, ethnicity, religion, and degree of affinity toward religion; 2) physician training and experience with abortion: Physicians were asked whether they watched abortions in medical school, whether they watched or did abortions during residency training, whether they include abortion services in their practices, whether they would refer patients to an abortion provider, and how many abortion procedures they had done in the past 12 months; 3) personal attitudes about abortion: The attitude section involved responding to 18 vignettes in which a woman might request an abortion. Respondents circled a number on a Likert scale of 1 to 5 (1 = strongly disagree with statement, 5 = strongly agree with statement) to indicate whether the stated reason for abortion was morally acceptable.3 That 18-item set was further divided into two subgroups, a 13-item subset indicating nonmedical (socioeconomic or cultural) reasons for abortion (eg, the spouse does not want the mother to carry the pregnancy) and a five-item subset indicating medical reasons for abortion (eg, the pregnancy is a threat to the mother’s life). Each respondent was given an overall attitude score by adding the total responses and dividing by the number of responded items. Attitude scores for each subset were also calculated. Attitude scores, ranging from 1 to 5, measured attitudes about abortion, with a high score indicating a proponent attitude. For each subject, differences in attitudes toward medical versus nonmedical reasons for abortion were assessed by subtracting the nonmedical from medical subscores. A high positive value indicated that the subject was more receptive to medical than nonmedical reasons. 4) willingness to do abortion: The practice section used the same set of 18 circumstances as the attitude section and confronted the physician with the given circumstances to determine what would be the latest stage at which the physician would do the abortion. Respondents answered by circling a number from 0 to 2 for each given circumstance (0 = would never do abortion, 1 = would do the abortion only in the first trimester, and 2 = would do the abortion up to the end of the second trimester). Overall practice scores were calculated by adding total responses and dividing by the number of responded items. The 18-item set was divided into the same five-item medical subset and 13-item nonmedical subset as in the attitude section. Scores for each subset were calculated. The practice score ranged from 0 to 2, with a high score indicating more willingness to practice abortion. 5) preference for medical or surgical abortion: This section consisted of the following question: If you have a choice of performing a surgical or medical abortion on a given patient, which one would you prefer? A medical abortion was defined as one induced by drugs such as methotrexate, misoprostol, and mifepristone. Physicians could respond with one of the following answers: surgical, medical, no preference, I would not do any type of abortion. 6) reasons not to do abortion: In this section physicians were asked whether there were any circumstances in which they would not do abortions. Respondents who answered yes were asked to rank up to five factors (from a list of 15 factors) that were most important in arriving at a decision not to perform an abortion (1 = most important, 5 = least important). Each factor that received a rank was given a score; a rank = 1 was scored 5 points, rank = 2 was scored 4 points, rank = 3 was scored 3 points, rank = 4 was scored 2 points, and rank = 5 was scored 1 point. Each factor was given a total score by adding responses from all physicians. A high score indicated that the factor was very important in deciding not to do abortions.

Statistical Analysis Software (SAS Institute, Inc, Cary, NC) was used for data file management and statistical analysis. The two Likert scales, attitude and practice scores, were analyzed by nonparametric statistics. Associations between attitude scores and demographic variables, experiences with abortion, and preferences between surgical or medical abortion were examined by Wilcoxon rank-sum and Kruskal-Wallis tests. Correlations between attitude and practice scores were examined by Spearman rank correlation coefficient. Differences between medical and nonmedical attitude subscores were evaluated by signed rank test and compared among three subgroups—proponent, mixed, and opponent physicians—by Kruskal-Wallis test. P values were two-tailed.


   Results
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Abstract
 Materials and Methods
 Results
Discussion
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Of 152 surveys mailed, 82 (53.3%) were returned. Demographic characteristics of the respondents are shown in Table 1Go. Sixty-five percent of the respondents were male, 82% were white, 90% were attending physicians, and the mean age (± standard deviation) was 47.4 ± 13.8 years.


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  		Table 1. Associations Between Attitude Scores and Physician Characteristics
 
Median attitude score was 3.8 (interquartile range 3.3–4.3). Table 1Go shows that attitudes about abortion were significantly associated with physicians’ religion but not with other demographic factors, such as age, gender, ethnicity, marital status, position in the department, or years in practice. Attitude scores were correlated with physician experience with abortion (Table 1Go). Physicians who trained in residency programs in which watching abortions was compulsory had significantly higher (proponent) attitude scores than those who did not. Physicians who would or plan to include abortion services in their practices had higher scores (ie, proponent) than those who would not include abortion.

Physician attitudes about abortion were dependent on the reasons for abortion. The median medical attitude subscore of 4.8 (interquartile range 4.4–5) was higher than the nonmedical attitude subscore of 3.4 (2.8–4.1). There was a significant intraindividual difference in attitude scores between medical and nonmedical subsets (Table 2Go), indicating that physicians found medical reasons for abortion more acceptable than nonmedical reasons. Physicians were divided into three groups (proponent, mixed, and opponent) by tertiles of total attitude score. The intraindividual differences between medical and nonmedical attitude subscores were calculated for each of those groups. The greatest difference between the two subscores was in the opponent group and the least difference was seen in the proponent group. There was a greater likelihood of differing opinions between medical and nonmedical reasons for abortion if the respondent’s overall attitude about abortion was opposition. Proponents were less likely to distinguish between medical and nonmedical reasons for abortion.


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  		Table 2. Intraindividual Differences Between Medical Attitude Subscores and Nonmedical Attitude Subscores
 
Table 3Go shows the total scores for each factor that physicians considered important when deciding not to do legal surgical abortions. "Age of fetus" was the most important factor followed by "lack of proper training," "risk outweighs the benefits to the mother," and "ethical or moral beliefs." When the analysis was limited to practicing physicians (excluding residents), results were unchanged, with "lack of proper training" the second most important factor.


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  		Table 3. Total Scores for Each Important Factor in Decisions Not to Do Surgical Abortions
 
The median practice score was 1.2 (interquartile range 0.8–1.9). There was a significant difference between medical and nonmedical practice subscores (P < .001), with a median intraindividual difference of 0.2 (interquartile range 0–0.7). Physicians were less willing to do abortions for nonmedical reasons compared with medical reasons.

The correlations between attitude scores and practice scores are summarized in Table 4Go. The Spearman correlation coefficients ranging from 0.3 to 0.5 indicate moderate correlations between attitude scores and practice scores; however, preferences of surgical versus medical abortions were not associated with attitude scores (Table 5Go).


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  		Table 4. Correlation of Attitude Scores With Practice Scores
 

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  		Table 5. Attitude Score by Preferences of Surgical or Medical Abortion
 

   Discussion
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Abstract
 Materials and Methods
 Results
 Discussion
References
 
One problem with this study was small sample size, which decreased the statistical power to detect differences. The low response rate might be due to the method of distributing the questionnaire. Mailing was intended to insure anonymity and confidentiality, but abortion is a highly sensitive topic and those polled might have felt uncomfortable answering questions about their attitudes toward it. An anonymous survey was deemed the best method to obtain honest and truthful responses, but reliance on physicians to mail back questionnaires probably led to fewer responses. Although telephone interviews or other direct contact with physicians might have increased the sample size, it could have decreased the likelihood of genuine responses. The response rate was consistent with those of other abortion studies that used mailings to obtain information. This study was also limited by being done in one medical school in the Bronx with mainly male, white, and Jewish participants, so results might not be generalizable to other physician populations across the country.

This study confirmed previous investigations that found religion to be a significant demographic factor affecting attitudes about abortion.4–9 Catholics tended to have the most opponent and Jews the most proponent attitude scores. Although associations between attitude and gender or age were reported previously,10–14 they were not found consistently in this and other studies.7–9 The present study found associations between attitudes about abortion and past experiences with abortion. Physicians who reported being compelled to watch abortions during residency tended to be proponents of abortion, and those who reported being compelled to do abortions during residency were also proponents. However, it is uncertain whether proponent attitudes about abortion were developed during residency training by watching and doing abortions. One might argue that physicians who are already proponents of abortion might elect to train in residency programs in which watching or doing abortions is compulsory.

We found a significant correlation between attitude and practice scores. Physicians who would or do include abortion in their practices also had proponent attitude scores. Those results reinforced the widely held assumption that physicians with proponent views about abortion are more likely to do them.7,13 Among those willing to do abortions, attitudes did not seem to significantly influence preference for surgical or medical abortions.

This study cannot show that opponent physician attitudes about abortion harm women who seek abortions. Physicians who would not do abortions stated that they would refer patients to other physicians who do. Physicians other than obstetricians and gynecologists are being trained in abortion techniques, and several studies have involved those groups15–16; however, some areas of the country have serious shortages of physicians trained in abortion.17 It is common for women to travel several hours to have abortions. Although wealthier women are able to travel to private physicians in other towns, cities, or states to have abortions, poorer women have fewer resources and are more likely to depend on local providers for their health care.18 If the number of hospitals and physicians doing abortions continues to decrease, access to abortion will become severely limited for that population.

It is uncertain whether compulsory training in abortion techniques would increase access to abortion. The attitude factor "ethical or moral beliefs" received just as many first-place ranks as "lack of proper training" by physicians who cited important reasons not to do abortions. If personal beliefs are also involved in decision making, as shown in this study, then increasing abortion availability would have to involve changing those beliefs, which is a difficult and controversial undertaking. Although it might not be possible or desirable to try to change physicians’ beliefs, offering training in abortion, currently unavailable in many medical centers, would allow physicians who are proponents to be trained to do abortion, thereby circumventing a potential shortage of abortion providers.


   Footnotes
 
PII S0029-7844(98)00467-0

Received June 16, 1998. Received in revised form September 28, 1998. Accepted October 15, 1998.


   References
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Abstract
 Materials and Methods
 Results
 Discussion
 References
 
1. Henshaw SK, Van Vort J. Abortion services in the United States, 1991 and 1992. Fam Plann Perspect 1994;26:100–6,112.[Medline]

2. Nathanson CA, Becker MH. Obstetricians’ attitudes and hospital abortion services. Fam Plann Perspect 1980;12:26–32.[Medline]

3. Koslowsky M, Pratt GL, Wintrob RM. The application of Guttman scale analysis to physicians’ attitudes regarding abortion. J Appl Psychol 1976;61:301–4.[Medline]

4. Halverson P, Halverson G, Scheele C. A survey of Milwaukee obstetricians and gynecologists attitudes toward abortion. Wis Med J 1972;71:134–9.[Medline]

5. Weisman CS, Nathanson CA, Teitelbaum MA, Chase GA, King TM. Abortion attitudes and performance among male and female obstetrician-gynecologists. Fam Plann Perspect 1986;18:67–73.[Medline]

6. Wassertheil-Smoller S, Lerner RC, Arnold CB, Heimrath SL. New York state physicians and the social context of abortion. Am J Public Health 1973;63:144–9.[Free Full Text]

7. Stewart PL. A survey of obstetrician-gynecologists’ abortion attitudes and performances. Med Care 1978;16:1035–44.

8. LoSciuto LA, Balin H, Zahn MA. Physicians’ attitudes toward abortion. J Reprod Med 1972;9:70–4.[Medline]

9. Pratt GL, Koslowsky M, Wintrob RM. Connecticut physicians’ attitudes toward abortion. Am J Public Health 1976;66:288–90.[Free Full Text]

10. Rosenblatt RA, Mattis R, Hart LG. Abortions in rural Idaho: Physicians’ attitudes and practices. Am J Public Health 1995;85: 1423–5.[Abstract/Free Full Text]

11. Gammeltoft M, Somers RL. Abortion views and practices among Danish family physicians. J Biosoc Sci 1976;8:287–92.[Medline]

12. Margolis AH, Greenwood S, Heilbron D. Survey of men and women residents entering United States obstetrics and gynecology programs in 1981. Am J Obstet Gynecol 1983;146:541–6.[Medline]

13. Nathanson CA, Becker MH. The influence of physicians’ attitudes on abortion performance, patient management and professional fees. Fam Plann Perspect 1977;9:158–63.[Medline]

14. McKee K, Adams E. Nurse midwives’ attitudes toward abortion performance and related procedures. J Nurse Midwifery 1994;39: 300–11.[Medline]

15. Steinauer JE, DePineres T, Robert AM, Westfall J, Darney P. Training family practice residents in abortion and other reproductive health care: A nationwide survey. Fam Plann Perspect 1997; 29:222–7.[Medline]

16. Lerner D, Taylor F. Family physicians and first-trimester abortion: a survey of residency programs in southern California. Fam Med 1994;26:157–62.[Medline]

17. Seims S. Abortion availability in the United States. Fam Plann Perspect 1980;12:88, 93–101.[Medline]

18. Shelton JD, Brann EA, Schulz KF. Abortion utilization: Does travel distance matter? Fam Plann Perspect 1976;8:260–2.[Medline]




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