title: "She's on her own": a thematic analysis of clinicians' comments on abortion referral.
abstract: OBJECTIVE
  The objective was to understand the motivations around and practices of abortion referral among women's health providers.
  
  
  METHODS
  We analyzed the written comments from a survey of Nebraska physicians and advanced-practice clinicians in family medicine and obstetrics-gynecology about their referral practices and opinions for a woman seeking an abortion. We analyzed clinician's responses to open-ended questions on abortion referral thematically.
  
  
  RESULTS
  Of the 496 completed surveys, 431 had comments available for analysis. We found four approaches to abortion referral: (a) facilitating a transfer of care, (b) providing the abortion clinic name or phone number, (c) no referral and (4) misleading referrals to clinicians or facilities that do not provide abortion care. Clinicians described many motivations for their manner of referral, including a fiduciary obligation to refer, empathy for the patient, respect for patient autonomy and the lack of need for referral. We found that abortion stigma impacts referral as clinicians explained that patients often desire additional privacy and clinicians themselves seek to avoid tension among their staff. Other clinicians would not provide an abortion referral, citing moral or religious objections or stating they did not know where to refer women seeking abortion. Some respondents would refer women to other providers for additional evaluation or counseling before an abortion, while others sought to dissuade the woman from obtaining an abortion.
  
  
  CONCLUSIONS
  While practices and motivations varied, few clinicians facilitated referral for abortion beyond verbally naming a clinic if an abortion referral was made at all.
  
  
  CONCLUSIONS
  Interprofessional leadership, enhanced clinician training and public policy that addresses conscientious refusal of abortion referral are needed to reduce abortion stigma and ensure that women can access safe care.
authors.affiliation: Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Nazeneen
authors.initials: N
authors.lastname: Homaifar
authors.affiliation: Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA; Advancing New Standards in Reproductive Health, Oakland, CA, USA; Bixby Center for Global Reproductive Health, San Francisco, CA, USA.
authors.forename: Lori
authors.initials: L
authors.lastname: Freedman
authors.affiliation: Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA; Bixby Center for Global Reproductive Health, San Francisco, CA, USA. Electronic address: vfrench@kumc.edu.
authors.forename: Valerie
authors.initials: V
authors.lastname: French
mesh_terms: D000028:Abortion, Induced / Q000941:ethics / Q000523:psychology; D001291:Attitude of Health Personnel; D003376:Counseling; D005194:Family Practice / Q000941:ethics / Q000706:statistics & numerical data; D005260:Female; D006176:Gynecology; D006801:Humans; D000072577:Moral Status; D009774:Obstetrics; D010818:Practice Patterns, Physicians' / Q000941:ethics / Q000706:statistics & numerical data*; D011247:Pregnancy; D012017:Referral and Consultation / Q000941:ethics / Q000706:statistics & numerical data*; D012067:Religion; D057545:Social Stigma; D011795:Surveys and Questionnaires
keywords: Abortion; Abortion referral; Crisis pregnancy center; Professionalism; Referral