Understanding U.S. non-religious hospital inpatient approval mechanisms for induced abortion

To evaluate whether inpatient abortion approval mechanisms are used in U.S. non-religious obstetric tertiary care hospitals and describe the scope of use and perceived role of these mechanisms from the perspective of Labor and Delivery Medical Directors.

We conducted an exploratory cross-sectional, web-based survey in the Spring, 2024. Using purposeful distribution based on the January 2024 Guttmacher Institute's state abortion policy map, we recruited a convenience sample of Labor and Delivery Medical Directors divided between restricted, intermediate, and protective states with a goal of nine responses each. We included those that accepted high-risk maternal inpatient referrals, had a level II or III neonatal intensive care unit, and had ever provided inpatient induced abortions. The survey collected information on ability to provide abortion care, existing approval mechanisms, and reasons for use of these mechanisms in non-emergency and emergency situations.

Of 45 invited directors, we received 37 (82.2%) responses of which 29 met inclusion criteria (11 restricted, nine intermediate, nine protective). Most respondents indicated ability to provide inpatient induced abortions in non-emergent (25 [86.2%]) and emergent (29 [100%]) situations. Among restrictive and intermediate settings, all reported having abortion-specific approval mechanisms in non-emergent situations. Primary reasons for approval mechanisms were avoiding potential legal risk (52.0%) and controversy among team members (32.0%).

Medical Directors of Labor and Delivery Units in our sample indicate that contemporary U.S. non-religious obstetric tertiary care hospitals, especially in politically restrictive settings, are utilizing approval mechanisms for inpatient induced abortion care. These mechanisms are perceived to be in place to avoid controversy, both legal and among hospital team members.

Our exploratory sample suggests U.S. non-religious tertiary care hospitals commonly apply approval mechanisms for inpatient abortion care to navigate vague legal standards and institutional risk. These approval mechanisms require additional steps, such as multiple physician approval, and focus on the perceived needs of hospitals and physicians rather than the patient.