Obstacles to Abortion and Comprehensive Reproductive Health Care

1. Obstacles to Abortion and Comprehensive Reproductive Health Care Martin Donohoe, MD, FACP

2. 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)

3. Abortion in the U.S. • 21.3 abortions/1,000 fertile women/year • 250 induced abortions/1,000 recognized pregnancies • 37% decline since 1982

4. 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

5. 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

6. 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%

7. 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

8. 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%)

9. Abortion in the U.S.:Public Opinion Split • 49% consider themselves more “pro-choice,” 46% more “pro-life” • 55% support woman’s right to first trimester abortion • Republicans less supportive than Democrats • 25-30% of members of both parties would not vote for a candidate who did not share their views on abortion

10. Abortion in the U.S.:Public Opinion • 25-30% of American women think abortion should be legal and available in all circumstances • 17-19% think abortion should be illegal under all circumstances • The remainder would restrict abortion to cases of rape, incest, or to save a woman’s life

11. Abortion in the U.S.:Public Opinion • Top priorities for the women’s movement • Reducing domestic violence and sexual assault 92% • Equal pay for equal work 90% • Keeping abortion legal 41% • 2/3 believe the Supreme Court will not overturn Roe v Wade • Center for the Advancement of Women surveys, 2001-2003 • Are we taking Roe v Wade for granted?

12. Abortion Worldwide • 42 million/year • 48 unsafe (97% of these in developing countries) • 67,000 to 80,000 annual deaths (up to 8/hour) • 13% of all maternal deaths (585,000/year) • 1/4 - 1/2 of maternal deaths in Latin America

13. Abortion Worldwide • 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

14. 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%

15. 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

16. 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

17. Barriers to Abortion:Misconceptions about Contraception • Common among adolescents and physicians • Duration of oral contraceptive use not a factor

18. Common misconceptions about OCPs • They cause weight gain (reality = 30% fain 1-2kg from fluid retention) • They cause acne and hirsutism (reality = less acne, no hirsutism) • They cause breast cancer (reality = minimal, if any, effect) • They impair future reproduction (reality = not true)

19. Common misconceptions about OCPs: Lack of awareness of benefits re … • Decreased risk of ovarian and endometrial cancer • Regulation of cycles, prevention of dysmenorrhea and iron deficiency anemia • Decreased prevalence of PID and ensuing salpingitis and infertility • Increased bone density

20. Barriers to Abortion:Availability of Contraception • Limited access to health care and lack of coverage • Until recently, Oregon Medicaid covered Viagra but not oral contraceptives • Planned Parenthood, other sliding scale clinics

21. Barriers to Abortion:Availability of Contraception • OTC status for OCPs would improve access, is considered safe • Equity in Prescription Insurance and Contraceptive Coverage Act • Introduced in Congress in 1997; still unpassed • Would require health insurers to pay for birth control as they pay for prescription drugs

22. 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)

23. 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

24. 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

25. Barriers to Abortion:Coverage • Medicaid: • Between 18% and 35% of Medicaid-eligible women who would have had abortions instead continue their pregnancies if public funding is unavailable

26. 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

27. Barriers to Abortion:Coverage • Title X Family Planning Clinics: • Cover women from low income households at over 4500 family planning clinics • Ethnic minority women disproportionately represented • Funding has not kept up with inflation • Prohibited from using federal and non-federal funds for all abortions • “Gag rule” – 1981 to 1993

28. Barriers to Abortion:Coverage • Indian Health Service: • Covers 1.5 million American Indians and Alaska Natives • Subject to Hyde Amendment restrictions

29. Barriers to Abortion:Coverage • Military Personnel: • TRICARE (funded by Defense Dept.) covers 8.3 million uniformed personnel and their families • Permanent ban on abortion except where the life of the women is endangered

30. Barriers to Abortion:Military Hospital Abortions Ban • Military women serving abroad, and their dependents, are prohibited from obtaining abortions at military hospitals, even if they pay with personal funds • EC not available at all military treatment facilities • Alternatives: • Travel long distances for abortion – expensive and requires permission from commander to take leave • Have abortion locally – unsafe in certain countries (e.g., in Middle East)

31. Barriers to Abortion:Coverage • Federal Employees Health Benefits Program (FEHBP) • Covers over 8.5 million federal employees, their dependents, and retirees; 45% women • Since 1983 (except for 1994), abortion coverage permitted only in cases of life endangerment, rape, or incest

32. Barriers to Abortion:Coverage • Peace Corps • 7300 volunteers; 61% women • Funds cannot be used for abortions, even when the woman’s life is endangered

33. Barriers to Abortion:Coverage • Federal Prisons • 11,250 women • From 1987-present (except for 1994), ban on funding abortions except when woman’s life endangered or the pregnancy the result of rape

34. Barriers to Abortion:Funding Cuts • U.S. opposes language in the Cairo Action Plan, such as “reproductive health care,” stating that this is a proxy for abortion • This halts U.S. participation in global efforts to prevent unintended pregnancies and control the spread of STDs, including HIV • Domestic family planning budget cuts will increase unwanted pregnancies and the abortion rate

35. 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

36. 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

37. 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

38. Barriers to Abortion:Emergency Contraception in Oregon ERs, 2003 • 61% of Oregon hospitals routinely offer EC to rape patients • Catholic hospitals = non-Catholic hospitals • 46% of Oregon ERs discourage prescribing EC to non-rape patients • Catholic hospitals < non-Catholic hospitals

39. EC and Oregon Pharmacies • 70% of all pharmacists surveyed reported that their pharmacy stocked emergency contraception. • Of those pharmacists who do not stock emergency contraception, 30% will not fill a prescription for the medication due a moral objection.

40. Barriers to Abortion:Limits on Availability of Emergency Contraception • Public awareness low: • ¾ of reproductive-age women have not heard of EC • Advance access to EC does not promote risky sexual behavior • Congress has considered bills to prohibit the use of federal funds to prescribe, distribute, or provide emergency contraception to minors in elementary and secondary schools

41. Barriers to Abortion:Limits on Availability of Emergency Contraception • Laws in Arkansas, Mississippi, Georgia, and South Dakota explicitly protect pharmacists who refuse to dispense EC • Other states are considering similar legislation • Wal-Mart offered EC as of 3/06, but does not require pharmacists to dispense it (guns, ammo, on the other hand…) • Military clinics not required to stock EC

42. Barriers to Abortion:Mifepristone • Bush supports re-evaluation of FDA approval of mifepristone (RU-486, the “abortion pill”) • Approved for medical termination of pregnancies 49 days or less from LMP • Cost approx. $500

43. Barriers to Abortion:Mifepristone • Medicaid funding for mifepristone restricted to cases of rape, incest, or to preserve the pregnant woman’s life • Proposed state and federal legislation to curtail availability of mifepristone and limit the number of doctors who can prescribe it • Alternative = Methotrexate termination, cost approx. $450

44. The Black Market in Misoprostol (Cytotec) • 95% effective in conjunction with mifepristone • 85% effective alone • $2 per pill on black market • Use increasingly common among low income immigrants • Self-induced abortion illegal in 39 states

45. 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

46. Barriers to Abortion:Provider Availability • Medical school training: • 17% no formal education • Clinical years: • 23% no formal education • 32% lecture • 45% third-year clinical experience (participation low) • ½ fourth-year reproductive health elective (participation low)

47. Barriers to Abortion:Provider Availability • Provider training • 51% of Ob/Gyn residency programs houve routine training; 39% optional training • California law now requires all ob/gyn residency programs to comply with ACGME requirements, including training in abortion (with opt-out provision for conscientious objectors) • 44 states bar non-physicians from performing abortions

48. 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)

49. Barriers to Abortion:Harassment of Patients and Providers • Scheidler v. National Organization for Women U.S. Supreme Court, 2/06) • Federal extortion and racketeering laws cannot be used to stop anti-choice extremists from obstructing access to clinics, trespassing on or damaging clinic property, or using violence or threats of violence against clinics, their employees, or their patients • 2007: Massachusetts enacts toughest restrictions in US on protestors at abortion clinics • Buffer zone = 35 feet

50. 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.”