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Obstacles to Abortion Public Health and Social Justice

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					Obstacles to Abortion and
    Comprehensive
Reproductive Health Care
   Martin Donohoe, MD, FACP
         Abortion in the U.S.
 30 million women have had abortions since
  legalization (1973)
 3 million unintended pregnancies per year
  in the U.S.
 1.2 million abortions in 2006 (↓ from 1.6
  million in 1990, ↓27% since 1980)
          Abortion in the U.S.
 19   abortions/1,000 fertile women/year
   Lowest rate since 1974
   9/10 abortions are in first 12 weeks

 236 induced abortions/1,000 live
 births
  Over 1/3 decline since early 1980s
             Abortion in the U.S.
   49% of all pregnancies are unintended, including more
    than 30% within marriage


   80% of teen pregnancies unintended

   Teen pregnancy have recently risen, after a long
    decline
           Abortion in the U.S.
   Patients:
     48% over age 25

     14% married (67% never married)

     56% have children

     43% Protestant, 27% Catholic, 8%
      other, 22% no religion
       Abortion in the U.S.
 Patients:
   59%   white
   African-Americans and Hispanics more
    likely to have abortions than Caucasians, in
    part due to:
      Higher levels of poverty
      Higher rates of unintended pregnancy
      Greater proportion of conceptions that end in
       abortion
     Most Important Reason Given for
    Terminating an Unwanted Pregnancy
 Inadequate finances - 21%
 Not ready for responsibility - 21%

 Woman’s life would be changed too much
  - 16%
 Problems with relationship; unmarried -
  12%
 Too young; not mature enough - 11%
       Most Important Reason Given for
      Terminating an Unwanted Pregnancy
   Children are grown; woman has all she wants -
    8%
   Fetus has possible health problem - 3%
   Woman has health problem          - 3%
   Pregnancy caused by rape, incest - 1%
   Other                             - 4%

   Average number of reasons given = 3.7
           Abortion in the U.S.

 By age 45, the average female will have had
  1.4 unintended pregnancies
 By age 45, 35% of US women will have had
  an induced abortion
 54% of women with unintended pregnancies
  get pregnant while using birth control
    1 year contraceptive failure rates: periodic
     abstinence (21%), OCPs (7%), IUD (1-2%)
          Abortion in the U.S.:
          Public Opinion Split
 2009: 42% consider themselves more “pro-
  choice,” 51% more “pro-life” (was
  44%/50% in 2008)
    Men 46% pro-choice, women 51% pro-
     choice
 2010: 45% pro-choice, 47% pro-life
 2010: Abortion should be “generally
  available” (36%), “available under strict
  limits” (39%), not permitted” (2%)
           Abortion in the U.S.:
                 Politics
   Republicans less supportive than
    Democrats

   25-30% of members of both parties would
    not vote for a candidate who did not share
    their views on abortion
              Abortion in the U.S.:
                Public Opinion
   25-30% of American women think abortion
    should be legal and available in all circumstances
   17-19% think abortion should be illegal under all
    circumstances
   The remainder would restrict abortion to cases
    of rape, incest, or to save a woman’s life
               Abortion in the U.S.:
                 Public Opinion
   Top priorities for the women’s movement
      Reducing domestic violence and sexual assault 92%

      Equal pay for equal work 90%

      Keeping abortion legal 41%

   2/3 believe the Supreme Court will not overturn Roe v
    Wade
         Center for the Advancement of Women surveys,
          2001-2003
   Are we taking Roe v Wade for granted?
        Abortion Worldwide

 42 million/year
 20 million unsafe (97% of these in
  developing countries)
   Cost of treating women for
    complications of botched abortions
    = $19 million/yr (vs. $4.8 million to
    provide contraception)
           Abortion Worldwide
 70,000  annual deaths (7/hour)
  13% of all maternal deaths
    (585,000/year)
     1/4 - 1/2 of maternal deaths in Latin
      America
 5 million hospitalizations annually

 30 infections/injuries for every one
  abortion death
          Abortion Worldwide
 220,000 children orphaned each year by
  poorly performed abortions
 Legal restrictions have no effect on
  abortion incidence
 Use of mid-level providers can decrease
  complications and deaths
     Common Grounds on Which
    Abortion is Permitted Worldwide
   To save woman’s life – 98%
   To preserve physical health – 63%
   To preserve mental health – 62%
   Rape or incest – 43%
   Fetal impairment – 39%
   Economic or social reasons – 33%
   On request – 27%
         Worldwide, every minute
   380 women become pregnant
   190 women face unplanned or unwanted
    pregnancies
   110 women experience pregnancy-related
    complications
   40 women have unsafe abortions
   1 woman dies
        Historical and Contemporary
        Methods of Unsafe Abortion
   Many used for millennia
   Examples:
     Toxic solutions taken orally or intra-vaginally: e.g.,
      turpentine, bleach, mercury, acid, detergents, etc.
     Uterine stimulant drugs

     Foreign bodies placed in the cervix/uterus – e.g.,
      sticks, wires, coat hangers, air blown from pump
     Direct/indirect trauma
           Barriers to Abortion:
Misconceptions about Sex and Contraception
   Common among adolescents and physicians

   40% of children age 13-17 who had intercourse
    did so before any parental discussion of STDs
    and birth control

   Duration of oral contraceptive use not a factor
           Barriers to Abortion:
Misconceptions about Sex and Contraception
   20% of 18-29 yr olds say they never had school-
    based sex education
   63% acknowledge “little to no knowledge”
    about contraception pills
   30% for condoms
   28% of men think wearing two condoms at once
    better (actually promotes condom breakage)
     - National Campaign to Prevent Teen Pregnancy, 2009
     Common misconceptions about
              OCPs
   They cause weight gain (reality = 30% fain 1-2kg
    from fluid retention)
   They cause acne and hirsutism (reality = less
    acne, no hirsutism)
   They cause breast cancer (reality = minimal, if
    any, effect)
   They impair future reproduction (reality = not
    true)
Common misconceptions about OCPs: Lack
    of awareness of benefits re …
   Decreased risk of ovarian and endometrial
    cancer
   Regulation of cycles, prevention of
    dysmenorrhea and iron deficiency anemia
   Decreased prevalence of PID and ensuing
    salpingitis and infertility
   Increased bone density
              Barriers to Abortion:
           Availability of Contraception
   Limited access to health care and lack of
    coverage
      Only 27 states require health insurance
       policies that cover other prescription drugs to
       include contraceptives
   Until recently, Oregon Medicaid covered Viagra
    but not oral contraceptives
   Planned Parenthood, other sliding scale clinics
              Barriers to Abortion:
           Availability of Contraception
   OTC status for OCPs would improve
    access, is considered safe
   Equity in Prescription Insurance and
    Contraceptive Coverage Act
     Introduced in Congress in 1997; still not passed
     Would require health insurers to pay for birth
      control as they pay for prescription drugs
               Barriers to Abortion:
            Availability of Contraception
   Savings (from averted pregnancy-related costs)
    for various methods of contraception, per $1
    spent (2007 study):
     Contraceptive implant/IUD: $7.00
     Injectable contraceptives: $5.60

     Oral contraceptives: $4.07

     Contraceptive patch: $2.99

     Vaginal ring: $2.55

     Barrier methods: $1.34
          Barriers to Abortion:
             Legal Viability
 Roe vs. Wade (1973): Abortion legalized
  up to “point of viability” (currently 24
  weeks)
    After viability, states can ban abortion
     except when necessary to protect the
     woman’s life or health
 Gestational limits (fetus < 500g or < 20
  weeks gestational age)
                Barriers to Abortion:
                        Cost
   Cost: approx. $350-$450 (1st trimester); $750-$1800 (2nd
    trimester)
      ¾ of patients pay out of pocket

      only 1/3 of patients have private insurance coverage;
       only 1/3 of private insurance companies cover (after
       deductible met)
      5 states restrict abortion coverage by private
       insurance plans (ID, KY, MO, ND, OK)
      most insured patients reluctant to file due to
       confidentiality concerns
              Barriers to Abortion:
                    Coverage
   Medicaid:
     Hyde Amendment (1978) prohibits federal
      Medicaid dollars from being spent on
      abortion, except to preserve the woman’s life
      or in cases of rape or incest
     But, 17 states allocate Medicaid funding to
      cover most abortions
            Barriers to Abortion:
                  Coverage
   Medicaid:
     Between 18% and 35% of Medicaid-
      eligible women who would have had
      abortions instead continue their
      pregnancies if public funding is
      unavailable
             Barriers to Abortion:
                   Coverage
   Medicare:
     Hyde Amendment applied to Medicare in
      1998
     Bans federal funding for abortions for
      disabled women except in cases of life
      endangerment, rape, or incest
     No state funding of Medicare to make up the
      gap
              Barriers to Abortion:
                    Coverage
   Title X Family Planning Clinics:
     Cover women from low income households
      at over 4500 family planning clinics
     Ethnic minority women disproportionately
      represented
     Funding has not kept up with inflation
     Prohibited from using federal and non-federal
      funds for all abortions
     “Gag rule” – 1981 to 1993
           Barriers to Abortion:
                 Coverage
 Indian  Health Service:
   Covers 1.5 million American Indians
    and Alaska Natives
   Subject to Hyde Amendment
    restrictions
             Barriers to Abortion:
                   Coverage
   Military Personnel:
     TRICARE (funded by Defense Dept.) covers
      8.3 million uniformed personnel and their
      families
     Permanent ban on abortion except where the
      life of the women is endangered (Senate
      Armed Services Committee voted to lift ban
      in mid 2010, bill pending)
             Barriers to Abortion:
       Military Hospital Abortions Ban
   Military women serving abroad, and their dependents,
    are prohibited from obtaining abortions at military
    hospitals, even if they pay with personal funds
      EC not available at all military treatment facilities
      Alternatives:
         Travel long distances for abortion – expensive
          and requires permission from commander to take
          leave
         Have abortion locally – unsafe in certain
          countries (e.g., in Middle East)
              Barriers to Abortion:
                    Coverage
   Federal Employees Health Benefits Program
    (FEHBP)
      Covers over 8.5 million federal employees,
       their dependents, and retirees; 45% women
      Since 1983 (except for 1994), abortion
       coverage permitted only in cases of life
       endangerment, rape, or incest
          Barriers to Abortion:
                Coverage
 Peace Corps
   7300 volunteers; 61% women

   Funds cannot be used for abortions,
    even when the woman’s life is
    endangered
            Barriers to Abortion:
                  Coverage
   Federal Prisons
     11,250 women

     From 1987-present (except for 1994),
      ban on funding abortions except when
      woman’s life endangered or the
      pregnancy the result of rape
        Obama Health Care Plan
   Executive Order states that federal funds cannot
    be used for abortion (except in cases of rape or
    incest or when the life of the woman is
    endangered)
   Prohibits discrimination against health care
    facilities and providers because of unwilliness to
    provide or refer for abortions
        Obama Health Care Plan
   Bans tax credits and federal subsidies for people
    required to purchase private insurance from
    being used to pay for abortion (except in cases
    of rape or incest or when the life of the woman
    is endangered)
     Means most policies will require two separate
      monthly premiums
     Will discourage plans from offering abortion

     Will exclude poor
                 Barriers to Abortion:
                    Funding Cuts
   Under Bush II, U.S. opposed language in the
    Cairo Action Plan, such as “reproductive health
    care,” stating that this is a proxy for abortion
       This halted U.S. participation in global efforts to
        prevent unintended pregnancies and control the
        spread of STDs, including HIV
   Domestic family planning budget cuts under
    Bush II
                   Barriers to Abortion:
     Limits on Availability of Emergency Contraception

   EC available in 102 countries
      Available OTC in parts of Canada and in S. Africa, UK,
       France, other European countries
   Cost: $25-$40
      Less expensive options involving OCPs

      $1.43 cost savings (from averted pregnancy-related costs) for
       every $1 spent
      2009 Utah study demonstrates association between increasing
       rates of EC use and decreasing abortion rates
                  Barriers to Abortion:
    Limits on Availability of Emergency Contraception

   French study showed that only 15% of EC
    pill use instances were reported by women
    using no contraception (in 45% of cases,
    women had been taking OCPs; in 35% of
    cases, partner(s) had been wearing
    condoms)
                  Barriers to Abortion:
    Limits on Availability of Emergency Contraception

   2009: FDA allows Plan B OTC for those 17 and
    older (younger women require a prescription) in
    response to US District Court ruling
      Supported by ACOG, AAFP, AAP

   2010: FDA panel unanimously endorses
    Ulipristal (effective for EC for up to 5 days
    post-coitus)
                   Barriers to Abortion:
     Limits on Availability of Emergency Contraception

   17 states mandate that emergency contraception
    be available to rape victims
   9 states allow pharmacists to directly prescribe
    emergency contraception
      Other states considering

   Military clinics not required to stock EC
               Barriers to Abortion:
    Emergency Contraception in Oregon ERs, 2003
   61% of Oregon hospitals routinely offer EC to
    rape patients
      Catholic hospitals = non-Catholic hospitals

   46% of Oregon ERs discourage prescribing EC
    to non-rape patients
      Catholic hospitals < non-Catholic hospitals
      EC and Oregon Pharmacies
   70% of all pharmacists surveyed reported that
    their pharmacy stocked emergency
    contraception.
   Of those pharmacists who do not stock
    emergency contraception, 30% will not fill a
    prescription for the medication due a moral
    objection.
                   Barriers to Abortion:
     Limits on Availability of Emergency Contraception

   Public awareness low:
      ¾ of reproductive-age women have not heard of
       EC, only 17% of teens have used (2006-8 data)
   Advance access to EC does not promote risky sexual
    behavior
   Congress has considered bills to prohibit the use of
    federal funds to prescribe, distribute, or provide
    emergency contraception to minors in elementary and
    secondary schools
                  Barriers to Abortion:
    Limits on Availability of Emergency Contraception

   Laws in Arkansas, Mississippi, Georgia, and
    South Dakota explicitly protect pharmacists who
    refuse to dispense EC
   Other states are considering similar legislation
   Wal-Mart offered EC as of 3/06, but does not
    require pharmacists to dispense it (guns, ammo,
    on the other hand…)
   Military clinics not required to stock EC
           Barriers to Abortion:
               Mifepristone
   Bush supported re-evaluation of FDA
    approval of mifepristone (RU-486, the
    “abortion pill”)
      Approved for medical termination of
       pregnancies 49 days or less from LMP
      Cost approx. $500
      Has been used by over 30 million
       women worldwide
          Barriers to Abortion:
              Mifepristone
 Medicaid funding for mifepristone
  restricted to cases of rape, incest, or to
  preserve the pregnant woman’s life
 Proposed state and federal legislation to
  curtail availability of mifepristone and limit
  the number of doctors who can prescribe it
 Alternative = Methotrexate termination,
  cost approx. $450
         Misoprostol (Cytotec)

 95% effective in conjunction with
  mifepristone
 85% effective alone

 Buccal administration (vs vaginal
  administration) with routine provision of
  antibiotics decreases risks of serious
  infections dramatically
        Misoprostol (Cytotec)
 $2 per pill on black market
 Use increasingly common among low
  income immigrants
 Americans who cannot afford abortion
  crossing into Mexico to buy cheap
  misoprostl
 Self-induced abortion illegal in 39 states
         Barriers to Abortion:
         Provider Availability
 87% of counties have no abortion
 provider
  35% of women live in these areas


 30% of metropolitan areas have no
 provider
           Barriers to Abortion:
           Provider Availability
 1800 physicians provide abortion services
 (↓ from 2400 in 1992)
  57% are aged 50 and older
  Family physicians facing denial of
   coverage, huge malpractice premium
   increases
                Barriers to Abortion:
                Provider Availability
   Medical school training:
     17% no formal education

     Clinical years:

        23% no formal education

        32% lecture

        45% third-year clinical experience (participation
         low)
        ½ fourth-year reproductive health elective
         (participation low)
             Barriers to Abortion:
             Provider Availability
   Provider training
      51% of Ob/Gyn residency programs houve
       routine training; 39% optional training
      California law now requires all ob/gyn residency
       programs to comply with ACGME requirements,
       including training in abortion (with opt-out
       provision for conscientious objectors)
   44 states bar non-physicians from performing
    abortions
       Barriers to Abortion:
Harassment of Patients and Providers

 55%-86% of providers harassed
 80,000 acts of violence and/or disruption at
  clinics in U.S. and Canada since 1977:
    Including 8 murders, 17 attempted
     murders, 41 bombings, 643 bomb threats,
     175 arsons, 184 assaults, 100 acid attacks,
     661 anthrax threats (487 since
     9/11/2001)
             Barriers to Abortion:
      Harassment of Patients and Providers
   Abortioncam.com, Army of God, Nuremberg
    Files website (closed), link with extremist
    groups/militias

   1 year prevalence of intimate partner physical
    violence 9.9% and sexual violence 2.5% among
    women who had elective abortions
           Barriers to Abortion:
    Harassment of Patients and Providers
   Scheidler v. National Organization for Women U.S.
    Supreme Court, 2/06)
      Federal extortion and racketeering laws cannot be
       used to stop anti-choice extremists from obstructing
       access to clinics, trespassing on or damaging clinic
       property, or using violence or threats of violence
       against clinics, their employees, or their patients
   2007: Massachusetts enacts toughest restrictions in US
    on protestors at abortion clinics
       Buffer zone = 35 feet
            Barriers to Abortion:
     Harassment of Patients and Providers
   Federal Freedom of Access to Clinic
    Entrances Law
     Passed 1994

     Somewhat effective
               Barriers to Abortion:
        Harassment of Patients and Providers
   15 states and D.C. prohibit certain specified
    actions aimed at patients and providers
     11 states and D.C. prohibit blocking entrance and
      exit from facilities
     5 states and D.C. prohibit threatening of
      intimidating staff
     3 states have “bubble zones” to protect patients
      from protestors
               Barriers to Abortion:
              Inflammatory Oratory
   President Bush, declaring January 20, 2002 (20th
    anniversary of Roe v. Wade) “National Sanctity
    of Life Day,” likened abortion to terrorism:
       “On September 11, we clearly saw that evil
       exists in this world, and that it does not value
       life. Now we are engaged in a fight against
       evil and tyranny to preserve and protect life.”
               Barriers to Abortion:
              Inflammatory Oratory
   Ad campaigns supporting proposed Georgia
    abortion ban claims to protect African-
    Americans and Asian Americans from
    “coerced” race- and sex-selection abortions
       “Black children are an endangered species” because
        of abortion
           Barriers to Abortion:
          Inflammatory Oratory
 Virginia State Legislator Bob Marshall, speaking in
  opposition to state funding for Planned Parenthood
  (stating that according to the Old Testament, being
  forced to bear a disabled child is punishment for the
  mother’s having earlier aborted her first-born):
 “(W)hen you abort the first-born…nature takes its
  vengeance on the subsequent children.”
 The organization ought to call itself “Planned
  Barrenhood.”
 - Richmond News Leader, 2/22/10 (he later apologized)
Point-Counterpoint
       Barriers to Abortion

          “Right’s” unscientific
 Religious
 polemics →
            Barriers to Abortion:
             Religious Hospitals
   Religious hospitals
     15% of US hospitals

     ½ of twenty largest health systems in US
      are Catholic, as measured by patient
      revenue
        Barriers to Abortion:
         Religious Hospitals
 Religious hospitals
   Granted special exemptions by federal
    government to use religious doctrine to
    guide patient care yet still retain
    government funding
   e.g., Catholic hospitals prohibit provision
    of abortion services, as well as
    contraception, sterilization, and infertility
    services
               Barriers to Abortion:
                Religious Hospitals
   Catholic hospitals deny approval of uterine
    evacuation while fetal heart tones present,
    forcing physicians to delay care or transport
    miscarrying patients to non-Catholic-owned
    facilities
       Some physicians violated protocol to avoid
        compromising patient safety
Christian Science Pharmacist Refuses To
          Fill Any Prescription
         Barriers to Abortion:
                 Legal
 Spousal Notification Laws
 Parental Consent and Notification Laws
  for Teen Abortions
 Mandated waiting periods

    25 states

    Most have 24 hour waiting period
  Parental Consent and Notification
        Laws for Teen Abortions
 20 states require parental consent
 10 states require parental notification
 4 states requires both
 16 states do not require parental
  permission
Parental Consent and Notification Laws
          for Teen Abortions
   All states have a judicial bypass procedure

   2006: CA and OR ballot measures to
    require parental consent failed
    Parental Consent and Notification
        Laws for Teen Abortions
 Notification dangerous if pregnancy
  resulted from incest or if home situation
  abusive or otherwise unstable
 U.S. Supreme Court struck down a
  Nebraska statute because it did not have an
  exception to save a pregnant woman’s life
  or health and returned a similar New
  Hampshire law to the lower courts
 Parental Consent and Notification
     Laws for Teen Abortions
 National  survey of female adolescents
 Laws would likely increase risky or
  unsafe sexual behavior and, in turn,
  the incidence of STDs and adolescent
  pregnancy
                  - JAMA 2005;293:340-8
    Parental Consent and Notification
        Laws for Teen Abortions
 Studies show can prevent up to half of
  teens from utilizing Planned Parenthood
  services, including contraception
 Could cause only 1% of teens to stop
  having sex
                      - JAMA 2002;288:710-4.
Potential Annual Costs of Parental Consent and Law
 Enforcement Reporting Requirements For Texas

   $43.6 million for girls younger than 18
    currently using publicly funded services
      Based on projected number of additional
       pregnancies, births, abortions, and
       untreated STDs and resulting cases of
       PID
         -Arch Ped Adol Med 2004;158:1140-6.
Texas Parental Notification Law
   Enactment associated with a decline of 11-20%
    in abortion rates among minors from ages 15-17
   Enactment associated with increased birth rates
    and rates of abortion during the second
    trimester among a subgroup of minors who
    were 17.50-17.75 years old at time of conception
                                  NEJM 2006;354:1031-8
             Barriers to Abortion:
            Biased Counseling Laws
   More than 20 states
   Often deceptively labeled “Mandated Informed
    Consent” or “Women’s Right to Know” Laws
   Scare tactics re safety of abortion
      Women read a lengthy list of possible but
       very rare complications from abortion (but
       not list of benefits of abortion)
           Barriers to Abortion:
Publicly-Funded “Crisis Pregnancy Centers”
   2500-4000 nationwide, some receive state
    funding
   Outnumber abortion clinics
   Listed in phone book under “pregnancy
    services” or “abortion services”
   48% of college health clinics routinely refer
    women who might be pregnant to CPCs
       81% routinely refer to full-service health clinics
           Barriers to Abortion:
Publicly-Funded “Crisis Pregnancy Centers”
 Staff try to dissuade clients from having
  abortions through misinformation
  exaggeration of risks, myths, and fetal
  photos/body scans
 Stop Deceptive Advertising for Women’s
  Services Act died in House Committee
               Barriers to Abortion:
Scare Tactics, Misinformation, and Pseudoscience
   Scare tactics re safety of abortion, contraception,
    and STD prevention:
      E.g., Cardinal Alfonso Lopez Trujillo (the
       Vatican’s spokesperson on family affairs):
     “Relying on condoms is like betting on your
       own death...They [the WHO] are wrong about
       that [condoms are a highly efficient means of
       preventing the spread of HIV]”
           Facts re Abortion
 One of the safest and most common
  medical procedures available
 Risk of death from legal abortion less than
  that from a shot of penicillin
 10-30 times more dangerous to carry a
  fetus to term than to undergo a legal
  abortion
    Risks Associated with Abortion
 Risk of death:
   1/1 million up to 8 weeks

   1/29,000 at 16-18 weeks

   1/11,000 at 21 or more weeks

   1/7,000 for carrying full-term pregnancy

 O.3% have complication requiring
  hospitalization
               Facts re Abortion

   No long-term emotional or psychological
    sequelae
      Women denied abortions often
       experience resentment and distrust
      Their children may face social and
       occupational deficiencies
               Barriers to Abortion:
Scare Tactics, Misinformation, and Pseudoscience
   Neither medical nor surgical abortion increase
    subsequent risk of ectopic pregnancy, spontaeous
    abortion, preterm birth, or low birth weight
   No overall effect on the risk of breast cancer
      NCI removed information re abortion and breast
       cancer from website; later posted unsupported “data
       controversial” statement
            C.f., NIH and CDCP websites removal of
             information about the effectiveness of
             condoms and sex education curricula
        Abstinence-Only Education
   77% of Americans have had sexual intercourse
    by age 20
   Average number of sex partners over lifetime:
     Wealthy country = 10
     Poor country = 6

   Federal government spent $178 million in 2008
     0% on comprehensive sex ed
         Abstinence-Only Education
   2% of school districts in 1988; 23% in 1999
   Over 80% of curricula, used by 2/3 of grantees,
    contain false, misleading, or distorted
    information about reproductive health
   Does not decrease sexual activity, STD rates,
    teen pregnancies; does not increase use of
    condoms and contraceptives
       Teen pregnancy and birth rates rose in 2006 (first
        rise in 14 years)
        Abstinence-Only Education
   c.f. “Virginity Pledges”
      88% violated

      Pledgers have identical STD rates to non-
       pledgers
      Pledgers are less likely than other to use
       condoms and to be tested and diagnosed with
       STDs
                           - J Adol Hlth 2005;36:271-8
        Abstinence-Only Education
   Attempts to instill guilt, fear and shame into students
   Places responsibility for refusing sexual advances on
    women
   Blurs science and religion
   Treats stereotypes about boys and girls as scientific fact
      Stereotypes undermine girls’ achievment, claim that
       girls are weak and need protection, and reinforce
       male sexual aggressiveness
        Abstinence-Only Education
   Prohibits any discussion of contraceptives
    beyond failure rates
   Presents worst case scenarios of abortions and
    STDs
   Since 2001, success defined as “completion of a
    course,” rather than by actual outcomes
         Abstinence-Only Education
   Programs have used funds to buy bibles,
    subsidize crisis pregnancy centers
   New Jersey program funded “Free Teens USA,”
    connected to the Sun Myung Moon’s
    Unification Church
       Moon has described homosexuals as “dung-eating
        dogs” and American women as “a line of
        prostitutes”
         Abstinence Only Education:
                 Examples
   Bizarre scare tactics:
       “Today being an adult means being able to …
        participate in any and all types of perverse activities
        that depraved minds can imagine.”
   Errors:
       “Studies show that five to ten percent of women will
        never again be pregnant after having a legal
        abortion.”
       Abstinence Only Education:
               Examples
   Sexism/Sex Stereotypes:
      “Deep inside every man is a kinght in
       shining armor, ready to rescue a maiden
       and slay a dragon.”
      “Females have the uncanny ability to
       remember the most insignificant details
       about past experiences.”
     Abstinence Only Education:
             Examples
   Sexism/Sex Stereotypes:
      “Men tend to be more tuned in to what
       is happening today and what needs to be
       done for a secure future.”
      “Girls will feel “dirty and cheap” when
       they “lose” their boyfriends after having
       sex
       Abstinence-Only Education
   24 states rejected abstinence-only funding
    in 2008

   Programs eliminated by Obama
    administration in 2010 budget
Comprehensive sex education programs

 Delay   onset of intercourse

 Reduce   the frequency of intercourse

 Reduce   numbers of sexual partners
Comprehensive sex education programs

 Increase   condom and contraceptive
  use.
 Reduce numbers of unwanted
  pregnancies
 Supported by large majority of
  Americans
               Barriers to Abortion:
                   TRAP Laws
   Targeted Regulation of Abortion Providers
    Laws
       Over 30 states
   Regulate hallway corridor and door frame width,
    temperature of operating rooms, numbers of
    hours of training each staff member much
    receive, increase licensing fees, impose
    burdensome documentation requirements, etc.
             Barriers to Abortion:
                 TRAP Laws
   Not applicable to other ambulatory health
    centers
   Increase retrofitting, design and training costs;
    put some clinics out of business
   Zoning ordinances – some clinics forced to
    relocate; others shut down
   Effect: decreased access to and increased costs
    of abortion
               Barriers to Abortion:
                    State Laws
 2010: 20 states have enacted laws that
  encourage or require the use of ultrasound
 As of 2010, 4 states require ultrasounds
  prior to abortion (AL, LA, MS, OK)
       OK protects doctors from malpractice suits if they
        do not inform parents that fetus has a birth defect
           Barriers to Abortion:
       State Laws Banning Abortion
   In 2005, a Michigan anti-abortion law
    passed, prohibiting physicians from
    performing most abortions, even when the
    mother’s health or life is endangered
      It is currently held up in federal court
             Barriers to Abortion:
         State Laws Banning Abortion
   2006 – South Dakota voters reject measure to ban
    abortion
       No exception for rape, incest or to protect woman’s health;
        contains inadequate and poorly-worded exception for “life
        endangerment”
       Violation is a felony
       2008 ballot initiative to outlaw “partial birth abortion” also
        failed
   Similar bills have been introduced in Alabama, Georgia,
    Indiana, Kentucky, Ohio, Mississippi, Rhode Island,
    South Carolina, Tennessee, and West Virginia
             Barriers to Abortion:
                  State Laws
   2005 – Cook County judge ruled that parents of
    a frozen embryo accidently destroyed by a
    Chicago fertility clinic could file a wrongful
    death lawsuit
   Very few states have both pro-choice legislatures
    and a pro-choice governor
             Barriers to Abortion:
                  State Laws
   Colorado’s Human Life Amendment, which
    would have given full legal rights to fertilized
    eggs, defeated 3-1 (2008)
   22 states have “Choose Life” laws, allowing
    motorists to purchase “Choose Life” license
    plates
      Proceeds support “Crisis Pregnancy Centers”
       and anti-choice organizations in 12 states,
       adoption in 14 states
South Dakota’s “Informed Consent”
               Law
 Passed in 2005
 Planned Parenthood sought and
  received injunction to suspend Law
 6/08: Eighth Circuit Court of Appeals
  (Planned Parenthood Minnesota v.
  Rounds) lifted injunction
South Dakota’s “Informed Consent”
       Law: Requirements
   Physician must give pregnant women a description of
    scientifically-unsupported “risks of abortion”
   Women must be told that they have an “existing
    relationship with fetus that enjoys protection under the
    U.S. Constitution and under the laws of South Dakota,”
    and that abortion terminates that relationship
    terminates that relationship along with “her existing
    constitutional rights with regards to that relationship”
       Neither the Constitution nor SD laws explicitly mention such
        a relationship
South Dakota’s “Informed Consent”
       Law: Requirements
   Disclosures must be made in writing, and
    women must sign each page of the state-crafted
    script
   Physicians who do not satisfy statute subject to
    license suspension or revocation and may be
    charged with a class 2 misdemeanor
   Physicians thus must violate Hippocratic Oath
    and lie to patients or violate SD law and face
    sanctions and possible prosecution
      “Fetal Research Rights”
 Under Bush II, Mission of Advisory
 Committee on Human Research
 Protection – which oversees the safety
 of human research volunteers –
 expanded to include embryos
         Insuring Fetuses
 Bush  II administration pushed “adopt
 the unborn” campaign, extending State
 Children’s Health Insurance Program
 (SCHIP) to fetuses
   But full prenatal care not extended
    to all women
              Barriers to Abortion:
           “Partial Birth Abortion” Ban
   Criminalizes intact dilatation and extraction
     0.17%     of all abortions
   31 states have such bans
       Some have exceptions for health of woman
   Similar 2000 Nebraska state law found
    unconstitutional by U.S. Supreme Court (Stenberg
    v. Carhart)
       Despite this, 17 states since enforcing ban
           Barriers to Abortion:
        “Partial Birth Abortion” Ban
   Lawsuits filed to overturn
     SF Appeals Court blocked
      administration enforcement of act
      against Planned Parenthood Clinics and
      their doctors, who perform roughly ½ of
      the nation’s abortions
           Barriers to Abortion:
        “Partial Birth Abortion” Ban
   2007: US Supreme Court upholds ban
    (Gonzales v. Carhart)
     Physicians subject to 2 years in prison, fine of
      up to $250,000, and monetary damages for
      psychological injury to the husband or parents
      of the pregnant woman
               Barriers to Abortion:
                       Legal
   “Unborn Victims of Violence Law”
      Criminalizes harming fetus; e.g., conviction in Texas
       (6-05)
      Supposedly will “help protect victims from domestic
       violence”
         Irony: Domestic violence programs in U.S.
          woefully under-funded
      Could limit women’s freedom to work in certain
       settings/at certain jobs
      2010: 37 states have “attempted feticide” laws
            Barriers to Abortion
   “Born Alive Infants Protection Act”
   DHHS using BAIPA in enforcing EMTALA
    (Emergency Medical Treatment and Active
    Labor Act)
   Will cause conflicts relevant to desire for
    palliation vs treatment
        Legal Barriers to Abortion:
      The “Teen Endangerment Act”
   Part I: “Child Custody Protection Act”:
      Would make it a federal crime for anyone other than
       a parent, including other relatives and religious
       counselors, from accompanying a young woman
       across state lines for an abortion, without complying
       with the home state’s parental involvement statutes
      Would delay abortion, increasing cost and
       physical/emotional health risks to teenager
        Legal Barriers to Abortion:
      The “Teen Endangerment Act”
   Part II: “Child Interstate Abortion Notification Act”:
      Would make it a federal crime to provide an abortion to a
       teenager outside of her home state unless the physician has
       notified a parent at least 24 hrs. in advance.
      No exception when abortion necessary to protect the
       teenager’s health
      Requires 24 hr. waiting period and written notification even if
       a parent accompanies teen to an out-of-state abortion
       provider
     Legal Barriers to Abortion:
   The “Teen Endangerment Act”
 Passed   by the U.S. House of
  Representatives in 2005
 Senate currently considering a similar
  bill, but without interstate abortion
  notification procedures
            Barriers to Abortion:
                    Legal
   Unborn Child Pain Awareness Act
     Mandates that women seeking abortion
      after 20 weeks be provided specific
      information regarding fetal pain during
      abortion, and that they sign a form
      accepting or refusing “pain medications
      for the unborn fetus”
        Barriers to Abortion:
         Legal – The Courts
 Nominations    of anti-choice judges

   ?Supreme    Court nomination(s)?

   ?Overturn   Roe vs. Wade?
Bush Nominates First-Trimester Fetus
  To Supreme Court – The Onion, 9/05
             Barriers to Abortion:
                     Legal
   Unsuccessful attempt to subpoena medical
    records from family planning clinic
    (violating patient confidentiality)
      Storm Lake, Iowa – resisted by Jill June,
       one of Ms. Magazine’s 2002 Women of
       the Year
             Barriers to Abortion:
                     Legal
   Maine Rep. Brian Duprey submitted bill to
    state legislature to make it a crime to abort
    an unborn child if that child is determined
    to be carrying the “homosexual gene”
      Such a gene is not known to exist

      Duprey got idea for bill “from Rush
       Limbaugh”
           Barriers to Abortion:
        Bush Political Appointments
   Political appointments to government
    scientific organizations/committees based
    on ideology, not knowledge and experience
      E.g., Drs. David Hager, Susan Crockett
       and Joseph Stanford appointed to the
       FDA’s Reproductive Health Drugs
       Advisory Committee
            Barriers to Abortion:
         Bush Political Appointments
   Example: Ob/Gyn Hager
     Author of “As Jesus Cared for Women”

     Has advocated Scripture reading and
      prayer for PMS and reportedly refuses to
      provide contraceptives to unmarried
      women
     Accused by wife of “serial anal rape”
            Barriers to Abortion:
         Bush Political Appointments
   Erik Keroack (head of “crisis pregnancy center,”
    anti-birth control, anti-sex education) appointed
    Deputy Asst Scty. For Population Affairs in
    DHHS – later resigned
   FDA Representative Dr. Janet Woodcock:
      Selling Plan B OTC would transform it into
       an “urban legend” that would tempt
       adolescents to create “sex-based cults”
        Church Amendment
 Protects those who choose to
 participate and those who choose not
 to participate in abortion at federally
 funded public health institutions
             Coats Amendment
   Passed 1996
   Maintains federal funding and legal status of
    medical institutions that do not offer abortion
    training or provide referrals for individuals
    seeking abortion training at another institution
   Prohibits discrimination against institutions and
    individuals who refuse to provide abortion
    training
          Barriers to Abortion:
     The Weldon Federal Refusal Clause
   Signed by President Bush in 12/04
   Allows federally-funded health care entities to
    deny women information on abortion services,
    even if state laws mandate that such information
    be given upon request
   46 states have similar conscience clauses
          Barriers to Abortion:
     The Weldon Federal Refusal Clause
   Opposing lawsuit filed December, 2004, by the
    National Family Planning and Reproductive
    Health Association
   Lawsuit by state of California rejected by federal
    judge (2008)
             Barriers to Abortion:
               Refusal Clauses
   46 states enacted shortly after Roe v. Wade

   14 states allow some health care providers
    to refuse to provide contraceptive services

   18 states allow some health care providers
    to provide sterilization services
          Barriers to Abortion:
            Refusal Clauses
 Permit certain medical personnel, health
  facilities, and/or institutions to refuse to
  participate in abortion
 DHHS regulations (9/08) allow health care
  workers and institutions to refuse on
  religious grounds to perform or refer
  patients for abortions
          Effects of Refusal Clauses
   Employers can refuse to provide contraceptive
    coverage in their health plans
   Pharmacists can refuse to dispense, or provide
    referrals for, lawfully-prescribed OCPs
   Health care professionals can deny patients
    information on, or referral for, family planning
    services, regardless of the patient’s health care
    needs
                ACOG Position
   Dcotors whose personal beliefs require them to
    deviate from standard practices such as
    providing abortion, sterilization, or
    contraceptives should:
     Give patients prior notice
     Offer timely referral
     Provide medically-indicated services in an emergency
     Practice close to physicians who will provide legal
      serivces or ensure that referral processes are in place
      so that patient access is not impeded
          Barriers to Abortion:
           Global “Gag Rule”
 Firstadopted by Reagan Administration
  in 1984
   aka Mexico city policy

 Rescinded by President Clinton in 1993

 Reinstated by Bush in 2001

 Overturned by Obama in 2009
              Barriers to Abortion:
               Global “Gag Rule”
   After Global Gag Rule reinstated by Bush
    Administration in 2001
     430 organizations in 50 countries stopped
      performing abortions or speaking about abortion
      laws in order to qualify for U.S. funding
         1/16 women in sub-Saharan Africa die during
          pregnancy or childbirth
     Did not cover condoms procured with HIV/AIDS
      funds
        Barriers to Abortion:
        Domestic “Gag Rule”
 Adopted   by Reagan administration in
 1988

 Overturned   by Clinton in 1992
                  The Good News
   27 states require insurers that cover
    prescription drugs to provide full coverage
    of FDA-approved contraceptive drugs and
    devices
       Exceptions exist
   Parents very accepting of idea of sexually
    transmitted disease vaccination for their
    adolescent children
                 - Arch Ped Adol Med 2005;159:132-7
              The Good News
   States and U.S. Congress introducing bills
    to improve sex education and affirm
    women’s right to choose “Freedom of
    Choice” bills

   The European Court of Human Rights has
    declined to extend full human rights to
    fetuses
   Barriers to Abortion: Worldwide

 Abortion   broadly legal in 60% of
  countries
   6% of developing countries

 1/3 of developing world lives where
  abortion is prohibited or allowed only in
  cases of rape or incest or to save the
  mother’s life
     Barriers to Abortion: Worldwide
   Lack of access to contraception
     Average number of lifetime abortions: Russia
      (9), Romania (18 - pre-fall of communism)
     215 million women have an unmet need for
      contraception
     Catholic Church opposes contraception (even
      condoms)
    Barriers to Abortion: Worldwide
   Under Bush II, U.S. cut $34 million in funding
    for U.N. Population Fund and withdrew support
    from a population control program that stressed
    access to reproductive health care and education
      Based on unsubstantiated argument that the
       program supports China’s coercive
       population control policy
      However, selective abortion of female infants
       common (119F/100M born in China)
  Barriers to Abortion: Worldwide
 U.N.  Population Fund
   Obama re-instated funding ($50
    million) in 2009 budget
     Barriers to Abortion: Worldwide
   Education:
      More years of education translates to decreased childbearing,
       higher salaries, improved status of women and families, and
       better education for their children
      Average number of children based on mother’s years of
       education:
         No school: 4.5

         Few years primary school: 3

         One or two years of secondary school: 1.9

         One or two years of college: 1.7
    Barriers to Abortion: U.S. Pressure on
         World Health Organization
   WHO expert committee recommended
    that mifepristone and misoprostol should
    be added to its Essential Medicines list

   WHO has failed to act, possibly in
    response to pressure from the U.S. Dept.
    of Health and Human Services
                Perspective:
            Poverty and Priorities
   Amount of money needed each year ( in
    addition to current expenditures) to provide
    reproductive health care for all women in
    developing countries = $12 billion
   Amount of money spent annually on perfumes
    in Europe and the U.S. = $12 billion
              Conclusions
 Restrictions on access to abortion and
  other reproductive health services
  increased dramatically under the Bush
  administration
 Backed by inflammatory/hostile rhetoric
  and pseudoscience
 Obama: ?change?
              Conclusions

 Vigilanceand legislative efforts at
 federal and state level and in the
 courts necessary to preserve and
 protect women’s right to choose
                       References
   Donohoe MT. “Teen Pregnancy: A call for sound science and
    public policy,” in Current Controversies in Teen Pregnancy and
    Parenting, Lisa Frick, Ed. (Farmington Hills, MI: Greenhaven
    Press/Thomson Gale, 2006). [Reprinted from Z Magazine 2003
    (April);16(4):14-16. Available at
    http://zmagsite.zmag.org/Apr2003/donohoe0403.html]
   Donohoe MT. Increase in obstacles to abortion: The American
    perspective in 2004. J Am Med Women’s Assn
    2005;60(1)(Winter):16-25. Available at http://www.amwa-
    doc.org/index.cfm?objectid=1B138032-D567-0B25-
    57EE86AC69902184
                     References
   Adams KE, Donohoe MT. Reproductive Rights –
    Commentary: Provider willingness to prescribe
    emergency contraception. American Medical
    Association Virtual Mentor 2004 (Sept.);6(9). Available
    at http://www.ama-
    assn.org/ama/pub/category/12783.html
   Donohoe MT. Obstacles to abortion in the United
    States. Medscape Ob/Gyn and Women’s Health
    2005;10(2):posted 7/7/05. Available at
    http://www.medscape.com/viewarticle/507404
                 References
   Donohoe MT. Parental notification and consent
    laws for teen abortions: overview and 2006
    ballot measures. Medscape Ob/Gyn and
    Women’s Health 2007. Posted 2/9/07.
    Available at
    http://www.medscape.com/viewarticle/549316.
       Contact Information
Public Health and Social Justice Website

        http://www.phsj.org
       martindonohoe@phsj.org

				
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