Meet Sara. She works as a hair stylist and is just making ends meet. She had a baby earlier this year and took 8 weeks off, but now she can barely pay her rent. She had a birth control failure and just found out she is pregnant again. She came to me because she knows she cannot afford to take good care of 2 children at this point.

Meet Allie. She is 14 years old. Her mother’s boyfriend raped her a few weeks ago and then she missed her period. She is pregnant. She came to me because she doesn’t want to have a rapist’s baby at ae 14.

Meet Janine. She is a member of the Apostolic Lutheran church. Her husband was sent to jail last year and she had an affair. She is pregnant. She doesn’t believe in abortion, but she came to me because in this situation, she wants one.

These are all real women. I changed their names, but their stories are real and I provided abortions to all three of them. These types of stories are common, but the ability of women like them to obtain abortions is under threat, due in part to a shortage of abortion providers. We, as emergency physicians, can help.

It is important to start with the basic facts. Abortion is one of the most frequently performed medical procedures in America.1 One third of women will have an abortion by age 45, yet 89% of counties in the U.S. do not have a single abortion provider.2 This means that despite abortion being legal, for many women it is not reasonably obtainable.

I can provide a personal example of the shortage. The area I serve as an abortion provider is about 300 miles across. Between myself and one other woman, we provide for an area larger than the entire state of Massachusetts. Some women drive four hours to see me for an abortion. They then get counseled, get their medications, and drive four hours home.

Because of the shortage of abortion providers, the travel and cost burdens of abortion can be significant. For women in cities, most are able to travel only a few miles, but for women outside cities, one in three has to travel over 100 miles for an abortion.3 Think of a young woman in Wisconsin. There are only three clinics in her state. Hers is one of the few states which require an initial counseling session be done in person. Then there is a 24 hour waiting period after which she must come back to the same clinic. If she lives in a northern part of the state, that means hours of driving in one week. What if, like many women seeking abortions, she has a job paid hourly and needs the money to pay her rent? What if, like most women obtaining abortions, she has children and would need childcare for two days in one week? What if she doesn’t have a car? Or has gas for one trip but not enough for two? In states with waiting periods and long travels to clinics, the cost of abortion can double due to missed work, childcare and transportation costs.4 At my clinic, I see these issues all the time. Women fail to make their appointment because the car they were hoping to borrow fell through. Or they get there but had to buy gas on the way and are scrambling with a crumpled piles of bills to pay for their abortion. Sometimes they come up short and have to get back in their borrowed car, and try again for next week. It’s truly heartbreaking.

As emergency physicians, is helping with this issue our responsibility? Aren’t OB-GYNs the specialists in this area? It is commonly assumed that OB-GYNs are taking responsibility for providing abortions in America, but it’s not enough.  Only 14% of OB-GYNs end up providing abortions as part of their practice.5 Family doctors also provide abortions but the proportion providing abortions is low. The numbers of providers and clinics are dropping in records levels. Since 2011 at least 162 abortion providers have closed or stopped performing abortions, and only 21 clinics have opened.6 On a national scale, the number of abortion providers is currently 2/3 of what it was in the 1980s.7 There is a need and it is not being met.

The reasons for the drop in providers are complicated. Some physicians are morally opposed to abortion. Others would provide them but the hospital they work in prohibits them from performing abortions. There may be pressure from a senior member of their group not to do it. Not to mention personal fear of the violence directed toward abortion providers.

Not only are physicians struggling with personal reasons not to provide abortions, but state legislatures are passing unprecedented numbers of new laws causing clinic to close. One type are those requires abortion clinics to be outfitted as ambulatory surgical centers. With no added value to the patients, clinics must spend money, sometimes hundreds of thousands of dollars, on construction to comply with these mandates. A second type of law are those requiring an abortion provider to have admitting privileges at nearby hospitals. In addition to the paperwork hassle of obtaining these privileges, success depends on the whims of local hospitals.  A law requiring abortion providers to have admitting privileges was passed in Mississippi. The abortion providers at the last open clinic in that state applied for admitting privileges at seven nearby hospitals. They were rejected by every single one.8 With these barriers, even those who want to provide abortions can be completely blocked.

These factors are having a true impact on women. Take Anna Yocca for example. In 2015 she found herself with an unwanted pregnancy in Tennessee. Tennessee is one of the states with many hurdles for women wanting an abortion, including a 48 hour waiting period between clinic visits. Only 4% of counties in Tennessee have an abortion clinic. Anna’s was not one of those counties. Anna panicked when her fetus was at 24 weeks and attempted a coat-hanger abortion in her bathtub at home. She bled profusely and had to go to a hospital. The fetus was delivered by caesarean section. Once Anna was medically stable she was imprisoned for one year on a charge of attempted murder.9

Anna’s is an extreme case, but the stress of carrying an unwanted pregnancy is significant. Women who want and cannot get an abortion are three times more likely to fall below the poverty line. They are more also likely to stay with an abusive partner, and more likely to experience negative psychological effects like anxiety compared those who are able to obtain an abortion.10, 11 Most concerning, with all the barriers to obtaining abortions, cases like Anna’s may be on the rise.

In 2015, there were 700,000 Google searches for “how to self-abort” in America.12 These women are asking for specific methods — should they take a handful of pills, have someone punch them hard in the stomach, or worse, shoot themselves in the abdomen? Like Anna Yocca, there are women doing more than just googling. Before abortion was legal, every year 1000 women died of trying to self-abort.13 If something isn’t done, we are headed backward. We, as physicians, cannot forget that women will suffer if safe abortions are inaccessible.

To meet the need for abortions in America, we need to team up. OB-GYNs are trying and family docs are helping as well. Why not us?

When I went to medical school, I knew I was smart and competent and I wanted to use those powers to help people, especially women. When it came to day-in-day-out work, I fell in love with Emergency Medicine. And because of that, I thought I couldn’t be a women’s health physician. It wasn’t until five years later, just a month or two after graduating from residency, my friend who worked at an academic hospital in my state told me that my region was down to one abortion provider. That doctor was hoping to retire and there was no one in the pipeline to take over providing abortions at the local clinic. I was intrigued. Could I help? As an emergency physician?

I called the Planned Parenthood state office and was connected to their medical director. They were interested and were willing to train me if I would put in the time. I spent about 30 hours doing online training and did hands-on training in transvaginal ultrasound. After about 2 months of preparation, I was ready. And now I offer medication abortion services twice a month in addition to working full time in EM.

That’s how I met the women that I mentioned at the opening of this talk. I help single moms and college students and women stricken by all kinds of chaos and poverty. It feels like an extension of what I love most about EM- caring for society’s most vulnerable people at a time when they are more vulnerable than ever.

You can help too. Here is what you can do:

  1. You can become an abortion provider. If you’re interested, the training is do-able and you are capable of learning to provide both medical and surgical abortions. In my experience, abortion clinics are happy for any support you can offer (Step-by-step instructions below)
  2. Spread the word that EM docs can become abortion providers. After I started working at an abortion clinic, I told a physician friend about what I was doing. She called her local abortion clinic, got trained, and now she provides both medical and surgical abortions in a metropolitan area.
  3. Educate. If I had known that I could combine my passion for women’s health with EM, I would have been integrating this into my training even during residency. Tell your residents. Tell your med students. They need to know this is an option

Now you have this information, please go out and share it. You care for the vulnerable every day as emergency physicians. This is another chance for you to help. These women need a champion and it could be you. Thank you.

Step-by-step instructions for becoming an abortion provider:

  1. Find the abortion clinic(s) nearest to you (https://www.safeplaceproject.com/)
  2. Call, email, or visit them to see if they need additional abortion providers
  3. Be open to learning new skills

 

References

  1. https://www.guttmacher.org/journals/psrh/2004/01/abortion-incidence-and-services-united-states-2000
  2. Jones RK and Jerman J, Abortion incidence and service availability in the United States, 2014, Perspectives on Sexual and Reproductive Health,2017, 49(1), doi:10.1363/psrh.12015.
  3. https://www.guttmacher.org/news-release/2013/one-third-us-women-seeking-abortions-travel-more-25-miles-access-services
  4. https://www.theatlantic.com/health/archive/2015/05/waiting-periods-and-the-price-of-abortion/393962/
  5. Stulberg DB, Dude AM, Dahlquist I, Curlin FA. Abortion Provision Among Practicing Obstetrician–Gynecologists. Obstetrics and gynecology. 2011;118(3):609-614. doi:10.1097/AOG.0b013e31822ad973.
  6. https://www.bloomberg.com/features/2016-abortion-business/
  7. Jones, R. K. and Jerman, J. (2014), Abortion Incidence and Service Availability In the United States, 2011. Perspect Sex Repro H, 46: 3–14. doi:10.1363/46e0414
  8. http://theweek.com/articles/559840/admitting-privileges-sham-future-abortion-america
  9. https://www.nytimes.com/2017/01/11/us/tennessee-abortion-crime.html
  10. https://www.researchgate.net/blog/post/best-practice-for-abortion-policies-listen-to-womens-stories
  11. http://onlinelibrary.wiley.com/doi/10.1363/psrh.12024/full
  12. https://www.nytimes.com/2016/03/06/opinion/sunday/the-return-of-the-diy-abortion.html?mcubz=0&_r=0
  13. Grimes DA (with Brandon LG). Every Third Woman in America: How Legal Abortion Transformed Our Nation. Carolina Beach, NC: Daymark Publishing, 2014. ISBN-13: 978-0-990-83360-4.