In states where abortion is currently legal, OB-GYN clinics affiliated with hospitals and health systems are an important access point for individuals seeking abortion care. However, hospital policies limiting sedation in office-based settings push the procedure into the operating room, making abortion care more difficult to obtain and likely more expensive. Hospital administrators should reevaluate their sedation policies with these questions of access in mind.
The Society for Family Planning recommends mild and moderate sedation to manage pain during first and second trimester abortions. Independent women’s health clinics, such as Planned Parenthood, often offer mild and moderate sedation in their own ambulatory and office-based clinics.
However, my RAND colleagues and I recently published a study on abortion access, experiences, and policies in Virginia and found that some hospital systems require any non-medication abortion to be done in an operating room, even though there is no state requirement to do so.
Often these institutional restrictions exist because hospital systems have not established protocols or invested in equipment that may be needed in cases of emergency. For example, the American Society for Anesthesiologists recommends that code carts be available in facilities using moderate sedation, but those may not have been supplied to OB-GYN clinics or offices located within hospital systems.
Some hospital systems may argue that it is reasonable to offer moderate-sedation procedural abortions only in an operating room because they often presume it is safer than an out-patient procedure. However, our report suggests that this is more expensive and cumbersome for patients, providers, and health care systems. One physician in our study practiced at both a hospital system and an independent clinic. She estimated that the cost was $10,000 more to receive a procedural abortion at the hospital-based institution because of the OR requirement. Another provider in a hospital system said that she did not have dedicated OR time; she had to find a hole in the OR schedule to provide abortion care for her patients. Thus, she limited the number of patients that she cared for, instead often referring patients to an independent clinic in the area.
She wasn’t alone. Providers in our study reported referring patients outside their affiliated health system to independent and Planned Parenthood clinics, where they knew the patient could receive more affordable abortion care with mild or moderate sedation (e.g., laughing gas). This inefficient referral pattern suggests that hospital systems should review and potentially update policies and equipment if necessary to allow for mild and moderate sedation in OB-GYN offices and clinics.
The doctors we spoke with said it wasn’t cost, but lack of motivation, that lets these outdated sedation policies remain in place. Some of our participants suggested that this lack of motivation may be due to hospital systems not wanting to draw attention to abortions being offered at their clinics. Some suggested that moving procedural abortions outside of the OR would likely make the procedure less costly for health care systems, as well as patients. It could also free up OR time for patients with complex sedation and medical needs, generating more revenue for hospitals.
Changing mild and moderate sedation policies could produce other benefits for hospital systems and patients alike. It might allow patients to receive other routine gynecological care like hysteroscopies in an office-based setting. One physician in our study noted that using IV sedation in the office setting for other procedures could increase the amount the department was being paid. As reimbursement is often procedure- rather than location-based, performing gynecological procedures in an office-based setting rather than OR would decrease the facility costs, leading to increased revenue. In addition, moving procedures from the OR to the outpatient setting could improve the workflow of OB-GYNs. By equipping some OB-GYN offices with necessary equipment, physicians would no longer need to travel between the hospital and ambulatory and/or office-based setting. That could enable more patient visits overall.
While our study examined institutional restrictions in Virginia, previous work suggests that these institutional restrictions also exist in other states, especially when these institutions are religiously affiliated. These hospital-based restrictions, thus, may be widespread.
Hospital administrators should revisit their sedation practices to ensure that institutional policies do not unnecessarily hamper abortion and other gynecological care. These sedation policies are even more crucial to revisit in states where abortion is legal and where there has been a rise in out-of-state patients needing abortion care, like Virginia. Revisiting these policies not only could lower costs, but also reduce waiting times and allow more patients to get care inside and outside of health care systems.
Skye A. Miner is a sociologist-bioethicist at RAND who specializes in using empirical methods to study experiences with health care and emerging biotechnologies.