Access to Second Trimester Abortions: A Public Health Perspective

1
Access to Second Trimester Abortions A Public
Health Perspective

• Tracy Weitz, PhD, MPA
• Director
• Advancing New Standards in Reproductive Health
  (ANSIRH)
• Bixby Center for Reproductive Health Research
  Policy
• University of California, San Francisco

2
Todays Presentation

• Overview of 2nd trimester abortion
• Current barriers to provision
• A recommitment to 2nd trimester abortion care

3
What is 2nd Trimester Abortion?
1st Tri 2nd Tri 3rd Tri
ACOGs Committee on Coding and Nomenclature LMP to lt 14 wks 14 -28 wks 28 wks
Roe v Wade LMP to12 wks 13-24 wks 25 wks
4
2nd Trimester Abortion in Practice

• Generally
• Abortions between (14) and (24) weeks LMP
• Involves use of Dilation and Extraction (DE)
• Can be done with medications as an induction
• Providers vary on to what gestational limit they
  do abortions
• CPT Codes distinctions
• 59840 By DC Any trimester
• 59841 By DE -- 14 weeks 0 days up to 20 weeks 0
  days
• 59841-22 By DE -- 20 weeks 0 days or more

5

Abortions by Gestational Age
Almost 90 in the 1st Trimester
Source Elam-Evans et al., 2002 (1999
data)
6
Many Women Need Care

• 10 of 1.3 million is still a lot of women
• 130,000 procedures in the 2nd Trimester
• 26,000 women over 21 weeks LMP
• Women who need care
• Access barriers
• Social barriers
• Diagnosis barriers
• Life circumstances
• Health care disparity and human rights issue

7
Who Needs 2nd Trimester Abortions

• Greater likelihood for women who are
• Low income
• Non-Hispanic black
• Geographically isolated
• Young

8
What factors delay abortion

• Funding needs
• Only 17 states still allow for Medicaid funding
• Significant factor in use of 2nd Ti
• Late diagnosis of pregnancy
• Late diagnosis of medical need
• Logistics
• Difficulty finding a provider
• Referral from a prior clinic

9
Barriers to Provision

• Lack of Providers
• Increasing Regulation

10
Lack of Providers

• Graying of the Abortion Provider
• Concentration in High Volume Outpatient Clinics
  not in Hospitals
• Lack of Training
• In Residencies
• For the Practicing Physician
• Inadequate Compensation
• Out-of-Pocket Services
• Medicaid Restrictions
• Insurance Prohibitions

11
A More Complicated Story

• of providers is an inadequate measure
• MFM physicians may do procedures for fetal
  abnormalities
• Separating Good from Bad Abortions
• Newer providers unwilling to do such high volume
• ? requirements are ? cost without ? compensation
  gt ?specialization

12
Increasing Federal and State Regulation of 2nd
Trimester Abortion

• Partial Birth Abortion Bans
• Fetal Pain Consent Bills
• Targeted Regulation of Abortion Provider (TRAP)
  Laws

13
Partial Birth Abortion (PBA) Bans
14
What is PBA

• Not a medically recognized term
• Introduced into the public after a 1992
  presentation by Martin Haskell at the National
  Abortion Federation (NAF) meeting was leaked to
  anti-abortion activists
• Supposedly describes the dilation and extraction
  (DX) technique
• where the fetal body is brought through the
  cervix intact and then the skull is compressed to
  safely move it through the cervix
• There is no bright-line distinction between DE
  and DX
• most appropriately called intact DE

15
Why Perform an Intact DE?

• Reduce instrumentation of the uterus
• Fetus presentation necessitates
• Result of dialation of cervix with laminaria or
  misoprostol or other cervical preparation
  technique
• Process of fetal loss
• Preserve the fetus for post-procedure examination

16
Early Efforts to Ban PBA

• Federal legislation to ban PBA passed by
  Congress in March 1996 and again in October 1997
• President Bill Clinton vetod both bills
• Override votes passed in the House of
  Representative but failed in the Senate
• Many states began to pass PBA bans

17
State-based PBA Bans

• 26 states have bans on PBA that apply throughout
  pregnancy
• 18 bans have been specifically blocked by a court
• 7 bans remain unchallenged but are presumably
  unenforceable under Stenberg because they lack
  health exceptions
• Ohios ban has been challenged and upheld by a
  court
• 5 states have bans that apply after viability
• Utahs ban has been specifically blocked by a
  court because it lacks a health exception
• Montanas ban remains unchallenged but is
  presumably unenforceable under Stenberg because
  it lacks a health exception
• 3 bans are currently in effect
• 4 states have bans that include a health
  exception
• 2 states broadly allow the procedure to protect
  against physical or mental impairment
• 2 states narrowly allow the procedure to protect
  only against bodily harm
• 27 states have bans without a health exception
• 19 bans have been specifically blocked by a
  court.
• 8 bans remain unchallenged.

18
State-based PBA Bans

• Found unconstitutional in Stenberg v Carhart
  2000
• Challenge to the state of Nebraska ban on
  so-called Partial Birth Abortion
• Found unconstitutional on 5-4 decision
• Stevens, Breyer, Souter, Ginsburg, OConnor
• Four separate dissenting opinions were filed
  Rehnquist, Scalia, Kennedy, Thomas
• Must have a health exception
• In spite of this- Congress passed a the 2003
  Partial Birth Abortion Ban without a health
  exception

19
Signing the PBA Ban of 2003
20
What Does the Law Say

• An abortion in which the person performing the
  abortion, deliberately and intentionally
  vaginally delivers a living fetus until, in the
  case of a head-first presentation, the entire
  fetal head is outside the body of the mother, or,
  in the case of breech presentation, any part of
  the fetal trunk past the navel is outside the
  body of the mother, for the purpose of performing
  an overt act that the person knows will kill the
  partially delivered living fetus and performs
  the overt act, other than completion of delivery,
  that kills the partially delivered living fetus.

21
Immediately Challenged

• 3 Legal Challenges
• Planned Parenthood v. Ashcroft
• San Francisco
• National Abortion Federation v. Ashcroft
• New York
• Carhart v. Ashcroft
• Nebraska
• Temporary Injunction
• Who is covered?

22
Planned Parenthood v. Ashcroft/Gonzales

• Challenged by Planned Parenthood, joined by the
  City and County of San Francisco on behalf of San
  Francisco General Hospital
• Subpoena to obtain medical records
• Federal District Judge Phyllis Hamilton struck
  down the law on 3 grounds (6/1/04)
• Because it places an 'undue burden' (i.e., "a
  substantial obstacle in the path of a woman
  seeking an abortion of a nonviable fetus") on
  women seeking abortion
• Because its language is unconstitutionally vague
• Because it lacks constitutionally-required
  provisions to preserve women's health
• Upheld by 9th Circuit (1/31/06)

23
NAF v. Ashcroft/Gonzales

• Challenged by the ACLU Reproductive Freedom
  Project on behalf of the National Abortion
  Federation (NAF)
• New York District Judge Richard C. Casey
  (8/26/04)
• found the Partial Birth Abortion Ban Act
  unconstitutional
• ruled that the act must contain exceptions to
  protect a woman's health
• Very inflammatory language reg the fetus
• Upheld by 2nd Circuit (1/31/06)

24
Carhart v. Ashcroft/Gonzales

• Challenged by the Center for Reproductive Rights
  on behalf of a Nebraska physician Carhart
• U.S. District Judge Richard Kopf (9/8/04)
• The overwhelming weight of the trial evidence
  proves that the banned procedure is safe and
  medically necessary in order to preserve the
  health of women under certain circumstances.
• In the absence of an exception for the health of
  a woman, banning the procedure constitutes a
  significant health hazard to women."
• Upheld by the 8th Circuit Court of Appeals
  (7/8/05)

25
The Supreme Court

• 2 cases (Planned Parenthood Carhart) heard
  11/8/06
• Expect opinion at end of term
• What do we expect
• Will depend on Kennedys dissent in Carhart?
• Has science and evidence changed
• What is undue burden

26
Kennedys Strong Opposition

• states should be able to outlaw a procedure
  many decent and civilized people find so
  abhorrent as to be among the most serious of
  crimes against human life dissent in
  Stenberg v Carhart, 2000

27
Implications of Reversal

• Could ban all 2nd trimester abortions
• Impose criminal sentences on physicians who
  violate the ban
• Chilling effect on 2nd tri provider
• Fundamentally change the meaning of abortion
  right articulated in Roe
• Restrict abortion in states with more liberal laws

28
What Will Providers Do?

• Survey of 2nd Trimester providers attending the
  2006 meeting of the National Abortion Federation
• N 46 (US only)
• Average gestation limit 21wks LMPrange 16-27
• Median gestation limit 23 wks LMP

29
If PBA is upheld will you?

• alter the way you use misoprostol for cervical
  ripening
• use digoxin at earlier gestational ages
• reduce the gestational age to which you perform
  abortions
• stop performing intentionally intact DEs
• change who you allow in the procedure room
• change the clinical technique for performing DEs

30
Use Digoxin at Earlier Gestation Age?

• What is Digoxin (Dig)
• A feticide injected into the fetal heart to stop
  fetal cardiac activity
• Change clinical practice
• Yes 11 (24)
• No 28 (61)
• No Answer 7 (15)

31
Why Isnt Dixogin the Answer?

• Scientific evidence demonstrates does not
  increase safety or ease of procedure and has
  medical risks
• Drey, E. A., L. J. Thomas, N. L. Benowitz, N.
  Goldschlager, and P. D. Darney. 2000. "Safety of
  intra-amniotic digoxin administration before late
  second-trimester abortion by dilation and
  evacuation." Am J Obstet Gynecol 1821063-6.
• Jackson, R. A., V. L. Teplin, E. A. Drey, L. J.
  Thomas, and P. D. Darney. 2001. "Digoxin to
  facilitate late second-trimester abortion a
  randomized, masked, placebo-controlled trial."
  Obstet Gynecol 97471-6.

32
Other Complicating Factors

• Increased difficulty
• at reduced gestation age
• with obesity
• Cost
• What is fetal death
• How prove?

33
Where is the Pro-Choice Movement

• Wavering support
• Discomfort with the techniques of abortion
• A desire to not focus on the issue
• Belief that we lose when we discuss the issue
• Belief that few women will be hurt by these bans
• Focus on reframing and terminology rather than
  real understanding

34
Implications for Health Care Beyond Abortion

• Legislate a particular medical technique
• What does this mean to the concepts of informed
  consent?

35
Fetal Pain Bills
36
Fetal Pain Counseling Reqs.

• Require a doctor performing an abortion at 20 or
  more weeks to read to the woman a statement
  saying that the fetus may experience pain and to
  offer to give the fetus anesthesia
• In place in 3 states and under consideration in
  others

37
What is Pain

• Pain is a feeling a subjective sensory
  experience and as such, an individual must
  possess some level of consciousness or awareness
  in order to perceive a stimulus as unpleasant.
  To be conscious and capable of experiencing pain,
  an individual must have a functional cerebral
  cortex.

38
Inconsistent with Science

• Systematic review published in JAMA, 2005
• Pain vs Movement
• No pain prior to 29 wks gestation
• Wiring is in place but lights dont come on
• Even if pain, no means for fetal anesthesia
• Increased risk to the pregnant woman
• Other concerns
• Informed consent and notions of risk
• Mandated physician speech

39
Shouldnt Women Decide?

• I can understand why we shouldnt require fetal
  analgesia/anesthesia for all abortions, but why
  shouldnt we allow the woman to chose for herself
  whether she wants fetal analgesia/anesthesia
  during an abortion?

40
How to Answer the Question

• Patient autonomy is undoubtedly a consideration
  of primary importance. However, there is no
  known safe and effective fetal analgesia/anesthesi
  a to offer in the context of abortion.
• Additionally, patients should be advised that
  such measures are unnecessary because science
  does not support that fetuses feel pain before
  the third trimester.
• The goal of quality patient care is to inform
  women of the most up-to-date scientific
  information. Requiring that women be offered
  care that is not needed nor demonstrated as safe
  violates that goal.

41
Targeted Regulations of Abortion Providers (TRAP)
Laws
42
What are TRAP laws?

• Targeted Regulations of Abortion Providers
  (TRAP)
• TRAP laws Purported health facility
  regulations that apply only to facilities in
  which abortions are performed

43
TRAP laws often include

• Licensing and inspection provisions
• Authorization for searches
• Administrative requirements
• Minimum training requirements for staff
• Physical plant specifications

44
TRAP laws are different than other abortion laws

• Other abortion specific laws attempt to influence
  the pregnant womans decision
• premise to protect potential life
• TRAP regulate the medical aspects of the abortion
  procedure
• premise is to promote health

45
How prevalent are TRAP laws?

• Over half of all states have TRAP laws, all deal
  with 2nd Trimester care
• Legal challenges have failed to reverse TRAP laws
• Before 1992, many TRAP laws were struck down as
  unconstitutional
• Since Casey when the Supreme Court established
  the undue burden standard, almost impossible to
  prove

46
Not regulated like similar care

• Procedures with magnitude and risk greater than
  abortions up to 20 wks that are not regulated in
  the outpatient setting
• hysteroscopy
• surgical treatment of miscarriage
• diagnostic dilation curettage
• endometrial biopsy
• ovum retrieval
• sigmoidoscopy
• vasectomy
• What about after 20 wks?

47
What are the implications of TRAP laws?

• TRAP laws
• segregate abortion from the general practice of
  medicine
• deter physicians from becoming providers
• unnecessarily raise the cost of abortions
• Results in reduced access to and quality of
  abortion
• increasing disparities particularly for
  low-income rural women

48
The Mississippi Story

• The Last Abortion Clinic
• A Frontline Special

49
Clever TRAP Laws

• Regulate clinic as an outpatient surgical center
• Requires that physician have admitting privileges
  at the local hospital
• Physicians are flown in from out-of-state
• No hospitals would grant privileges
• Essentially outlawed 2nd Trimester Abortion in
  Mississippi

50

• It is the women with resources who continue to
  be able to get abortion. And it is the low-income
  women, people in marginalized populations, people
  that live in rural areas, who just don't have
  good access to legal abortion and turn to very
  unhealthy alternatives."
• Jones, 2006

51
Despite This Reality

• Very little attention by the Pro-Choice
  Movement
• Search of Mississippi and Abortion focuses on
  the overt ban not the convert ban
• Failed legal challenge by the Center for
  Reproductive Rights
• Desperate need to study the effects of this
  reality

52
Ensuring Access

• Womens Option Center, San Francisco General
  HospitalMedical Director Eleanor Drey, MD, EdM
• ACCESS/Womens Rights CoalitionExecutive
  Director Parker Dockray, MSW

53
Womens Options Clinic

• A provider of last resort

54
Serving the Most Acute Need

• Primary referral site for medically complicated
  patients
• Only provider in Northern California that accepts
  emergency Medi-Cal after 20 weeks in pregnancy
• Fee 1000 for 2nd trimester procedure

55
Turning Women Away

• Caring for 23 wks patients first
• Rescheduling 21-22 wk patients
• 1-2 patients a week
• Turning away patients who are gt23 weeks and one
  day
• A new study to look at health outcomes

56
What is happening in Southern California

• ?

57
ACCESS

• Making Choice A Reality Since 1993

58
Mission

• ACCESS exists to make reproductive health and
  freedom a concrete reality - not just a
  theoretical right - for ALL women
• ACCESS is a project of the Women's Health Rights
  Coalition, founded in 1974 as the Coalition for
  the Medical Rights of Women, a network of
  activists, consumers and health care professionals

59
The ACCESS Hotline

• Provides free and confidential information,
  referrals, peer counseling and consumer advocacy
  about all aspects of reproductive health
• Connects women with public insurance programs
• Refers to organizations that help with other
  issues such as IPV, sexual assault, drug
  addiction, homelessness, or child-care

60
Practical Support Network

• The Practical Support Network ensures that women
  can obtain abortions and other urgent
  reproductive health care without isolation or
  delay
• The network of over 125 volunteers provides the
  transportation, overnight housing, child-care and
  other support women need to actually get to their
  appointments
• ACCESS can also pay for hotel rooms and bus
  tickets when women must travel great distances to
  find a provider

61
Meeting Only Some of the Need

• Approx 600 calls per month
• Resources to help between 150-200 women
• English and Spanish only

62
Raising Awareness

• The Other Abortion Battle Abortion may be
  legal in California but that doesn't mean you
  can actually get one
• Tali Woodward
• The Bay Guardian
• 10/10/06

63
(No Transcript)
64
Working Together to Ensure Access and Care
Provision

• The Medi-Cal Reimbursement Project

65
Medi-Cal in California

• Estimated 90,946 Medi-Cal funding induced
  abortions
• Approx. 39 of all CA abortions (n236,000)

66
The Challenges for Medi-Cal Recipients

• Approximately 38 of reproductive aged CA women
  are eligible for Medi-Cal
• based on their income level
• Only 20 of practicing CA Ob/Gyns accept Medi-Cal
  
• 56 of Medi-Cal beneficiaries stated that finding
  doctors in close proximity who accepted Medi-Cal
  even for routine medical care was difficult or
  very difficult
• Medi-Cal Policy Institute. Speaking out What
  beneficiaries have to say about the Medi-Cal
  program. March 2006

67
Locating a Medi-Cal Abortion Provider

• Review of the 148 publicly-advertised CA abortion
  providers
• defined as all providers listed under abortion
  services in the yellow pages
• 53 accept Medi-Cal through the 1st trimester
• 20 accept Medi-Cal into the mid-second trimester
  (up to 20 weeks gestation)
• Only 4 accept Medi-Cal past 21 weeks

68
Acute Provider Shortage

• Of the 23 abortion providers who provide
  abortions past 20 weeks
• only 3 accept Medi-Cal through 24 weeks
• 10 dont take Medi-Cal at all

69
(No Transcript)
70
Not All Medi-Cal is Alike

• Medi-Cal Categories
• Full Scope Fee-for-Service
• Full Scope Managed Care
• Emergency Pregnancy-related Medi-Cal
• May accept one and not the other
• Impossible to acertain

71
Survey of Abortion Providers

• A survey of abortion providers who perform
  abortions through 24 weeks but no longer accept
  Medi-Cal
• Conducted by ACCESS
• Revealed that reimbursement rates for 2nd
  Trimester Abortions are too low to cover the
  expenses associated with the procedure
• Accepting Medi-Cal seen as not financially
  feasible

72
Estimating Cost v Reimbursement

• Freestanding clinics that provide abortions past
  20 weeks report
• an average of 467 in total reimbursements from
  Medi-Cal for the procedure, ultrasounds, tests,
  and medications and supplies
• providing these 2nd trimester abortions costs a
  clinic an average minimum of 637
• leaving an estimated deficit of at least 170 per
  procedure
• For a hospital to perform the same procedure is
  much more costly
• the average 2nd trimester abortion is reimbursed
  581
• total related hospital costs are approximately
  1,860
• leaving a deficit of 1,280 per 2nd trimester
  abortion

73
Advocacy Project

• California Coalition for Reproductive Freedom
• Proposal to State Office of Medi-Cal
• Increase reimbursement for later second trimester
  abortion
• ?--How deal with the We take Medi-Cal but not
  for that

74
Second Trimester Abortion as a Public Health and
Human Right

• Reverse the Provider Shortage
• Provide Medically Appropriate Care
• Ensure Access to Those Most in Need
• Stand Up for 2nd Trimester Care

75
Frances Kissling, CFFC

• a new era in prochoice advocacyone that
  combines a commitment to laws that affirm and
  enhance the right of each woman to decide whether
  to have an abortion or bear and raise a child
  with an expressed commitment to human values that
  include respect for life, recognition of fetal
  life as valuable and a concern for fostering a
  society in which all life is valued
• Is There Life After Roe? How to Think About the
  Fetus, Conscience, Winter 2004-05

76
William Saletan

• Maybe that six-month window made more sense in
  1973 than it does today. Maybe, if we spend the
  next 10 years helping women avoid
  second-trimester abortions, we won't have to
  spend the next 20 or 40 years defending them.
  Maybe the best way to end the assault on Roe is
  to make it irrelevant.
• Life After Roe, Washington Post, 3/5/06B01

77
Other Warning Signs

• NARAL Prochoice America refused to oppose the
  Unborn Pain Awareness Act
• Many public opinion polls ask questions only
  about 1st trimester abortion
• Advocates warn about bringing up the fact that
  abortion is legal in the 2nd trimester

78
Standing Up

• DO NOT sacrifice the human rights of the women
  who need them most in the name of keeping
  abortion legal for everyone
• DO NOT sacrifice the health of women who need
  abortion care simply because it is too difficult
  to talk about that care

79
The Illogic of It All

• Restricting 2nd Trimester Abortion
• Does not
• lead to increase prevention
• make people not have sex
• Does
• Make people parents who do not want to be
• Medically risk the lives/health of women
• Shift the burden to women of color, low income
  women and geographically isolated women

80
Thank you!