The Minister of Health, Mónica García, announced this Monday the incorporation of pharmacological abortion to the portfolio of Primary Care services. What do professionals in this specialty think? The Spanish Society of General and Family Physicians (SEMG) considers that primary care can assume the announced pharmacological abortion, but demands that its incorporation into health centers be accompanied by specific training, consultation time and sufficient resources.
Lorenzo Armenteros, head of the SEMG Women's Health Working Group, points out that the measure may be an opportunity to reinforce the role of primary care in comprehensive care for women's health, but warns that essential aspects for its implementation still remain to be specified. "This right now is an advertisement," says Armenteros, and assures that society has not participated so far in the definition of the model. In his opinion, it is necessary to "immediately" open dialogue with scientific societies to establish how the service will be organized and which professionals will participate in it.
For her part, Nuria Pascual, member of the Women's Care Working Group of the Spanish Society of Primary Care Physicians (Semergen), considers that bringing pharmacological abortion to primary care will mean that proximity to the patient will improve information: "Our main value is that we can clarify for the patient all the doubts they have, because we know them and they trust us. What pharmacological abortion entails, what effects the drug can have, what to do if a complication occurs...".
But not everything is good. The first issue raised by the SEMG is the care burden. Armenteros places "overload without additional provision" as one of the main risks of incorporating the benefit into agendas that are already stressed. Therefore, it demands that these consultations be specific and remain outside the ordinary quota.
Pascual expresses himself along the same lines, although he clarifies that in the Valencian Community, where he practices, "most of the cases are filtered by family planning centers." Despite this, he recognizes that "the portfolio of primary care services is beginning to look like a supermarket, we do everything with the same resources."
Furthermore, Armenteros maintains that, "without accredited training, it would be a risk to start it," he points out. Society considers it necessary to establish a training program for professionals and determine in a protocolized manner who prescribes, who monitors and what role family doctors, midwives and nurses can play.
Conscientious objection
Added to this is the need to provide for conscientious objection. SEMG warns that, if not organized properly, unequal access to care could occur between health centers. "It is a basic right, of course, but it can lead to even more overload for some centers," says Armenteros.
This measure comes when the modification of the Constitution is still on the table to protect the right to abortion "under conditions of real and effective equality, with all the necessary benefits and services" and the discomfort of some regions with the creation of registries of objectors to abortion.
Armenteros also considers it necessary to specify the healthcare and legal requirements of the process, including the responsibility of each professional and informed consent.
Ultrasound and bypass circuit
Another aspect that, according to the SEMG, must be resolved before extending the benefit is the availability of diagnostic means. The model requires confirming the gestational age and ruling out an ectopic pregnancy, in addition to establishing subsequent follow-up and referral if complications appear.
In this sense, the availability of ultrasound in health centers is currently heterogeneous, warns Armenteros. For this reason, it is proposed that the centers that are going to assume this service have ultrasound machines and a rapid emergency referral circuit in case of complications.
For this scientific society, bringing pharmacological abortion to primary care has advantages related to accessibility and the model of comprehensive care for women that Family Medicine defends. Society believes that family doctors can play a relevant role in supporting women throughout the different stages of their lives, but Armenteros also points to a structural problem of primary care: the loss of longitudinality (having the same family doctor over the years) and continuity of care. The rotation of professionals that occurs in some centers, he points out, makes it difficult for a patient to receive continuous care from their reference doctor.
With an eye on France, Canada, the United Kingdom...
SEMG's position is not against pharmacological abortion being performed in primary care. Armenteros emphasizes that the experience of other countries shows that it can be developed at this level of care and considers that it is a safe and effective provision when accompanied by appropriate protocols and resources. France, Canada and the United Kingdom are some of the models cited as a reference, with different degrees of participation of primary care and other health professionals.
"This is not a refusal," he emphasizes. In his opinion, the measure can "prestige" primary care and increase its resolution capacity in women's health, as long as it is accompanied by training, consultation time, clear care circuits and a defined distribution of tasks.
