Breaking Barriers: Enhancing Reproductive Health Care Access

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. 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

10. 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

11. 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

12. 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%

13. 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

14. Barriers to Abortion:Availability of Contraception • Cost, coverage, lack of OTC status • Savings (from averted pregnancy-related costs) for various methods of contraception, per $1 spent (2007 study): • Contraceptive implant/IUD: $7.00 • Injectable contraceptives: $5.60 • Oral contraceptives: $4.07 • Contraceptive patch: $2.99 • Vaginal ring: $2.55 • Barrier methods: $1.34

15. 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)

16. 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

17. 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

18. 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

19. 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 • $1.43 cost savings (from averted pregnancy-related costs) for every $1 spent • 2009 Utah study demonstrates association between increasing rates of EC use and decreasing abortion rates

20. Barriers to Abortion:Limits on Availability of Emergency Contraception • French study showed that only 15% of EC pill use instances were reported by women using no contraception (in 45% of cases, women had been taking OCPs; in 35% of cases, partner(s) had been wearing condoms)

21. Barriers to Abortion:Limits on Availability of Emergency Contraception • 2009: FDA allows Plan B OTC for those 17 and older (younger women require a prescription) in response to US District Court ruling • Supported by ACOG, AAFP, AAP

22. Barriers to Abortion:Limits on Availability of Emergency Contraception • 17 states mandate that emergency contraception be available to rape victims • 9 states allow pharmacists to directly prescribe emergency contraception • Other states considering • Military clinics not required to stock EC

23. 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 • Family physicians facing denial of coverage, huge malpractice premium increases

24. 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), link with extremist groups/militias

25. 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.”

26. Point-Counterpoint

27. Barriers to Abortion • Religious “Right’s” unscientific polemics →

29. Barriers to Abortion:Religious Hospitals • Religious hospitals • 15% of US hospitals • ½ of twenty largest health systems in US are Catholic, as measured by patient revenue

30. 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

31. Barriers to Abortion:Religious Hospitals • Catholic hospitals deny approval of uterine evacuation while fetal heart tones present, forcing physicians to delay care or transport miscarrying patients to non-Catholic-owned facilities • Some physicians violated protocol to avoid compromising patient safety

32. Christian Science Pharmacist Refuses To Fill Any Prescription

33. 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

34. 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

35. 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)

36. ACOG Position • Dcotors whose personal beliefs require them to deviate from standard practices such as providing abortion, sterilization, or contraceptives should: • Give patients prior notice • Offer timely referral • Provide medically-indicated services in an emergency • Practice close to physicians who will provide legal serivces or ensure that referral processes are in place so that patient access is not impeded

37. 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” • 48% of college health clinics routinely refer women who might be pregnant to CPCs • 81% routinely refer to full-service health clinics

38. 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

39. 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]”

40. 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

41. 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

42. 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

43. Abstinence-Only Education • 77% of Americans have had sexual intercourse by age 20 • Federal government spent $178 million in 2008 • 0% on comprehensive sex ed • Average number of lifetime sex partners: • Wealthy country = 10 • Poor country = 6

44. Abstinence-Only Education • 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 • Does not decrease sexual activity, STD rates, teen pregnancies; does not increase use of condoms and contraceptives

45. Abstinence-Only Education • 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

46. 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 • 24 states refused abstinence-only funding in 2008 • Programs eliminated by Obama in 2010 budget

47. 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.”

48. 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.”

49. Father-Daughter Purity Balls • Growing phenomenon • More than 4,000 in U.S. (2007) • Involve rings, roses, vows, and stereotypes

50. Comprehensive sex education programs • Delay onset of intercourse • Reduce the frequency of intercourse • Reduce numbers of sexual partners