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Abortion and Mental Health: Connected by Stigma

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Settling into work this morning, a headline concerning some mental health research out of Penn State College of Medicine caught my eye: "Rural Primary Care Physicians Offer Insight Into Rural Women's Health Care." The study grabbed my attention not only as an opportunity to learn more about the whole of rural women's and health care providers' experiences, but also because of some notable parallels between the delivery of mental health and reproductive health in rural health care systems.

The Penn State researchers interviewed 19 primary care physicians who provide care to rural women in central Pennsylvania, examining screening and diagnosis of mental health conditions, barriers to treatment, and the management of mental illnesses in rural women. Between 2007-2009, Provide (then Abortion Access Project) conducted an assessment of rural primary care clinicians' perceptions and practices regarding abortion and other reproductive health care. We surveyed 162 clinicians in five states (Colorado, Iowa, Maine, West Virginia and Wyoming).

The similarities in what we heard and what the Penn State researchers found are striking:

A lack of specialized providers in rural communities and the subsequent reliance on primary care providers who receive little specialized training. As of 2005, only 7.4 percent of all U.S. psychiatrists practiced in a rural area and only one-third of interviewed physicians routinely screened their patients for depression. Similarly, 97 percent of rural counties do not have an abortion provider and only two (1 percent) of the clinicians surveyed by Provide offered abortion care. However, 34 percent of our survey respondents expressed interest in medication abortion training. This echoes what one interviewee declared in the Penn State study: "I do a lot of psychiatry in my practice that I really wish I didn't have to do, but I do it because someone's got to do it."

Uncertainty regarding how much the care is needed among rural people. Two-thirds of the clinicians surveyed by Provide rated their patients' need for abortion as "low." The Penn State study notes that identification of patients with post-traumatic stress disorder is particularly challenging because most rural doctors don't feel PTSD is likely to affect rural women.

Stigma. "Extreme negative community reaction," declared one of our survey respondents. "Fear of judgment by family and friends," states an interviewee of Penn State's. Stigma creates reluctance among patients to seek care, masks patient need, and limits the resources and training available to providers. This may be the defining challenge we face.

The promise of better care through stronger professional networks. At Provide, our current emphasis is on building referral networks for abortion care within rural health systems. This made the Penn State study's identification of formalizing and expanding professional consulting networks as a creative and promising solution particularly interesting to us. How do we build the robust relationships that are needed, across sometimes daunting geographic and professional distances?

Abortion does not cause mental health problems. But this doesn't mean that there isn't shared work to be done in these two areas. Women experience neither abortion nor mental illness in isolation of other health and life circumstances. Nor are we as advocates confined solely to "our issue." As we seek to understand how we can most effectively situate abortion within rural health care delivery, it might help to look to mental health and other stigmatized and hard to access health services, and know that many of the challenges we face are not ours alone.

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