Developing a conceptual model of factors influencing abortion referral behavior

Ensuring timely access to abortion care minimizes individual- and population-level procedure-related morbidity and cost. Because multiple infrastructural and social barriers to abortion persist, care remains difficult to access for many women. Referrals from health care or social service providers hold the potential to assist women in overcoming these barriers. However, nationally representative surveys have demonstrated that many physicians believe it is acceptable to refuse to refer for abortion, despite professional guidelines discouraging such refusals. Developing evidence-based interventions to facilitate abortion referral constitutes an important strategy to reduce barriers to care. We conducted a review of the literature on referral best practices in stigmatized fields within health and social services, followed by a series of semi-structured, qualitative key informant interviews with abortion professionals. Key informants resided in five states and had diverse experiences as service providers and advocates. Based on this work, we developed a conceptual model that maps modifiable factors impacting referral provision. We conceptualize abortion referral as a collection of behaviors and posit that professionals' intention and capacity to refer will shape the extent to which they engage in these behaviors. We then schematize the beliefs, knowledge, and environmental factors that may impact intention and capacity. Grounding our work in behavioral theory, we argue that factors at the individual, institutional, professional, community, and policy or regulatory levels can affect both providers' ability to provide a quality referral and their willingness to do so. Our model thereby highlights multiple points of intervention to support increased abortion referral.