• BMGC

The Need for More Abortion: Education, Provision, & Access

Courtney Smith

BMGC Guest Author

October 20, 2020

Note: Though this article was written toward an audience of physicians, medical providers, medical students, and those with an interest in medical education, much of the information that follows pertains to the US population as a whole and is suitable for any reader. There are valuable statements, facts, and assertions woven throughout this piece that are important for all proponents, adversaries, and those undecided on abortion care today to consume and consider.

Physicians’ Professional Responsibilities in Abortion Care

In 2002, an article was published in the Annals of Internal Medicine that established the foundation of professionalism in medical practice today. The article, Medical Professionalism in the New Millennium: A Physician Charter, has since been cosigned by more than 130 professional organizations as the ethical exemplar of medical practice. The Charter, as it’s commonly referred, detailed three Fundamental Principles obligatory to all physicians:


Primacy of Patient Welfare dedication to serving the interest of the patient Patient Autonomy empowering patients to make informed decisions about their treatment Social Justice working actively to eliminate discrimination and promote fair distribution of resources

These Principles, the Charter states, are fundamental and universal imperatives to medical provision. In other words, the old ways of paternalistic medicine will no longer be tolerated in modern practice[1] . Today, we must all accept that our patients[2] [3] are the experts in their own lives and we, as their providers, have a moral obligation to center them in their own care (patient welfare); we must provide patients with accurate and complete medical information – devoid of our own personal beliefs or values – to allow them to make their own informed decisions (patient autonomy); and it is vital that we actively fight to dismantle societal and systemic structures that lead to disparities in medical provision and health outcomes in our communities (social justice).

The Charter goes further to describe ten additional Professional Responsibilities of medical providers. A few of the most pertinent examples include a commitment to honesty, improving access to care, and managing conflicts of interest. Each of these Responsibilities ties into one or more of the three Principles. For example, physicians have a responsibility to “completely and honestly” counsel patients if we are to follow the Principle of Patient Autonomy. We have a responsibility to disclose any conflicts of interest in our work, as well as to eliminate any effect individual conflicts of interest may have on our provision of care, in commitment to Patient Welfare. Most notably, with regard to healthcare access, the Charter states that we have a responsibility to “work to eliminate barriers … based on … laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventative medicine … without concern for the self-interest of the physician,” defining our duty toward Social Justice. In brief, the Charter details the professional and ethical obligation for physicians to provide care in the best interests of, and under the guidance of, their patients.

What happens, then, when a provider feels their personal beliefs and convictions don’t align with the care a patient desires? What if the physician’s individual sense of morality is in conflict with the care they’re obligated, under this Charter, to provide? This is where the idea of conscientious objection comes into play. Conscientious objection is “the refusal to participate in an activity that an individual considers incompatible with [their] religious, moral, philosophical, or ethical beliefs.” Conscientious objection was codified into US law via the Church Amendment (1973, in response to Roe v. Wade), establishing that physicians are able to refuse to participate in the care of patients with whom that care would compromise their personal convictions. According to the World Health Organization (WHO), however, conscientious objection is secondary to the professional responsibility of patient care. The WHO asserts that physicians may opt out of providing patient-desired medical services, but (and in accordance with the Charter) they may not do so without open disclosure of their conflicts of interest, provision of complete and accurate medical counseling, and timely referral to an alternate provider capable of delivering prompt and safe services. Going a step further, even, the WHO states that, if expeditious referral is not possible, physicians must provide services to patients if delay or refusal to do so would result in either morbidity or mortality for the patient.

It’s easy to see the implications these guidelines should have on abortion provision in today’s medical practice. In fact, many professional societies involved in reproductive healthcare do have statements regarding the necessity of abortion training within their curricula and provision of care within their specialties. For example, the American College of Obstetricians and[4] [5] Gynecologists (ACOG) “supports … clinical training for residents and advanced practice clinicians in abortion care in order to increase the availability of trained abortion providers.” The Accreditation Council for Graduate Medical Education (ACGME), responsible for the accreditation of medical residency programs in the United States, requires that Obstetrics and Gynecology (OB/GYN[6] ) residency programs “provide training or access to training in the provision of abortions, and this must be part of the planned curriculum.” The Council on Resident Education in Obstetrics[7] and Gynecology (CREOG), responsible for defining educational objectives for OB/GYN residents, requires trainees to perform “uterine aspiration procedures,” at a minimum for indications of incomplete abortion or fetal demise, as well as “provide unbiased, individualized counseling about available options for induced abortion,” “provide appropriate referral for patients seeking abortion services,” and “understand national, local, and institutional laws and policies related to [the] provision of abortion services.” Correspondingly, the American Academy of Family Physicians states that “when caring for women with unintended pregnancy … the physician should provide [the patient] with information about … the availability of safe, legal abortion services” and, in regard to Family Medicine residency programs, the ACGME requires that residents have “encounters dedicated to the care of women with gynecologic issues, including … family planning, contraception, and options counseling for unintended pregnancy.” In response to these professional requirements and recommendations, the Ryan Residency Training Program (OB/GYN) and the RHEDI Program (Reproductive Health Education in Family Medicine) were developed to standardize and integrate formal, comprehensive abortion, family planning, and contraception training into their corresponding residency curricula.

To adequately fulfill the obligations defined by the Charter and the WHO, though, it is important that every provider, especially those who work with AFAB (assigned female at birth)[8] individuals of reproductive age, and not just OB/GYNs and Family Medicine physicians, have a baseline understanding of abortion services. This becomes vitally clear when considering that 1 of every 4 AFAB individuals in the US will have an abortion by age 45, making abortion one of the most common surgical procedures performed. To repeat, approximately 25% of AFAB individuals in the United States will have an abortion by age 45. Thus, training must extend beyond OB/GYN and Family Medicine residencies, as nearly every physician will encounter one or more patients who may require safe and accessible abortion care, at which time complete and accurate counseling with prompt referral to a willing provider falls within their physician’s professional responsibilities, regardless of their medical specialty. ACOG’s Committee Opinion on Abortion Training and Education, therefore, states that efforts to destigmatize and integrate abortion training into medical education is a critical element of reproductive healthcare and they recommend that abortion education be included in the curricula of all medical schools.[9] APGO, the Association of Professors of Gynecology and Obstetrics, responsible for outlining US medical student educational objectives, requires that students are “knowledgeable about [the] public health importance, as well as techniques and safety implications [of pregnancy termination],” “regardless of their personal views about abortion.” They specifically state that students must be able to: “develop a thorough understanding of contraception, including sterilization and abortion,” “list surgical and non-surgical methods of pregnancy termination,” “describe the public health impact of the legal limitations of abortion,” and, during their clinical training, “provide non-directive [unbiased, accurate, and patient-centered] counseling to patients surrounding pregnancy, including unintended pregnancy.”

As you can see, there are an overwhelming number of recommendations focused on enhancing abortion understanding and training in the US. Why, though, is this much emphasis being placed on abortion provision? Why go so far as to recommend abortion education for every medical student, regardless of future medical specialty aspirations? Why are organizations like the WHO so adamant that conscientious objection falls secondary to patient-desired care?


The Turnaway Study

From 2008-2010 ANSIRH (Advancing New Standards in Reproductive Health) initiated the groundbreaking Turnaway Study, a project that chronicled the lives of nearly 1,000 AFAB individuals across the United States for a period of 5 years after seeking abortion services. Study participants were divided between those who received abortions upon presentation and those who were “turned away” if past their presenting facility’s gestational age limit. Data from these groups was later used to contrast the consequences of abortion denial on both individuals and society.

So, what did the study find? Most remarkably, it found that the vast majority of reasons individuals cite for seeking abortion services – financial difficulties, worries about intimate partner violence, and a need to care for current children – are incredibly justified concerns. Though study participants started on a level playing field, the moment they presented to their respective abortion clinics marked a point of drastic divergence in their life trajectories.

Individuals who were denied abortion services were:

Financial Difficulties • nearly four times more likely to live below the federal poverty level • three times more likely to be unemployed • more likely to have difficultly affording basic living expenses (such as food, housing, or transportation) • more likely to have an increased debt burden • more likely to have a lower credit score • more likely to have negative public financial records (such as evictions or bankruptcies) • six times less likely to achieve life goals at 1 year • less likely to have a positive outlook on the future Intimate Partner Violence • more likely to stay in contact with a violent partner • more likely to endure physical violence from their birthing partner (the rate of physical violence decreased among individuals able to receive abortions) • less likely to describe themselves as being in very good relationships • less likely to use contraception Care for Current Children • three times more likely to have children living below the federal poverty level (even when compared to the subsequent children born to individuals that initially received abortions) • more likely to raise children alone at 5 years • less likely to have their children meet developmental milestones • less likely to have an intended pregnancy within 5 years • less likely to bond with their children born after abortion denial

Notably, there were no differences between the two groups with regard to: mental health outcomes, including depression, anxiety, suicidal ideation, PTSD, or self-esteem; alcohol, tobacco, or drug use; or academic graduation rates.

Finally, the Turnaway Study estimated that more than 4,000 individuals are currently denied wanted abortions every year[10] [11] and predicted that, at the rate legal restrictions on abortion are being passed, thousands more will soon be affected annually.

The results of the Turnaway Study help to clarify why professional societies are so determined to increase the number of skilled, routine abortion providers and enhance patient access to abortion services. The negative impacts abortion denial can have on AFAB individuals and their children, compounded by the exceedingly large number of individuals affected by abortion denial, emphasize that restricted access to abortion is a public health issue.


Abortion Safety & TRAP Laws

“Banning abortion doesn’t end abortion – banning abortion ends safe abortion.” This line is so often repeated by pro-choice advocates, news articles, and research journals, that it’s now become virtually impossible to track back to its source. Nevertheless, the frequent echoing of this statement serves to highlight its integrity and leads us to our final points on abortion in the US today: abortion safety and unwarranted abortion regulations.

As previously mentioned, abortion is one of the most common surgical procedures performed in the US. Despite the widespread belief that abortion is dangerous, it is one of the safest medical procedures available – when it is legal. According to the Guttmacher Institute, following the legalization of abortion in the early 1970s, access to safe abortion procedures increased and subsequent mortality rates plummeted. Analogous results have been observed in other countries following legalization as well. In fact, abortion procedures are so safe today that carrying a pregnancy to term is 12-13 times more dangerous than having an abortion.[12] Other oft-quoted interventions with higher mortality rates than abortion include getting a colonoscopy, having your wisdom teeth or tonsils removed, or even receiving a shot of penicillin!

Targeted Regulations of Abortion Providers (TRAP) laws, often proposed under the guise of patient safety, actually (and intentionally) serve the opposite interest. As quoted by the Guttmacher Institute, these laws “place unreasonable burdens on abortion providers and can [and have] result[ed] in clinic closures.” Some examples of [13] [14] previously-approved (and currently-mandated) TRAP laws include:[15] [16] abortion counseling requirements to provide misleading or false “medical information,” mandates that this counseling be completed in person rather than via phone or otherwise, mandatory waiting periods (typically a minimum of 24 hours) between counseling and procedure provision (requiring multiple office visits to obtain care), medically-unnecessary ultrasound obligations, requirements for abortion providers to have admitting privileges at a nearby hospital, physical distance limits between a hospital and an abortion clinic, fetal tissue disposal stipulations, or even clinic procedure room and hallway size dimensions and ventilation system specifications equivalent to outpatient surgical facilities (specific requirements that do not apply to similarly-complex or even more complex procedures frequently performed in other outpatient clinics), among many, many others.[17] [18] Therefore, considering the already-high safety profile of abortion procedures, these laws do little to nothing to improve patient safety and do far more to delay services and close clinics while simultaneously injecting unnecessary and cruel psychological manipulation tactics into patient encounters. Thus, these laws unquestionably serve little purpose beyond decreasing availability to abortion services. Decreased availability to those seeking services, who must then either continue an undesired pregnancy or now navigate the increasingly complex system to obtain a later-gestation abortion procedure, actually increases the danger to individuals for many reasons: as pregnancy gestation increases, abortion procedures become more complicated and consequently more dangerous; individuals may turn toward illegal and unregulated means of obtaining their desired pregnancy outcomes; and individuals who are medically-neglected into birthing an undesired pregnancy become saddled with the associated negative consequences detailed by the Turnaway Study. To add an additional layer of complexity, these laws also change so frequently and vary so drastically between states that it becomes extraordinarily difficult for medical providers who do not themselves regularly perform abortion procedures (and even for those who do) to remain well-versed and up-to-date on current regulations, exacerbating the difficulties patients face when seeking care.

If we reflect back on the Charter Principles, TRAP laws violate every rule of expected provider professionalism in medicine. Our responsibility to patient autonomy requires that we present complete and accurate medical information to our patients, capable of empowering them to make informed decisions; this is inherently hindered by legal mandates to include falsehoods and inaccuracies in our counseling sessions. Our responsibility to patient welfare requires that we remain dedicated to the interests of our patients; ultrasound visualization, waiting periods, and clinic closures all force undesired and needless regulations upon patients – many of which result in complete procedure denial and the myriad negative consequences that come from being turned away – conclusively disregarding our patients’ interests in their own care. Finally, our responsibility to social justice requires that we eliminate barriers to care access and actively fight against the systemic structures that lead to disparate care provision and health outcomes in our communities; every additional medically-unnecessary, unwarranted, and ultimately hazardous piece of legislation instilled into law is an affront to this obligation and a calculated strategy to preclude any possibility of justice or equality in reproductive healthcare.


See One, Do One, Teach One

So, what needs to be done for physicians to uphold our Charter-defined professional obligations to our patients? Following the age-old adage in medicine, one approach is to “see one, do one, teach one.” In this model, the initial step is addressing abortion education in medical schools. ACOG’s and APGO’s recommendations that every medical student be educated on medical and surgical abortion provision, patient-centered pregnancy options counseling, and the public health impact of legal restrictions on abortion services, would[19] [20] help to ensure all future providers have a basic understanding of patients’ pregnancy options and the difficulties patients face in accessing care. In this way, every future provider would “see one.” Furthermore, medical school is an ideal time to outline physicians’ professional responsibilities and delineate the limits of conscientious objection for providers who wish to remove themselves from any type of care their future patients may desire, even if that care has nothing to do with abortion. Starting “upstream,” if you will, of the negative consequences currently imposed on patients by ignorant or intolerant providers is vital. The next step is ensuring standardized, minimum training requirements for residency programs that have a role in reproductive healthcare, primarily OB/GYN and Family Medicine, but this could (and I would argue should) also include Internal Medicine, Pediatrics, and Emergency Medicine as well. Ensuring each of these key players have practiced providing guidance or services to patients seeking abortions means all future reproductive providers would have had opportunities to “do one.”[21] Finally, every provider, with an increased understanding of the complete and accurate medical information provided in medical school and residency, combined with their duty to fight for medical equity, would be aptly trained to provide education to their friends, their families, their colleagues, their students, and their legislators, in the true physician “teach one” fashion. Taking these initial steps allows us to begin to address many of the current barriers to abortion care, ultimately decreasing stigma, increasing access, and making positive change in the lives of our patients and our communities.[22]

Note: As the author of this article, I am acutely aware that I did not address many other critical subjects on the topic of abortion including reproductive justice, racial disparities, gender-inclusive care, global considerations, methods of abortion, the cost of abortion, telehealth provision, contraception; key legislative matters such as Roe v. Wade, the Hyde Amendment, the Helms Amendment, Planned Parenthood v. Casey, Title X; or numerous other essential elements necessary to provide a complete history and thorough explanation of abortion care today. For additional information, please refer to the websites of Planned Parenthood, ANSIRH, the National Abortion Federation, the Guttmacher Institute, Innovating Education, and the multitude of others dedicated to advancing access and understanding in this field.


Planned Parenthood: https://www.plannedparenthood.org/ ANSIRH: https://www.ansirh.org/ National Abortion Federation: https://prochoice.org/ Guttmacher Institute: https://www.guttmacher.org/ Innovating Education: https://www.innovating-education.org/

References:

1. 220_obgyn_abortion_training_clarification.pdf. http://www.acgme.org/portals/0/pfassets/programresources/220_obgyn_abortion_training_clarification.pdf

2. Abortion Training and Education. https://www.acog.org/Clinical/Clinical Guidance/Committee Opinion/Articles/2014/11/Abortion Training and Education

3. Common Program Requirements. Family Medicine.:62.

4. Ralph LJ, Foster DG, Rocca CH. Comparing Prospective and Retrospective Reports of Pregnancy Intention in a Longitudinal Cohort of U.S. Women. Perspect Sex Repro H. 2020;52(1):39-48. doi:10.1363/psrh.12134

5. Chavkin W, Leitman L, Polin K, for Global Doctors for Choice. Conscientious objection and refusal to provide reproductive healthcare: a White Paper examining prevalence, health consequences, and policy responses. Int J Gynaecol Obstet. 2013;123 Suppl 3:S41-56. doi:10.1016/S0020-7292(13)60002-8

6. Hampton BS, Cox SM, Craig LB, et al. Copyright © 2019 by Association of Professors of Gynecology and Obstetrics (APGO). Published online 2019:134.

7. Blank L, Kimball H, McDonald W, et al. Medical professionalism in the new millennium: a physician charter 15 months later. Ann Intern Med. 2003;138(10):839-841. doi:10.7326/0003-4819-138-10-200305200-00012

8. Moss DA, Snyder MJ, Lu L. Options for women with unintended pregnancy. Am Fam Physician. 2015;91(8):544-549.

9. Population Group Abortion Rates and Lifetime Incidence of Abortion: United States, 2008–2014 | AJPH | Vol. 107 Issue 12. https://ajph.aphapublications.org/doi/10.2105/AJPH.2017.304042

10. safety_of_abortion.pdf. https://prochoice.org/wp-content/uploads/safety_of_abortion.pdf

11. Targeted Regulation of Abortion Providers (TRAP) Laws. Guttmacher Institute. Published April 27, 2017. https://www.guttmacher.org/evidence-you-can-use/targeted-regulation-abortion-providers-trap-laws

12. Cates W. The Public Health Impact of Legal Abortion: 30 Years Later. Perspectives on Sexual and Reproductive Health. 2003;35(1):4.

13. the_harms_of_denying_a_woman_a_wanted_abortion_4-16-2020.pdf. https://www.ansirh.org/sites/default/files/publications/files/the_harms_of_denying_a_woman_a_wanted_abortion_4-16-2020.pdf

14. turnawaystudyannotatedbibliography.pdf. https://www.ansirh.org/sites/default/files/publications/files/turnawaystudyannotatedbibliography.pdf

15. turnaway_study_brief_web.pdf. https://www.ansirh.org/sites/default/files/publications/files/turnaway_study_brief_web.pdf

16. WHO | Safe abortion: technical and policy guidance for health systems. WHO. http://www.who.int/reproductivehealth/publications/unsafe_abortion/9789241548434/en/

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