Transcript 2nd Trimester Abortion - The Bixby Center on Population

Access to Second Trimester Abortions:
A Public Health Perspective
Tracy Weitz, PhD, MPA
Director
Advancing New Standards in Reproductive Health (ANSIRH)
Bixby Center for Reproductive Health Research & Policy
University of California, San Francisco
Today’s Presentation

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Overview of 2nd trimester abortion
Current barriers to provision
A recommitment to 2nd trimester
abortion care
What is 2nd Trimester Abortion?
1st Tri
2nd Tri
ACOG’s Committee LMP to 14 -28 wks
< 14 wks
on Coding and
Nomenclature
Roe v Wade
LMP to
12 wks
13-24 wks
3rd Tri
28 wks +
25 wks +
2nd Trimester Abortion in Practice

Generally
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Abortions between (14) and (24) weeks LMP
Involves use of Dilation and Extraction (D&E)
Can be done with medications as an induction
Providers vary on to what gestational limit
they do abortions
CPT Codes distinctions
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59840: By D&C –Any trimester
59841: By D&E -- 14 weeks 0 days up to 20
weeks 0 days
59841-22: By D&E -- 20 weeks 0 days or more
Abortions by Gestational Age
70%
% of abortions
60%
57.6%
Almost 90% in the 1st Trimester
50%
40%
30%
20.3%
20%
10.2%
6.2%
10%
4.3%
1.5%
0%
<9
9-10
11-12
13-15
Weeks
16-20
21+
Source: Elam-Evans et al., 2002
(1999 data)
Many Women Need Care

10% of 1.3 million is still a lot of women
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Women who need care

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130,000 procedures in the 2nd Trimester
26,000 women over 21 weeks LMP
Access barriers
Social barriers
Diagnosis barriers
Life circumstances
Health care disparity and human rights
issue
Who Needs 2nd Trimester Abortions

Greater likelihood for women who
are:
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Low income
Non-Hispanic black
Geographically isolated
Young
What factors delay abortion

Funding needs

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Only 17 states still allow for Medicaid
funding
Significant factor in use of 2nd Ti
Late diagnosis of pregnancy
Late diagnosis of medical need
Logistics
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
Difficulty finding a provider
Referral from a prior clinic
Barriers to Provision
Lack
of Providers
Increasing Regulation
Lack of Providers

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Graying of the Abortion Provider
Concentration in High Volume Outpatient
Clinics not in Hospitals
Lack of Training
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In Residencies
For the Practicing Physician
Inadequate Compensation

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Out-of-Pocket Services
Medicaid Restrictions
Insurance Prohibitions
A More Complicated Story

# of providers is an inadequate
measure

MFM physicians may do procedures for
fetal abnormalities

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Separating “Good” from “Bad” Abortions
Newer providers unwilling to do such
high volume
 requirements are  cost without
 compensation => specialization
Increasing Federal and State
Regulation of 2nd Trimester Abortion
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“Partial Birth Abortion” Bans
“Fetal Pain” Consent Bills
Targeted Regulation of Abortion
Provider (TRAP) Laws
“Partial Birth Abortion” (PBA) Bans
What is “PBA”
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Not a medically recognized term
Introduced into the public after a 1992
presentation by Martin Haskell at the
National Abortion Federation (NAF)
meeting was leaked to anti-abortion
activists
Supposedly describes the dilation and
extraction (D&X) technique
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where the fetal body is brought through the
cervix intact and then the skull is compressed
to safely move it through the cervix
There is no bright-line distinction between
D&E and D&X

most appropriately called intact D&E
Why Perform an Intact D&E?
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Reduce instrumentation of the
uterus
Fetus presentation necessitates
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Result of dialation of cervix with
laminaria or misoprostol or other
cervical preparation technique
Process of fetal loss
Preserve the fetus for postprocedure examination
Early Efforts to Ban PBA

Federal legislation to ban PBA
passed by Congress in March 1996
and again in October 1997

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President Bill Clinton vetod both bills
Override votes passed in the House of
Representative but failed in the Senate
Many states began to pass PBA
bans
State-based “PBA” Bans
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26 states have bans on PBA that apply throughout pregnancy
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5 states have bans that apply after viability

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Utah’s ban has been specifically blocked by a court because it
lacks a health exception
Montana’s ban remains unchallenged but is presumably
unenforceable under Stenberg because it lacks a health exception
3 bans are currently in effect
4 states have bans that include a health exception
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18 bans have been specifically blocked by a court
7 bans remain unchallenged but are presumably unenforceable
under Stenberg because they lack health exceptions
Ohio’s ban has been challenged and upheld by a court
2 states broadly allow the procedure to protect against physical or
mental impairment
2 states narrowly allow the procedure to protect only against
bodily harm
27 states have bans without a health exception
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19 bans have been specifically blocked by a court.
8 bans remain unchallenged.
State-based PBA Bans

Found unconstitutional in Stenberg v Carhart
[2000]
 Challenge to the state of Nebraska ban on socalled “Partial Birth Abortion”
 Found unconstitutional on 5-4 decision

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Stevens, Breyer, Souter, Ginsburg, O’Connor:
Four separate dissenting opinions were filed:
Rehnquist, Scalia, Kennedy, Thomas
Must have a health exception
In spite of this- Congress passed a the 2003
Partial Birth Abortion Ban without a health
exception
Signing the PBA Ban of 2003
What Does the Law Say
“An abortion in which the person
performing the abortion, deliberately and
intentionally vaginally delivers a living
fetus until, in the case of a head-first
presentation, the entire fetal head is
outside the body of the mother, or, in the
case of breech presentation, any part of
the fetal trunk past the navel is outside
the body of the mother, for the purpose of
performing an overt act that the person
knows will kill the partially delivered living
fetus; and performs the overt act, other
than completion of delivery, that kills the
partially delivered living fetus.”
Immediately Challenged

3 Legal Challenges

Planned Parenthood v. Ashcroft
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National Abortion Federation v. Ashcroft
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New York
Carhart v. Ashcroft
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San Francisco
Nebraska
Temporary Injunction

Who is covered?
Planned Parenthood v. Ashcroft/Gonzales

Challenged by Planned Parenthood, joined by the
City and County of San Francisco on behalf of San
Francisco General Hospital

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Federal District Judge Phyllis Hamilton struck
down the law on 3 grounds (6/1/04):
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Subpoena to obtain medical records
Because it places an 'undue burden' (i.e., "a
substantial obstacle in the path of a woman seeking
an abortion of a nonviable fetus") on women
seeking abortion
Because its language is unconstitutionally vague
Because it lacks constitutionally-required provisions
to preserve women's health
Upheld by 9th Circuit (1/31/06)
NAF v. Ashcroft/Gonzales
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Challenged by the ACLU Reproductive
Freedom Project on behalf of the National
Abortion Federation (NAF)
New York District Judge Richard C. Casey
(8/26/04)
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found the Partial Birth Abortion Ban Act
unconstitutional
ruled that the act must contain exceptions to
protect a woman's health
Very inflammatory language reg the fetus
Upheld by 2nd Circuit (1/31/06)
Carhart v. Ashcroft/Gonzales
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Challenged by the Center for
Reproductive Rights on behalf of a
Nebraska physician Carhart
U.S. District Judge Richard Kopf (9/8/04)
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“The overwhelming weight of the trial evidence
proves that the banned procedure is safe and
medically necessary in order to preserve the
health of women under certain circumstances.
In the absence of an exception for the health
of a woman, banning the procedure constitutes
a significant health hazard to women."
Upheld by the 8th Circuit Court of Appeals
(7/8/05)
The Supreme Court
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2 cases (Planned Parenthood &
Carhart) heard 11/8/06
Expect opinion at end of term
What do we expect
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Will depend on Kennedy’s dissent in
Carhart?
Has science and evidence changed
What is undue burden
Kennedy’s Strong Opposition
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states should be able to outlaw
“a procedure many decent and
civilized people find so abhorrent
as to be among the most serious
of crimes against human life”
dissent in Stenberg v Carhart, 2000
Implications of Reversal
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Could ban all 2nd trimester abortions
Impose criminal sentences on
physicians who violate the ban
Chilling effect on 2nd tri provider
Fundamentally change the meaning
of abortion right articulated in Roe
Restrict abortion in states with more
liberal laws
What Will Providers Do?

Survey of 2nd Trimester providers
attending the 2006 meeting of the
National Abortion Federation
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N = 46 (US only)
Average gestation limit 21wks LMP
range [16-27+]
Median gestation limit 23 wks LMP
If PBA is upheld will you:?
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alter the way you use misoprostol for
cervical ripening
use digoxin at earlier gestational ages*
reduce the gestational age to which you
perform abortions
stop performing intentionally intact D&Es
change who you allow in the procedure
room
change the clinical technique for
performing D&Es
Use Digoxin at Earlier Gestation Age?
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What is Digoxin (“Dig”)

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A feticide injected into the fetal heart
to stop fetal cardiac activity
Change clinical practice
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Yes: 11 (24%)
No: 28 (61%)
No Answer: 7 (15%)
Why Isn’t Dixogin the Answer?

Scientific evidence demonstrates does not
increase safety or ease of procedure and
has medical risks
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Drey, E. A., L. J. Thomas, N. L. Benowitz, N.
Goldschlager, and P. D. Darney. 2000. "Safety
of intra-amniotic digoxin administration before
late second-trimester abortion by dilation and
evacuation." Am J Obstet Gynecol 182:1063-6.
Jackson, R. A., V. L. Teplin, E. A. Drey, L. J.
Thomas, and P. D. Darney. 2001. "Digoxin to
facilitate late second-trimester abortion: a
randomized, masked, placebo-controlled trial."
Obstet Gynecol 97:471-6.
Other Complicating Factors
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Increased difficulty
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at reduced gestation age
with obesity
Cost
What is “fetal death”
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How prove?
Where is the “Pro-Choice Movement”
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Wavering support
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A desire to “not focus on the issue”
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Discomfort with the “techniques of abortion’
Belief that we lose when we discuss the issue
Belief that few women will be hurt by these
bans
Focus on “reframing” and terminology
rather than real understanding
Implications for Health Care Beyond
Abortion
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Legislate a particular medical
technique
What does this mean to the
concepts of informed consent?
“Fetal Pain” Bills
“Fetal Pain” Counseling Reqs.
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Require a doctor performing an
abortion at 20 or more weeks to
read to the woman a statement
saying that the fetus may
experience pain and to offer to give
the fetus anesthesia
In place in 3 states and under
consideration in others
What is Pain

Pain is a feeling – a subjective
sensory experience – and as such,
an individual must possess some
level of consciousness or awareness
in order to perceive a stimulus as
unpleasant. To be conscious and
capable of experiencing pain, an
individual must have a functional
cerebral cortex.
Inconsistent with Science

Systematic review published in JAMA,
2005
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Pain vs Movement
No “pain” prior to 29 wks gestation
“Wiring is in place but lights don’t come on”
Even if pain, no means for fetal anesthesia
Increased risk to the pregnant woman
Other concerns
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Informed consent and notions of risk
Mandated physician speech
Shouldn’t Women Decide?

I can understand why we shouldn’t
require fetal analgesia/anesthesia
for all abortions, but why shouldn’t
we allow the woman to chose for
herself whether she wants fetal
analgesia/anesthesia during an
abortion?
How to Answer the Question
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Patient autonomy is undoubtedly a consideration
of primary importance. However, there is no
known safe and effective fetal
analgesia/anesthesia to offer in the context of
abortion.
Additionally, patients should be advised that such
measures are unnecessary because science does
not support that fetuses feel pain before the third
trimester.
The goal of quality patient care is to inform
women of the most up-to-date scientific
information. Requiring that women be offered
care that is not needed nor demonstrated as safe
violates that goal.
Targeted Regulations of Abortion
Providers (TRAP) Laws
What are TRAP laws?
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Targeted Regulations of Abortion
Providers (TRAP)
TRAP laws = Purported health
facility regulations that apply only
to facilities in which abortions are
performed
TRAP laws often include:
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Licensing and inspection provisions
Authorization for searches
Administrative requirements
Minimum training requirements for
staff
Physical plant specifications
TRAP laws are different than other
abortion laws

Other abortion specific laws attempt
to influence the pregnant woman’s
decision
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premise to protect potential life
TRAP regulate the medical aspects
of the abortion procedure

premise is to promote health
How prevalent are TRAP laws?
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Over half of all states have TRAP
laws, all deal with 2nd Trimester care
Legal challenges have failed to
reverse TRAP laws
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Before 1992, many TRAP laws were
struck down as unconstitutional
Since Casey when the Supreme Court
established the undue burden
standard, almost impossible to prove
Not regulated like similar care
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Procedures with magnitude and risk
greater than abortions up to 20 wks that
are not regulated in the outpatient setting
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hysteroscopy
surgical treatment of miscarriage
diagnostic dilation & curettage
endometrial biopsy
ovum retrieval
sigmoidoscopy
vasectomy
What about after 20 wks?
What are the implications of TRAP laws?

TRAP laws
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segregate abortion from the general
practice of medicine
deter physicians from becoming
providers
unnecessarily raise the cost of
abortions
Results in reduced access to and
quality of abortion

increasing disparities particularly for
low-income & rural women
The Mississippi Story
“The Last Abortion Clinic”
A Frontline Special
Clever TRAP Laws

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Regulate clinic as an outpatient
surgical center
Requires that physician have
admitting privileges at the local
hospital
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Physicians are flown in from out-ofstate
No hospitals would grant privileges
Essentially outlawed 2nd Trimester
Abortion in Mississippi
“It is the women with resources who
continue to be able to get abortion.
And it is the low-income women,
people in marginalized populations,
people that live in rural areas, who
just don't have good access to legal
abortion and turn to very unhealthy
alternatives."
Jones, 2006
Despite This Reality

Very little attention by the
“Pro-Choice Movement”

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Search of “Mississippi” and “Abortion”
focuses on the overt ban not the
convert ban
Failed legal challenge by the Center
for Reproductive Rights
Desperate need to study the effects
of this reality
Ensuring Access
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
Women’s Option Center, San Francisco
General Hospital
Medical Director: Eleanor Drey, MD, EdM
ACCESS/Women’s Rights Coalition
Executive Director: Parker Dockray, MSW
Women’s Options Clinic
A provider of last resort
Serving the Most Acute Need

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Primary referral site for medically
complicated patients
Only provider in Northern California
that accepts “emergency” Medi-Cal
after 20 weeks in pregnancy
Fee $1000 for 2nd trimester
procedure
Turning Women Away

Caring for 23 wks patients first

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Rescheduling 21-22 wk patients
1-2 patients a week
Turning away patients who are >23
weeks and one day

A new study to look at health outcomes
What is happening in Southern California

?
ACCESS
Making Choice A Reality Since 1993
Mission


ACCESS exists to make reproductive
health and freedom a concrete reality not just a theoretical right - for ALL
women
ACCESS is a project of the Women's
Health Rights Coalition, founded in 1974
as the Coalition for the Medical Rights of
Women, a network of activists, consumers
and health care professionals
The ACCESS Hotline
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Provides free and
confidential information,
referrals, peer
counseling and
consumer advocacy
about all aspects of
reproductive health
Connects women with
public insurance
programs
Refers to organizations
that help with other
issues such as IPV,
sexual assault, drug
addiction, homelessness,
or child-care
Practical Support Network
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The Practical Support Network ensures
that women can obtain abortions and
other urgent reproductive health care
without isolation or delay
The network of over 125 volunteers
provides the transportation, overnight
housing, child-care and other support
women need to actually get to their
appointments
ACCESS can also pay for hotel rooms and
bus tickets when women must travel
great distances to find a provider
Meeting Only Some of the Need



Approx 600 calls per month
Resources to help between
150-200 women
English and Spanish only
Raising Awareness
“The Other Abortion Battle:
Abortion may be legal in California –
but that doesn't mean you can
actually get one”
Tali Woodward
The Bay Guardian
10/10/06
Working Together to Ensure
Access and Care Provision
The Medi-Cal Reimbursement Project
Medi-Cal in California


Estimated 90,946 Medi-Cal funding
induced abortions
Approx. 39% of all CA abortions
(n=236,000)
The Challenges for Medi-Cal Recipients

Approximately 38% of reproductive aged
CA women are eligible for Medi-Cal

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based on their income level
Only 20% of practicing CA Ob/Gyns
accept Medi-Cal
56% of Medi-Cal beneficiaries stated that
finding doctors in close proximity who
accepted Medi-Cal even for routine
medical care was difficult or very difficult
Medi-Cal Policy Institute. Speaking out: What beneficiaries have
to say about the Medi-Cal program. March 2006
Locating a Medi-Cal Abortion Provider

Review of the 148 publiclyadvertised CA abortion providers
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defined as all providers listed under
abortion services in the yellow pages
53% accept Medi-Cal through the 1st
trimester
20% accept Medi-Cal into the midsecond trimester (up to 20 weeks
gestation)
Only 4% accept Medi-Cal past 21
weeks
Acute Provider Shortage

Of the 23 abortion providers who
provide abortions past 20 weeks
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only 3 accept Medi-Cal through 24
weeks
10 don’t take Medi-Cal at all
Acceptance of Medi-Cal by Second Trimester Abortion Providers (21-24 Weeks)
23
21
19
Abortion Providers (N=23)
17
Medi-Cal
Accepted
15
13
Abortion
Peformed
11
9
7
5
3
1
16
18
20
Gestation (in weeks)
22
24
Not All Medi-Cal is Alike

Medi-Cal Categories
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
Full Scope Fee-for-Service
Full Scope Managed Care
“Emergency” Pregnancy-related
Medi-Cal
May accept one and not the other

Impossible to acertain
Survey of Abortion Providers

A survey of abortion providers
who perform abortions through
24 weeks but no longer accept
Medi-Cal



Conducted by ACCESS
Revealed that reimbursement rates for
2nd Trimester Abortions are too low to
cover the expenses associated with the
procedure
Accepting Medi-Cal seen as not
financially feasible
Estimating Cost v Reimbursement

Freestanding clinics that provide abortions past
20 weeks report
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an average of $467 in total reimbursements from
Medi-Cal for the procedure, ultrasounds, tests, and
medications and supplies
providing these 2nd trimester abortions costs a clinic
an average minimum of $637
leaving an estimated deficit of at least $170 per
procedure
For a hospital to perform the same procedure is
much more costly

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
the average 2nd trimester abortion is reimbursed
$581
total related hospital costs are approximately
$1,860
leaving a deficit of $1,280 per 2nd trimester abortion
Advocacy Project


California Coalition for Reproductive
Freedom
Proposal to State Office of Medi-Cal


Increase reimbursement for later
second trimester abortion
?--How deal with the
“We take Medi-Cal but not for that”
Second Trimester Abortion as a
Public Health and Human Right
Reverse
the Provider Shortage
Provide Medically Appropriate Care
Ensure Access to Those Most in Need
Stand Up for 2nd Trimester Care
Frances Kissling, CFFC
“a new era in prochoice advocacy—one that
combines a commitment to laws that affirm
and enhance the right of each woman to
decide whether to have an abortion or bear
and raise a child with an expressed
commitment to human values that include
respect for life, recognition of fetal life as
valuable and a concern for fostering a
society in which all life is valued”
Is There Life After Roe?: How to Think About the Fetus,
Conscience, Winter 2004-05
William Saletan
“Maybe that six-month window made
more sense in 1973 than it does
today. Maybe, if we spend the next 10
years helping women avoid secondtrimester abortions, we won't have to
spend the next 20 or 40 years
defending them. Maybe the best way
to end the assault on Roe is to make
it irrelevant.”
Life After Roe, Washington Post, 3/5/06;B01
Other Warning Signs



NARAL Prochoice America refused
to oppose the Unborn Pain
Awareness Act
Many public opinion polls ask
questions only about 1st trimester
abortion
Advocates warn about “bringing up
the fact that abortion is legal in the
2nd trimester”
Standing Up


DO NOT sacrifice the human rights
of the women who need them most
in the name of “keeping abortion
legal for everyone”
DO NOT sacrifice the health of
women who need abortion care
simply because it is too difficult to
talk about that care
The Illogic of It All

Restricting 2nd Trimester Abortion

Does not:
lead to increase prevention
 make people not have sex


Does
Make people parents who do not want to
be
 Medically risk the lives/health of women
 Shift the burden to women of color, low
income women and geographically
isolated women

Thank you!