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

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

Abortion in the U.S. 30 million women have had abortions since legalization (1973) 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. 1.2 million abortions in 2008 (↓ from 1.6 million in 1990, ↓27% since 1980) 1.2 million abortions in 2008 (↓ from 1.6 million in 1990, ↓27% since 1980)

Abortion in the U.S. 19 abortions/1,000 fertile women/year 19 abortions/1,000 fertile women/year Lowest rate since 1974 Lowest rate since 1974 9/10 abortions are in first 12 weeks 9/10 abortions are in first 12 weeks 9/10 abortions surgical 9/10 abortions surgical 236 induced abortions/1,000 live births 236 induced abortions/1,000 live births Over 1/3 decline since early 1980s Over 1/3 decline since early 1980s

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 80% of teen pregnancies unintended 80% of teen pregnancies unintended Teen pregnancy has decreased 37% since 1991 Teen pregnancy has decreased 37% since 1991

Abortion in the U.S. Patients: Patients: 48% over age 25 48% over age 25 14% married (67% never married) 14% married (67% never married) 56% have children 56% have children 43% Protestant, 27% Catholic, 8% other, 22% no religion 43% Protestant, 27% Catholic, 8% other, 22% no religion Catholics, mainline Protestants, and Evangelicals all have similarly high rates of contraceptive use (compared with other religions) Catholics, mainline Protestants, and Evangelicals all have similarly high rates of contraceptive use (compared with other religions)

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

Most Important Reason Given for Terminating an Unwanted Pregnancy Inadequate finances - 21% Not ready for responsibility - 21% Woman’s life would be changed too much - 16% Problems with relationship; unmarried - 12% Too young; not mature enough - 11%

Most Important Reason Given for Terminating an Unwanted Pregnancy Children are grown; woman has all she wants - 8% Fetus has possible health problem - 3% Woman has health problem - 3% Pregnancy caused by rape, incest - 1% Other - 4% Average number of reasons given = 3.7

Abortion in the U.S. By age 45, the average female will have had 1.4 unintended pregnancies By age 45, the average female will have had 1.4 unintended pregnancies By age 45, 35% of US women will have had an induced abortion By age 45, 35% of US women will have had an induced abortion 54% of women with unintended pregnancies get pregnant while using birth control 54% 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%)

Abortion in the U.S.: Public Opinion Split 2009: 42% consider themselves more “pro- choice,” 51% more “pro-life” (was 44%/50% in 2008) 2009: 42% consider themselves more “pro- choice,” 51% more “pro-life” (was 44%/50% in 2008) Men 46% pro-choice, women 51% pro- choice Men 46% pro-choice, women 51% pro- choice 2010: 45% pro-choice, 47% pro-life 2010: 45% pro-choice, 47% pro-life 2010: Abortion should be “generally available” (36%), “available under strict limits” (39%), “not permitted” (2%) 2010: Abortion should be “generally available” (36%), “available under strict limits” (39%), “not permitted” (2%)

Abortion in the U.S.: Politics 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

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

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?

Abortion Worldwide 42 million/year 42 million/year 22 million unsafe (98% of these in developing countries) 22 million unsafe (98% of these in developing countries) Cost of treating women for complications of botched abortions = $19 million/yr (vs. $4.8 million to provide contraception) Cost of treating women for complications of botched abortions = $19 million/yr (vs. $4.8 million to provide contraception)

Abortion Worldwide 70,000 annual deaths (7/hour) 70,000 annual deaths (7/hour) 13% of all maternal deaths (i.e., 13% of 585,000) each year 13% of all maternal deaths (i.e., 13% of 585,000) each year 1/4 - 1/2 of maternal deaths in Latin America 1/4 - 1/2 of maternal deaths in Latin America 5 million hospitalizations annually 5 million hospitalizations annually 30 infections/injuries for every one abortion death 30 infections/injuries for every one abortion death

Abortion Worldwide 220,000 children orphaned each year by poorly performed abortions 220,000 children orphaned each year by poorly performed abortions Legal restrictions have no effect on abortion incidence Legal restrictions have no effect on abortion incidence Use of mid-level providers can decrease complications and deaths Use of mid-level providers can decrease complications and deaths

Maternal Mortality 1/2100 in U.S. 3X higher in black than white women 1/31 in sub-Saharan Africa Cause: Lack of access to comprehensive reproductive health care/obstetrical care

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%

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

Historical and Contemporary Methods of Unsafe Abortion Many used for millennia Many used for millennia Examples: Examples: Toxic solutions taken orally or intra-vaginally: e.g., turpentine, bleach, mercury, acid, detergents, etc. Toxic solutions taken orally or intra-vaginally: e.g., turpentine, bleach, 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

Barriers to Abortion: Misconceptions about Sex and Contraception Common among adolescents and physicians Common among adolescents and physicians 40% of children age 13-17 who had intercourse did so before any parental discussion of STDs and birth control 40% of children age 13-17 who had intercourse did so before any parental discussion of STDs and birth control Duration of oral contraceptive use not a factor Duration of oral contraceptive use not a factor

Barriers to Abortion: Misconceptions about Sex and Contraception 20% of 18-29 yr olds say they never had school- based sex education 20% of 18-29 yr olds say they never had school- based sex education 63% acknowledge “little to no knowledge” about contraception pills 63% acknowledge “little to no knowledge” about contraception pills 30% for condoms 30% for condoms 28% of men think wearing two condoms at once better (actually promotes condom breakage) 28% of men think wearing two condoms at once better (actually promotes condom breakage) - National Campaign to Prevent Teen Pregnancy, 2009

Common misconceptions about OCPs They cause weight gain (reality = 30% gain 1- 2kg from fluid retention) They cause weight gain (reality = 30% gain 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)

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

Barriers to Abortion: Availability of Contraception Limited access to health care and lack of coverage Limited access to health care and lack of coverage Only 27 states require health insurance policies that cover other prescription drugs to include contraceptives Only 27 states require health insurance policies that cover other prescription drugs to include contraceptives 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

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 Would not increase sexual risk-taking behavior Would not increase sexual risk-taking behavior Equity in Prescription Insurance and Contraceptive Coverage Act Equity in Prescription Insurance and Contraceptive Coverage Act Introduced in Congress in 1997; still not passed Introduced in Congress in 1997; still not passed 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

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

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)

Barriers to Abortion: Cost Cost: approx. $350-$450 (1 st trimester); $750-$1800 (2 nd trimester) Cost: approx. $350-$450 (1 st trimester); $750-$1800 (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) 5 states restrict abortion coverage by private insurance plans (ID, KY, MO, ND, OK) 5 states restrict abortion coverage by private insurance plans (ID, KY, MO, ND, OK) most insured patients reluctant to file due to confidentiality concerns most insured patients reluctant to file due to confidentiality concerns

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, 17 states allocate Medicaid funding to cover most abortions But, 17 states allocate Medicaid funding to cover most abortions

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

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

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

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

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 (Senate Armed Services Committee voted to lift ban in mid 2010, bill pending) Permanent ban on abortion except where the life of the women is endangered (Senate Armed Services Committee voted to lift ban in mid 2010, bill pending)

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)

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

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

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

Obama Health Care Plan Executive Order states that federal funds cannot be used for abortion (except in cases of rape or incest or when the life of the woman is endangered) Executive Order states that federal funds cannot be used for abortion (except in cases of rape or incest or when the life of the woman is endangered) Prohibits discrimination against health care facilities and providers because of unwilliness to provide or refer for abortions Prohibits discrimination against health care facilities and providers because of unwilliness to provide or refer for abortions

Obama Health Care Plan Bans tax credits and federal subsidies for people required to purchase private insurance from being used to pay for abortion (except in cases of rape or incest or when the life of the woman is endangered) Bans tax credits and federal subsidies for people required to purchase private insurance from being used to pay for abortion (except in cases of rape or incest or when the life of the woman is endangered) Means most policies will require two separate monthly premiums Means most policies will require two separate monthly premiums Will discourage plans from offering abortion Will discourage plans from offering abortion Will exclude poor Will exclude poor

Barriers to Abortion: Funding Cuts Under Bush II, U.S. opposed language in the Cairo Action Plan, such as “reproductive health care,” stating that this is a proxy for abortion Under Bush II, U.S. opposed language in the Cairo Action Plan, such as “reproductive health care,” stating that this is a proxy for abortion This halted U.S. participation in global efforts to prevent unintended pregnancies and control the spread of STDs, including HIV This halted U.S. participation in global efforts to prevent unintended pregnancies and control the spread of STDs, including HIV Domestic family planning budget cuts under Bush II Domestic family planning budget cuts under Bush II

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-$50 Cost: $25-$50 Less expensive options involving OCPs Less expensive options involving OCPs $1.43 cost savings (from averted pregnancy-related costs) for every $1 spent $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 2009 Utah study demonstrates association between increasing rates of EC use and decreasing abortion rates

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) 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)

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 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 Supported by ACOG, AAFP, AAP 2010: FDA approves ulipristal (Ella) 2010: FDA approves ulipristal (Ella) effective for EC for up to 5 days post-coitus effective for EC for up to 5 days post-coitus 2010: Copper IUD found to be 100% effective up to 5 days for EC ($500) 2010: Copper IUD found to be 100% effective up to 5 days for EC ($500)

Barriers to Abortion: Limits on Availability of Emergency Contraception 17 states mandate that emergency contraception be available to rape victims 17 states mandate that emergency contraception be available to rape victims 9 states allow pharmacists to directly prescribe emergency contraception 9 states allow pharmacists to directly prescribe emergency contraception Other states considering Other states considering

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

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.

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, only 17% of teens have used (2006-8 data) ¾ of reproductive-age women have not heard of EC, only 17% of teens have used (2006-8 data) 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

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

Barriers to Abortion: Mifepristone Bush supported re-evaluation of FDA approval of mifepristone (RU-486, the “abortion pill”) Bush supported 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 30 million women worldwide Has been used by over 30 million women worldwide

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

Misoprostol (Cytotec) 95% effective in conjunction with mifepristone 95% effective in conjunction with mifepristone 85% effective alone 85% effective alone Buccal administration (vs vaginal administration) with routine provision of antibiotics decreases risks of serious infections dramatically Buccal administration (vs vaginal administration) with routine provision of antibiotics decreases risks of serious infections dramatically

Misoprostol (Cytotec) $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 Americans who cannot afford abortion crossing into Mexico to buy cheap misoprostl Americans who cannot afford abortion crossing into Mexico to buy cheap misoprostl Self-induced abortion illegal in 39 states Self-induced abortion illegal in 39 states

Barriers to Abortion: Provider Availability 87% of counties have no abortion provider 87% of counties have no abortion provider 35% of women live in these areas 35% of women live in these areas 30% of metropolitan areas have no provider 30% of metropolitan areas have no provider

Barriers to Abortion: Provider Availability 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

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)

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

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 8 murders, 17 attempted murders, 41 bombings, 643 bomb threats, 175 arsons, 184 assaults, 100 acid attacks, 661 anthrax threats (487 since 9/11/2001) Including 8 murders, 17 attempted murders, 41 bombings, 643 bomb threats, 175 arsons, 184 assaults, 100 acid attacks, 661 anthrax threats (487 since 9/11/2001)

Barriers to Abortion: Harassment of Patients and Providers Abortioncam.com, Army of God, Nuremberg Files website (closed), link with extremist groups/militias Abortioncam.com, Army of God, Nuremberg Files website (closed), link with extremist groups/militias 1 year prevalence of intimate partner physical violence 9.9% and sexual violence 2.5% among women who had elective abortions 1 year prevalence of intimate partner physical violence 9.9% and sexual violence 2.5% among women who had elective abortions

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

Barriers to Abortion: Harassment of Patients and Providers Federal Freedom of Access to Clinic Entrances Law Federal Freedom of Access to Clinic Entrances Law Passed 1994 Passed 1994 Somewhat effective Somewhat effective

Barriers to Abortion: Harassment of Patients and Providers 15 states and D.C. prohibit certain specified actions aimed at patients and providers 15 states and D.C. prohibit certain specified actions aimed at patients and providers 11 states and D.C. prohibit blocking entrance and exit from facilities 11 states and D.C. prohibit blocking entrance and exit from facilities 5 states and D.C. prohibit threatening of intimidating staff 5 states and D.C. prohibit threatening of intimidating staff 3 states have “bubble zones” to protect patients from protestors 3 states have “bubble zones” to protect patients from protestors

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

Barriers to Abortion: Inflammatory Oratory Ad campaigns supporting proposed Georgia abortion ban claims to protect African- Americans and Asian Americans from “coerced” race- and sex-selection abortions Ad campaigns supporting proposed Georgia abortion ban claims to protect African- Americans and Asian Americans from “coerced” race- and sex-selection abortions “Black children are an endangered species” because of abortion “Black children are an endangered species” because of abortion

Barriers to Abortion: Inflammatory Oratory Virginia State Legislator Bob Marshall, speaking in opposition to state funding for Planned Parenthood (stating that according to the Old Testament, being forced to bear a disabled child is punishment for the mother’s having earlier aborted her first-born): Virginia State Legislator Bob Marshall, speaking in opposition to state funding for Planned Parenthood (stating that according to the Old Testament, being forced to bear a disabled child is punishment for the mother’s having earlier aborted her first-born): “(W)hen you abort the first-born…nature takes its vengeance on the subsequent children.” “(W)hen you abort the first-born…nature takes its vengeance on the subsequent children.” The organization ought to call itself “Planned Barrenhood.” The organization ought to call itself “Planned Barrenhood.” - Richmond News Leader, 2/22/10 (he later apologized)

Point-Counterpoint

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

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

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

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 2010: Pope Benedict gives tacit approval to condom use for sex with prostitutes to decrease AIDS risk 2010: Pope Benedict gives tacit approval to condom use for sex with prostitutes to decrease AIDS risk

Christian Science Pharmacist Refuses To Fill Any Prescription

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 25 states 25 states Most have 24 hour waiting period Most have 24 hour waiting period South Dakota -72h, mandates counseling at CPC South Dakota -72h, mandates counseling at CPC

Parental Consent and Notification Laws for Teen Abortions 20 states require parental consent 20 states require parental consent 11 states require parental notification 11 states require parental notification 4 states requires both 4 states requires both 16 states do not require parental permission 16 states do not require parental permission

Parental Consent and Notification Laws for Teen Abortions All states have a judicial bypass procedure All states have a judicial bypass procedure 2006: CA and OR ballot measures to require parental consent failed 2006: CA and OR ballot measures to require parental consent failed

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

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

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.

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.

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

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)

Barriers to Abortion: Publicly-Funded “Crisis Pregnancy Centers” Over 4500 nationwide, some receive state funding Over 4500 nationwide, some receive state funding Outnumber abortion clinics (816) Outnumber abortion clinics (816) 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

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 2011: NYC, Austin (TX) pass “truth in advertising laws” related to CPCs 2011: NYC, Austin (TX) pass “truth in advertising laws” related to CPCs

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]”

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

Risks Associated with Abortion Risk of death: Risk of death: 1/1 million up to 8 weeks 1/1 million up to 8 weeks 1/29,000 at 16-18 weeks 1/29,000 at 16-18 weeks 1/11,000 at 21 or more weeks 1/11,000 at 21 or more weeks 1/7,000 for carrying full-term pregnancy 1/7,000 for carrying full-term pregnancy O.3% have complication requiring hospitalization O.3% have complication requiring hospitalization

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

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

Barriers to Abortion: Scare Tactics, Misinformation, and Pseudoscience 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 Even so, 5 states require that women seeking an abortion be counseled that doing so will increase their risk of breast cancer Even so, 5 states require that women seeking an abortion be counseled that doing so will increase their risk of breast cancer

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

Abstinence-Only Education 2% of school districts in 1988; 23% in 1999 2% of school districts in 1988; 23% in 1999 2006-8: 53% (teenage boys) and 65% (teenage girls) receiving comprehensive sex ed 2006-8: 53% (teenage boys) and 65% (teenage girls) receiving comprehensive sex ed 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

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

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

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

Abstinence-Only Education Programs have used funds to buy bibles, subsidize crisis pregnancy centers Programs have used funds to buy bibles, subsidize crisis pregnancy centers New Jersey program funded “Free Teens USA,” connected to the Sun Myung Moon’s Unification Church New Jersey program funded “Free Teens USA,” connected to the Sun Myung Moon’s Unification Church Moon has described homosexuals as “dung-eating dogs” and American women as “a line of prostitutes” Moon has described homosexuals as “dung-eating dogs” and American women as “a line of prostitutes”

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.”

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.”

Abstinence Only Education: Examples Sexism/Sex Stereotypes: Sexism/Sex Stereotypes: “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.” “Girls will feel “dirty and cheap” when they “lose” their boyfriends after having sex “Girls will feel “dirty and cheap” when they “lose” their boyfriends after having sex

Abstinence-Only Education 24 states rejected abstinence-only funding in 2008 24 states rejected abstinence-only funding in 2008 Total $1.5 billion spent on abstinence-only education under Bush II administration Total $1.5 billion spent on abstinence-only education under Bush II administration Programs eliminated by Obama administration in 2010 budget Programs eliminated by Obama administration in 2010 budget

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

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

Barriers to Abortion: TRAP Laws Targeted Regulation of Abortion Providers Laws Targeted Regulation of Abortion Providers Laws Over 30 states Over 30 states 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.

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

Barriers to Abortion: State Laws 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 2011: 18 states have laws that encourage or require the use of ultrasound 2011: 18 states have laws that encourage or require the use of ultrasound As of 2010, 4 states require ultrasounds prior to abortion (AL, LA, MS, OK) As of 2010, 4 states require ultrasounds prior to abortion (AL, LA, MS, OK) OK protects doctors from malpractice suits if they do not inform parents that fetus has a birth defect OK protects doctors from malpractice suits if they do not inform parents that fetus has a birth defect

Barriers to Abortion: State Laws Banning 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

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 2011 bill would classify the crime of a man killing a provider aborting his female partner’s fetus as justifiable homicide 2011 bill would classify the crime of a man killing a provider aborting his female partner’s fetus as justifiable homicide 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

Barriers to Abortion: State Laws 2005 – Cook County judge ruled that parents of a frozen embryo accidentally destroyed by a Chicago fertility clinic could file a wrongful death lawsuit 2005 – Cook County judge ruled that parents of a frozen embryo accidentally destroyed by a Chicago fertility clinic could file a wrongful death lawsuit Many states have introduced “fetal personhood laws” Many states have introduced “fetal personhood laws” 2011: Ohio “heartbeat bill” – would ban abortions if detectable heartbeat (happens at 6 wks embyonic development, long before many women realize they are pregnant) 2011: Ohio “heartbeat bill” – would ban abortions if detectable heartbeat (happens at 6 wks embyonic development, long before many women realize they are pregnant) 2011: OK, ID, NB, and KS ban abortions after 20/21 weeks

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) 2010: OK law prevents women who give birth to disabled child from suing doctor who misled or outright lied about health of fetus during pregnancy 2010: OK law prevents women who give birth to disabled child from suing doctor who misled or outright lied about health of fetus during pregnancy Protects doctors against violation of ethical mandate to tell truth Protects doctors against violation of ethical mandate to tell truth

Barriers to Abortion: State Laws 22 states have “Choose Life” laws, allowing motorists to purchase “Choose Life” license plates 22 states have “Choose Life” laws, allowing motorists to purchase “Choose Life” license plates Proceeds support “Crisis Pregnancy Centers” and anti-choice organizations in 12 states, adoption in 14 states Proceeds support “Crisis Pregnancy Centers” and anti-choice organizations in 12 states, adoption in 14 states

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

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

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

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

Insuring Fetuses Bush II administration pushed “adopt the unborn” campaign, extending State Children’s Health Insurance Program (SCHIP) to fetuses Bush II administration pushed “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

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 31 states have such bans 31 states have such bans Some have exceptions for health of woman Some have exceptions for health of woman 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) Despite this, 17 states since enforcing ban Despite this, 17 states since enforcing ban

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

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

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 2010: 37 states have “attempted feticide” laws 2010: 37 states have “attempted feticide” laws

Barriers to Abortion “Born Alive Infants Protection Act” “Born Alive Infants Protection Act” DHHS using BAIPA in enforcing EMTALA (Emergency Medical Treatment and Active Labor Act) DHHS using BAIPA in enforcing EMTALA (Emergency Medical Treatment and Active Labor Act) Will cause conflicts relevant to desire for palliation vs treatment Will cause conflicts relevant to desire for palliation vs treatment

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

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

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

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”

“Fetal Pain” Counseling Required for all women in 6 states Required for all women in 6 states Required after 20-22 weeks in 4 states Required after 20-22 weeks in 4 states Sensory structures to feel pain don’t develop until after 23 weeks Sensory structures to feel pain don’t develop until after 23 weeks

Barriers to Abortion: Legal Proposed Congressional legislation would: Allow hospitals to let a pregnant woman die rather than perform a life-saving abortion Effectively prevent women from using their own money to purchase insurance that includes abortion coverage in the new insurance exchanges Tax small businesses that pay for health plans that cover abortion (and people who pay for abortions) Permanently ban federal spending on abortion

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?

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

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

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”

Barriers to Abortion: Bush 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

Barriers to Abortion: Bush 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”

Barriers to Abortion: Bush 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”

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

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

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 Obama overturns, but allows individual conscientious objection protections Obama overturns, but allows individual conscientious objection protections

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)

Barriers to Abortion: Refusal Clauses 46 states enacted shortly after Roe v. Wade 46 states enacted shortly after Roe v. Wade 14 states allow some health care providers to refuse to provide contraceptive services 14 states allow some health care providers to refuse to provide contraceptive services 18 states allow some health care providers to provide sterilization services 18 states allow some health care providers to provide sterilization services

Barriers to Abortion: Refusal Clauses 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

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

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

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 Overturned by Obama in 2009 Overturned by Obama in 2009

Barriers to Abortion: Global “Gag Rule” After Global Gag Rule reinstated by Bush Administration in 2001 After Global Gag Rule reinstated by Bush Administration in 2001 430 organizations in 50 countries stopped performing abortions or speaking about abortion laws in order to qualify for U.S. funding 430 organizations in 50 countries stopped 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 Did not cover condoms procured with HIV/AIDS funds Did not cover condoms procured with HIV/AIDS funds

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

The Good News 27 states require insurers that cover prescription drugs to provide full coverage of FDA-approved contraceptive drugs and devices 27 states require insurers that cover prescription drugs to provide full coverage of FDA-approved contraceptive drugs and devices Exceptions exist Exceptions exist 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

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

Barriers to Abortion: Worldwide Abortion broadly legal in 60% of countries Abortion broadly legal in 60% of countries 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

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) 215 million women have an unmet need for contraception 215 million women have an unmet need for contraception Catholic Church opposes contraception (even condoms) Catholic Church opposes contraception (even condoms)

Barriers to Abortion: Worldwide Under Bush II, 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 Under Bush II, 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)

Barriers to Abortion: Worldwide U.N. Population Fund U.N. Population Fund Obama re-instated funding ($50 million) in 2009 budget Obama re-instated funding ($50 million) in 2009 budget

Barriers to Abortion: Worldwide Education: Education: More years of education translates to decreased childbearing, higher salaries, improved status of women and families, and better education for their children More years of education translates to decreased childbearing, higher salaries, improved status of women and families, and better education for their children Average number of children based on mother’s years of education: Average number of children based on mother’s years of education: No school: 4.5 No school: 4.5 Few years primary school: 3 Few years primary school: 3 One or two years of secondary school: 1.9 One or two years of secondary school: 1.9 One or two years of college: 1.7 One or two years of college: 1.7

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

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

Conclusions Restrictions on access to abortion and other reproductive health services increased dramatically under the Bush administration Restrictions on access to abortion and other reproductive health services increased dramatically under the Bush administration Backed by inflammatory/hostile rhetoric and pseudoscience Backed by inflammatory/hostile rhetoric and pseudoscience Obama: ?change? Obama: ?change?

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

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

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

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 Guttmacher Institute: http://www.guttmacher.org/ Guttmacher Institute: http://www.guttmacher.org/ http://www.guttmacher.org/

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

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

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