THE ABORTION ISSUE: There Is No Choice Without Providers

THE ABORTION ISSUE: There Is No Choice Without Providers

by Norine Dworhin

For a moment, after 12 years of Ronald Reagan and George Bush’s antiabortion policies and their winking, indulgent attitude toward antiabortion groups’ violence against abortion providers, it looked like the prochoice community had finally gotten a break with the Clinton administration. Just moments into office, Bill Clinton repealed the Title X “gag rule,” reversed Reagan’s 1982 Mexico City policy – that any monies allocated for international family planning could not be used for abortion or information on abortion – and lifted the bans on abortions performed in military hospitals, the importation ofRU-486, and the use of fetal tissue in research. But sentiment about abortion simply won’t be legislated, as indicated by the shooting of Dr. David Gunn outside an abortion clinic in Pensacola, Florida, just two months after Clinton’s actions.

The problem runs deep – and it starts in the medical community. Volunteer clinic escorts stand in freezing cold and sweltering heat to shepherd clients past aggressive antiabortion “sidewalk counselors” who shove photos of burned, mangled fetuses in their faces. In some cities, pro choice women will turn out by the thousands to keep clinics open when Operation Rescue threatens to blockade them. But, in too many small metro and rural areas in this country, while clinics remain open, there simply aren’t enough doctors willing to perform the procedure . According to the Alan Outmarch Institute, as of 1988, 50 percent of all urban counties and 93 percent of all rural counties had no identified abortion providers.

In many ways, the reluctance is understandable: No other medical procedure comes with so much politically and socially flammable baggage as abortion.

Certainly physicians in other fields are not routinely picketed outside their hospitals, nor are their faces plastered on “wanted” signs, their families or patients harassed, their offices trashed – nor do they face the very real threat of being murdered. Early on, antiabortion groups targeted doctors as the weakest link in the prochoice community, and doctors have buckled under the pressure. Recently, two doctors quit the Aware Woman Clinic in Melbourne, Florida after Operation Rescue began an intensive picketing and harassment campaign. The antiabortion movement’s greatest success is that they have succeeded in bullying an entire generation of physicians into not providing abortions – or, if they do provide them, not to publicize it – no matter how the government safeguards a woman’s right to choose.

In much the same way that many artists and art institutions began censoring themselves with regard to “objectionable” art after harassment from Sen. Jesse Helms (R-NC) and the Rev. Donald Wildmon, the medical community in many instances has closed its ranks to abortion providers. According to notes from a 1990 symposium sponsored by the National Abortion Federation (NAF) and the American College of Obstetricians and Gynecologists: “Some state medical boards have pursued their oversight and peer review functions more zealously with abortion providers than others, and some hospital boards have disaffiliated with physicians because they perform abortions.”

Such pressure has, understandably, taken its toll. Patricia Anderson, special projects director at NAF, first noticed a shortage of doctors willing to perform abortions in 1988 when NAF members began calling, looking for doctors to staff their clinics. At the time, Anderson remembers, calls were coming in at a rate of perhaps one or two a month. A noticeable trend then, she says. Now it’s gotten worse. These days NAF fields such calls once or twice a week.

Some attribute the current shortage to the “graying phenomena” – – the aging and retirement of sympathetic physicians who witnessed firsthand the life and death effects of botched, illegal abortions and dedicated themselves to providing safe abortions to women in need.

By itself, this “graying” would not be so worrisome. It’s to be expected that a generation of doctors will eventually retire. The problem is that as these doctors leave their practices, younger ob/gyns are not stepping in behind them to take up the slack.

The Shrinking Pool of Abortion Providers The subject has found a wide forum from the pages of Self to Family Planning Perspectives and has been the topic of many physician seminars. Now that the country is seemingly on a more liberal backswing from 12 years of conservative rule, how is the medical community going to address this glaring hole in women’s healthcare?

According to Trent MacKay, an associate clinical professor of obstetrics/gynecology at the University of California, Davis, who firsthand “dealt with death and complications from illegal abortions, the need for abortion providers has never before been this great. “For a long time there was a sense that safe, legal abortions were being done by a subset of doctors, and if that’s being taken care of, why should I do it? That’s been fine up until recently.”

Thomas Easterling, associate professor in the ob/gyn department at the University of Washington in Seattle, agrees. “As we got an influx of people doing abortion in the communities, patterns of care got established. You knew who the providers were, and there wasn’t the driving need [for more]. This was being taken care of. Things were too good to be true.”

Now, however, many new ob/gyn physicians seem to be put off by the accompanying harassment. “It’s seen as a threat to the rest of the practice because of community pressure,” MacKay says. “They don’t want to lose patients because of pickets or articles in the paper.”

Karen Bruder is recently out of her residency and now in private ob/gyn practice in Newport News, Virginia. She says that although she is prochoice, she will only perform abortions for established patients who are using responsible birth control. And she keeps it on the q. t. In her location, she has no wish to become known as an abortion provider. Then, Bruder says, her practice would consist of nothing else.

Likewise, another young woman ob/ gyn, also recently out of her residency and now in private practice in south Florida, stated that she, too, would only perform abortions for long term patients. Not wanting to link her practice with abortion’s attendant controversy, this doctor spoke only on the condition that her name not be used.

The sensitizing of ob/gyns and the training of abortion providers is a complex issue, apart from the antiabortion timbre of the Reagan/ Bush era and the scare tactics of antiabortion groups. This probably owes something to the centralization of abortion services in clinics, away from the learning ground that hospital-based residency programs provide, as well as to low prestige and payment factors that may stem from abortion’s illegal past – that it was something’ ‘abortionists,” not physicians, performed.

Even more alarming is the disquieting lack of interest on the part of many faculty physicians and ob/gyn residents, who perceive abortion as a relatively simple, rather humdrum procedure and want to move on to more “exciting” surgeries.

“By the end of your residency, it gets to be routine to do abortions, and it gets pushed off to other people,” says Bruder, who during her residency at a New York hospital did the requisite number and moved on. “It’s not that difficult. They’re quick to do, and there are a lot more fulfilling and exciting things to do than abortions.”

But the fact is that first trimester abortion, even more than second trimester abortion, is actually complex. Seemingly simple, the first trimester procedure, which accounts for 89.4 percent of all abortions according to the Alan Guttmacher Institute, is fraught with subtleties that experienced practitioners say can confound beginners. According to Easterling, the first trimester learning curve flattens out at about 500 to 1,000 procedures, while the second trimester abortion learning curve is about 25 procedures. He described “more subtle, intuitive, kinesthetic” nuances that can make learning to do first trimester abortion difficult to pick up. Plus, research conducted by Philip Damey, director of the family planning clinic at San Francisco General Hospital, indicates that complication rates are higher when residents perform first trimester abortions than when experienced doctors perform them. “That says to me that training is helpful,” Damey says.

Many attending physicians and residents also believe that if residents are taught D&C techniques to deal with miscarriages, they can then extrapolate the skills to perform abortions. According to experienced ob/gyns, that’s not particularly accurate. States Damey: “D&C is a lousy way to do an abortion.”

Says Easterling: “It’s the same procedure for dealing with miscarriages, so in theory they have the skills. The problem is you need another set of skills to be an effective, safe abortionist. It helps to have the training. It’s perceived as a simple procedure, but there are real risks. Plus, the physical part of doing the abortion is only half of it. The other part is emotional – dealing with loss, the guilt, hopelessness is at least half of what’s important when teaching abortion.”

Yet despite its complexities and the fact that abortion remains women’s number one outpatient surgery, a recent survey conducted by MacKay revealed that as of 1991 (the last year for which data is available) only 12.4 percent of responding ob/gyn residency programs provide first trimester abortion training as a routine part of study. MacKay had sent out 268 surveys and received an 85 percent response. This reflects a 53 percent drop in the number of programs offering routine first trimester training since 1976 when 26.3 percent of programs provided it.

MacKay’s study also discovered that 56.4 percent of ob/gyn programs offer optional training in first trimester abortion, a 14 percent increase since 1985 when the last data was collected. At first glance, one might say optional training is certainly better than no training at all. However, another study conducted in 1987 by Darney indicates that when training is optional, rather than required, residents tend to opt out.

Catherine Budd is a first-year ob/gyn resident at Thomas Jefferson University Hospital in Philadelphia and a mother of two. Budd says that although she is prochoice, she is personally uncomfortable with abortion and is not interested in learning the procedure. “I think it’s an essential service that has to be available to women in a legal and safe manner, but I think it should be an option for the person training as to whether they want to do it or not.”

“It’s astounding when people tell you that, because abortion is the most common outpatient surgery women have,” says NAF’s Anderson. “You wonder what they’re [learning].”

Easterling shed some light on the situation: “[Abortion’s] not felt to be at the core of ob/gyn. The core is normal and high-risk obstetrics and outpatient and operative gynecology.”

Liz Karlin, an internist in Madison, Wisconsin who performs first trimester abortions, agrees. “What residents are learning is hysterectomies, cryosurgery, cancer operations, chemotherapy – operation-based specialties. Residents don’t see abortion as a prime area.”

So, how does the number one women’s outpatient surgical procedure vanish from the teaching curricula? Simply put, lack of motivation on the part of ob/gyn program faculty to institute training and teach the procedure. According to Family Planning Perspectives, a survey conducted shortly after abortion was legalized revealed that many university departments had not fully integrated elective abortion training into their programs. A follow-up study done five years later reported little improvement. That study revealed that 20 to 40 percent of all ob/gyn residents had no clinical experience in first trimester abortion.

“After 1970 when New York legalized abortion and 1973 [when abortion was legalized nationwide], hospitals were not eager to add abortion to their curricula,” says Alex Sanger, president and CEO of Planned Parenthood of New York City.

“The staff objected. There’s a small minority of gynecologists who have strong prolife feelings. And doctors being a collegial club, those who are prochoice don’t want to offend them.”

Apart from simple antiabortion sentiment, Karlin says she’s experienced a pervasive “”pronatalist attitude” that cuts across all facets of women’s reproductive healthcare, not just pregnancy termination. In fact, she says that many of her abortion requests come from older women whom she says were originally refused tubal ligations. “A lot of gynecologists will say, “I’m here to produce life, not terminate it,” says Karlin. “Folks on medical school faculties don’t look toward the health of the mother, but to a narrow view of gynecology. It doesn’t occur to them that abortion is a natural part of life, unfortunate or not, and it needs to be done and done well.”

Training in abortion is actually required of all ob/gyn residency programs seeking accreditation, according to Bruder, a former junior fellow on the Residency Review Committee for Obstetrics and Gynecology. The trouble is, the language of the ob/gyn specialty requirements states that ob/gyn residents demonstrate proficiency in “family planning.” There is no mention of abortion, and the language is vague enough to allow programs to skirt the issue. “It’s meant to include abortion, but it’s not specific,” Bruder says. She adds that if programs leave out abortion, that simply opens the door to begin leaving out other components of medical practice that residents either aren’t interested in learning or doctors don’t feel like teaching. “If you’re going to be an ob/gyn, you need to know the whole breadth of the specialty, even if you’re not going to do it later.”

“Every residency program in ob/gyn should not only offer it, but make it a routine part of training,” Darney says. “They should not force it over religious objections, but also not simply require the person who wanted it to do it in their spare time. Residents work 80-100 hours a week. There is no spare time.”

But because the RRC is not a punitive body, it can only cite programs for being delinquent if they do not offer abortion training. And although the RCC can rescind a program’s accreditation, which means the resident’s work with that program will not count toward her or his board requirements, according to Bruder, it takes a lot more than the absence of abortion training to lose accreditation.

Interestingly, abortion is the only medical procedure taught that residents are currently permitted to excuse themselves from learning. And moral dilemmas aside, directing an ob/gyn residency program in which abortion is not offered at all or merely as an optional component of the study of women’s reproductive healthcare sends a disturbing message that abortion is not an important procedure, especially when the control of one’s reproductive life is considered a core tenet of women’s self-actualization and liberation. The responsibility lies with the faculty doctors and program heads who create and staff the curricula. According to the south Florida ob/gyn, receiving training in abortion “depends on whether the doctors in the program are providers. You do what the doctors on staff do because you learn their cases. If they do abortions, you do them.”

If attending physicians lead, residents will undoubtedly follow. In fact, Darney’s study also revealed that if program heads expect their residents to participate in abortion training, most usually do. But again, it goes back to a desire to teach the procedure. MacKay says that of the 268 ob/gyn residency programs in this country, only 20 to 25 have doctors on staff with a “real serious interest in abortion.”

The good news on this front, however, is that the Accreditation Council is considering changing its specialty requirements to include the words “induced abortion.” According to Bruder, this discussion has come up from time to time over the last two years. But when the RRC met in January, she said the committee discussed it at length. “The RRC wants programs and residents to know that we consider abortion a necessary part of training. This gives it the force to state it specifically.”

“We are discussing making the language more explicit to get the message across that we think abortion is important,” confirms Paul O’Connor, a Chicago, Illinois ob/gyn and a member of the Accreditation Council. “It’s an evolutionary process, and we’re slowly turning it around. But the committee is reluctant to change without discussion, and it takes time.”

Which brings us to the question of adequate learning opportunities – something that Damey found were severely lacking in many hospital-based ob/gyn residency programs. It’s not surprising. Centralizing abortion in specialized and certainly more cost-effective clinics has meant that hospitals provide fewer abortions. Only about 10 percent of abortions are currently performed in hospitals, while outpatient clinics handle approximately two-thirds of the procedures. Although Darney maintains that this was not strictly economics, but also a response to antiabortion pressure, the end result is that hospital-based residents actually have little opportunity to practice the procedure. The logical solution is to send the residents to where abortions are performed – clinics.

According to Darney, however, many program heads also object to their residents moonlighting in abortion clinics. “Residents should be given opportunities to work in freestanding clinics if that’s where the training is available,” he says. “Programs should develop relationships with these clinics.”

Planned Parenthood of New York City has developed such a program. Started in September 1992, at the cost of approximately $300,000, it’s certainly not the first to provide links between hospitals and abortion clinics – Vermont Women’s Health Center, and for years many private practices have offered residents the opportunity to moonlight to gain abortion training. But with its solid network of clinics, Planned Parenthood is in a position to provide other opportunities as well. According to Sanger, the program is open to third year ob/gyn and family planning residents and provides both “didactic and clinical training.” Residents spend one week or four Saturdays in Planned Parenthood clinics.

Sanger admits a week isn’t a long time. “Having someone for a week doing 50 procedures is a start. The idea is to have them continue when they get back to their residencies. And if hospitals refuse to go along, residents have to take matters into their own hands.” Sanger added that residents are always welcome in Planned Parenthood clinics, which have, along with many other clinics, felt the physician shortage, frequently having to cancel appointments if they cannot find replacements when doctors call in sick. “Residents are part of the staff and from an administrative standpoint, we really need the doctors there.”

Three residents have already been trained through this program. On June 18 the program was launched on a large scale basis and Sanger hopes to train approximately 35 residents a year.

But in addition to training, seasoned ob/gyns say support from the public in general and the medical community in particular will go a long way toward helping retain abortion providers. “It’s going to be easier if there’s a sense of organized support,” says MacKay. “Not only has the federal government been a negative factor, but the American Medical Association, which might have been supportive, has not been supportive.”

And restructuring the clinic model so that doctors have more than minimal contact with the patients, may alter the perception that abortion is unfulfilling work, not worthy of a physician’s time and interest. “Part of the gratification you get is realizing how much you’re helping the person involved. And you don’t get that when you do it in a factory mode,” Easterling says. “You’re the one that hurt them and all you did was hurt them. You’re the most obvious person to transfer emotions to. The counselors get all the strokes.”

But if ob/gyns continue to avoid training in and then performing abortions, there may be other medical and lay people who will shoulder the load. Says Karlin, “Eventually, if gynecologists feel that it’s not their area of interest, family practitioners will take over, and they’re more receptive to this as general healthcare. The presumption is [abortion’s] a filthy job and someone has got to do it, but it’s far more rewarding and exciting than internal medicine.”

Physicians’ assistants have been performing abortions at the Vermont Women’s Health Center for more than 20 years and teaching others to do it through a two-month community rotation at the center. The University of Vermont, which has no on-site abortion training, uses this clinic as a training ground forks second-year residents. The 1990 NAF/ACOG symposium also recommended training mid-level clinicians, nurse practitioners, and midwives in abortion to replenish the pool of providers. Too, there’s been a resurgence of self help groups. These women-only groups tend to be involved in total healthcare, of which gynecological healthcare is a part. They are teaching themselves to perform menstrual extractions – early removal of the uterine contents using a homemade suction-aspiration device – as a way of ensuring their independence from the frequently fickle medical establishment.

Meanwhile, although the situation still looks bleak, many abortion providers are taking heart. Says Easterling: “Training is better at this point in time at our institution man during the Reagan/Bush years.” “Our feeling is it’s improved somewhat,” says Anderson. “It angers some physicians that we are in this situation, and anger has been a motivator. Now we’re hearing from clinics that there is more interest from residents. And it does make a difference to have a friendly administration.”

But Darney suggests starting training earlier. “It’s harder for residents because they are beholden to the program directors for their next jobs. Medical school students can make the difference.”

Norine Dworkin is a freelance writer living in New York City.