Attitudes towards models of abortion care in sexual and reproductive health: perspectives of Australian health professionals

Introduction

Changes to service delivery in the sexual and reproductive health (SRH) sector have been proposed many times by academics and those working in SRH globally to address barriers to early abortion access, such as the lack of appropriately trained abortion providers (Sharma and Guthrie 2006; Culwell and Hurwitz 2013; Mainey et al. 2020). Abortion care is typically led by a doctor: usually an obstetrician and gynaecologist or general practitioner (GP); however, several models of nurse-led care have been proposed both in Australia (de Moel-Mandel et al. 2019) and in the UK (Sheldon and Fletcher 2017) to increase access to abortion services, while maintaining high levels of safety and efficacy. Limitations to implementing nurse-led models of care include a lack of training, lack of funding, and current regulations and legislation (Moulton et al. 2021). Additionally, the rate of self-managed abortions is increasing, with medications obtained online (Aiken et al. 2018), although little is known about this practice in Australia (de Moel-Mandel et al. 2019). Our research aimed to explore Australian health professionals’ perceptions of models of service delivery. Specifically, we were interested in health professionals working in SRH care’s attitudes towards nurse-led care and self-administered abortion care. We were also interested in whether different groups of health professionals (i.e. doctors and nurses) held differing attitudes towards the various models.

Abortions performed earlier in pregnancy are safer than those performed at later gestations, as complications increase with increasing gestational age of the pregnancy (RCOG 2004). A globally recognised strategy to improve access and address the shortage of abortion providers is to enlist nurses and or midwives. Research supports safe, effective provision of early medical abortion by these other clinicians (Barnard et al. 2015; WHO 2015). Currently in Australia, medication abortion can be accessed via telemedicine and in-person/in-clinic care, and is delivered by a range of services, such as non-government organisations and primary care (GP’s, family planning, etc.). Additionally, some practices offer nurse-facilitated provision with GP oversight until 63 days’ gestation (de Moel-Mandel et al. 2019). Surgical abortion is also available, with some arguing that nurses could also provide manual vacuum aspiration abortions safely (Sheldon and Fletcher 2017). Although barriers to completely nurse-led care are regularly under review, such as the 2023 regulatory changes that enabled nurses to access medical abortion training and become prescribers, or jurisdictional legislative changes (i.e. Queensland) that reduce risk of nurse prescribers being criminalised (Queensland Government 2023), many other legislative and regulatory requirements continue to render nurse-led models unfeasible.

One factor influencing public and organisational policy decisions regarding models of care, and hence the services available, is the attitudes of key stakeholders, such as health professionals. Attitudes towards nurse-led abortion care tend to be mixed. For example, de Moel-Mandel et al. (2019) found that a panel of physicians, nurses and experts provided overall support for a nurse-led model of medical abortion in Australia (75%), but only 58% of respondents felt that nurses should be allowed to solely manage the entire abortion process. Desai et al. (2022) found that 62.3% of nurses and midwives who responded to their Queensland-based survey believed that specialist doctors and GPs should provide abortion care, compared with 35.5% believing that abortion provision should be within the scope of nurses. However, in the US, across states, 31–65% of nurse-midwives supported nurse-led models. Less is known about attitudes toward self-administered abortion, with qualitative studies suggesting ~50% of abortion providers perceive self-administered abortions as unsafe (Kerestes et al. 2019a). These mixed attitudes and the lack of consensus from the key providers of abortion create barriers to change at a legislative, educational and practical level (Mainey et al. 2020). Similarly, attitudes about abortion generally tend to be quite strongly held, making changes to legislation often difficult and untimely (Arisi 2003).

One factor influencing whether an attitude will change is the strength with which it is held. Stronger attitudes tend to be more stable over time, resistant to change, crystallised, and impact information processing and behaviour, compared with weak attitudes (Krosnick and Abelson 1992; Krosnick et al. 1994; Haddock and Maio 2009). Although there are many components of attitude strength, the current study measured attitude ambivalence. Attitude ambivalence is defined as the ‘simultaneous endorsement of both favourable and unfavourable positions’ (Haddock and Maio 2009, p. 77), and research suggests that highly ambivalent attitudes are more susceptible to change (Armitage and Conner 2000).

Method

Results

Percentages of those reporting favourable, unfavourable, and neutral attitudes were calculated and are shown in Table 1. Both nurse-led and doctor-led models of care were perceived favourably, whereas self-administered care was generally perceived unfavourably.

Three repeated measures ANOVAs assessed whether attitudes differed towards doctor-led, nurse-led and self-administered care. There were significant differences in how favourably the three models of care were viewed (F(1, 53) = 38.32, p < 0.001, ηp2=0.420). Post hoc analyses showed that doctor-led care was viewed significantly more favourably than self-administered care (p < 0.001), but not nurse-led care (p = 0.276). Nurse-led care was viewed significantly more favourably than self-administered care (p < 0.001). Means are shown in Table 2.

There were significant differences between how conflicted participants felt about the three models of care (F(1, 50) = 38.55, p < 0.001, ηp2=0.435). Post hoc analyses showed that participants were significantly less conflicted about doctor-led care than nurse-led care (p = 0.019) and self-administered care (p < 0.001). Participants also felt significantly less conflicted about nurse-led care than self-administered care (p < 0.001).

Finally, there were significant differences in whether participants held mixed feelings about the three models of care (F(1, 50) = 28.850, p < 0.001, ηp2=0.366). Post hoc analyses showed that participants had significantly less mixed feelings about doctor-led care than nurse-led care (p = 0.031) and self-administered care (p < 0.001). Participants also had significantly less mixed feelings about nurse-led care than self-administered care (p = 0.001).

The professions significantly differed on how favourably they viewed doctor-led models of care (F(1, 2) = 5.146, p = 0.009). Post hoc analyses showed that doctors held more favourable views of doctor-led models of care than nurses (p = 0.005). The comparison between doctors and administrative staff was approaching significance (p = 0.064), suggesting doctors hold marginally more favourable views of doctor-led care than administrative staff. Nurses and administrative staff were not significantly different in how favourably they viewed doctor-led care (p = 1.00). Means are shown in Table 2 and presented in Fig. 1.

Fig. 1.

Attitudes towards models of care by participant profession.

There were no significant differences between the three professions in how favourably they viewed nurse-led models of care (F(1, 2) = 2.310, p = 0.110), and self-administered models of care (F(1, 2) = 1.432, p = 0.248).

Three one-way ANOVAs were conducted to test whether the three professions differed in how conflicted they felt about each of the three models of care. The professions significantly differed on how conflicted they felt about doctor-led care (F(1, 2) = 3.693, p = 0.032). Post hoc analyses showed that doctors held less conflicted views of doctor-led models of care than administrative staff (p = 0.027), but not nurses (p = 0.286). Nurses and administrative staff were also not significantly different in how conflicted they were about doctor-led care (p = 0.503).

The three professions did not differ on how conflicted they felt about nurse-led care and self-administered care (F(1, 2) = 1.545, p = 0.223 and F(1, 2) = 2.752, p = 0.074, respectively), although the latter was approaching significance. Post hoc comparisons suggest that doctors held marginally more conflicted views of self-administered care than administrative staff (p = 0.074), but not nursing staff (p = 0.776). Nurses and administrative staff were also not significantly different in how conflicted they were about self-administered care (p = 0.444).

Three one-way ANOVAs were conducted to test for differences between the three professions in whether they had mixed feelings about the three models of care. There were no significant differences between the professions on the degree to which they had mixed feelings about doctor-led care (F(1, 2) = 2.511, p = 0.091) and nurse-led care (F(1, 2) = 0.929, p = 0.0402).

The one-way ANOVA for the self-administered model of care was significant (F(1, 2) = 3.491, p = 0.038). Post hoc analyses showed that doctors had significantly more mixed feelings about self-administered abortion care than administrative staff (p = 0.049), but not nurses (p = 1.00). Nurses and administrative staff were also not significantly different (p = 0.150).

Qualitative findings

We discuss below the concepts identified by the Leximancer analysis for each of the models of care (see Fig. 2). Key concepts are displayed as coloured circles, and relationships between the concepts/co-occurring words are connected by lines. Exemplar quotes that relate to each of the concepts are presented.

Fig. 2.

Leximancer concept map by model of care.

Doctor-led care

The predominant concept pertaining to doctor-led care was that it was the best model of care (see Fig. 2). Participants stated doctor-led care was the ‘gold standard’ (P41, nurse) and ‘best practice’ (P51, doctor) model of care for patients, with most stating it was fine or good and worked well, ‘Good model, but there is capacity for follow up by nurses … Provision of TOPs should be performed by Drs’ (P25, doctor). Participants provided several reasons why it was best, but, essentially, they felt it worked. Doctor-led care was considered comprehensive care, where patients not only received care pertaining to their abortion, but also contraception and their health in general. This viewpoint was particularly endorsed by doctors. For example, P83 (doctor) stated, ‘I feel [doctor-led care is] a vital service and gave [sic] women a face-to-face opportunity to discuss her options and consider contraception at the same visit’, while P62 (doctor) noted, ‘I am able to discuss in depth every aspect of abortion and sexual health/contraception … I have an in-depth knowledge of all aspects of women’s health care.’

Several participants also claimed this model was the safest model for patients, ‘This is safest model’ (P64, nurse). For some, there was a sense this was the way things were done; that the ‘status quo’ was being maintained for the doctors (P27, nurse). Others associated medical procedures with doctors, ‘Abortion is a medical procedure; therefore, it should be doctor led’ (P23, doctor).

Several participants described doctor-led care as a holistic model or ‘community-based approach’ (P86, admin), where health professionals, such as nurses and social workers, had significant roles, and the doctor’s role was clearly delineated within the team (i.e. prescribing). They disagreed that the predominant model was doctor led; ‘I don’t really agree that this was the case for many abortions … The Drs may prescribe and complete a procedure, but I don’t consider this to be ‘led’ by Dr’ (P66, nurse), although definitions of what constitutes care may differ, ‘… I believe it has always been an integrated model, as doctors have very little input into bookings or client calls until the situation has been presented to the doctors’ (P16, doctor).

Several comments were made about the resources/staffing required to offer doctor-led care, ‘I feel it certainly has its place, but can become limited due to unavailability’ (P49, nurse). There was also a concern expressed by some participants that this model of care was not the best use of a doctor’s time and expertise, ‘This has always been acceptable, but problematic with skilled GPs or proceduralist availability. Limited precare/consultation and phone when follow-up appointments were required’ (P65, nurse). Others directly called the model into question, ‘… The [doctor-] led model showed little respect for the role of the registered nurses and midwives. There has been little encouragement and value placed on those showing initiative and developing/maintaining skills within their scope of practice’ (P27, nurse).

Nurse-led care

Central to the nurse-led care model were concepts of clients, care and access, with medical abortions most commonly mentioned. Most participants felt nurse-led models of care were appropriate and acceptable, with nurse-led clinics seen as the ‘future’ of abortion care (P26, nurse), ‘… I would like to see a nurse practitioner lead in the clinic, driving medical terminations. This would expand on service delivery and allow clients to have better access to care’ (P49, nurse). Provision of abortion was considered well within the scope of practice for nurses. Many participants specified that for this model to be acceptable, nurses needed appropriate training, education and experience. Others specified this model was acceptable for low-risk, uncomplicated care and MTOPS, but not for procedures such as vacuum aspiration, ‘Nurse-led care is appropriate where there is adequate and specialised training in abortion is provided in low-risk cases’ (P62, doctor). For others, nurse-led models were only appropriate when doctor-led care was not feasible, ‘suitable for medical abortion in remote areas where no doctor is readily available’ (P81, doctor).

Advantages of this model were increased accessibility and decreased wait times, while also diversifying the workload for nurses, ‘… helps to give our nurses a more diverse work routine, which in turn improves their satisfaction with the role’ (P12, nurse). One doctor also noted ‘Anything that make abortion care more accessible is a good thing’ (P82). Others felt that nurse-led models provided a better patient experience, ‘patient feedback is usually centred around the nurses, who generally receive rave reviews! … Patients may report feeling rushed and unsure of doctor-led information, but do not seem to feel this from the nurses. Patients report feeling supported by the nurses, so again, nurse-led care seems like a positive change when looked at from a patient’s perspective’ (P20, admin).

However, some concerns were raised regarding increased responsibility, workload and pressure on nurses, ‘A step forward to nurses and nurse practitioner opportunities, however, did increase duties/responsibilities, which can be difficult to resource’ (P65, nurse).

Self-administered care

The self-administered model of care received mixed feedback, and was associated strongly with the concept of danger, ‘Doesn’t sound good. Dangerous. There’s a reason we have nurses and doctors. It’s HEALTH CARE’ (P74, admin), and not to be encouraged, ‘Where there is ready access to abortion care supported by trained healthcare practitioners, I don’t feel it is best practice or to be encouraged’ (P82, doctor). Others noted feeling ‘scared’ (P58, nurse), with concerns raised about patient health literacy, access to appropriate aftercare and the person not having support, ‘Self-administered abortion care is dangerous due to low health literacy with regard to reproductive health and high stigma regarding abortion, leading to misinterpretation, misuse and delays in seeking emergency care’ (P12, nurse).

Some felt it might be appropriate for some women, whereas others felt it was never appropriate, ‘It is not appropriate, as many women have no realistic concept of their gestation or risks’ (P16, doctor). ‘I believe there should be medical input for abortion care always given the risk of ectopic, incorrect administration, what to do with excessive bleeding/pain etc.’ (P31, doctor). Approximately half of the doctors who participated felt this model resulted in missed opportunities to provide comprehensive care, ‘I worry women may not have an appropriate health check, and also contact with a health professional is often a good time to perform some health screening and contraceptive counselling’ (P25, doctor). Others noted this model might be possible, with appropriate checks and balances, ‘I wouldn’t be opposed. Most important is that people self-administering have access to clear, easy to understand information about the process, ideally in a language of their choice; as well as a clear path to seeking assistance for any questions or complications’ (P82, doctor), and in circumstances where other models of care were not available, ‘women should definitely have the choice to self-administration in circumstance where doctor-led or nurse-led care is not possible’ (P41, nurse).

Those in favour of self-administered abortion highlighted the importance of this model in facilitating timely access to an abortion, ‘This needs to be the reality for all clients accessing early and timely intervention in unplanned pregnancy. Most women and pregnant people are able to manage this process with adequate support and education. It is an essential service and needs to be more accessible’ (P27, nurse). Others saw self-abortion as part of a woman’s choice, enabling autonomy, and empowering women. ‘Totally for it with appropriate support and education. Creates a space which is empowering women and pregnant people to access choice and autonomy of care’ (P45, admin).

Discussion

Our study aimed to examine the acceptability of different models of abortion care, and whether attitudes towards the different models of care differed by profession. We found that both doctor-led and nurse-led models of care were both perceived favourably, with >80% of participants perceiving a nurse-led model favourably. However, self-administered care was perceived unfavourably by ~60% of participants, and associated with significant safety concerns. Participants were most conflicted and had more mixed feelings about self-administered care, followed by nurse-led models, and least ambivalence around doctor-led care.

Regarding differences in attitudes by the three professions, we found that doctors perceived doctor-led care more favourably than nurses, and doctors had less ambivalence around their preference for doctor-led care than administrative staff. Qualitative findings suggested doctors believed doctor-led care provided those seeking abortion care with a more holistic experience, that opportunistically facilitated discussions about other sexual and reproductive health matters. Consistent with de Moel-Mandel’s study (de Moel-Mandel et al. 2019), we found that ~75% of doctors and nurses reported favourable attitudes towards nurse-led care, and the model was perceived as key to providing timely and accessible abortion care. It was also seen as an opportunity to diversify the workload for nursing staff, although several concerns were raised regarding the need for training, support and whether the workforce would manage the additional pressure/responsibility. The proportion of those with favourable attitudes is significantly higher than the levels of acceptability found by Desai et al. (2022) in their Queensland study, perhaps suggesting that attitudes held nationally are more favourable than those in Queensland. Conversely, it may be that those working in sexual and reproductive health, where nurse-facilitated care is common, hold more favourable attitudes than Desai’s broader sample.

Approximately 60% of our nurses reported somewhat favourable attitudes towards self-administered abortion compared with only 16% of doctors. Interestingly, attitudes for administrative staff were split roughly 60:40 and mostly unfavourable. To our knowledge, no other research has compared attitudes towards self-administered abortion across health professionals. However, qualitative studies from the US suggest that 50% of health professionals perceive self-administered abortion as unsafe (Kerestes et al. 2019b), with a tension between safety and promoting patient autonomy (Baldwin et al. 2022). This is consistent with our qualitative findings, but not emerging evidence on the efficacy of self-administered medical abortions, which ranges from 75 to 99.5% efficacy (Moseson et al. 2020). Although our findings suggest low overall rates of favourability, we also found high levels of ambivalence around self-administered abortion. Research suggests ambivalent attitudes are more susceptible to change, and thus, as more research emerges on the efficacy of self-administered abortion, attitudes may become more positive.