Tracy A Weitz, PhD, MPA
Director
Advancing New Standard in Reproductive Health (ANSIRH)
Bixby Center for Global Reproductive Health
University of California, San Francisco
January 25, 2010
In Trying to Find Common Ground, Do We Hurt Abortion Rights?
1. In trying to find
UCLA
In trying to find
common ground,
do we hurtJanuary 25, 2010 do we hurt
abortion rights?
Tracy A Weitz, PhD, MPA
Director
Advancing New Standard in Reproductive Health (ANSIRH)
Bixby Center for Global Reproductive Health
University of California, San Franciscoy
2. UCLA
Common Ground and
Abortion Rights
Today’s Talk
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Define “common ground” approach
to abortion
Review its development
Discuss the implications of thep
search for common ground on
abortion rights
Offer an alternative approach
October 2009 |
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C G dCommon Ground
Reducing the Need for Abortion / Prevention FirstReducing the Need for Abortion / Prevention First
Most major pro-choice social movement organizations
Obama and the Democratic Leadership
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Case Study: NARAL
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NARAL, first formed in 1967 as the National Association
for the Repeal of Abortion Laws
With legalization changed its name to the National
Abortion Rights Action League in 1973
In 1993 NARAL changed its name to the National
Abortion and Reproductive Rights Action League and
launched the "Real Choices" campaign “to highlight thelaunched the Real Choices campaign to highlight the
goals of its expanded mission: to preserve access to
abortion while working to enact policies to make
abortion less necessary”
In 2003 changed its name to “NARAL Pro-Choice
America”
NARAL became a word rather than an acronym,
i th d b ti f it ti lremoving the word abortion from its name entirely
In 2005 NARAL’s work prioritized a “prevention first
campaign” to reduce the need for abortion
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Obama and Abortion
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Internationally
Removal of Global Gag Rule
Appointment of Hilary Clinton as Sect of StateAppointment of Hilary Clinton as Sect. of State
Domestically
The search for common ground
Acknowledging the importance of legality
No further expansion of abortion rights
Reducing the need for abortion
Bringing Pro-Choice and Anti-Abortion activists
together to identify places where they agree
Agree to disagree
October 2009 |
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Obama’s Statement Commemorating Roe
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"Today we recognize the 37th anniversary of the Supreme
Court decision in Roe v. Wade, which affirms every
fwoman’s fundamental constitutional right to choose
whether to have an abortion, as well as each American’s
right to privacy from government intrusion. I have, and
continue to, support these constitutional rights.”
“I also remain committed to working with people of good
will to prevent unintended pregnancies, support pregnant
women and families, and strengthen the adoption system.”
“T d d d t t i t th t ll“Today and every day, we must strive to ensure that all
women have limitless opportunities to fulfill their dreams.”
Obama, 2010Obama, 2010
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Components of the new “Common
Ground” agenda
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g
R d i t d d iReduce unintended pregnancies
50 % of all pregnancies in the U.S. are unintended
½ of all unintended pregnancies end in abortion
Increase support for adoption
Data on adoptions is poor but somewhere between
1-5% of all unintended pregnancies
Increase support for families
Low-income women and women of color have higher
rates of abortion
Goal: Reduce the need for abortion
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The Underlying Assumptions
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Decreasing the number of unintended pregnancies
will result in a significant decline in the number of
abortions
Reducing the number of abortions will somehowg
reduce the social conflict over abortion
Acknowledging that abortions should be used lessAcknowledging that abortions should be used less
frequently will demonstrate that we take abortion
seriously and thus enhance people’s support fory p p pp
abortion rights
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Women’s individual desires to
avoid an unintended pregnancy is
lit ti l diff t fqualitatively different from a
social goal of reducing the need
for abortionfor abortion.
Helping a woman achieve her
reproductive desires is a laudablereproductive desires is a laudable
goal, not because it reduces the
need for abortion, but because it
is what she wants for her life.
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A brief review of the how we got to
th “ d” hthe “common ground” approach
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1973: Abortion as a social positive
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Roe decision articulated as a way for women to shape
the course and destiny of their lives
Seen as central to women’s equality in society
Synonymous with notions of modern feminism
Unqualified support for both the right to and use of
abortion
abortion on demand
abortion without apology
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1980’s: Changing the Social
Meaning of Abortion
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g
1970’s time of growing strength of the anti-abortion
movementmovement
Rise of single issue politics
Election of Ronald Reagan
Administrative restrictions on abortion
Changes in the composition of the Supreme Court
The “Culture War”
Goal:
To change the hearts and minds of the AmericanTo change the hearts and minds of the American
public
To make abortion a non-normative practice
unworthy of societal approval
Tactics:
Humanizing the fetus
Vilifying women
Solidifying the relationship between religiousSolidifying the relationship between religious
identification and abortion opposition
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Understanding Abortion as Violent
Social Conflict
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Rise of direct actionRise of direct action
Rescues
Siege on Atlanta
Summer of MercySummer of Mercy
Clinic defense as a response
Extensive media coverage
The violent wing
Direct targeting of abortion doctors and clinics
Murders and attempted murders
Abortion is an angry hostile debate between two sides
willing to win at all costs.
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Longing for a way out of the war
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The introduction of the mantra “abortion should be safe,
legal and rare”
Bill Clinton in 1992 presidential campaign
First day in office, reversed anti-abortion policies of
Reagan and Bush I with the affirmation that his vision
was “an America where abortion is safe, legal and
rare”rare
Since introduction in 1990 almost every pro-choice
politician has used the phrase
From the left and from the center/rightFrom the left and from the center/right
Accepted as the middle ground
USA Today editorial, 2003
Abortion is a “right most Americans want preserved:
reproductive choice that makes abortions safe, legal
d ”and rare.”
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“Reducing the Need for Abortion”
is Next Iteration
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SLR is still used
Used in conjunction with “Reducing the Need,” which is
the implementation efforts of the sentiment
Core of the current common ground approach
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What’s so wrong about wanting to
d th d f b ti ?reduce the need for abortion?
Discounts the role of abortion as a positive force inDiscounts the role of abortion as a positive force in
women’s lives
Increases the stigma surrounding abortion
Provides the fertile ground for the “abortion hurts women”Provides the fertile ground for the abortion hurts women
message of the anti-abortion movement
Reduces access to care
I di itiIncreases disparities
Does nothing to reduce the structural factors that produce
larger social inequalities in which reproduction is imbedded
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Produces a normative judgment
about abortion
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Suggest that abortion is happening more than it should
Separates the “good” and the “bad” abortions
Those that could have been avoided
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Understanding the Contradiction
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Pastor Rick Warren challenge to Obama’s position on
abortion:
“Now, I don't understand the, the idea of it should be rare
and, and less. Well, either you believe it's life or you don't.
It--why would you believe it should be rare? Because if ifIt--why would you believe it should be rare? Because if, if
it's not--if a baby, a fetus is not a life, then why restrict it?”
Meet the Press Nov. 29, 2009,
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Creates an understanding that
women’s individual decision making
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g
is the cause of social conflict
Which women’s decisions are implicated?
African American women have 5x the abortion rate of
WhitWhite women
Latina women have women have 2x the abortion rate
of White women
W ith i l th 100% f th FPL hWomen with income less than 100% of the FPL have
an abortion rate 3.2x as high as those at 200% of the
FPL
Rates for low-income and minority women are notRates for low income and minority women are not
declining as fast as for higher-income and white women
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Increases stigma and creates theIncreases stigma and creates the
fertile ground for acceptance of the
new “Abortion Hurts Women” framenew Abortion Hurts Women frame
of the Anti-Abortion Movement
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Central Arguments
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Women are victims of society, men and the abortion
industry
Promotion of restricted laws that prescribe the type and
timing of information women receive related to abortion
Focus is on telling women about the psychological risks
of abortion
Push for formal recognition of Post-Abortion Syndrome
(currently not recognized by the American Psychiatric
Association)
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Connectingg
Personal experience
Post-abortion recoveryy
Social activism
Religion
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David Reardon
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Architect of this approach
Founder of Women Exploited by
Abortion (WEBA) in 1982 toAbortion (WEBA) in 1982 to
minister to the needs of aborted
women and to help them heal their
pain.
A h f Ab d W Sil NAuthor of Aborted Women Silent No
More (1987)
Founder of the Elliott Institute in
Springfield IL 1988Springfield, IL, 1988
Since 1987 –7 books and a dozen
articles
26. UCLA
Common Ground and
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Weitz 1/25/10 the fetus with the
guilt-ridden, grief-
stricken images ofstricken images of
women victimized
by abortionby abortion
1996
1987
1996
1997
2002
1997
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Common Ground and
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Using the Apparatus of the Gov’t
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Anti-abortion Surgeon General
tasked with investigating effects
fof abortion on women
1989 Koop finds insufficient data
to determine that abortion harms womento determine that abortion harms women
Koop’s Conclusion
“The pro-life movement always focused- rightly, I though-p y g y g
on the impact of abortion on the fetus. They lost their
bearings when the approached the issue on the grounds
f th h lth ff t th th ”of the health effect on the mother.”
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Common Ground and
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Supported by the Science
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1990 American Psychological Association (APA) report
published in Science:
Exhaustive review of literature
“Women tend to cope successfully and go on with
their lives”
Position of most professional medical associations
American Psychological Association
American Psychiatric Association
American Public Health AssociationAmerican Public Health Association
American Pediatric Association
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What do Women Experience?
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Most feel relief
Some experience short-term feelings of:
Anger regret guilt/sadnessAnger, regret, guilt/sadness
Natural emotions to big life decisions
Rare cases of psychological problems
Best predictor of mental health after an abortion is
mental health before an abortion
No such entity as “post-abortion syndrome”
Conducting this research has many serious
methodological challenges
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Common Ground and
Abortion Rights
Significant methodological flaws to
research finding harm
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g
Using data not designed to answer the question
Incorrect comparison groups
Ignoring prior mental health statusg g p
Recall bias
Abortion underreporting
Conflation of association with causationConflation of association with causation
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Policy Change
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Texas Information Booklet: “A Woman’s Right to Know”
“You should know that women experience different
emotions after an abortion. Some women may feel guilty,emotions after an abortion. Some women may feel guilty,
sad, or empty, while others may feel relief that the
procedure is over. Some women have reported serious
psychological effects after their abortion, including
d i i f i t l d lf t tdepression, grief, anxiety, lowered self-esteem, regret,
suicidal thoughts and behavior, sexual dysfunction,
avoidance of emotional attachment, flashbacks, and
substance abuse. These emotions may appearsubsta ce abuse ese e ot o s ay appea
immediately after an abortion, or gradually over a longer
period of time. These feelings may recur or be felt stronger
at the time of another abortion, or a normal birth, or on the
i f th b ti ”anniversary of the abortion”
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Validation from the Supreme Court
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“Respect for human life finds an ultimate expression in the
bond of love the mother has for her child....While we find
no reliable data to measure the phenomenon, it seems
unexceptionable to conclude some women come to regret
their choice to abort the infant life they once created and
sustained…Severe depression and loss of esteem can
follow.”
Gonzales v Carhart, 2007
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But the Evidence is Still the Same
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2008 APA report
Critical review of recent literature (2006)
“Women who have abortions have no greater risk ofWomen who have abortions have no greater risk of
mental-health problems than if they deliver the
pregnancy.”
35. UCLA
Common Ground and
Abortion Rights But focusing on reducing the need
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for abortion increases the
legitimacy of these arguments at a
i t l l lsocietal level
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H #2 N N d f S iHarm #2: No Need for Services
Real implications for access to careReal implications for access to care
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Abortion Services Today
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Only 1,787 abortion providers (facilities) remained in
2005
Abortion clinics (>50% of patient visits are for abortion
services) provide 71% of all abortions
87% of U.S. counties have no abortion provider
35% of women live in these counties
97% of counties in nonmetropolitan areas have no
provider
Significant maldistribution across and within states
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Declining Number of Abortion Providers
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41% of counties are
now without
an abortion provider
Guttmacher Institute
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No Solution in Common Ground
Approach
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pp
Focus is reducing need not meeting access goals
Further negates mandates for routine training
Currently less than 50% of Ob/Gyn residencyy y y
programs offer routing training
Only 11 of 480 Family Practice programs
acknowledge abortion in the curriculum
No NP/CNM/PA training programs incorporate
Limits our ability to critique reductions in accessy q
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Common Ground and
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Further legitimizes efforts to restrict
use of abortion
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1989/1992 shift from abortion as a fundamental right to
“ d b d ” th h lda new “undue burden” threshold
States allowed to demonstrate a preference against
abortion
W iti i d t l i l t d tWaiting periods, parental involvement, mandatory
information, scripted provider speech
Allowances for misinformation
Breast cancer (6 states)Breast cancer (6 states)
Fetal pain (8 states)
Mental health consequences (7 states)
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Common Ground and
Abortion Rights
South Dakota
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Physician must tell the woman that the abortion will
“terminate the life of a whole, separate, unique, living
human being; that the pregnant woman has an existing
relationship with that unborn human being, and that the
relationship enjoys protection under the United States
Constitution and under the laws of South Dakota; and that
by having an abortion, her existing relationship and her
existing constitutional rights with regards to thatexisting constitutional rights with regards to that
relationship will be terminated.”
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Proliferation of Policies to Reduce Use
and Provision of Abortion CareWeitz 1/25/10
and Provision of Abortion Care
Targeting the Woman Targeting the ProviderTargeting the Woman
State-mandated
information
Targeting the Provider
Public facilities and
employees exclusionsinformation
Waiting periods
(usually 24-48 hours)
Two visit minimums
employees exclusions
Broad refusal clauses
TRAP laws
Two visit minimums
Parental involvement
Funding Restrictions
Hospital admitting
privileges
Abortion procedure bans
Mandated ultrasound
provision and viewing
Reporting requirements
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Impact of Reduced Access
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Increases gestational age at which abortions are
performed
Medical risk
Costs
Emotional consequences
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Timing of Abortion Differences
by Race/Ethnicity*
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y y
70%
50%
60%
70%
30%
40%
50%
Black
Hispanic
10%
20%
30% Hispanic
White
0%
10%
<8 weeks 9-12 weeks >12 weeks
* Data does not include CA and 3 other states
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Common Ground and
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Timing Differences by Age*
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70%
80%
50%
60%
70%
<15
15-19
30%
40%
50% 15 19
20-14
25-29
>30
10%
20%
30% 30
0%
10%
< 8 weeks 9-12 weeks 13-20 weeks >21 weeks
* Data does not include CA and 3 other states
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Two Other Components of the
C G d A dCommon Ground Agenda
No federal fundingNo federal funding
Allowances for denials of care
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Health Care Compromise
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“I want to clear up - under our plan, no federal dollars will
be used to fund abortions, and federal conscience laws will
remain in place”
(Obama, Joint Session of Congress
on Health Reform, 2009).
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State Medicaid Coverage for Abortion
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17 states use state funds for all or most medically necessary abortions17 states use state funds for all or most medically necessary abortions
AK, AZ, CA, CT, HI, IL, MA, MD, MN, MT, NJ, NM, NY, OR, VT, WA, WV.
• 4 of these states provide such funds voluntarily
•13 of these states do so pursuant to a court order•13 of these states do so pursuant to a court order
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North Carolina’s Natural Experiments
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Cook et al, 1999
Examined impact of episodic lack of state funds for
indigent women’s abortions between 1980-1993
Happened at different times of the year
F d d i b i d i iFound a decrease in abortion rates and an increase in
birthrates when funds were not available
Conclude that 37% of women who obtained an
abortion on Medicaid would have continued theabortion on Medicaid would have continued the
pregnancy if funds were not available
10% more abortions among black women and 1%
more among white womeng
Morgan and Parnell, 2002 added additional
administrative variables
Approx 3% of white women and 5% of black womenpp
would have carried a pregnancy to term without
funding
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Denials of Information, Referral and
Services
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Refusal clauses, often called “conscience clauses,” in
which institutions and individuals are shielded from
liability for failing to provide health services, counseling
and/or referrals because the individual or institution has
an objection to the service;j
Institutional prohibitions in which institutions override
physician-patient decision-making and prohibit the
provision of certain services in their facilities, refuse to
cover those services in their insurance products orcover those services in their insurance products, or
otherwise restrict services that meet evidence-based
standards of care; and
Political restrictions including those laws and regulationsPolitical restrictions including those laws and regulations
that are enacted based on political ideology or electoral
politics and mandate how health care must be delivered,
where and how it can be delivered, or what care is
covered by health care payerscovered by health care payers.
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An Exercise of “Conscience”
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Carla who lives in eastern Oklahoma thought she had the
flu. Her family doctor referred her to an Ob/Gyn who
discovered she was pregnant and that she had a largediscovered she was pregnant and that she had a large
mass growing on her uterus. The Ob/Gyn refused to
remove the mass because it would endanger the
pregnancy. The anesthesiologist in the practice group
refused to give her any drugs that would harm therefused to give her any drugs that would harm the
pregnancy. At this point the mass was shutting off her
colon and bladder. Eventually Carla found a doctor in
another city who found that after substantial delay, he had
to remo e her ter s a proced re that o ld ha e beento remove her uterus, a procedure that would have been
unnecessary if the abortion had been performed earlier in
her pregnancy.
Carla was uninsured. Her hospital bill for
the abortion and the hysterectomy was
$40 000over $40,000.
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A Snapshot of Institutional
Prohibitions on Care
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43 states allow health care institutions to refuse to
provide services
Only 1 state (California) limits that refusal to religious
health care entitieshealth care entities
Federal level—The Weldon Amendment to the
FY 2005 Appropriations bill limits the ability of federal,
state, and local laws to mandate abortion carestate, and local laws to mandate abortion care
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Catholic-Owned HealthCare
Facilities
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Broadest religiously-based health care restrictions
Control > 16% of the U.S. hospital beds
Serve 1 in 6 patients in the U.S.
Governed by the Ethical and Religious Directives forGoverned by the Ethical and Religious Directives for
Catholic Health Care Services (ERDs)
Promulgated by the U.S. Conference of Catholic
Bishops
Prohibit abortion, sterilization, contraceptives and
most forms of assisted reproductive technology
Contain no exceptions
Many patients who seek care or physicians who provide
care do not adhere to the beliefs of the Catholic
Hierarchy
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Example: PROM
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Premature Rupture of Membranes (PROM)
Amniotic membranes rupture pre-term
Risk: infection sepsis maternal mortalityRisk: infection, sepsis, maternal mortality
< 24 weeks: only 30% fetuses survive
ACOG and AAP standard of care:
balance risk to woman v potential for fetal survivalbalance risk to woman v potential for fetal survival
Ob/Gy must counsel about risks and woman must
decide whether to abort or attempt to continue
pregnancy
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“And at this point their personal decision-making runs
afoul of their hospital’s policies Inducing laborafoul of their hospital s policies. Inducing labor
before membranes have ruptured, or before there is
a maternal indication such as infection, is technically
an abortion This hospital like most hospitals in thean abortion. This hospital, like most hospitals in the
metropolitan area in which they live, has a strict
non-elective-abortion policy…”
“You might wonder, reading this vignette, how I
happen to know so many details about this case, or
even whether this is a fictional teaching care that so
bedevils medical student. The unfortunate truth is
that this is real life: I am the husband in this story ”
Ramesh Raghavan, MD, PhD
JAMA, 4/4/07
that this is real life: I am the husband in this story.
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Prohibits Willing Doctors from
Providing Care
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“I’ll never forget this; it was awful—I had one of my
hi i 19 k [P f] hpartners accept this patient at 19 weeks. [Part of] the
pregnancy was in the vagina. It was over…. And so he
takes this patient and transferred her to [our] tertiary
medical center, which I was just livid about, and, you
know, “we’re going to save the pregnancy.” So of course,
I’m on call when she gets septic and she’s septic to the
point that I’m pushing pressors on labor and delivery trying
to keep her blood pressure up and I have her on a cooling
blanket because she’s 106 degrees. And I needed to get
everything out. And so I put the ultrasound machine on
and there was still a heartbeat and [the ethics committee]
wouldn’t let me because there was still a heartbeat. This
woman is dying before our eyes…She was so sick she
was in the ICU for about ten days and very nearly died… “
Freedman, Landy, & Steinauer,, 2008
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Low-Income and Minority Women
More Vulnerable to Prohibitions
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Less choice of care providers
Default enrollment
Less capacity to advocate for alternatives
Catholic-owned facilities more likely to be in low-incomeCatholic owned facilities more likely to be in low income
communities
Historical providers of charity care
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Examples to the Contrary
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Dr. Tiller
South DakotaSouth Dakota
California parental consent
Perhaps the best argument for abortion is its
commonness
1.2 million abortions per year
1 in 3 women by age 45
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So is there room for any “common
d”?ground”?
Common ground is different from common purposeCommon ground is different from common purpose
Done without the expectation that it will depolarize the
abortion debate in this country
Important goals in their own right and not because theyImportant goals in their own right and not because they
offer us a solution to the abortion wars
i.e. reducing poverty, increasing self-efficacy, etc.
H lth f d b t t ht i f l lHealth care reform debate taught us a painful lesson
Support for prevention did not translate unto support
for abortion
Shifti th ti f b ti t UPShifting the stigma from abortion to UP
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Alternative Approach
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Acceptance that abortion is a polarizing issue in the
U.S.
Acceptance that abortion has and will always be part of
the human condition
Internationally abortion is common even where it is
highly restricted
Difference is safety and social validation of the
decision
Engage in the hard conversations about abortion
Moral status of life
Rights and autonomy of women
Right of the state to limit decisionsg
Role of religion in public life
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What Do We Value?
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Women deserve the legal right to abortion
Women deserve to have an abortion(s) without
judgment
Women deserve high quality accessible and culturally
appropriate abortion care
U f t t l th h fUnfortunately the search for common
ground moves us further away from
achieving each of these objectivesachieving each of these objectives.