National Partnership for Women & Families

Monthly Women's Health Research Review

Commentary discusses how OB-GYNs can support abortion access amid proliferation of restrictions

Summary of: "Ensuring access to safe, legal abortion in an increasingly complex regulatory environment," Paul/Norton, Obstetrics & Gynecology, July 2016.

Maureen Paul, affiliated with the obstetrics departments of Beth Israel Deaconess Medical Center and Harvard Medical School, and Mary Norton, affiliated with the obstetrics department at the University of California-San Francisco School of Medicine, discuss the role of OB-GYNs in helping U.S. women access abortion care in the face of increasing regulations. Citing Guttmacher Institute data showing that state legislatures enacted 288 abortion restrictions between 2011 and 2015, the researchers explain that "[r]estrictions on access to abortion services ... have reached a magnitude unseen since the nationwide legalization of abortion in 1973."

Background

According to Paul and Norton, many abortion restrictions "impede access by affecting the timeliness, affordability, or availability of care." For instance, they noted that "as of March 2016, 14 states require[d] women to receive in-person, state-mandated information about abortion 24-72 hours before the procedure." However, they cited research showing that mandatory delays "requiring multiple visits increase travel and logistic burdens for women and delay care." They also pointed to the "rapid decrease" in Texas' abortion rate following the implementation of a 2013 omnibus antiabortion-rights law (HB 2).

Paul and Norton wrote that while many abortion restrictions "are touted as necessary to protect women's health," research finds that abortion care provided in outpatient clinics is "at least as safe as" abortion care provided in a hospital. Nonetheless, almost 60 percent of reproductive-age women live in states with at least four abortion restrictions, Paul and Norton noted, adding that "highly restrictive states predominate in the South and Midwest, creating marked geographic disparities in access."

According to Paul and Norton, abortion restrictions "have a profound effect on women's health and particularly affect those women with the fewest resources." They referenced studies that have found women seeking abortion care "may face numerous barriers, including difficulties raising the requisite funds, inadequate or inaccurate referrals, and problems reaching a health care provider." Further, Paul and Norton wrote that because of federal and state restrictions on abortion coverage, "most women pay out of pocket for abortion care" in addition to facing costs "related to travel and time away from work and family."

Such obstacles "delay and compound" challenges women face in seeking abortion care, "particularly after the first trimester," as just one-third of abortion providers offer abortion care at 20 weeks, Paul and Norton wrote. Moreover, Paul and Norton highlighted "other consequences" of denial of abortion care, citing one study that found women seeking abortion care who were denied the procedure "were less likely to rise out of poverty or achieve 1-year aspirational life plans and more likely to continue in relationships marked by interpersonal violence" than those able to access care.

Paul and Norton praised the work of physicians working to provide and promote safe abortion care "[b]oth before and after Roe v. Wade," noting that providers today "continue to offer abortion services despite stigmatization, harassment, arsons, bombings, and threats of injury and even death." Nonetheless, despite the efforts of these providers and several professional organizations to support abortion care and train future providers and advocates, "access to abortion is in jeopardy," the researchers wrote. They posed the question, "As obstetrician-gynecologists, ... what more can we do to address this threat to comprehensive reproductive health care?"

OB-GYNs' role in promoting abortion care access

Paul and Norton suggested "ensuring that women's health care providers have (or know where to find) accurate information about the rapidly changing regulatory landscape of abortion is a place to start." They explained that providers have misconceptions about some abortion regulations, citing research showing only 56 percent of several reproductive health organizations' members "knew whether their states' Medicaid regulations permitted funding for abortion," and only about 15 percent were unsure whether a married woman required her spouse's consent for abortion care -- a restriction the Supreme Court has struck down as unconstitutional. According to the researchers, another study found that only 58 percent of frontline phone staff at abortion clinics provided information about judicial bypass for minors seeking abortion care, while other research found that 38 percent of clinicians incorrectly cited state bans as the reason they did not provide abortion care after 24 weeks of pregnancy in the case of a fatal fetal anomaly, even though the state where they were located did not impose such bans.

Paul and Norton wrote, "Greater dissemination of information about abortion regulations and legal resources through national and state professional societies could improve access by ensuring that patients receive accurate information and that health care providers of abortion care have the knowledge necessary to practice within the full extent allowed by law."

Further, noting that "nearly all practicing ob-gyns encounter women requesting abortion but only 14% offer these services," Paul and Norton called for "health care providers and others involved in patient education or coordination of care (eg, counselors, frontline phone staff) [to] have accurate and timely information about abortion referrals." The researchers cited research showing that "referral problems figure prominently in abortion delay," as well as a recent report that found "only 46% of calls to ob-gyns' offices in 11 states led to a direct referral ...; 9% resulted in an inappropriate referral ... and 27% in no referral at all." According to the researchers, "greater dissemination [of referral resources] through ... professional and community organizations and through clinical staff trainings would improve referrals and reduce delays for patients seeking abortions."

Paul and Norton also noted that "[d]epartmental leaders in mainstream medical centers also can facilitate access by ensuring that abortion services ... and management of complications ... are integrated and respected components of care." The researchers pointed to studies that have suggested certain factors -- such as abortion-rights opposition among staff, unsupportive administration, logistical difficulties and hospital policy restrictions -- can pose barriers to hospital-based abortion care. Paul and Norton suggested a number of ways to address these obstacles, including departmental meetings with maternal-fetal medicine teams to evaluate problems and brainstorm solutions, boosting research or education for family planning services when those services "are marginalized in part because they are not self-supporting" and supporting the "integration of family planning services through collaborative models of obstetric care." According to the researchers, "Ultimately, addressing these barriers will require institutional commitment to ensure that all health care providers function within an organizational culture of respect and that all reproductive health services are fully and similarly integrated and supported."

In addition, Paul and Norton discussed the importance of "prepar[ing] the next generation of practitioners to meet the reproductive health care needs of women, including family planning." They noted, "Teaching students and residents about patient-centered contraceptive counseling and provision to prevent unintended pregnancies is a fundamental part of this endeavor." For example, they recommended that residency programs include abortion care training "as required by the Accreditation Council for Graduate Medical Education and endorsed by the [American College of Obstetricians and Gynecologists]." They also urged providers to support the extension of other medical professional roles, such as nurse practitioners and physician assistants, to include first-trimester abortion care.

Paul and Norton wrote that providers, regardless of whether they provide abortion care, "can model professionalism by demonstrating the importance of respecting women's autonomy in decisions about pregnancy" and educate future providers on "how to counsel women about their pregnancy options and make appropriate referrals." The researchers wrote, "Although only some of us may choose to teach the 'how' of abortion care, all of us can teach the 'why' underlying women's decisions by giving trainees the opportunity to hear these women's stories."

According to Paul and Norton, "As ob-gyns, we work diligently to meet the reproductive health care needs of women by offering safe, high-quality care and by advocating for policies that decrease disparities and promote our patients' health and welfare." As such, abortion care "remains well within the scope of our professional advocacy," the researchers wrote, noting that about one in three U.S. women by age 45 will have an abortion. Paul and Norton called for collaboration over reproductive health treatment and referrals, individually tailored family planning care and support "policies that address the inequities affecting women's agency and access to care." They concluded, "Ultimately, ... ensuring that all women have access to comprehensive reproductive health care services will take many hands and many voices. In both large and small ways, we ob-gyns can make a difference."