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) 30 million women have had abortions since legalization (1973) 3 million unintended pregnancies per year in the U.S. 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) 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 21.3 abortions/1,000 fertile women/year 250 induced abortions/1,000 recognized pregnancies 250 induced abortions/1,000 recognized pregnancies 37% decline since 1982 37% decline since 1982

4. Abortion in the U.S. 49% of all pregnancies are unintended, including more than 30% within marriage 49% of all pregnancies are unintended, including more than 30% within marriage Patients: Patients: 48% over age 25 48% over age 25 20% married 20% married 56% have children 56% have children 43% Protestant, 27% Catholic 43% Protestant, 27% Catholic

5. Abortion in the U.S. Patients: Patients: 59% white 59% white African-Americans and Hispanics more likely to have abortions than Caucasians, in part due to: African-Americans and Hispanics more likely to have abortions than Caucasians, in part due to: Higher levels of poverty Higher levels of poverty Higher rates of unintended pregnancy Higher rates of unintended pregnancy Greater proportion of conceptions that end in abortion 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 By age 45, the average female will have had 1.4 unintended pregnancies 43% will have had an induced abortion 43% will have had an induced abortion 58% of women with unintended pregnancies get pregnant while using birth control 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%) 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” 49% consider themselves more “pro- choice,” 46% more “pro-life” 55% support woman’s right to first trimester abortion 55% support woman’s right to first trimester abortion Republicans less supportive than Democrats 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 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 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 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 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 Top priorities for the women’s movement Reducing domestic violence and sexual assault 92% Reducing domestic violence and sexual assault 92% Equal pay for equal work 90% Equal pay for equal work 90% Keeping abortion legal 41% Keeping abortion legal 41% 2/3 believe the Supreme Court will not overturn Roe v Wade 2/3 believe the Supreme Court will not overturn Roe v Wade Center for the Advancement of Women surveys, 2001-2003 Center for the Advancement of Women surveys, 2001-2003 Are we taking Roe v Wade for granted? Are we taking Roe v Wade for granted?

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

13. Abortion Worldwide 30 infections/injuries for every one abortion death 30 infections/injuries for every one abortion death 220,000 children orphaned each year by poorly performed abortions 220,000 children orphaned each year by poorly performed abortions Use of mid-level providers can decrease complications and deaths 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 save woman’s life – 98% To preserve physical health – 63% To preserve physical health – 63% To preserve mental health – 62% To preserve mental health – 62% Rape or incest – 43% Rape or incest – 43% Fetal impairment – 39% Fetal impairment – 39% Economic or social reasons – 33% Economic or social reasons – 33% On request – 27% On request – 27%

15. Worldwide, every minute 380 women become pregnant 380 women become pregnant 190 women face unplanned or unwanted pregnancies 190 women face unplanned or unwanted pregnancies 110 women experience pregnancy-related complications 110 women experience pregnancy-related complications 40 women have unsafe abortions 40 women have unsafe abortions 1 woman dies 1 woman dies

16. Historical and Contemporary Methods of Unsafe Abortion Many used for millenia Many used for millenia Examples: Examples: Toxic solutions taken orally or intravaginally – e.g., mercury, acid, detergents, etc. Toxic solutions taken orally or intravaginally – e.g., mercury, acid, detergents, etc. Uterine stimulant drugs Uterine stimulant drugs Foreign bodies placed in the cervix/uterus – e.g., sticks, wires, coat hangers, air blown from pump Foreign bodies placed in the cervix/uterus – e.g., sticks, wires, coat hangers, air blown from pump Direct/indirect trauma Direct/indirect trauma

17. Barriers to Abortion: Misconceptions about Contraception Common among adolescents and physicians Common among adolescents and physicians Duration of oral contraceptive use not a factor 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 weight gain (reality = 30% fain 1-2kg from fluid retention) They cause acne and hirsutism (reality = less acne, no hirsutism) They cause acne and hirsutism (reality = less acne, no hirsutism) They cause breast cancer (reality = minimal, if any, effect) They cause breast cancer (reality = minimal, if any, effect) They impair future reproduction (reality = not true) 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 Decreased risk of ovarian and endometrial cancer Regulation of cycles, prevention of dysmenorrhea and iron deficiency anemia Regulation of cycles, prevention of dysmenorrhea and iron deficiency anemia Decreased prevalence of PID and ensuing salpingitis and infertility Decreased prevalence of PID and ensuing salpingitis and infertility Increased bone density Increased bone density

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

21. Barriers to Abortion: Availability of Contraception OTC status for OCPs would improve access, is considered safe OTC status for OCPs would improve access, is considered safe Equity in Prescription Insurance and Contraceptive Coverage Act Equity in Prescription Insurance and Contraceptive Coverage Act Introduced in Congress in 1997; still unpassed Introduced in Congress in 1997; still unpassed Would require health insurers to pay for birth control as they pay for prescription drugs 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) 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 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) Gestational limits (fetus < 500g or < 20 weeks gestational age)

23. Barriers to Abortion: Cost Cost: approx. $350-$450 (1 st trimester); $750- $1300 (2 nd trimester) Cost: approx. $350-$450 (1 st trimester); $750- $1300 (2 nd trimester) ¾ of patients pay out of pocket 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) 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 most insured patients reluctant to file due to confidentiality concerns

24. Barriers to Abortion: Coverage Medicaid: 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 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 But, 22 states allocate Medicaid funding to cover most abortions

25. Barriers to Abortion: Coverage Medicaid: Medicaid: Between 18% and 35% of Medicaid- eligible women who would have had abortions instead continue their pregnancies if public funding is unavailable 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: Medicare: Hyde Amendment applied to Medicare in 1998 Hyde Amendment applied to Medicare in 1998 Bans federal funding for abortions for disabled women except in cases of life endangerment, rape, or incest 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 No state funding of Medicare to make up the gap

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

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

29. Barriers to Abortion: Coverage Military Personnel: Military Personnel: TRICARE (funded by Defense Dept.) covers 8.3 million uniformed personnel and their families 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 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 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 EC not available at all military treatment facilities Alternatives: Alternatives: Travel long distances for abortion – expensive and requires permission from commander to take leave 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) Have abortion locally – unsafe in certain countries (e.g., in Middle East)

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

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

33. Barriers to Abortion: Coverage Federal Prisons Federal Prisons 11,250 women 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 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 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 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 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 EC available in 102 countries Available OTC in parts of Canada and in S. Africa, UK, France, other European countries Available OTC in parts of Canada and in S. Africa, UK, France, other European countries Cost: $25-$40 Cost: $25-$40 Less expensive options involving OCPs 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 Only seven states allow drug stores to sell over-the-counter emergency contraception AK, CA, NM, WA, HI, ME, NH AK, CA, NM, WA, HI, ME, NH NY may be next NY may be next Supported by ACOG, AAFP, AAP 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 Only five states mandate that emergency contraception be available to rape victims IL, WA, NM, CA, NY IL, WA, NM, CA, NY HI and CA have passed bills allowing pharmacists to directly prescribe emergency contraception HI and CA have passed bills allowing pharmacists to directly prescribe emergency contraception Other states considering Other states considering

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

39. EC and Oregon Pharmacies 70% of all pharmacists surveyed reported that their pharmacy stocked emergency contraception. 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. 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: Public awareness low: ¾ of reproductive-age women have not heard of EC ¾ of reproductive-age women have not heard of EC Advance access to EC does not promote risky sexual behavior 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 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 Laws in Arkansas, Mississippi, Georgia, and South Dakota explicitly protect pharmacists who refuse to dispense EC Other states are considering similar legislation 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…) 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 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”) 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 Approved for medical termination of pregnancies 49 days or less from LMP Cost approx. $500 Cost approx. $500 Has been used by over 900,000 women since its approval in 2000 Has been used by over 900,000 women since its approval in 2000

43. Barriers to Abortion: Mifepristone Medicaid funding for mifepristone restricted to cases of rape, incest, or to preserve the pregnant woman’s life 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 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 Alternative = Methotrexate termination, cost approx. $450

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

45. Barriers to Abortion: Provider Availability 87% of counties have no abortion provider 87% of counties have no abortion provider 30% of metropolitan areas have no provider 30% of metropolitan areas have no provider Situation worst in rural areas Situation worst in rural areas 1800 physicians provide abortion services (↓ from 2400 in 1992) 1800 physicians provide abortion services (↓ from 2400 in 1992) 57% are aged 50 and older 57% are aged 50 and older Family physicians facing denial of coverage, huge malpractice premium increases Family physicians facing denial of coverage, huge malpractice premium increases

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

47. Barriers to Abortion: Provider Availability Provider training Provider training 51% of Ob/Gyn residency programs houve routine training; 39% optional 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) 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 44 states bar non-physicians from performing abortions

48. Barriers to Abortion: Harassment of Patients and Providers 55%-86% of providers harassed 55%-86% of providers harassed 80,000 acts of violence and/or disruption at clinics in U.S. and Canada since 1977: 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) 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) 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) 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 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 2007: Massachusetts enacts toughest restrictions in US on protestors at abortion clinics Buffer zone = 35 feet Buffer zone = 35 feet

50. Barriers to Abortion: Inflammatory Oratory President Bush, declaring January 20, 2002 (20 th anniversary of Roe v. Wade) “National Sanctity of Life Day,” likens abortion to terrorism: President Bush, declaring January 20, 2002 (20 th 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.”

51. Point-Counterpoint

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

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

55. Barriers to Abortion: Religious Hospitals Religious hospitals Religious hospitals Granted special exemptions by federal government to use religious doctrine to guide patient care yet still retain government funding 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 e.g., Catholic hospitals prohibit provision of abortion services, as well as contraception, sterilization, and infertility services

56. 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 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 Some physicians violated protocol to avoid compromising patient safety

57. Christian Science Pharmacist Refuses To Fill Any Prescription

58. Barriers to Abortion: Legal Spousal Notification Laws Spousal Notification Laws Parental Consent and Notification Laws for Teen Abortions Parental Consent and Notification Laws for Teen Abortions Mandated waiting periods Mandated waiting periods 24 states 24 states Most have 24 hour waiting period Most have 24 hour waiting period Alabama requires sonogram prior to pregnancy termination Alabama requires sonogram prior to pregnancy termination

59. Parental Consent and Notification Laws for Teen Abortions 21 states require parental consent 21 states require parental consent 13 states require parental notification 13 states require parental notification 1 state requires both 1 state requires both 16 states do not require parental permission 16 states do not require parental permission 2006: CA and OR ballot measures to require parental consent failed 2006: CA and OR ballot measures to require parental consent failed

60. Parental Consent and Notification Laws for Teen Abortions Notification dangerous if pregnancy resulted from incest or if home situation abusive or otherwise unstable Notification dangerous if pregnancy resulted from incest or if home situation abusive or otherwise unstable U.S. Supreme Court struck down a Nebraska statute because it did not have an exception to save a pregnant woman’s life or health and returned a similar New Hampshire law to the lower courts U.S. Supreme Court struck down a Nebraska statute because it did not have an exception to save a pregnant woman’s life or health and returned a similar New Hampshire law to the lower courts

61. Parental Consent and Notification Laws for Teen Abortions National survey of female adolescents National survey of female adolescents Laws would likely increase risky or unsafe sexual behavior and, in turn, the incidence of STDs and adolescent pregnancy Laws would likely increase risky or unsafe sexual behavior and, in turn, the incidence of STDs and adolescent pregnancy - JAMA 2005;293:340-8

62. Parental Consent and Notification Laws for Teen Abortions Studies show can prevent up to half of teens from utilizing Planned Parenthood services, including contraception Studies show can prevent up to half of teens from utilizing Planned Parenthood services, including contraception Could cause only 1% of teens to stop having sex Could cause only 1% of teens to stop having sex - JAMA 2002;288:710-4.

63. Potential Annual Costs of Parental Consent and Law Enforcement Reporting Requirements For Texas $43.6 million for girls younger than 18 currently using publicly funded services $43.6 million for girls younger than 18 currently using publicly funded services Based on projected number of additional pregnancies, births, abortions, and untreated STDs and resulting cases of PID Based on projected number of additional pregnancies, births, abortions, and untreated STDs and resulting cases of PID -Arch Ped Adol Med 2004;158:1140-6.

64. Texas Parental Notification Law Enactment associated with a decline of 11-20% in abortion rates among minors from ages 15-17 Enactment associated with a decline of 11-20% in abortion rates among minors from ages 15-17 Enactment associated with increased birth rates and rates of abortion during the second trimester among a subgroup of minors who were 17.50-17.75 years old at time of conception Enactment associated with increased birth rates and rates of abortion during the second trimester among a subgroup of minors who were 17.50-17.75 years old at time of conception NEJM 2006;354:1031-8

65. Barriers to Abortion: Biased Counseling Laws More than 20 states More than 20 states Often deceptively labeled “Mandated Informed Consent” or “Women’s Right to Know” Laws Often deceptively labeled “Mandated Informed Consent” or “Women’s Right to Know” Laws Scare tactics re safety of abortion 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) Women read a lengthy list of possible but very rare complications from abortion (but not list of benefits of abortion)

66. Barriers to Abortion: Publicly-Funded “Crisis Pregnancy Centers” 2500-4000 nationwide, some receive state funding 2500-4000 nationwide, some receive state funding Outnumber abortion clinics Outnumber abortion clinics Listed in phone book under “pregnancy services” or “abortion services” Listed in phone book under “pregnancy services” or “abortion services” 48% of college health clinics routinely refer women who might be pregnant to CPCs 48% of college health clinics routinely refer women who might be pregnant to CPCs 81% routinely refer to full-service health clinics 81% routinely refer to full-service health clinics

67. 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 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 Stop Deceptive Advertising for Women’s Services Act died in House Committee

68. Barriers to Abortion: Scare Tactics, Misinformation, and Pseudoscience Scare tactics re safety of abortion, contraception, and STD prevention: Scare tactics re safety of abortion, contraception, and STD prevention: E.g., Cardinal Alfonso Lopez Trujillo (the Vatican’s spokesperson on family affairs): 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]”

69. Facts re Abortion One of the safest and most common medical procedures available One of the safest and most common medical procedures available Risk of death from legal abortion less than that from a shot of penicillin 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 10-30 times more dangerous to carry a fetus to term than to undergo a legal abortion

70. Facts re Abortion No long-term emotional or psychological sequelae No long-term emotional or psychological sequelae Women denied abortions often experience resentment and distrust Women denied abortions often experience resentment and distrust Their children may face social and occupational deficiencies Their children may face social and occupational deficiencies

71. 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 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 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 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 C.f., NIH and CDCP websites removal of information about the effectiveness of condoms and sex education curricula

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

73. Abstinence-Only Education 2% of school districts in 1988; 23% in 1999 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 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 Does not decrease sexual activity, STD rates, teen pregnancies; does not increase use of condoms and contraceptives Teen birth rate rose in 2006 (first rise in 14 years) Teen birth rate rose in 2006 (first rise in 14 years)

74. Abstinence-Only Education c.f. “Virginity Pledges” c.f. “Virginity Pledges” 88% violated 88% violated Pledgers have identical STD rates to non- pledgers 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 Pledgers are less likely than other to use condoms and to be tested and diagnosed with STDs - J Adol Hlth 2005;36:271-8

75. Abstinence-Only Education Diversion of government funds to abstinence only programs and cuts to family planning programs and diversion of money away from other social programs into AOE and “Healthy Families Initiative” will likely increase the number of unwanted pregnancies and thus the number of women seeking pregnancy termination Diversion of government funds to abstinence only programs and cuts to family planning programs and diversion of money away from other social programs into AOE and “Healthy Families Initiative” will likely increase the number of unwanted pregnancies and thus the number of women seeking pregnancy termination

76. Abstinence-Only Education Attempts to instill guilt, fear and shame into students Attempts to instill guilt, fear and shame into students Places responsibility for refusing sexual advances on women Places responsibility for refusing sexual advances on women Blurs science and religion Blurs science and religion Treats stereotypes about boys and girls as scientific fact Treats stereotypes about boys and girls as scientific fact Stereotypes undermine girls’ achievment, claim that girls are weak and need protection, and reinforce male sexual aggressiveness Stereotypes undermine girls’ achievment, claim that girls are weak and need protection, and reinforce male sexual aggressiveness

77. Abstinence-Only Education Prohibits any discussion of contraceptives beyond failure rates Prohibits any discussion of contraceptives beyond failure rates Presents worst case scenarios of abortions and STDs Presents worst case scenarios of abortions and STDs Since 2001, success defined as “completion of a course,” rather than by actual outcomes Since 2001, success defined as “completion of a course,” rather than by actual outcomes Some states have rejected abstinence-only funding Some states have rejected abstinence-only funding

78. Abstinence Only Education: Examples Bizarre scare tactics: 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.” “Today being an adult means being able to … participate in any and all types of perverse activities that depraved minds can imagine.” Errors: Errors: “Studies show that five to ten percent of women will never again be pregnant after having a legal abortion.” “Studies show that five to ten percent of women will never again be pregnant after having a legal abortion.”

79. Abstinence Only Education: Examples Sexism/Sex Stereotypes: Sexism/Sex Stereotypes: “Deep inside every man is a kinght in shining armor, ready to rescue a maiden and slay a dragon.” “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.” “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.” “Men tend to be more tuned in to what is happening today and what needs to be done for a secure future.”

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

81. Comprehensive sex education programs Increase condom and contraceptive use. Increase condom and contraceptive use. Reduce numbers of unwanted pregnancies Reduce numbers of unwanted pregnancies Supported by large majority of Americans Supported by large majority of Americans

82. Barriers to Abortion: TRAP Laws Targeted Regulation of Abortion Providers 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. 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.

83. Barriers to Abortion: TRAP Laws Not applicable to other ambulatory health centers Not applicable to other ambulatory health centers Increase retrofitting, design and training costs; put some clinics out of business Increase retrofitting, design and training costs; put some clinics out of business Zoning ordinances – some clinics forced to relocate; others shut down Zoning ordinances – some clinics forced to relocate; others shut down Effect: decreased access to and increased costs of abortion Effect: decreased access to and increased costs of abortion

84. Barriers to Abortion: TRAP Laws As of 2004: As of 2004: 19 states and Puerto Rico enforce TRAP laws that apply to abortions performed at any stage of pregnancy 19 states and Puerto Rico enforce TRAP laws that apply to abortions performed at any stage of pregnancy 14 states enforce TRAP laws that only apply to abortions performed after the first trimester 14 states enforce TRAP laws that only apply to abortions performed after the first trimester

85. Barriers to Abortion: State Laws States enacted 34 new anti-choice measures in 2002, bringing the cumulative total to 335 since 1995 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 In 2003, 20 states introduced 37 bills criminalizing harm to an embryo or fetus As of 2008, 4 states require ultrasounds prior to abortion (AL, LA, MS, OK) As of 2008, 4 states require ultrasounds prior to abortion (AL, LA, MS, OK)

86. Barriers to Abortion: State Laws Banning Abortion In 2003, 10 states introduced 15 measures that would ban all or most 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 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 It is currently held up in federal court

87. Barriers to Abortion: State Laws Banning Abortion 2006 – South Dakota voters reject measure to ban 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” No exception for rape, incest or to protect woman’s health; contains inadequate and poorly-worded exception for “life endangerment” Violation is a felony Violation is a felony 2008 ballot initiative to outlaw “partial birth abortion” also failed 2008 ballot initiative to outlaw “partial birth abortion” also failed Similar bills have been introduced in Alabama, Georgia, Indiana, Kentucky, Ohio, Mississippi, Rhode Island, South Carolina, Tennessee, and West Virginia Similar bills have been introduced in Alabama, Georgia, Indiana, Kentucky, Ohio, Mississippi, Rhode Island, South Carolina, Tennessee, and West Virginia

88. Barriers to Abortion: State Laws In January, 2005 alone: In January, 2005 alone: 15 states introduced 19 bills that would require counseling and waiting periods for abortion 15 states introduced 19 bills that would require counseling and waiting periods for abortion 12 states introduced 17 bills that would mandate parental involvement in minors’ abortions 12 states introduced 17 bills that would mandate parental involvement in minors’ abortions

89. Barriers to Abortion: State Laws 2005 – Cook County judge ruled that parents of a frozen embryo accidently destroyed by a Chicago fertility clinic could file a wrongful death lawsuit 2005 – Cook County judge ruled that parents of a frozen embryo accidently destroyed by a Chicago fertility clinic could file a wrongful death lawsuit Very few states have both pro-choice legislatures and a pro-choice governor Very few states have both pro-choice legislatures and a pro-choice governor

90. Barriers to Abortion: State Laws Colorado’s Human Life Amendment, which would have given full legal rights to fertilized eggs, defeated 3-1 (2008) Colorado’s Human Life Amendment, which would have given full legal rights to fertilized eggs, defeated 3-1 (2008) 3 states have “Choose Life” laws, allowing motorists to purchase “Choose Life” license plates 3 states have “Choose Life” laws, allowing motorists to purchase “Choose Life” license plates Proceeds support “Crisis Pregnancy Centers” Proceeds support “Crisis Pregnancy Centers”

91. South Dakota’s “Informed Consent” Law Passed in 2005 Passed in 2005 Planned Parenthood sought and received injunction to suspend Law Planned Parenthood sought and received injunction to suspend Law 6/08: Eighth Circuit Court of Appeals (Planned Parenthood Minnesota v. Rounds) lifted injunction 6/08: Eighth Circuit Court of Appeals (Planned Parenthood Minnesota v. Rounds) lifted injunction

92. South Dakota’s “Informed Consent” Law: Requirements Physician must give pregnant women a description of scientifically-unsupported “risks of abortion” Physician must give pregnant women a description of scientifically-unsupported “risks of abortion” Women must be told that they have an “existing relationship with fetus that enjoys protection under the U.S. Constitution and under the laws of South Dakota,” and that abortion terminates that relationship terminates that relationship along with “her existing constitutional rights with regards to that relationship” Women must be told that they have an “existing relationship with fetus that enjoys protection under the U.S. Constitution and under the laws of South Dakota,” and that abortion terminates that relationship terminates that relationship along with “her existing constitutional rights with regards to that relationship” Neither the Constitution nor SD laws explicitly mention such a relationship Neither the Constitution nor SD laws explicitly mention such a relationship

93. South Dakota’s “Informed Consent” Law: Requirements Disclosures must be made in writing, and women must sign each page of the state-crafted script Disclosures must be made in writing, and women must sign each page of the state-crafted script Physicians who do not satisfy statute subject to license suspension or revocation and may be charged with a class 2 misdemeanor Physicians who do not satisfy statute subject to license suspension or revocation and may be charged with a class 2 misdemeanor Physicians thus must violate Hippocratic Oath and lie to patients or violate SD law and face sanctions and possible prosecution Physicians thus must violate Hippocratic Oath and lie to patients or violate SD law and face sanctions and possible prosecution

94. “Fetal Research Rights” Mission of Advisory Committee on Human Research Protection – which oversees the safety of human research volunteers –expanded to include embryos Mission of Advisory Committee on Human Research Protection – which oversees the safety of human research volunteers –expanded to include embryos

95. Insuring Fetuses Bush administration pushing “adopt the unborn” campaign, extending State Children’s Health Insurance Program (SCHIP) to 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 But full prenatal care not extended to all women

96. Barriers to Abortion: “Partial Birth Abortion” Ban Criminalizes intact dilatation and extraction Criminalizes intact dilatation and extraction 0.17% of all abortions 0.17% of all abortions No exceptions for health of woman No exceptions for health of woman 31 states have such bans 31 states have such bans Similar 2000 Nebraska state law found unconstitutional by U.S. Supreme Court (Stenberg v. Carhart) Similar 2000 Nebraska state law found unconstitutional by U.S. Supreme Court (Stenberg v. Carhart)

97. Barriers to Abortion: “Partial Birth Abortion” Ban Lawsuits filed to overturn 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 SF Appeals Court blocked administration enforcement of act against Planned Parenthood Clinics and their doctors, who perform roughly ½ of the nation’s abortions

98. Barriers to Abortion: “Partial Birth Abortion” Ban 2007: US Supreme Court upholds ban (Gonzales v. Carhart) 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 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

100. Barriers to Abortion: Legal “Unborn Victims of Violence Law” “Unborn Victims of Violence Law” Criminalizes harming fetus; e.g., conviction in Texas (6-05) Criminalizes harming fetus; e.g., conviction in Texas (6-05) Supposedly will “help protect victims from domestic violence” Supposedly will “help protect victims from domestic violence” Irony: Domestic violence programs in U.S. woefully under-funded Irony: Domestic violence programs in U.S. woefully under-funded Could limit women’s freedom to work in certain settings/at certain jobs Could limit women’s freedom to work in certain settings/at certain jobs

101. Legal Barriers to Abortion: The “Teen Endangerment Act” Part I: “Child Custody Protection Act”: Part I: “Child Custody Protection Act”: Would make it a federal crime for anyone other than a parent, including other relatives and religious counselors, from accompanying a young woman across state lines for an abortion, without complying with the home state’s parental involvement statutes Would make it a federal crime for anyone other than a parent, including other relatives and religious counselors, from accompanying a young woman across state lines for an abortion, without complying with the home state’s parental involvement statutes Would delay abortion, increasing cost and physical/emotional health risks to teenager Would delay abortion, increasing cost and physical/emotional health risks to teenager

102. Legal Barriers to Abortion: The “Teen Endangerment Act” Part II: “Child Interstate Abortion Notification Act”: Part II: “Child Interstate Abortion Notification Act”: Would make it a federal crime to provide an abortion to a teenager outside of her home state unless the physician has notified a parent at least 24 hrs. in advance. Would make it a federal crime to provide an abortion to a teenager outside of her home state unless the physician has notified a parent at least 24 hrs. in advance. No exception when abortion necessary to protect the teenager’s health No exception when abortion necessary to protect the teenager’s health Requires 24 hr. waiting period and written notification even if a parent accompanies teen to an out-of-state abortion provider Requires 24 hr. waiting period and written notification even if a parent accompanies teen to an out-of-state abortion provider

103. Legal Barriers to Abortion: The “Teen Endangerment Act” Passed by the U.S. House of Representatives in 2005 Passed by the U.S. House of Representatives in 2005 Senate currently considering a similar bill, but without interstate abortion notification procedures Senate currently considering a similar bill, but without interstate abortion notification procedures

105. Barriers to Abortion: Legal Unborn Child Pain Awareness Act 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” 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”

106. Barriers to Abortion: Legal – The Courts Nominations of anti-choice judges Nominations of anti-choice judges ?Supreme Court nomination(s)? ?Supreme Court nomination(s)? ?Overturn Roe vs. Wade? ?Overturn Roe vs. Wade?

107. Bush Nominates First-Trimester Fetus To Supreme Court – The Onion, 9/05

108. Barriers to Abortion: Legal Unsuccessful attempt to subpoena medical records from family planning clinic (violating patient confidentiality) Unsuccessful attempt to subpoena medical records from family planning clinic (violating patient confidentiality) Storm Lake, Iowa – resisted by Jill June, one of Ms. Magazine’s 2002 Women of the Year Storm Lake, Iowa – resisted by Jill June, one of Ms. Magazine’s 2002 Women of the Year

109. Barriers to Abortion: Legal Maine Rep. Brian Duprey submitted bill to state legislature to make it a crime to abort an unborn child if that child is determined to be carrying the “homosexual gene” Maine Rep. Brian Duprey submitted bill to state legislature to make it a crime to abort an unborn child if that child is determined to be carrying the “homosexual gene” Such a gene is not known to exist Such a gene is not known to exist Duprey got idea for bill “from Rush Limbaugh” Duprey got idea for bill “from Rush Limbaugh”

110. Barriers to Abortion: Political Appointments Political appointments to government scientific organizations/committees based on ideology, not knowledge and experience 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 E.g., Drs. David Hager, Susan Crockett and Joseph Stanford appointed to the FDA’s Reproductive Health Drugs Advisory Committee

111. Barriers to Abortion: Political Appointments Example: Ob/Gyn Hager Example: Ob/Gyn Hager Author of “As Jesus Cared for Women” Author of “As Jesus Cared for Women” Has advocated Scripture reading and prayer for PMS and reportedly refuses to provide contraceptives to unmarried 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” Accused by wife of “serial anal rape”

112. Barriers to Abortion: Political Appointments Erik Keroack (head of “crisis pregnancy center,” anti-birth control, anti-sex education) appointed Deputy Asst Scty. For Population Affairs in DHHS – later resigned Erik Keroack (head of “crisis pregnancy center,” anti-birth control, anti-sex education) appointed Deputy Asst Scty. For Population Affairs in DHHS – later resigned FDA Representative Dr. Janet Woodcock: FDA Representative Dr. Janet Woodcock: Selling Plan B OTC would transform it into an “urban legend” that would tempt adolescents to create “sex-based cults” Selling Plan B OTC would transform it into an “urban legend” that would tempt adolescents to create “sex-based cults”

113. Church Amendment Protects those who choose to participate and those who choose not to participate in abortion at federally funded public health institutions Protects those who choose to participate and those who choose not to participate in abortion at federally funded public health institutions

114. Coats Amendment Passed 1996 Passed 1996 Maintains federal funding and legal status of medical institutions that do not offer abortion training or provide referrals for individuals seeking abortion training at another institution Maintains federal funding and legal status of medical institutions that do not offer abortion training or provide referrals for individuals seeking abortion training at another institution Prohibits discrimination against institutions and individuals who refuse to provide abortion training Prohibits discrimination against institutions and individuals who refuse to provide abortion training

115. Barriers to Abortion: The Weldon Federal Refusal Clause Signed by President Bush in 12/04 Signed by President Bush in 12/04 Allows federally-funded health care entities to deny women information on abortion services, even if state laws mandate that such information be given upon request Allows federally-funded health care entities to deny women information on abortion services, even if state laws mandate that such information be given upon request 46 states have similar conscience clauses 46 states have similar conscience clauses

116. Barriers to Abortion: The Weldon Federal Refusal Clause Opposing lawsuit filed December, 2004, by the National Family Planning and Reproductive Health Association Opposing lawsuit filed December, 2004, by the National Family Planning and Reproductive Health Association Lawsuit by state of California rejected by federal judge (2008) Lawsuit by state of California rejected by federal judge (2008)

117. Barriers to Abortion: Refusal Clauses 46 states enacted shortly after Roe v. Wade 46 states enacted shortly after Roe v. Wade Permit certain medical personnel, health facilities, and/or institutions to refuse to participate in abortion Permit certain medical personnel, health facilities, and/or institutions to refuse to participate in abortion DHHS regulations (9/08) allow health care workers and institutions to refuse on religious grounds to perform or refer patients for abortions DHHS regulations (9/08) allow health care workers and institutions to refuse on religious grounds to perform or refer patients for abortions

118. Effects of Refusal Clauses Employers can refuse to provide contraceptive coverage in their health plans Employers can refuse to provide contraceptive coverage in their health plans Pharmacists can refuse to dispense, or provide referrals for, lawfully-prescribed OCPs Pharmacists can refuse to dispense, or provide referrals for, lawfully-prescribed OCPs Health care professionals can deny patients information on, or referral for, family planning services, regardless of the patient’s health care needs Health care professionals can deny patients information on, or referral for, family planning services, regardless of the patient’s health care needs

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

120. Barriers to Abortion: Global “Gag Rule” First adopted by Reagan Administration in 1984 First adopted by Reagan Administration in 1984 aka Mexico city policy aka Mexico city policy Rescinded by President Clinton in 1993 Rescinded by President Clinton in 1993 Reinstated by Bush in 2001 Reinstated by Bush in 2001

121. Barriers to Abortion: Global “Gag Rule” Global Gag Rule reinstated by Bush Administration in 2001 Global Gag Rule reinstated by Bush Administration in 2001 Has caused 430 organizations in 50 countries to stop performing abortions or speaking about abortion laws in order to qualify for U.S. funding Has caused 430 organizations in 50 countries to stop performing abortions or speaking about abortion laws in order to qualify for U.S. funding 1/16 women in sub-Saharan Africa die during pregnancy or childbirth 1/16 women in sub-Saharan Africa die during pregnancy or childbirth Does not cover condoms procured with HIV/AIDS funds Does not cover condoms procured with HIV/AIDS funds Senate narrowly voted to overturn, bill now in committee Senate narrowly voted to overturn, bill now in committee

122. Barriers to Abortion: Domestic “Gag Rule” Adopted by Reagan administration in 1988 Adopted by Reagan administration in 1988 Overturned by Clinton in 1992 Overturned by Clinton in 1992 Could be reinstated by Bush Could be reinstated by Bush

123. The Good News Since 1988, 21 states have passed comprehensive laws or regulations ensuring equity in private insurance coverage for prescription contraception Since 1988, 21 states have passed comprehensive laws or regulations ensuring equity in private insurance coverage for prescription contraception Parents very accepting of idea of sexually transmitted disease vaccination for their adolescent children Parents very accepting of idea of sexually transmitted disease vaccination for their adolescent children - Arch Ped Adol Med 2005;159:132-7

124. The Good News States and U.S. Congress introducing bills to improve sex education and affirm women’s right to choose “Freedom of Choice” bills States and U.S. Congress introducing bills to improve sex education and affirm women’s right to choose “Freedom of Choice” bills The European Court of Human Rights has declined to extend full human rights to fetuses The European Court of Human Rights has declined to extend full human rights to fetuses

125. Barriers to Abortion: Worldwide Abortion on request permitted in only 22% of countries worldwide Abortion on request permitted in only 22% of countries worldwide 6% of developing countries 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 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

126. Barriers to Abortion: Worldwide Lack of access to contraception Lack of access to contraception Average number of lifetime abortions: Russia (9), Romania (18 - pre-fall of communism) Average number of lifetime abortions: Russia (9), Romania (18 - pre-fall of communism) 100 million women have an unmet need for contraception 100 million women have an unmet need for contraception Catholic Church opposes contraception (even condoms) Catholic Church opposes contraception (even condoms)

128. Barriers to Abortion: Worldwide U.S. cut $34 million in funding for U.N. Population Fund and withdrew support from a population control program that stressed access to reproductive health care and education U.S. cut $34 million in funding for U.N. Population Fund and withdrew support from a population control program that stressed access to reproductive health care and education Based on unsubstantiated argument that the program supports China’s coercive population control policy Based on unsubstantiated argument that the program supports China’s coercive population control policy However, selective abortion of female infants common (119F/100M born in China) However, selective abortion of female infants common (119F/100M born in China)

129. Barriers to Abortion: U.S. Pressure on World Health Organization WHO expert committee recommended that mifepristone and misoprostol should be added to its Essential Medicines list WHO expert committee recommended that mifepristone and misoprostol should be added to its Essential Medicines list WHO has failed to act, possibly in response to pressure from the U.S. Dept. of Health and Human Services WHO has failed to act, possibly in response to pressure from the U.S. Dept. of Health and Human Services

130. 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 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 Amount of money spent annually on perfumes in Europe and the U.S. = $12 billion

131. Conclusions Restrictions on access to abortion and other reproductive health services have increased dramatically over the last 8 years, particularly under the Bush administration 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 Backed by inflammatory/hostile rhetoric and pseudoscience

132. Conclusions Vigilance and legislative efforts at federal and state level and in the courts necessary to preserve and protect women’s right to choose Vigilance and legislative efforts at federal and state level and in the courts necessary to preserve and protect women’s right to choose

133. 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. “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] 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.amwa- doc.org/index.cfm?objectid=1B138032-D567-0B25- 57EE86AC69902184 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.amwa- doc.org/index.cfm?objectid=1B138032-D567-0B25- 57EE86AC69902184http://www.amwa- doc.org/index.cfm?objectid=1B138032-D567-0B25- 57EE86AC69902184http://www.amwa- doc.org/index.cfm?objectid=1B138032-D567-0B25- 57EE86AC69902184

134. 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.ama- assn.org/ama/pub/category/12783.html 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.ama- assn.org/ama/pub/category/12783.htmlhttp://www.ama- assn.org/ama/pub/category/12783.htmlhttp://www.ama- assn.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 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 http://www.medscape.com/viewarticle/507404

135. 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. 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. http://www.medscape.com/viewarticle/549316

136. Contact Information Public Health and Social Justice Website http://www.phsj.org martindonohoe@phsj.org