The Delivery of Medical
Abortion Services: The Views
of Experienced Providers
Linda J. Beckman, PhD
California School of Professional Psychology
Los Angeles, California
S. Marie Harvey, DrPH
Center for the Study of Women in Society
University of Oregon
Sarah J. Satre, MA
Applied Research Northwest
This study examined beliefs about the delivery of medical abortion services
and current roles of 76 providers of methotrexate-induced abortion. The sampleincluded physicians, midlevel professionals, administrators, and counselors/othermedical staff. Over 75% of participants believed that, given proper training andemergency backup, physicians and midlevel clinicians alike could provide medicalabortions. Over 85% agreed that methotrexate-induced abortions could be provided inany physician’s office or medical facility. There were no differences in perceptions byparticipant group. Involvement of midlevel providers in provision of medical abortioncould potentially increase access and options for women seeking to terminate an earlypregnancy.
type of abortion available to most American women has been surgical(suction curettage) abortion. Women’s health advocates have longrecognized the need for more than one abortion method. The impor-
tance that women place on individual attributes of abortion as well as thesociocultural contexts of their lives influence their comfort and satisfactionwith surgical abortion. Some women may greatly prefer an alternative methodthat is nonsurgical and less medicalized. Medical abortion provides such analternative.
Medical abortion, induced by drugs administered orally, vaginally, or by
injection usually within 49 to 56 days of gestation has been available in some
countries for over a decade. The two major drugs used to induce abortions are
of Women’s HealthPublished by Elsevier Science Inc.
mifepristone, an antiprogestin, and methotrexate, an antimetabolite. Both
usually are followed by one or more dosages of the prostaglandin, misoprostol,
BECKMAN ET AL: PROVIDERS’ VIEWS OF MEDICAL ABORTION 103
administered vaginally or orally. Although many clinicians consider mifepris-tone the more promising of these drugs because it is more predictable andmore quickly allows completion of the abortion,1,2 the unavailability ofmifepristone for distribution in the United States led medical researchers in theearly 1990s to examine the use of methotrexate to induce abortion.3–5 Metho-trexate has had U.S. Food and Drug Administration (FDA) approval since 1953for the treatment of cancer. Therefore, its off label use allows clinicians tolegally prescribe this drug for medical abortion. Recently, mifepristone alsobecame available for women in the United States. On September 28, 2000, after12 years of political struggle, the FDA gave final approval for physicians toprovide the drug for use as an abortifacient.
Both mifepristone and methotrexate have been shown to be safe and
relatively effective, with completed abortion rates exceeding 90% for womenwith pregnancies of less than 49 to 56 days’ duration.4,6,7 Thus, whenconsidering its effectiveness, in conjunction with few side effects and the earlygestational age at which the abortion can take place, drug-induced abortionprovides a feasible option for women who are seeking an early abortion. Inparticular, this method is a valuable alternative to the standard therapy ofsuction curettage for women who desire a nonsurgical method, prefer amethod that they perceive as more natural and more private, or have lifecircumstances that make a drug-induced abortion a preferable option.8,9Moreover, women who have used mifepristone or methotrexate both in theUnited States and abroad generally have been satisfied and would choose themethod again to terminate an unwanted pregnancy.8,9
The availability of medical abortion in the United States is closely tied to
the issue of expanding abortion services for women. In recent years, thenumber and geographic dispersion of surgical abortion providers has de-creased,10 raising concerns about women’s continued access to safe legalabortion in the United States. Moreover, a trend toward concentration ofabortions in specialized freestanding clinics in largely urban settings hasintensified, with almost 70% of all abortions performed in such settings.10 Thisconcentration of abortion services heightens the ability of antiabortion dem-onstrators and provocateurs to identify and target abortion providers and theirpatients. The harassment and violence directed toward abortion providers mayhave led many physicians to choose not to offer surgical abortions because oflegitimate concerns about harassment, threats, and danger to self and family.
Although medical abortion shares certain service delivery characteristics
with its surgical cousin (e.g., preabortion counseling, need for emergencybackup, aftercare), it holds promise for expanding options, increasing access toservices, and improving continuity of care for women in the United States whoseek to terminate an early pregnancy. Medical abortion could be administered
outside of an identified abortion clinic, under confidential circumstances and
by a variety of health care providers. Thus, it potentially could decentralize theprovision of abortion, increase the numbers, types, and geographic distribution
of abortion providers and thereby reduce other barriers such as antiabortion
To maximally increase access and options for abortion services, practitio-
ners other than physicians will need to be allowed to provide medical abortion.
In particular, midlevel clinicians such as nurse practitioners (NPs), certifiednurse midwives (CNMs), and physician assistants (PAs) could be trained toroutinely provide these methods. Professional groups such as the NationalAbortion Federation (NAF) and Clinicians for Choice have strongly advocatedthat qualified providers others than physicians be fully empowered to deliverall types of abortion services. Yet, all but six states have enacted laws thatrestrict the practice of abortion to physicians only.12 Few studies haveexamined the beliefs of experienced abortion providers regarding appropriate
WOMEN’S HEALTH ISSUES VOL. 12, NO. 2 MARCH/APRIL 2002
health professionals and health care settings for the provision of medicalabortion. A recent national study of health care providers found that onlyabout one-third of obstetricians/gynecologists and family practice physiciansbelieved midlevel providers should be allowed to offer medical abortion.2 Onthe other hand, in Joffe’s study1 of a small sample of 25 providers of surgicalabortion, many of whom also had some experience with medical abortion,respondents saw medical abortion as a vehicle to draw midlevel practitionersinto the provision of direct abortion services.
This study examined the perceptions of experienced methotrexate abor-
tion providers about who could provide methotrexate abortions and in whatsettings it could be provided. Our objectives were to: a) compare the specificroles of different health care personnel in provision of methotrexate-inducedabortion; b) determine whether current providers of methotrexate-inducedabortions believe that midlevel clinicians could provide this type of abortion;c) examine current providers’ views about the health care settings in whichmethotrexate abortion could be safely provided; and d) explore the concerns ofcurrent providers related to provision of methotrexate-induced abortion bynew providers and new health care settings. Health care practitioners whohave recent experiences with both medical and surgical abortion regimes aremost familiar with required protocols and procedures, and are, therefore, in thebest position to evaluate which professional groups possess the skills andexperience to adequately provide medical abortion. Because many types ofprofessionals participate in the provision of medical abortion, includingphysicians, midlevel clinicians, counselors, and administrators, all of thesegroups were included in this study.
Seventy-six telephone interviews were conducted with providers of metho-trexate-induced abortion during May and June of 1997. Drawing from a NAFlist of facilities that offered medical abortion, snowballing sampling techniqueswere used to identify potential participants. With snowball sampling, it ispossible that providers identified colleagues whose views were similar to theirown. The fact that many different respondents often referred the sameindividuals suggests that we obtained good coverage of those providingmethotrexate abortions in the United States.
The sample included individuals who had provided methotrexate abortions
in the United States before 1997. As previously mentioned, because of the key roleplayed by nonphysicians, “providers” included all staff who had close contactwith methotrexate patients or were significantly involved in the provision of theseabortions. The sample included providers from five private practices; all othersworked in clinic settings. Facilities were located in 18 states. Seventy-six of the 107providers contacted (70%) agreed to participate. The response rate among physi-cians was lower (53%) than among nonphysicians (82%).
The sample was composed of physicians (28%); NPs, CNMs, and PAs
(13%); administrators (29%); and counselors/other medical staff (30%). Therespondents were largely non-Hispanic white (89%) and were between 35 and50 years of age (Table 1). Fifteen (20%) were men and 61 (80%) were women.
The median number of methotrexate patients seen was 30, but almost 30% ofthe sample had provided 60 or more methotrexate-induced abortions.
Using structured interview guides, trained staff conducted 30-min telephone
interviews with respondents. Responses to closed-ended questions were codedand detailed notes of participants’ open-ended responses were recorded. Pretestedcoding schemes were developed to capture the content, themes, or sentiments ofopen-ended responses and comments made during the interview. The content of
BECKMAN ET AL: PROVIDERS’ VIEWS OF MEDICAL ABORTION 105
DEMOGRAPHIC CHARACTERISTICS OF THE SAMPLE
these data was then summarized by a member of the team and verified by another.
Descriptive and quantitative analysis of responses to the close-ended questionsand the sociodemographic characteristics of the sample were conducted usingSPSS (Statistical Package for the Social Sciences) software.
We asked participants to describe their specific roles in the provision ofmethotrexate-induced abortion in their facilities. Seven types of roles emerged:administrative tasks, screening, counseling, medical evaluation, preabortionultrasound, injection, and follow-up care (Table 2). With the exception of themethotrexate injection, providers were not given a list of tasks and askedwhich tasks they performed. Rather they were asked an open-ended questionabout their roles. Therefore, the data most likely reflect what participants seeas their main roles in the provision of methotrexate-induced abortions; othertasks may be underreported.
Physicians, more than any other participant group, described administra-
tive tasks when asked to describe what roles they play in provision ofmethotrexate-induced abortions. Nearly two-thirds of physicians (62%) re-ported performing these duties—most often writing and teaching protocols,supervising staff, and having ultimate responsibility for patient care. Physicianinvolvement with patients varied widely among facilities. Some physicianshad no contact with patients except to intervene when complications arosewhereas others handled all phases of the abortion. Typically physicians choseto participate in the process to some extent. For instance, 43% mentionedhandling patients’ initial medical evaluations, and 38% said they took part inwomen’s follow-up care. Interestingly, just over half (57%) of the physicians
WOMEN’S HEALTH ISSUES VOL. 12, NO. 2 MARCH/APRIL 2002
PERCENT REPORTING SPECIFIC ROLES IN THE PROVISION OF
METHOTREXATE-INDUCED ABORTIONS BY PARTICIPANTGROUP
*Scheduling patients; handling billing, insurance, or collections; initiating, researching, writing, or teaching theprotocol for methotrexate-induced abortions; supervising or having ultimate responsibility for patient care; andpublic relations and community education.
†Initial or final screening of patients to assess their eligibility or appropriateness for methotrexate; candidateselection.
‡Providing substantive information to patients about the abortion methods available; helping patients choose themethod appropriate for them; providing emotional support; obtaining informed consent; filling out paperwork;instructing patient on how to care for herself during the abortion (when to insert the tablets, how to identifyproblem bleeding, using pain medication); and how to complete diaries.
§Taking vital signs, performing physical exams, drawing blood, taking medical histories; calculating the dosageof methotrexate; and lab work.
Answering patients’ questions once they have gone home after the injection; performing the postabortionultrasound; handling follow-up visits.
surveyed gave the methotrexate injections themselves. Among them, somereported that state regulations or insurance companies require that they do so.
Data indicate that midlevel providers play a prominent role in the provision
of methotrexate-induced abortions. All ten midlevel professionals surveyed re-ported doing preabortion ultrasounds, eight handled medical evaluations, eightgave methotrexate injections, six handled follow up care, and four performedcounseling duties. Not surprisingly, midlevel personnel often serve as the princi-pal provider for the methotrexate patients in their facilities.
One of the principal duties of administrators, counselors, and other
medical staff was to ensure that women had appropriate knowledge and
information about both methotrexate and surgical abortions. Almost three-
quarters of administrators, counselors, and other medical staff indicated thatthey were responsible for some level of counseling in their facilities. Forty-onepercent of staff classified as administrators reported being responsible foradministrative duties and half also participated in follow-up care, oftenhandling off hours calls. Few were involved, however, in the more medicalaspects of methotrexate abortions. Nearly half (48%) in the counselor and othermedical group reported taking part in medical evaluations and almost one-third (30%) performed preabortion ultrasounds and/or provided follow-upcare for patients. Eighteen percent reported giving the injections.
Appropriate Providers and Settings
All participants were asked if they agreed or disagreed with the statement: “Giventhat they are properly trained and have access to appropriate emergency backup, anyphysician could provide methotrexate-induced abortions.”
They were also asked if theyagreed or disagreed with the same statement for the following three healthprofessionals: PA, NP, and CNM. The majority of participants felt that physicians
BECKMAN ET AL: PROVIDERS’ VIEWS OF MEDICAL ABORTION 107
and midlevel providers alike could appropriately provide methotrexate abortions(Table 3). Given that the health professional is properly trained and has access toemergency backup, 73% reported physicians were qualified providers of metho-trexate abortions. The percentages who agreed that other health professionalswere qualified were even higher: 85% for NPs, 88% for CNMs, and 80% for PAs.
Chi-square tests showed no significant differences among the four respondentgroups. The responses of physicians mirrored closely those of participants as awhole. In fact, physicians were somewhat more likely to report that any NP orCNM could provide a methotrexate abortion (95%) than they were to report thatany physician could (76%)
An opinion voiced by many participants, regardless of whether or not they
believed nonphysicians should provide medical abortion, was that providersof methotrexate abortions should have specific medical training and skills.
Sixteen percent commented that methotrexate providers should be trained inobstetrics/gynecology, or have specialized training in women’s health. Twen-ty-one percent believed these providers, as a condition of qualification, musthave the experience of performing surgical abortions; 12% stated that provid-ers needed to have some training in surgical abortion even if they did notactually perform them. Finally 9% said the methotrexate providers must haveaccess to and/or be able to perform an ultrasound. Many believed that thesecompetencies were a prerequisite to offering medical abortion. The followingquotes illustrate these points of view:
I agree [that any physician can provide methotrexate-induced abortions],
I suppose, but I have concerns. The risk is that the general practitioners willthink that they can just give it. I can see them getting into horrendousproblems, such as methotrexate-exposed fetuses. They also have to be adeptat ultrasound, and have it available. They have to have the ability to take careof patients facing emergency situations— be able to do a D&C and to havebackup. (physician)
I think the provider should be a gynecologist who can do a D&C.
Someone who can provide surgical care if the patient needs it. With medicalabortion there is a certain percentage where they need a D&C. I don’t thinkit’s fair to dump them in an emergency room. (administrator)
Respondents also emphasized the importance of meeting the emotional and
informational needs of patients. Twelve percent commented that a qualified
provider must be able to meet the psychosocial needs of women facing an
abortion, or they must have staff members who can do so. These concerns,expressed most frequently by participants who provided abortion counseling,
were usually directed at physicians. Indeed, only 61% of participants categorizedas “counselors and other medical staff” agreed that any physician could providemethotrexate-induced abortion. The majority of their concerns centered on issuesof appropriate counseling, taking time with patients, and physician’ recognition ofthe need to hire the appropriately trained staff if they cannot take the timethemselves. For instance, one participant stated:
Physically, yes [any doctor could give a methotrexate-induced abortion], butemotionally I disagree . . . the counseling involved is important. Lots ofdoctors’ offices don’t have people to provide the emotional counseling, anddoctors often don’t have the empathy skills either. So they need to have thecounseling staff to meet the emotional needs of women. (counselor/othermedical)
Ten percent also voiced concerns about continuity of care, often relating theirconcerns to medical training of abortion providers and/or their ability toperform surgical abortions. The ability to follow through with all levels of care
WOMEN’S HEALTH ISSUES VOL. 12, NO. 2 MARCH/APRIL 2002
PERCENT WHO AGREE THAT PROVIDERS AND SETTINGS
ARE APPROPRIATE FOR METHOTREXATE ABORTION BYPARTICIPANT GROUP
was particularly important to those who felt that women should stay with oneprovider throughout the procedure.
My concern is really the continuity. I feel strongly that the same person whohandles the medical abortion should be able to perform a surgical abortion ifit fails. A woman already has rapport with the doctor. To juggle them aroundwould be difficult emotionally, I would think. I think it is important for thesame person to do the pelvic, the ultrasound, and the D&C. (counselor/othermedical)
Despite the concerns expressed, most participants seemed confident in theabilities of midlevel clinicians, especially CNMs, to successfully and safelyadminister methotrexate. As one person summed up the prevailing sentiment,“A midwife can deliver a baby. She can handle an abortion.” This high level ofapproval is undoubtedly due to nurse–midwives’ focus and training onwomen’s reproductive health.
Finally, 10 respondents (13%) spontaneously mentioned that being
prochoice was essential for those involved in women’s health care.
I don’t think physicians should [offer methotrexate] if it’s just one of the officeprocedures they offer. They need to look at it as an important service. To havea political conscience. To believe in abortion and a woman’s right to choose.
All participants were asked if they agreed or disagreed with the statement:“Methotrexate-induced abortions could be safely provided in a medical facility thatdoes not perform surgical abortions as long as they had access to appropriate emergencybackup.
” They were also asked if they agreed or disagreed with the samestatement for provision of abortion in any physician’s office. Eighty-six percentagreed that methotrexate-induced abortions could safely be provided in amedical facility that does not offer surgical abortions as long as access toappropriate emergency backup was available. Similarly, 85% agreed thatmethotrexate could safely be provided in any physician’s office. No significantdifferences were found in levels of agreement among the four participantgroups. Nearly all who disagreed or had concerns with these questions citedreasons surrounding continuity of care.
For example, several respondents were concerned about emergency
backup plans if the clinic itself did not offer surgical abortions. They felt thatrelying on an emergency room to handle problems was not only risky, butmight augment an already traumatic experience.
I disagree [that methotrexate could be provided in a facility that does not
do surgical abortions]. A general physician could do this procedure, but we’re
BECKMAN ET AL: PROVIDERS’ VIEWS OF MEDICAL ABORTION 109
ultrasounding again to make sure the tissue has passed. If it’s offered by anonabortion provider, there will be more people in the ERs, more complica-tions related to tissue not passing. In most ERs, there isn’t even a GYNresident available. (administrator)
Methotrexate should only be provided in a center that is known to
provide that type of [abortion] care all the time. Otherwise it may be a carelessarrangement. I suppose you could
do it if a hospital emergency room isavailable and willing to take them, but you know a lot of ERs won’t.
Others were concerned about a woman’s emotional health and the negativeoutcomes she might face if surgical abortion were not readily available. Thisgroup felt that by offering both surgical and medical abortion, a clinic wouldprovide not only a healthier, more stable environment, but also more choicesfor women. As one respondent commented:
Well, that’s the goal—to make it more accessible. But the problem is that
surgical abortion is not necessarily seen as an emergency. I wouldn’t want tosee her have to explain everything to another provider; sit and wait in anotherplace with people she hasn’t met before. Ideally, a woman should have morecontinuity. (midlevel provider)
The current findings suggest that midlevel providers can and do play a criticalrole in the provision of abortion options for women. Despite state legislationthat greatly limits the role of midlevel providers, in our study these cliniciansappear to be actively participating in all aspects of the provision of methotrex-ate abortion, particularly the medical aspects. Moreover, the vast majority ofcurrent providers of medical abortion, the group presumed most knowledge-able about the skills and training needed to provide this service, agree that anymidlevel provider, given proper training and access to appropriate emergencybackup, could safely administer methotrexate. This finding concurs withJoffe’s1 conclusions based on a small sample of providers of surgical abortion,most of whom had some experience with medical abortion. It does, however,partially conflict with results of the 1998 Kaiser Family Foundation nationalsurvey.2 The survey found that 82% of NPs and PAs believed that midlevelproviders like themselves should be allowed to offer medical abortions, butonly 29% of obstetricians/gynecologists and 39% of family practice physiciansagreed. The reasons for differences in physician attitudes between studies mayin part be attributed to whether or not the providers surveyed have beeninvolved in the provision of abortions, either medical or surgical.
Midlevel professionals have the opportunity to be pioneers in the provi-
sion of new abortion services. Moreover, the greatest potential for increasingwomen’s abortion options and access may rest with midlevel practitioners. Inthe recent Kaiser Family Foundation survey2 only 2% of NPs and PAs had everprovided surgical abortion but 54% stated they would be likely to offermifepristone if it were approved and legal for them to do so.
Although participants in the present study were not specifically ques-
tioned about mifepristone, our findings would appear to also apply to theprovision of mifepristone-induced abortion. Mifepristone abortions generallyrequire less time and effort for providers as they are completed more quickly.
Indeed, when our sample was asked about satisfaction with methotrexate, 12respondents spontaneously mentioned mifepristone, with 5 indicating thatthey clearly preferred mifepristone.13
While most participants believed that any properly trained physician or
WOMEN’S HEALTH ISSUES VOL. 12, NO. 2 MARCH/APRIL 2002
midlevel provider could safely offer methotrexate-induced abortion, manyvoiced concerns about proper training, the availability of counseling services,and continuity of care. The attitudes and beliefs of these experienced abortionproviders, particularly the belief that health professionals should not providemedical abortions unless they also provide surgical abortions, could pose asignificant barrier to increased access to medical abortion. On the other hand,these beliefs reflect legitimate concerns and suggest that midlevel providersshould have the opportunity to receive comprehensive training in abortioncare, including the physical, emotional, and political aspects. Moreover,medical abortion techniques should be included as an option in the trainingcurricula of all qualified provider groups.
The current political climate in the United States and state laws and
statutes, however, may limit the involvement of midlevel clinicians in theprovision of medical abortion. Professional organizations and women’s healthadvocates must, therefore, continue to challenge physician-only laws thatrestrict qualified midlevel practitioners from providing abortion, proposedlegislation to limit the prescription of medical abortion to surgical providers,12and current FDA regulations that only allow physicians to perform orsupervise the provision of mifepristone-induced abortions.14 The majority ofparticipants in our study agreed that medical abortion could be safelyprovided in multiple types of facilities. The provision of medical abortion inmore varied health care settings in combination with an influx of midlevelproviders could increase access to and quality of abortion services. Forexample, decentralizing the provision of abortion and including the practice asa component of reproductive health care offered in a provider’s privatepractice would increase availability. Moreover, without the visibility of spe-cialized clinics, abortions could be provided under more confidential circum-stances, thereby eliminating the threat of harassment and violence. Thus,women would not be subjected to harassment by antiabortion picketers, whichmay cause negative psychological consequences.15
One critical concern voiced by current providers involved continuity of
care, specifically in the case of a failed drug-induced abortion and the need fora surgical procedure. These concerns fail to consider that, in fact, a womanmight experience better continuity of care if her primary care provider couldadminister the abortion when her choice of method was medical abortion.
Abortions might be less anxiety-provoking for women if the service wasoffered at their primary health care facility. In addition, the provision ofservices by midlevel clinicians in the woman’s primary care setting mayincrease patient satisfaction, because midlevel providers may have more timethan physicians to be involved in the multiple patient-related services associ-ated with medical abortion, thus further contributing to continuity of care.
Another theme that was evident in providers’ remarks involved the
importance of options for women. We think it important that multiple methodsof abortion, medical and surgical, be available to U.S. women. Given thecurrent political climate in the U.S., any abortion method that can be nonob-trusively provided by midlevel clinicians can increase women’s choices andperhaps their satisfaction with service delivery.
This study has several limitations that need to be considered when interpret-
ing results. The relatively small sample was not representative. Moreover, therewere differences in response rates between physicians and other groups, withfewer physicians agreeing to participate. The physicians who participated in thestudy could be a relatively select group, more likely to support the expansion ofproviders and settings for medical abortion than physicians who refused toparticipate or could not be contacted. Also, health care providers in general maybe much less accepting of midlevel clinicians as medical abortion providers thanwere the experienced abortion providers in our sample.
BECKMAN ET AL: PROVIDERS’ VIEWS OF MEDICAL ABORTION 111
Despite these limitations, the study strongly supports efforts to extend the
provision of medical abortion to new health settings and midlevel clinicians.
Such changes, if implemented, are likely to increase access and options forwomen seeking to terminate an early pregnancy.
We want to thank the abortion providers who participated in this study forsharing their perceptions and experiences. Sincere appreciation is also extended to:Susan Dudley, Vicki Saporta, and Kay Amdorfer at the National AbortionFederation for their assistance in recruiting providers; Mary Lockhart, CarlaSchmidt, and Christy Sherman for conducting the interviews; and MeredithRoberts for assistance in data analysis. We also thank the Huber Foundation andthe Tortuga Foundation for their generous support of this research.
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3. Creinen MD, Darley PD. Methotrexate and misoprostol for early abortion. Contra-
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5. Schaff EA, Eisinger SH, French P, et al. Combined methotrexate and misoprostol for
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eds. The new civil war: the psychology, culture and politics of abortion. Washing-ton, DC: American Psychological Association; 1998;61– 80.
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improving access to abortion services. In: Beckman LJ, Harvey SM, eds. The newcivil war: the psychology, culture and politics of abortion. Washington, DC:American Psychological Association; 1998;353–366.
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and reproductive rights (10th edition), 2001, xiv–xviii. Online: http://naral.org/mediasources/publications/2001/whod.html.
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methotrexate-induced abortions among US providers. J Am Med Womens Assoc2000;55(3, Suppl):161–163.
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er’s agreement 9/28/00. Online: http://www.fda.gov/cder/drug/infopage/mife-pristone/
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abortions. In: Beckman LJ, Harvey SM, eds. The new civil war: the psychology,culture and politics of abortion. Washington, DC: American Psychological Associ-ation; 1998;81–104.
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