Provider Mistrust and Telemedicine Abortion Care Preferences Among Patients in Ohio,West Virginia,and Kentucky

Abstract

Objectives:

The convenience and privacy provided by telemedicine medication abortion may make this service preferable to patients who mistrust their abortion provider. We assessed associations between mistrust in the abortion provider and preferences for telemedicine abortion.

Study Design:

From April 2020 to April 2021, we surveyed patients seeking abortion in Ohio, West Virginia, and Kentucky. Using unconditional logistic regression models, we examined unadjusted and adjusted associations between mistrust in the abortion provider and preferences for telemedicine abortion among all participants, and among only participants undergoing medication abortion.

Results:

Of 1,218 patients who met inclusion criteria, 546 used medication abortion services. Just more than half (56%) of all participants and many (64%) of medication abortion participants preferred telemedicine services. Only 6% of medication abortion participants received telemedicine medication dispensing services. Only 1.4% of all participants and 1% of medication abortion participants mistrusted the abortion provider. Participants who mistrusted the abortion provider were somewhat more likely to prefer telemedicine abortion (unadjusted odds ratio [OR]: 2.5, 95% CI: 0.8–7.9; adjusted OR: 2.9, 95% CI: 0.9–9), and medication abortion participants who mistrusted the abortion provider were also somewhat more likely to prefer telemedicine abortion (unadjusted OR: 3.5, 95% CI: 0.4–28.9; adjusted OR: 5.0, 95% CI: 0.6–43), although these associations were not statistically significant.

Conclusions:

In three abortion-restrictive states, most patients expressed preferences for telemedicine abortion, but few accessed them. Provider mistrust was rare, but those experiencing mistrust trended toward preferring telemedicine services. Telemedicine may improve access to abortion services for patients experiencing medical mistrust.

Introduction

Telemedicine allows for safe, effective, and private access to medication abortion care, especially for patients who face legal or geographic barriers.^1

–5 Medical mistrust or suspicion of health care providers or organizations can impact health care utilization, adherence, and outcomes.^6,7 Because of their convenience and relative privacy, telemedicine interventions can build trust, particularly among racial and sexual minorities, and among patients with stigmatized health conditions, including HIV and mental illness.^8
–10 Abortion care and abortion providers are highly stigmatized,^11
–13 which could affect patient trust in their abortion services. Telemedicine abortion may, therefore, appeal to patients experiencing medical mistrust as it can promote engagement without the stigma associated with face-to-face encounters.⁸

Most telemedicine abortion research has focused on patients who successfully utilize telemedicine medication abortion, and these patients find the services highly convenient and acceptable.^3,4 Less is known about telemedicine abortion preferences among patients with limited abortion access.

We examined demographic and clinical associations between preferences for telemedicine abortion among patients seeking abortion care in three states with restrictions on accessing telemedicine abortion: Ohio, West Virginia, and Kentucky. We hypothesized that those patients who mistrusted the abortion provider would prefer telemedicine abortion.

Materials and Methods

STUDY SETTING AND PARTICIPANT RECRUITMENT

From April 2020 to April 2021, we recruited patients from 10 abortion facilities in Ohio, West Virginia, and Kentucky to complete an 80-item online survey about their experiences seeking and obtaining abortion care. We included patients aged 18 and older, who could read English, and were seeking abortion care. In Ohio clinics, only Ohio residents could participate. In West Virginia and Kentucky clinics, residents from all three states could participate. Clinic staff distributed study fliers to patients and recommended survey completion within 24 h. Prospective participants completed an electronic prescreening eligibility questionnaire. If they met inclusion criteria and wished to enroll, they provided electronic consent before completing the online survey. Those who completed the survey received a $30 gift card.

We recruited from seven clinics in Ohio. We based recruitment goals in Ohio on each clinic's patient volume in 2018 (at least 50 patients from clinics with <2,000 patients; at least 150 patients from clinics with >2,000 patients). We recruited from one clinic in West Virginia and two clinics in Kentucky. We classified these clinics as high volume as they represent the only abortion clinics in each state.¹⁴

DATA COLLECTION AND KEY MEASURES

The survey captured demographic variables, including age, race, ethnicity, relationship status, gender identity, and level of education; and clinical variables including pregnancy history and abortion characteristics, such as abortion method (procedural or medication) and gestational stage.

We asked all participants if they would have preferred that some or all of their abortion occur through telemedicine services, defined as “talk[ing] to [the] doctor over video, and receiv[ing] medication by mail or pick up from [a] local pharmacy.” Answer choices allowed for preferences that the initial counseling visit occur in person or through telemedicine (phone or video), and for preferences that the subsequent abortion visit occur in person or through telemedicine (medications mailed to home or available at a local pharmacy). All three states have state-mandated counseling visits followed by 24-h waiting periods before initiating an abortion. In Ohio, the counseling visit must occur in person, which necessitates two visits. In Kentucky, the counseling visit can occur through videoconferencing, and in West Virginia, by phone.¹⁵ We classified all responses indicating any preference for telemedicine as “preferring telemedicine services.”

If participants selected “medication” as their abortion method, we then asked whether the medication would be dispensed by video (i.e., through video telemedicine services). The survey did not ask whether participants used telemedicine services for their counseling visit.

To assess trust in the abortion provider, we used questions from the Consumer Assessment of Health care Providers and Systems cultural competency item set, a validated tool to assess the cultural competence of health care providers from a patient's perspective.¹⁶ We asked participants if they trusted the last health care provider they saw, and whether they felt they could trust the abortion provider from their current visit. All survey data were collected in REDCap.^17,18

DATA ANALYSIS

Our analysis has three parts. First, we examined correlates of preferring telemedicine abortion. Second, we examined correlates of mistrust in the abortion provider. Third, we examined associations between mistrust in the abortion provider and preferences for telemedicine abortion. For all three parts, we first looked in the entire sample, and second looked at only participants using medication abortion. Although a procedural abortion cannot occur through telemedicine, in states with required in-person counseling visits such as Ohio, patients may prefer that the first appointment occur through telemedicine.

We examined frequencies of demographic, clinical, and telemedicine preferences using Pearson chi-squared tests for categorical data and Mann–Whitney U tests for continuous data. We then specified unconditional logistic regression models to generate unadjusted and adjusted associations between mistrust in the abortion provider, and preferences for telemedicine abortion. We included in the adjusted models, variables associated with medical mistrust and preferences for telemedicine use in prior analyses, including age, race, ethnicity, pregnancy history, and level of education.^3,19

All analyses occurred using Stata (Version 16, Stata Corp, TX). The Institutional Review Board (IRB) at The University of Cincinnati (UC) approved this study. The Ohio State University IRB ceded ethical review to the UC IRB through a reliance agreement.

Results

SAMPLE CHARACTERISTICS

We planned for study staff to directly recruit patients in clinics. However, when the COVID-19 pandemic restricted in-person recruitment, we modified our protocol to distribute fliers to clinic staff to distribute to patients. Although we know the number of fliers we distributed to clinics, we do not know how many fliers were distributed from clinic staff directly to patients, and how many were not distributed or disposed of. Our response rate is, therefore, a conservatively low estimate, calculated using the largest possible denominator. Of the 6,910 study fliers we distributed to clinic staff, 2,052 patients (30%) started the eligibility screener and 1,771 (26%) patients met eligibility criteria and provided consent. Surveys were completed by 1,567 participants (23%). Of these, 1,218 (18%) provided complete responses for telemedicine preferences and abortion provider mistrust questions. Nearly half of participants (n = 546, 45%) underwent medication abortion (Fig. 1).

Fig. 1.

Flowchart of the study.

Of all participants, 77% received care in Ohio, 11% in West Virginia, and 12% in Kentucky. The majority (61%) were White and 38% were Black; 5% reported Hispanic ethnicity. Most (67%) had completed at least some college credit. A minority (34%) were nulliparous and most (68%) reported at least one prior abortion. A majority (84%) presented for abortion care at ≤10 weeks' gestation, and 7% presented in the second trimester (13–21 weeks' gestation) (Table 1).

Table 1.

Characteristics of All Participants Undergoing Either Procedural or Medication Abortion, by Telemedicine Preference (n = 1,218)

	TOTAL	PREFERENCE FOR TELEMEDICINE	NO PREFERENCE FOR TELEMEDICINE	p-VALUE^*
Total	1,218	681	537
Age (y)		27.7 ± 5.8	26.8 ± 5.7	0.007
Race
Black	467 (38)	241 (52)	226 (48)	0.017
White	742 (61)	422 (57)	320 (43)	0.4
Asian	27 (2)	22 (81)	5 (19)	0.007
Other	50 (4)	30 (60)	20 (40)	0.6
Ethnicity				0.6
Hispanic/Latinx	64 (5)	33 (52)	31 (48)
Non-Hispanic	1142 (94)	640 (56)	502 (44)
Education				0.001
0–11th grade	50 (4)	26 (52)	24 (48)
HS/GED	353 (29)	194 (55)	159 (45)
Some college/AD	587 (48)	307 (52)	280 (48)
College degree/+	227 (18)	154 (68)	73 (32)
Annual income				<0.001
$0–9,999	250 (21)	137 (55)	113 (45)
$10K–29,999	472 (39)	238 (50)	234 (50)
$30K–49,999	240 (20)	142 (59)	98 (41)
$50K+	184 (15)	128 (70)	56 (30)
Parity				0.4
Nulliparous (no live births)	417 (34)	226 (54)	191 (46)
Parous (one or more live births)	801 (66)	455 (57)	346 (43)
Abortion history				0.12
No prior abortion	385 (32)	226 (59)	159 (41)
1 or more prior	831 (68)	455 (55)	376 (45)
State of abortion				<0.001
Ohio	942 (77)	489 (52)	453 (48)
Kentucky	146 (12)	104 (71)	42 (28)
West Virginia	130 (11)	88 (67)	42 (32)
Abortion method				<0.001
Medication	546 (45)	348 (63)	198 (36)
Procedural	647 (53)	315 (49)	332 (51)
Don't know	25 (2)	18 (72)	7 (28)
Trust general health care provider				0.8
Yes	1,102 (90)	615 (90)	487 (90)
No	116 (10)	66 (10)	50 (10)
Trust abortion provider				0.086
Yes	1,201 (99)	668 (56)	533 (44)
No	17 (1)	13 (76)	4 (23)

Data are in n (%).

Pearson chi-squared tests used for categorical data and Mann–Whitney U test used for continuous data.

HS, high school; GED, general educational development; AD, associate's degree.

Among medication abortion participants, demographics were similar, except that participants were more likely to be White, to have higher education and income levels, and to receive care in Kentucky.

TELEMEDICINE PREFERENCES

Just more than half of participants (56%) expressed a preference for telemedicine abortion services. Those who preferred telemedicine services were significantly more likely to be older, to identify as Asian, to have a college degree or higher, to earn $50,000 or more annually, and to receive care in West Virginia or Kentucky (Table 1).

Many (64%) medication abortion participants expressed preferences for telemedicine abortion services. Demographic associations were similar to those of all participants, except without differences by race. Only 6% (n = 33) of participants using medication abortion reported successfully accessing medication dispensing services through telemedicine (Table 2). All of these respondents received care in Ohio (Fig. 2).

Fig. 2.

Participants undergoing medication abortion who preferred any telemedicine abortion service compared with those who got medication dispensed through video in Ohio, West Virginia, and Kentucky.

Table 2.

Characteristics of Participants Using Medication Abortion, by Telemedicine Preference (n = 546)

	TOTAL	PREFERENCE FOR TELEMEDICINE	NO PREFERENCE FOR TELEMEDICINE	p-VALUE^*
Total	546	348 (64)	198 (36)
Age (y)		27.4 ± 5.6	25.9 ± 5.2	0.002
Race
Black	164 (30)	101 (28)	63 (30)	0.5
White	372 (68)	236 (66)	136 (65)	0.8
Asian	12 (2)	10 (3)	2 (1)	0.2
Other	19 (3)	12 (3)	7 (3)	1.0
Ethnicity				0.2
Hispanic/Latinx	32 (6)	16 (5)	16 (8)
Non-Hispanic	510 (93)	329 (95)	181 (92)
Education				0.04
0–11th grade	16 (3)	10 (3)	6 (3)
HS/GED	144 (26)	86 (25)	58 (29)
Some college/AD	268 (49)	164 (47)	104 (53)
College grad+	117 (21)	88 (25)	29 (15)
Annual income				0.02
$0–9,999	95 (17)	59 (18)	36 (19)
$10K–29,999	209 (38)	121 (37)	88 (48)
$30K–49,999	114 (21)	75 (23)	39 (21)
$50K+	98 (17)	76 (23)	22 (12)
Parity				0.4
Nulliparous	214 (39)	132 (38)	82 (41)
Parous	332 (61)	216 (62)	116 (59)
Abortion history				0.2
No prior abortion	191 (39)	124 (36)	67 (34)
1 or more prior	353 (65)	224 (64)	129 (66)
State of abortion				<0.001
Ohio	370 (68)	211 (61)	159 (80)
Kentucky	110 (20)	80 (23)	30 (15)
West Virginia	66 (12)	57 (16)	9 (5)
Trust general health care provider				1.0
Yes	501 (92)	319 (92)	182 (92)
No	45 (8)	29 (8)	16 (8)
Trust abortion provider				0.2
Yes	539 (99)	342 (98)	197 (99)
No	7 (1)	6 (2)	1 (1)
Got medications dispensed through video				<0.001
Yes	33 (6)	27 (8)	6 (3)
No	270 (49)	149 (43)	121 (61)
No response or don't know	243 (45)	172 (49)	71 (36)

Data are in mean ± SD or n (%).

Pearson chi-squared tests used for categorical data and Mann–Whitney U test used for continuous data.

MISTRUST IN THE ABORTION PROVIDER

Among all participants, abortion provider mistrust was rarely reported. Only 1.4% (n = 17) did not trust their abortion provider, whereas 9.5% did not trust their general health care provider. Predictors of abortion provider mistrust were younger age and mistrust in the general health care provider (Table 3).

Table 3.

Characteristics of All Participants, by Trust in the Abortion Provider (n = 1,218)

	TOTAL	TRUST THE ABORTION PROVIDER	DO NOT TRUST THE ABORTION PROVIDER	p-VALUE^*
Total	1,218	1,201	17
Age (y)		27.3 ± 5.7	23.3 ± 3.8	0.003
Race
Black	467 (38)	460 (36)	7 (39)	0.8
White	742 (61)	732 (58)	10 (56)	0.8
Asian	27 (2)	26 (2)	1 (5)	0.3
Other	50 (4)	50 (4)	0 (0)	0.4
Ethnicity				0.9
Hispanic/Latinx	64 (5)	63 (5)	1 (6)
Non-Hispanic	1142 (94)	1126 (95)	16 (94)
Education				1.0
0–11th grade	50 (4)	49 (4)	1 (6)
HS/GED	348 (29)	348 (29)	5 (29)
Some college/AD	587 (48)	578 (48)	9 (53)
College grad+	227 (18)	225 (19)	2 (12)
Annual Income				0.3
$0–9,999	250 (21)	244 (22)	6 (38)
$10K–29,999	472 (39)	464 (41)	8 (50)
$30K–49,999	240 (20)	239 (21)	1 (6)
$50K+	184 (15)	183 (16)	1 (6)
Abortion history				0.7
No prior abortion	385 (32)	378 (32)	7 (41)
1 or more prior	831 (68)	821 (68)	10 (59)
State of abortion				1.0
Ohio	942 (77)	929 (77)	13 (76)
Kentucky	146 (12)	144 (12)	2 (12)
West Virginia	130 (11)	128 (11)	2 (12)
Abortion method				0.8
Medication	546 (45)	539 (45)	7 (41)
Procedural	647 (53)	637 (53)	10 (59)
Don't know	25 (2)	25 (2)	0 (0)
Trust general health care provider				<0.001
Yes	1,102 (90)	1,091 (91)	11 (65)
No	116 (10)	110 (9)	6 (35)
Got medication distribution through telemedicine				0.07
Yes	33 (3)	31 (3)	2 (12)
No	270 (22)	267 (22)	3 (18)
Don't know, no answer or not asked (got procedural abortion n = 647)	915 (75)	903 (75)	12 (70)

Data are in mean ± SD or n (%).

Pearson chi-squared tests used for categorical data and Mann–Whitney U test used for continuous data.

Among medication abortion participants, demographic associations with abortion provider mistrust were similar, except that age was not a predictor (p = 0.08).

ABORTION PROVIDER MISTRUST AND PREFERENCE FOR TELEMEDICINE ABORTION

Among all participants, those who mistrusted the abortion provider had somewhat higher preferences for telemedicine abortion, although this was not statistically significant (unadjusted odds ratio [OR]: 2.5, 95% confidence interval [CI]: 0.8–7.9). This measure of effect was slightly larger after adjustment for age, race, ethnicity, parity, level of education, and prior abortion (adjusted OR: 2.9, 95% CI: 0.9–9) (Table 4).

Table 4.

Association Between Mistrust in the Abortion Provider and Preferences for Telemedicine, Among All Participants (n = 1,218) and Among Participants Who Used Medication Abortion (n = 546)

		UNADJUSTED OR (95% CI)	ADJUSTED OR (95% CI)
All participants
Mistrust in abortion provider	1,218 (100)
No	1,201 (99)	3.5 (0.4–28.9)	5.0 (0.6–42.1)
Yes	17 (1)	1 (ref)	1 (ref)
Participants using medication abortion
Mistrust in abortion provider	546 (45)	2.6 (0.8–8.0)
No	539 (99)	2.6 (0.8–8.0)	2.8 (0.9–8.9)
Yes	7 (1)	1 (ref)	1 (ref)

Data are in n (%).

Among medication abortion participants, both unadjusted and adjusted associations were somewhat larger in magnitude, although still not statistically significant (unadjusted OR: 3.5, 95% CI: 0.4–28.9; adjusted OR: 5.0, 95% CI: 0.6–43) (Table 4).

Discussion

More than half of respondents expressed preferences for telemedicine abortion services. Respondents who preferred telemedicine abortion services were older, with higher levels of education and incomes, and more likely to get care outside of Ohio. Few participants received medication distribution through telemedicine services. Trust in the abortion provider was high. Participants who mistrusted the abortion provider trended toward preferring telemedicine abortion services, although this was not statistically significant.

In a prospective study among patients who obtained telemedicine abortion, patients preferring in-person visits were younger with lower educational attainment.³ Our study of patients with limited access to telemedicine services showed similar demographic associations.

Medical mistrust has been associated previously with younger age, lower income, lower educational status, Black race, and Hispanic ethnicity.^19
–21 We also found associations between mistrust and younger age.

Almost all respondents (98.6%) reported that they trusted the abortion provider. This high level of trust, higher even than that of general health care providers (90.5%), directly contrasts with the traditional antiabortion narrative of the abortion provider as performing “dirty” or unethical work, of “exist[ing] in public discourse as dangerous, deviant or illegitimate practitioners.”¹² No prior study has queried individual patients receiving abortion care about provider trust. Our findings contrast with how providers view themselves in the public narrative.²²

Despite high levels of telemedicine abortion preferences, only 6% of our respondents reported accessing medication dispensing telemedicine services. Regulations banning telemedicine abortion in Kentucky²³ and West Virginia,²⁴ and requiring in-person clinic visits for medication abortion distribution in Ohio²⁵ restrict clinics in these states from expanding telemedicine abortion services.²⁶ Patients in Kentucky and West Virginia had the highest preferences for telemedicine abortion services (72% and 86%, respectively), likely because telemedicine counseling services are still legally available in these states. These findings also add to mounting evidence that many patients desire telemedicine abortion services, particularly in abortion-restrictive states, even as access to these services are reduced.^3,27
–29

Participants who mistrusted the abortion provider showed some preference for telemedicine abortion care, although given how few participants mistrusted their provider, this finding was imprecise, with a wide confidence interval. In other stigmatized areas of health care, telemedicine has been posited as an intervention to overcome medical mistrust as it allows for medical engagement without the stigma associated with in-person encounters.⁸ Telemedicine may provide a unique opportunity to meet the needs of patients experiencing abortion provider mistrust.

This study enrolled a large diverse sample from multiple clinical sites in three abortion-restrictive states. By querying telemedicine abortion preferences in states with limited telemedicine abortion options, we could explore preferences among patients unlikely to access these services, which is understudied.

Our estimated response rate of 30% is low, although this is a conservative estimate as it assumes all surveys were distributed to patient. The true response rate is likely higher. The estimated response rate invites selection bias, as patients with more time or resources to complete a survey may be more likely to participate. Patients experiencing medical mistrust may be less likely to present to clinics or to complete surveys, which could underestimate abortion provider mistrust. In addition, data collection for this project occurred during the COVID-19 pandemic, which may have affected patient willingness to participate in a research survey. Participant experiences of abortion care may also have been different because of the pandemic.

Most of our respondents received care in Ohio, which skews our results toward the experiences of Ohioans. These differences likely reflect the realities of abortion care and access in the Midwest, rather than a difference in response rate by state. Ohio has a population of >11 million residents, whereas West Virginia and Kentucky are more sparsely populated, with populations of 1.8 million and 4.5 million, respectively. The volume of abortion care occurring in Ohio is also higher, with >20,000 abortion occurring in Ohio in 2017, compared with ∼1,400 in West Virginia and 3,200 in Kentucky.¹⁴ Kentucky had the highest survey response rate (46%), compared with Ohio (28%) and West Virginia (31%).

The survey did not ask participants whether they accessed telemedicine for their initial counseling visit, only whether they preferred it. We therefore, did not capture these data among participants in West Virginia and Kentucky who may have utilized these services. Participants who successfully utilized telemedicine for their counseling visit may prefer telemedicine abortion, as is reflected in the high rates of telemedicine preferences among patients in West Virginia and Kentucky. We also did not query preferences for or access to postabortion follow-up by telemedicine.

Although we did find an association between identifying as Asian and preferences for telemedicine abortion, we interpret this finding with caution because only 2% of participants identified as Asian.

The small number of participants who reported mistrust in the abortion provider, while reassuring to clinical practice, limited our ability to interrogate associations with this variable more deeply. Our medical mistrust questions only allowed for “yes,” “no,” or “I don't know” answers, which may not adequately capture more nuanced aspects of medical mistrust. We also did not query additional layers of medical mistrust, such as patient mistrust of clinic protestors or fears of being recognized while seeking abortion care. More research on mistrust in both the abortion provider and of the abortion experience is necessary, including through qualitative methods.

We document high levels of trust in abortion providers in abortion-restrictive states, which highlights the disconnect between abortion-restrictive legislation that disrupts the doctor–patient relationship, and the realities of clinical care. For example, by “curtailing the sharing of information and support” Texas Senate Bill 8, a near complete abortion ban, “clearly violates the patient-physician relationship.”³⁰ Ohio House Bill 214³¹ similarly promotes secrecy and mistrust between doctors and patients by banning abortion for a diagnosis of Trisomy 21, but only if the physician is aware of the patient's motive for seeking an abortion.

For most patients surveyed, telemedicine abortion is not an available option. Preferences for telemedicine are, therefore, hypothetical, rather than reflective of the realities of care. However, these hypothetical preferences still matter, even as abortion access and decisional autonomy is reduced for pregnant people living in abortion-restrictive states. Patient hypothetical care preferences in restrictive abortion environments are even more relevant given a near complete loss of abortion access in large swaths of the United States, including the states surveyed in this study, following the Dobbs v. Jackson Women's Health Organization decision.³²

Conclusions

Our findings have implications both for the importance of improving access to telemedicine abortion, and for medical mistrust more generally. Telemedicine may provide an avenue for accessing services that feels more comfortable and safer to patients experiencing mistrust. However, very few of our participants successfully obtained telemedicine services. Ohio, West Virginia, and Kentucky are not meeting the needs and preferences of their residents. Rather than imposing additional restrictions on telemedicine abortion, local and state officials should work to expand access.

Footnotes

Acknowledgments

The authors thank our study participants and supporting clinics and staff for their collaboration in these findings.

Authors' Contributions

Conceptualization, formal analysis, writing—original draft, writing—review and editing, and visualization by K.R.; methodology, software, formal analysis, investigation, data curation, writing—review and editing, and project administration by J.B.-L.; conceptualization, writing—review and editing, and supervision by T.O.; writing—review and editing and project administration by Z.M.; writing—review and editing, supervision, and funding acquisition by A.N.; conceptualization, methodology, software, formal analysis, data curation, writing—review and editing, analysis, and supervision by A.N.T.; conceptualization, investigation, resources, writing—review and editing, supervision, project administration, and funding acquisition by D.B.

Disclosure Statement

The authors report no conflicts of interest.

Funding Information

This study was supported by an Anonymous Foundation. The funder had no involvement in study design, data collection, analysis, or data interpretation, nor in article writing or the decision to submit the article for publication. Grant number G402194.

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