The reproductive health workforce has changed considerably in the past few years. It is possible it will continue to evolve over the next decade.
COVID-19 placed an incredible strain on the workforce, says Julia Strasser, DrPH, MPH, director of the Jacobs Institute of Women’s Health and an assistant professor of health policy and management at George Washington University’s Milken Institute School of Public Health.
The workforce is facing a second huge strain because of the U.S. Supreme Court’s decision to overturn Roe v. Wade. Strasser and co-investigators studied how the dual crises of the pandemic and anti-reproductive health policies have affected the workforce that provides contraceptive care and abortion care. The results were startling. “We found the number of physicians providing contraceptive services decreased substantially from 2019 to 2020,” Strasser says. “There was a dramatic decrease in the number of physicians providing contraceptive services. From 2020 to 2021, we saw a little increase, but it never regained that 2019 pre-COVID number, so we’re seeing this loss of physicians in the workplace.”1
When researchers studied the overall number of clinicians providing contraceptive and abortion services, they found the number decreased in 2020 and was restored in 2021, but the type of clinicians providing contraceptive services changed.
For instance, in-person contraception care by physicians decreased from 68,574 in 2019 to 66,904 in 2021. But in-person contraception care by advanced practice clinicians increased from 26,853 in 2019 to 28,782 in 2021.
“The number of advanced practice clinicians — nurses, midwives, nurse practitioners, and physician assistants — stayed almost identical from 2019 to 2020,” Strasser says. “Then, in 2021, we saw an increase in advanced practice clinicians — about 2,000 more advanced practice clinicians in 2021, compared to 2020 and 2019.”
The pandemic also led to a large decrease in contraceptive services in 2020, but they were restored to pre-pandemic levels by 2021. Medication abortions increased from 14,347 in January 2019 to 16,074 in December 2020.
“For this study, we wanted to look at services that had to be provided in person, including injection, IUD, and implant, and not prescription contraception like the pill, patch, and ring,” Strasser explains. “We wanted to look at that during COVID because we knew that prescriptions could continue during COVID, but in-person services got paused, especially in the first months, with clinic closures.”
It is possible the physicians who withdrew from the contraceptive care workforce shifted their services to provide different types of contraception, or they may have switched to working in primary care. Some may have quit working in clinical care due to burnout and lack of support during the pandemic.
“They may have shifted to other services — or dropped out of the workforce altogether,” Strasser says.
Another notable finding was that more physicians provided abortion care in 2021 than in 2019. Both medication and procedural abortions increased, with 3,136 physicians providing abortions in 2019 and 3,293 doctors providing abortions in 2021. In 2020, the overall number of physicians providing abortion care decreased to 3,020.
“We were not completely surprised by the findings,” Strasser acknowledges. “We saw an increase in physicians providing abortions while seeing a decrease in contraceptive clinicians.”
The data came from insurance claims, so researchers could only capture information about providers that bill insurance for their claims. “A number of people do not use insurance, or can’t because of state policies,” Strasser says. “This is not the entire universe of every abortion provider, but a comprehensive look at abortion providers who can bill for their services.”
Investigators will continue to assess data through 2022. “We want to get data on 2022 so we can see what happened to the workforce after the Dobbs ruling, to see if there is a huge drop,” Strasser explains. “This study gives us a look at the workforce in the years leading up to Dobbs, but 2022 data are not available yet.”
The loss of physicians providing contraception care and the gain of advanced practice providers is not an even exchange because physicians are training the next generation of reproductive health clinicians. Fewer physicians may mean fewer well-trained medical students and residents, and the cycle can escalate.
“If providers cannot gain the clinical skills they need to provide an abortion or insert an IUD, they cannot adequately train the next generation of providers,” Strasser says. “Emergency medicine clinicians may see more [pregnant patients], and they may have less training to handle it.”
Another factor will be even worse health discrepancies between those who have the resources to leave the state for contraception and/or abortion care and those who do not. “When people do not receive the care they need, this definitely results in worse outcomes,” says Ellen Schenk, MPP, study co-author and a research associate at the Fitzhugh Mullan Institute for Health Workforce Equity at the Milken Institute School of Public Health.
The pandemic’s effect on the physician workforce may continue in the next few years. “Our findings suggest there is an ongoing loss of physicians providing contraception services, which is concerning,” Schenk says. “Targeted investments in women’s health and primary care clinicians and state-level expanded scope of practice policies may strengthen this segment of the workforce.” More primary care clinicians should offer a full scope of care, including family-planning services, she adds.
Primary care providers need to be prepared to provide reproductive healthcare, including abortion care, to fill the access gap in many states, according to the authors of a recent paper.2
“For a medication abortion, you have to have some baseline knowledge of how the medications work and who it is appropriate to prescribe the medications to,” says Rachel S. Casas, MD, EdM, lead author of the paper and an associate professor of medicine in the division of general internal medicine at Penn State Milton S. Hershey Medical Center. “But it’s not like learning an abortion procedure, where you need a whole bunch of training to be proficient.”
More general internists need to know how to prescribe a medication abortion, or at least be aware of what is going on and support patients when they seek abortion care — even if they do not prescribe it themselves.
“With the pandemic, we’ve all become much more comfortable and adept at providing appropriate care and telehealth,” Casas says. “Medication abortion is safe and effective to provide through telehealth. That’s an area where we’ll continue to see more telehealth in the future as we progress further past the pandemic.”
In the Dobbs era, people who self-managed abortions may hesitate to seek medical care out of fear of arrest and prosecution. There are no federal or state laws that require clinicians to report someone suspected of a self-managed abortion and doing so is a HIPAA violation. Primary care providers can direct patients to resources to minimize their legal risk and encourage them to only ingest or use a safe medication abortion pill when attempting to end their pregnancy.2
Many physicians and general internists are ready to help women maintain their reproductive rights and have access to contraception and abortion care, but they are not sure what to do, says Hillary J. Gyuras, MA, a research associate in public health at The Ohio State University.
“There’s a lot we can do that is already aligned with what we do in primary care,” Gyuras adds. “We can reach out to colleagues in internal medicine and other departments.”
General internists also can support hospitals providing appropriate patient care and collaborate with OB/GYNs and other colleagues in making institutional policies and procedures that facilitate doctors making the best decision for pregnant women’s health and medical care.
“We can advocate for our patients on the political level,” Gyuras says. “There are a lot of areas where we’re interested and ready to help.”
REFERENCES
- Strasser J, Schenk E, Dewhurst E. Changes in the clinical workforce providing contraception and abortion care in the US, 2019-2021. JAMA Netw Open 2022;5:e2239657.
- Casas RS, Horvath SK, Schwarz EB, et al. Managing undesired pregnancy after Dobbs. J Gen Intern Med 2022;37:4272-4275.
The reproductive health workforce has changed considerably in the past few years. It is possible it will continue to evolve over the next decade. COVID-19 placed an incredible strain on the workforce, and it is facing a second huge strain because of the U.S. Supreme Court’s decision to overturn Roe v. Wade.
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