Transcript Obstacles to Abortion and Comprehensive Reproductive Health Care

Obstacles to Abortion and
Comprehensive
Reproductive Health Care
Martin Donohoe, MD, FACP
Abortion in the U.S.
30 million women have had abortions since
legalization (1973)
 3 million unintended pregnancies per year
in the U.S.
 1.3 million abortions in 2000 (↓ from 1.6
million in 1990, ↓27% since 1980)

Abortion in the U.S.
 21.3
abortions/1,000 fertile
women/year
 250 induced abortions/1,000
recognized pregnancies
 37% decline since 1982
Abortion in the U.S.
49% of all pregnancies are unintended,
including more than 30% within marriage
 Patients:
 48% over age 25
 20% married
 56% have children
 43% Protestant, 27% Catholic

Abortion in the U.S.
 Patients:
 59%
white
 African-Americans and Hispanics more
likely to have abortions than Caucasians, in
part due to:
 Higher
levels of poverty
 Higher rates of unintended pregnancy
 Greater proportion of conceptions that end in
abortion
Most Important Reason Given for
Terminating an Unwanted Pregnancy
Inadequate finances - 21%
 Not ready for responsibility - 21%
 Woman’s life would be changed too much 16%
 Problems with relationship; unmarried 12%
 Too young; not mature enough - 11%

Most Important Reason Given for
Terminating an Unwanted Pregnancy

Children are grown; woman has all she wants 8%
Fetus has possible health problem - 3%
Woman has health problem
- 3%
Pregnancy caused by rape, incest - 1%
Other - 4%

Average number of reasons given




3.7
Abortion in the U.S.
By age 45, the average female will have had
1.4 unintended pregnancies
 43% will have had an induced abortion
 58% of women with unintended pregnancies
get pregnant while using birth control
 1 year contraceptive failure rates: periodic
abstinence (21%), OCPs (7%), IUD (1-2%)

Historical and Contemporary
Methods of Unsafe Abortion


Many used for millenia
Examples:
Toxic solutions taken orally or intravaginally – e.g.,
mercury, acid, detergents, etc.
 Uterine stimulant drugs
 Foreign bodies placed in the cervix/uterus – e.g.,
sticks, wires, coat hangers, air blown from pump
 Direct/indirect trauma

Abortion Worldwide


50 million/year
80,000 annual deaths (8/hour)
 13% of all maternal deaths (585,000/year)
 1/4 - 1/2 of maternal deaths in Latin America
 30 infections/injuries for every one abortion death
 220,000 children orphaned each year by poorly
performed abortions
 Use of mid-level providers can decrease complications
and deaths
Common Grounds on Which
Abortion is Permitted Worldwide







To save woman’s life – 98%
To preserve physical health – 63%
To preserve mental health – 62%
Rape or incest – 43%
Fetal impairment – 39%
Economic or social reasons – 33%
On request – 27%
Worldwide, every minute





380 women become pregnant
190 women face unplanned or unwanted
pregnancies
110 women experience pregnancy-related
complications
40 women have unsafe abortions
1 woman dies
Barriers to Abortion:
Legal Viability
Roe vs. Wade (1973): Abortion legalized up
to “point of viability” (currently 24 weeks)
 After viability, states can ban abortion
except when necessary to protect the
woman’s life or health
 Gestational limits (fetus < 500g or < 20
weeks gestational age)

Barriers to Abortion:
Cost

Cost: approx. $350-$450 (1st trimester); $750$1300 (2nd trimester)
 ¾ of patients pay out of pocket
 only 1/3 of patients have private insurance
coverage; only 1/3 of private insurance
companies cover (after deductible met)
 most insured patients reluctant to file due to
confidentiality concerns
Barriers to Abortion:
Coverage

Medicaid:
 Hyde Amendment (1978) prohibits federal
Medicaid dollars from being spent on
abortion, except to preserve the woman’s life
or in cases of rape or incest
 But, 22 states allocate Medicaid funding to
cover most abortions
Barriers to Abortion:
Coverage

Medicare:
 Hyde Amendment applied to Medicare in
1998
 Bans federal funding for abortions for
disabled women except in cases of life
endangerment, rape, or incest
 No state funding of Medicare to make up the
gap
Barriers to Abortion:
Limits on Availability of Emergency Contraception
 EC
available in 102 countries
 Available OTC in parts of Canada
and in S. Africa, UK, France, other
European countries
 Cost: $25-$40
 Less
expensive options involving OCPs
Barriers to Abortion:
Limits on Availability of Emergency Contraception

Only seven states allow drug stores to sell
over-the-counter emergency contraception
 AK, CA, NM, WA, HI, ME, NH
 NY
may be next
 Supported
by ACOG, AAFP, AAP
Barriers to Abortion:
Limits on Availability of Emergency Contraception

Only five states mandate that emergency
contraception be available to rape victims
 IL, WA, NM, CA, NY
HI and CA have passed bills allowing
pharmacists to directly prescribe emergency
contraception
 Other states considering

Military clinics not required to stock EC

Barriers to Abortion:
Provider Availability

87% of counties have no abortion provider
 30% of metropolitan areas have no
provider
 Situation worst in rural areas
 1800 physicians provide abortion services
(↓ from 2400 in 1992)
- 57% are aged 50 and older
Barriers to Abortion:
Harassment of Patients and Providers



55%-86% of providers harassed
80,000 acts of violence and/or disruption at
clinics in U.S. and Canada since 1977:
 Including 7 murders, 17 attempted murders, 41
bombings, 166 arsons, 125 assaults, 654 anthrax
threats (480 since 9/11/2001)
Abortioncam.com, Army of God, Nuremberg
Files website (closed)
Barriers to Abortion:
Inflammatory Oratory

President Bush, declaring January 20, 2002 (20th
anniversary of Roe v. Wade) “National Sanctity
of Life Day,” likens abortion to terrorism:
“On September 11, we clearly saw that evil
exists in this world, and that it does not value
life. Now we are engaged in a fight against
evil and tyranny to preserve and protect life.”
Point-Counterpoint
Barriers to Abortion
 Religious
“Right’s” unscientific
polemics →
Barriers to Abortion:
Religious Hospitals

Religious hospitals
 13% of US hospitals
 ½ of twenty largest health systems in US
are Catholic, as measured by patient
revenue
Barriers to Abortion:
Religious Hospitals
 Religious
hospitals
 Granted special exemptions by federal
government to use religious doctrine to
guide patient care yet still retain
government funding
 e.g., Catholic hospitals prohibit provision
of abortion services, as well as
contraception, sterilization, and infertility
services
Christian Science Pharmacist Refuses To
Fill Any Prescription
Barriers to Abortion:
Legal



Spousal Notification Laws
Parental Consent and Notification Laws for
Teen Abortions
Mandated waiting periods
24 states
 Most have 24 hour waiting period
 Alabama requires sonogram prior to pregnancy
termination

Parental Consent and Notification
Laws for Teen Abortions
 21 states require parental consent
 13 states require parental notification
 1 state requires both
 16 states do not require parental
permission
 2006: CA and OR ballot measures to
require parental consent failed
Barriers to Abortion:
Biased Counseling Laws



More than 20 states
Often deceptively labeled “Mandated Informed
Consent” or “Women’s Right to Know” Laws
Scare tactics re safety of abortion
 Women read a lengthy list of possible but
very rare complications from abortion (but
not list of benefits of abortion)
Barriers to Abortion:
Publicly-Funded “Crisis Pregnancy Centers”
2500-4000 nationwide, some receive state
funding
 Outnumber abortion clinics
 Listed in phone book under “pregnancy
services” or “abortion services”

Barriers to Abortion:
Publicly-Funded “Crisis Pregnancy Centers”
Staff try to dissuade clients from having
abortions through misinformation
exaggeration of risks, myths, and fetal
photos/body scans
 Stop Deceptive Advertising for Women’s
Services Act died in House Committee

Barriers to Abortion:
Scare Tactics, Misinformation, and Pseudoscience

Scare tactics re safety of abortion,
contraception, and STD prevention:
 E.g., Cardinal Alfonso Lopez Trujillo (the
Vatican’s spokesperson on family affairs):
“Relying on condoms is like betting on your
own death...They [the WHO] are wrong
about that [condoms are a highly efficient
means of preventing the spread of HIV]”
Facts re Abortion
One of the safest and most common
medical procedures available
 Risk of death from legal abortion less than
that from a shot of penicillin
 10-30 times more dangerous to carry a
fetus to term than to undergo a legal
abortion

Facts re Abortion

No long-term emotional or psychological
sequelae
 Women denied abortions often
experience resentment and distrust
 Their children may face social and
occupational deficiencies
Barriers to Abortion:
Scare Tactics, Misinformation, and Pseudoscience


Neither medical nor surgical abortion increase
subsequent risk of ectopic pregnancy, spontaeous
abortion, preterm birth, or low birth weight
No overall effect on the risk of breast cancer
 NCI removed information re abortion and breast
cancer from website; later posted unsupported “data
controversial” statement
 C.f., NIH and CDCP websites removal of
information about the effectiveness of
condoms and sex education curricula
Abstinence-Only Education




77% of Americans have had sexual intercourse
by age 20
Federal government spends $204 million in 2007
 Amount continues to increase
2% of school districts in 1988; 23% in 1999
Over 80% of curricula, used by 2/3 of grantees,
contain false, misleading, or distorted
information about reproductive health
Abstinence-Only Education


Does not decrease sexual activity, STD rates,
teen pregnancies; does not increase use of
condoms and contraceptives
c.f. “Virginity Pledges”
88% violated
 Pledgers have identical STD rates to non-pledgers
 Pledgers are less likely than other to use condoms
and to be tested and diagnosed with STDs
- J Adol Hlth 2005;36:271-8

Abstinence-Only Education




Prohibits any discussion of contraceptives
beyond failure rates
Presents worst case scenarios of abortions and
STDs
Since 2001, success defined as “completion of a
course,” rather than by actual outcomes
Some states have refused abstinence-only
funding
Abstinence Only Education:
Examples

Bizarre scare tactics:


“Today being an adult means being able to …
participate in any and all types of perverse activities
that depraved minds can imagine.”
Errors:

“Studies show that five to ten percent of women will
never again be pregnant after having a legal
abortion.”
Abstinence Only Education:
Examples

Sexism/Sex Stereotypes:
“Deep inside every man is a kinght in shining armor,
ready to rescue a maiden and slay a dragon.”
 “Females have the uncanny ability to remember the
most insignificant details about past experiences.”
 “Men tend to be more tuned in to what is happening
today and what needs to be done for a secure
future.”

Comprehensive sex education programs
 Delay
onset of intercourse
 Reduce
the frequency of intercourse
 Reduce
numbers of sexual partners
Comprehensive sex education programs
 Increase
condom and contraceptive
use.
 Reduce numbers of unwanted
pregnancies
 Supported by large majority of
Americans
Barriers to Abortion:
TRAP Laws


Targeted Regulation of Abortion Providers
Laws
Regulate hallway corridor and door frame width,
temperature of operating rooms, numbers of
hours of training each staff member much
receive, increase licensing fees, impose
burdensome documentation requirements, etc.
Barriers to Abortion:
State Laws
 States
enacted 34 new anti-choice
measures in 2002, bringing the
cumulative total to 335 since 1995
 In 2003, 20 states introduced 37 bills
criminalizing harm to an embryo or
fetus
Barriers to Abortion:
State Laws Banning Abortion

In 2003, 10 states introduced 15 measures
that would ban all or most abortion
 In 2005, a Michigan anti-abortion law
passed, prohibiting physicians from
performing most abortions, even when
the mother’s health or life is endangered
 It is currently held up in federal court
Barriers to Abortion:
State Laws Banning Abortion

2006 – South Dakota voters reject measure to
ban abortion
No exception for rape, incest or to protect woman’s
health; contains inadequate and poorly-worded
exception for “life endangerment”
 Violation is a felony


Similar bills have been introduced in Alabama,
Georgia, Indiana, Kentucky, Ohio, Mississippi,
Rhode Island, South Carolina, Tennessee, and
West Virginia
Insuring Fetuses
 Bush
administration pushing “adopt
the unborn” campaign, extending State
Children’s Health Insurance Program
(SCHIP) to fetuses
 But full prenatal care not extended
to all women
Barriers to Abortion:
“Partial Birth Abortion” Ban

Criminalizes intact dilatation and extraction
 0.17%
of all abortions
No exceptions for health of woman
 31 states have such bans


Similar 2000 Nebraska state law found
unconstitutional by U.S. Supreme Court (Stenberg
v. Carhart)
Barriers to Abortion:
“Partial Birth Abortion” Ban

Lawsuits filed to overturn
 SF Appeals Court blocked
administration enforcement of act
against Planned Parenthood Clinics and
their doctors, who perform roughly ½
of the nation’s abortions
Barriers to Abortion:
“Partial Birth Abortion” Ban

2007: US Supreme Court upholds ban
(Gonzales v. Carhart)
 Physicians
subject to 2 years in prison, fine of
up to $250,000, and monetary damages for
psychological injury to the husband or parents
of the pregnant woman
Barriers to Abortion:
Legal

Unborn Child Pain Awareness Act
 Mandates that women seeking abortion
after 20 weeks be provided specific
information regarding fetal pain during
abortion, and that they sign a form
accepting or refusing “pain medications
for the unborn fetus”
Barriers to Abortion:
Legal – The Courts
 Nominations
 ?Supreme
 ?Overturn
of anti-choice judges
Court nomination(s)?
Roe vs. Wade?
Bush Nominates First-Trimester Fetus
To Supreme Court – The Onion, 9/05
Barriers to Abortion:
Political Appointments

Political appointments to government
scientific organizations/committees based
on ideology, not knowledge and experience
 E.g., Drs. David Hager, Susan Crockett
and Joseph Stanford appointed to the
FDA’s Reproductive Health Drugs
Advisory Committee
Barriers to Abortion:
Political Appointments

Example: Ob/Gyn Hager
 Author of “As Jesus Cared for Women”
 Has advocated Scripture reading and
prayer for PMS and reportedly refuses to
provide contraceptives to unmarried
women
 Accused by wife of “serial anal rape”
Barriers to Abortion:
Global “Gag Rule”
 First
adopted by Reagan
Administration in 1984
aka Mexico city policy
 Rescinded by President Clinton in
1993
 Reinstated by Bush in 2001
Barriers to Abortion: Worldwide
 Abortion
on request permitted in only
22% of countries worldwide
6% of developing countries
 1/3 of developing world lives where
abortion is prohibited or allowed only in
cases of rape or incest or to save the
mother’s life
Barriers to Abortion: Worldwide

Lack of access to contraception
 Average number of lifetime abortions: Russia
(9), Romania (18 - pre-fall of communism)
 100 million women have an unmet need for
contraception
 Catholic Church opposes contraception (even
condoms)
Perspective:
Poverty and Priorities


Amount of money needed each year ( in
addition to current expenditures) to provide
reproductive health care for all women in
developing countries = $12 billion
Amount of money spent annually on perfumes
in Europe and the U.S. = $12 billion
Conclusions
Restrictions on access to abortion and
other reproductive health services have
increased dramatically over the last 8 years,
particularly under the Bush administration
 Backed by inflammatory/hostile rhetoric
and pseudoscience

Conclusions
 Vigilance
and legislative efforts at
federal and state level and in the
courts necessary to preserve and
protect women’s right to choose
References


Donohoe MT. “Teen Pregnancy: A call for sound science and
public policy,” in Current Controversies in Teen Pregnancy and
Parenting, Lisa Frick, Ed. (Farmington Hills, MI: Greenhaven
Press/Thomson Gale, 2006). [Reprinted from Z Magazine 2003
(April);16(4):14-16. Available at
http://zmagsite.zmag.org/Apr2003/donohoe0403.html]
Donohoe MT. Increase in obstacles to abortion: The American
perspective in 2004. J Am Med Women’s Assn
2005;60(1)(Winter):16-25. Available at http://www.amwadoc.org/index.cfm?objectid=1B138032-D567-0B2557EE86AC69902184
References


Adams KE, Donohoe MT. Reproductive Rights –
Commentary: Provider willingness to prescribe
emergency contraception. American Medical
Association Virtual Mentor 2004 (Sept.);6(9). Available
at http://www.amaassn.org/ama/pub/category/12783.html
Donohoe MT. Obstacles to abortion in the United
States. Medscape Ob/Gyn and Women’s Health
2005;10(2):posted 7/7/05. Available at
http://www.medscape.com/viewarticle/507404
References

Donohoe MT. Parental notification and consent
laws for teen abortions: overview and 2006
ballot measures. Medscape Ob/Gyn and
Women’s Health 2007. Posted 2/9/07. Available
at
http://www.medscape.com/viewarticle/549316.
Contact Information
Public Health and Social Justice Website
http://www.phsj.org
[email protected]