Dissertations and Theses
Date of Degree
6-1-2026
Document Type
Dissertation
Degree Name
Doctor of Philosophy (Ph.D.)
Department
Community Health and Social Sciences
Advisor(s)
Meredith Manze
Committee Members
Heidi Jones
Sasha Fleary
Dalia Brahmi
Subject Categories
Public Health | Women's Health
Keywords
medication abortion, implementation science, primary care, mixed methods, access to care
Abstract
Integrating medication abortion into diverse, community-based primary care settings can expand timely, patient-centered services and normalize abortion as routine healthcare. Despite strong evidence of safety, feasibility, and acceptability, adoption in primary care remains limited due to structural barriers rooted in longstanding stigma and exceptionalization of abortion. While current research has identified barriers and facilitators to integrating medication abortion into primary care, there is limited understanding of effective strategies to incorporate this care into practice. This mixed-methods implementation science study evaluates whether and how a Virtual Learning Collaborative (VLC) created by the Reproductive Health Access Project facilitates the integration of medication abortion among participating primary care organizations. This research sought to: 1) evaluate implementation outcomes; 2) examine contextual factors influencing implementation; and 3) assess change in implementation attitudes among clinic staff at participating organizations.
From 2024-2025, teams of staff medication abortion “champions” from 12 organizations participated in a 12-month VLC to integrate medication abortion into primary care. I conducted baseline (pre-VLC, 2024) and follow-up surveys and focus groups 15 months later with teams of clinical, administrative, and leadership champions from ten organizations. Surveys measured implementation outcomes (initiation, adoption, penetration, clinical practice changes). The Consolidated Framework for Implementation Research and Theory of Organizational Readiness for Change guided focus groups to explore factors influencing implementation. I conducted descriptive analyses of survey data, thematic analysis of baseline focus groups, and matrixed case study analyses of follow-up data to identify themes within and across organizations and timepoints. To assess changes in staff attitudes toward implementation, champions administered my online pre- (N=683) and post-surveys (N=613) to staff at clinics preparing to integrate medication abortion. Eligible respondents were non-champion staff who could directly or indirectly be involved in a medication abortion visit. Surveys assessed acceptability of implementation, belonging in primary care, readiness for change, and comfort working in a clinic that offers medication abortion; open-ended questions queried on benefits and concerns. Mixed effects linear and logistic regressions examined aggregate attitude changes; McNemar’s and Wilcoxon Rank Sum tests assessed change among a matched subset. Bivariate and multivariable linear and logistic regressions, with cluster robust standard errors (CR2) to adjust for clustering within clinical sites, examined characteristics associated with post-survey attitudes.
At follow-up champions advanced implementation, but with various degrees of progress. One of ten organizations began providing medication abortion, three reported launch dates within one year, and four expanded miscarriage care, options counseling, and abortion referrals. Factors influencing implementation success included: staff stability, leadership support, proximity to power, financial sustainability, aligning medication abortion to organizational priorities, and dedicated champions. While the VLC catalyzed efforts to implement medication abortion, workforce stability, political context, relationships with OBGYN stakeholders, and leadership support shaped the extent of champions’ progress. Among seven organizations that participated in both clinic staff surveys, 318 of 528 pre-survey respondents (60.2%) were complete and eligible and 263 of 421 (62.4%) post-survey respondents. In both samples, respondents’ attitudes were largely positive. Accounting for within-person correlation and clinic clustering, aggregate attitudes did not change significantly. Among a matched subset (n=74), discomfort with offering medication abortion decreased (21.6% vs 8.1%; p=0.02), median comfort increased (4.0 vs 4.5/5, p< 0.01), and median acceptability increased (4.4 vs 5.0/5.0, p=0.04). Benefits of offering medication abortion included mitigating access barriers, aligning with primary care values, improving health outcomes, and promoting reproductive autonomy. Concerns included safety risks, political risks, training staff, and staff opposition. Religiosity was significantly associated with all post-survey attitudes in unadjusted and adjusted analyses.
This study demonstrates how the VLC supported champions to take incremental steps to change systems and culture around offering medication abortion in primary care. Strategies that build sustainable multidisciplinary teams, engage leadership, and support the navigation of structural barriers may advance progress toward integrating medication abortion, thereby increasing patient access and reducing abortion-related stigma over time.
Recommended Citation
Srinivasulu, Silpa, "Integrating Medication Abortion in Primary Care Settings: An Implementation Science Study" (2026). CUNY Academic Works.
https://academicworks.cuny.edu/sph_etds/128
