Identifying Opportunities to Improve the Integration of Sexual and Reproductive Health Services into Primary Care: Qualitative and Quantitative Approaches

Abstract

Objectives: Unintended pregnancy is endemic in the United States. Primary care physicians (PCPs) are optimally positioned within the health care system to improve the prevention and management of unintended pregnancy by offering comprehensive contraception and abortion care. Factors at the individual, health center, health systems, and policy levels may influence whether PCPs offer these services. Current practice, knowledge, and attitudes about contraception and abortion among PCPs are poorly understood. This investigation fills these gaps using original quantitative and qualitative data. Methods: This mixed-methods investigation included: 1) a quantitative survey querying a national probability sample of practicing PCPs about contraception, abortion, and other sexual and reproductive health services; 2) a qualitative investigation of determinants of provision of long-acting reversible contraception (LARC) in community health centers (CHCs) through focus group discussions. We applied case weights to survey responses and generated population estimates of current and lifetime abortion provision and current provision of contraceptive methods. Logistic regression modeling identified factors associated with abortion and LARC provision. Qualitative data were coded inductively by multiple investigators using an iterative consensus-based method. Results: Factors at the health systems and health center levels influence provision of abortion and contraception in primary care. In the survey data, the strongest correlate of having received training in, endorsing training in, or reporting current provision of abortion and all contraceptive methods was residency training in family medicine, as compared to general internal medicine or other residency. PCPs generally support residency training in abortion and contraception. The primary reported barriers to abortion provision were lack of training and resources. Prior training, practice type, and health systems-level factors were associated with provision of abortion and contraception; most physician demographics were not. In the qualitative investigation, insurance issues, device stocking, and scheduling of LARC method placement emerged as primary influences on the pathway to care for women seeking these methods. Conclusions: PCPs are receptive to contraception and abortion training and service provision. Efforts to support delivery of these services could include enhanced clinical training and interventions at the health center and health systems levels to ensure access to requisite resources.