The abortion restrictions that conservative Republicans shoehorned into Paul Ryan’s American Health Care Act last month were just the latest volley in their ongoing, grim war on reproductive choice.
Notwithstanding the Ryan bill’s spectacular collapse, President Donald Trump and Congressional Republicans could well succeed in banning abortion or further squeezing off legal access to the procedure and other family planning services. Regardless of the law, however, desperate women will still seek to terminate their pregnancies as they did before 1973, when Roe v. Wade allowed women to decide whether to carry their pregnancy to term.
How then will physicians respond?
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In recent years, the campaign against abortion has mostly focused on persuading – and shaming – women into not ending their pregnancies. How else to explain the blizzard of state laws requiring waiting periods, invasive vaginal ultrasounds and “counseling” about adoption or the faux health risks of abortion?
Trump took an ominous step further on this path during his campaign when he flippantly suggested there “has to be some form of punishment” for women who have abortions. In response to the uproar that followed, he quickly recanted, insisting instead that “the doctor or any other person performing this illegal act upon a woman would be held legally responsible, not the woman.”
The Ryan bill took a diabolical new tack, going after insurers instead of clinics or providers. Under the now-dead plan, women enrolled in any insurance plan that covers abortion would not have been eligible for the federal tax credits designed to shave premium costs. A final version did make an exception in cases of rape or incest, or if the abortion is needed to save the woman’s life. But if enacted, the measure would have effectively eliminated private insurance coverage of abortion, further limiting the procedure to women wealthy enough to pay for it out of pocket.
With that approach dead for now, and since Trump seems to have ruled out prosecuting women, physicians could well be the target of anti-abortion lawmakers.
Criminalizing the procedure will saddle individual doctors, whether in private practice or prestigious university teaching hospitals, with a miserable dilemma – serve their frantic patients or risk their professional livelihood. Violating the law would be hard under any circumstances; for younger doctors still paying off steep medical school loans, the financial consequences could be ruinous.
Certainly doctors who oppose abortion may be comfortable with significant new restrictions or an outright ban. But most members of the American Congress of Obstetricians and Gynecologists “are very concerned about the future of women’s health generally in this country and see abortion access as one of the areas of great vulnerability,” said Lucia DiVenere, ACOG’s senior director of government affairs. “It’s very clear that Trump wants to limit that access.”
Older doctors, particularly those who trained in the pre-Roe years, say they still shudder recalling women who were mutilated or died following back-alley or self-induced abortions, and they are determined to continue providing care. As these older practitioners retire, younger ob-gyns have taken up the challenge of training new abortion providers.
One is Dr. Angela Chen, who directs UCLA’s family planning fellowship program, which trains medical students and residents in contraception and family planning, including abortion. Her program is one of about 30 nationwide.
Chen and her UCLA colleagues now often treat patients from Texas and other states, many of whom have learned they are carrying a fetus with catastrophic anomalies and either have no access to abortion or refuse to run a gantlet of humiliating state rules and clinic protesters.
These regulations “are terribly misguided,” Chen said, “a slow creep against what women need to maintain their health.”
Most women can’t afford to travel to Los Angeles so Chen and other practitioners see easier access to mifepristone as a compassionate and safe alternative to surgical abortion, particularly in early pregnancy. Available in France since 1987, the so-called abortion pill was approved for use in the U.S. in 2000. Used in a two-drug combination, it has proved to be overwhelmingly safe and effective. Because its approval was so controversial, the U.S. Food and Drug Administration has required that patients cannot purchase mifepristone, marketed as Mifeprex, from a pharmacy but only from a physician. They must take it in the doctor’s office and be examined in a follow-up visit there.
The long experience with Mifeprex prompted the FDA to issue new guidelines last year that underscore its safety, allowing the drug’s use later in pregnancy at a lower dose and with fewer doctor visits. Many doctors support liberalizing this process even further by dispensing Mifeprex through pharmacies, like most other drugs, and allowing women to do the second doctor visit via phone or video rather than face-to-face. They need to speak up.
In states with a tightening knot of restrictions and a dwindling number of clinics, easier access to mifepristone would grant women a welcome measure of privacy as they make what is nearly always a wrenching decision to end a pregnancy. Already women in Texas and other parts of the Southwest are heading to Mexico where mifepristone, called Cytotec there, can be had without a prescription. But these do-it-yourself abortions – no doctor prescribes the correct dosage or follows the patient afterward – are inherently risky.
If abortion becomes illegal nationwide – if a conservative majority on the Supreme Court determines that a zygote has Fourteenth Amendment rights or the “heartbeat bill” now before Congress barring abortion after about six weeks becomes law – what will doctors do when women ask for help?
“I’ve thought I could set up a clinic in my basement, maybe,” one ob-gyn told me. But he worries. “Someone might wonder, ‘why are all these women coming to this house,’ ” and report him.
That this long-tenured professor at a prestigious Bay Area medical school didn’t want me to use his name speaks to the fear that still surrounds abortion, even in California.
Short of a clandestine network of doctors, he continued, “we will start seeing lots more incomplete abortions with coat hangers and other drugs.” The U.S. “begins to look like Africa,” he added.
Or, more to the point, American looks like the way it used to look.
In the years just before abortion became legal, the Jane Collective, a kind of underground railroad of Chicago women, performed more than 11,000 safe, surgical abortions. None of the women had attended medical school. They worked out of two apartments and a local doctor risked his license by doing post-operative checkups on their patients. The group disbanded in 1973 when Roe became the law.
This back-to-the-future is not what doctors or their patients want.
Molly Selvin, a former staff writer for the Los Angeles Times, is a freelance writer based in Los Angeles. She can be contacted at email@example.com.