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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. Today’s Presentation.

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access to second trimester abortions a public health perspective

Access to Second Trimester Abortions: A Public Health Perspective

Tracy Weitz, PhD, MPA


Advancing New Standards in Reproductive Health (ANSIRH)

Bixby Center for Reproductive Health Research & Policy

University of California, San Francisco

today s presentation
Today’s Presentation
  • Overview of 2nd trimester abortion
  • Current barriers to provision
  • A recommitment to 2nd trimester abortion care
2 nd trimester abortion in practice
2nd Trimester Abortion in Practice
  • Generally
    • Abortions between (14) and (24) weeks LMP
    • Involves use of Dilation and Extraction (D&E)
    • Can be done with medications as an induction
  • Providers vary on to what gestational limit they do abortions
  • CPT Codes distinctions
    • 59840: By D&C –Any trimester
    • 59841: By D&E -- 14 weeks 0 days up to 20 weeks 0 days
    • 59841-22: By D&E -- 20 weeks 0 days or more

Abortions by Gestational Age

Almost 90% in the 1st Trimester

Source: Elam-Evans et al., 2002

(1999 data)

many women need care
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
who needs 2 nd trimester abortions
Who Needs 2nd Trimester Abortions
  • Greater likelihood for women who are:
    • Low income
    • Non-Hispanic black
    • Geographically isolated
    • Young
what factors delay abortion
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
barriers to provision

Barriers to Provision

Lack of Providers

Increasing Regulation

lack of providers
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
a more complicated story
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 => specialization
increasing federal and state regulation of 2 nd trimester abortion

Increasing Federal and State Regulation of 2nd Trimester Abortion

“Partial Birth Abortion” Bans

“Fetal Pain” Consent Bills

Targeted Regulation of Abortion Provider (TRAP) Laws

what is pba
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 (D&X) 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 D&E and D&X
    • most appropriately called intact D&E
why perform an intact d e
Why Perform an Intact D&E?
  • 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
early efforts to ban pba
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
state based pba bans
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
    • Ohio’s ban has been challenged and upheld by a court
  • 5 states have bans that apply after viability
    • Utah’s ban has been specifically blocked by a court because it lacks a health exception
    • Montana’s 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.
state based pba bans1
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, O’Connor:
      • 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
what does the law say
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.”

immediately challenged
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?
planned parenthood v ashcroft gonzales
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)
naf v ashcroft gonzales
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)
carhart v ashcroft gonzales
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)
the supreme court
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 Kennedy’s dissent in Carhart?
    • Has science and evidence changed
    • What is undue burden
kennedy s strong opposition
Kennedy’s 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
implications of reversal
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
what will providers do
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
if pba is upheld will you
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 D&Es
  • change who you allow in the procedure room
  • change the clinical technique for performing D&Es
use digoxin at earlier gestation age
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%)
why isn t dixogin the answer
Why Isn’t 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 182:1063-6.
    • 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 97:471-6.
other complicating factors
Other Complicating Factors
  • Increased difficulty
    • at reduced gestation age
    • with obesity
  • Cost
  • What is “fetal death”
    • How prove?
where is the pro choice movement
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
implications for health care beyond abortion
Implications for Health Care Beyond Abortion
  • Legislate a particular medical technique
  • What does this mean to the concepts of informed consent?
fetal pain counseling reqs
“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
what is pain
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.
inconsistent with science
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 don’t 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
shouldn t women decide
Shouldn’t Women Decide?
  • I can understand why we shouldn’t require fetal analgesia/anesthesia for all abortions, but why shouldn’t we allow the woman to chose for herself whether she wants fetal analgesia/anesthesia during an abortion?
how to answer the question
How to Answer the Question
  • Patient autonomy is undoubtedly a consideration of primary importance. However, there is no known safe and effective fetal analgesia/anesthesia 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.
what are trap laws
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
trap laws often include
TRAP laws often include:
  • Licensing and inspection provisions
  • Authorization for searches
  • Administrative requirements
  • Minimum training requirements for staff
  • Physical plant specifications
trap laws are different than other abortion laws
TRAP laws are different than other abortion laws
  • Other abortion specific laws attempt to influence the pregnant woman’s decision
    • premise to protect potential life
  • TRAP regulate the medical aspects of the abortion procedure
    • premise is to promote health
how prevalent are trap laws
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
not regulated like similar care
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?
what are the implications of trap laws
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
the mississippi story

The Mississippi Story

“The Last Abortion Clinic”

A Frontline Special

clever trap laws
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
“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

despite this reality
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
ensuring access

Ensuring Access

Women’s Option Center, San Francisco General HospitalMedical Director: Eleanor Drey, MD, EdM

ACCESS/Women’s Rights CoalitionExecutive Director: Parker Dockray, MSW

women s options clinic

Women’s Options Clinic

A provider of last resort

serving the most acute need
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
turning women away
Turning Women Away
  • Caring for 23 wks patients first
    • Rescheduling 21-22 wk patients
    • 1-2 patients a week
  • Turning away patients who are >23 weeks and one day
    • A new study to look at health outcomes


Making Choice A Reality Since 1993

  • 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
the access hotline
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
practical support network
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
meeting only some of the need
Meeting Only Some of the Need
  • Approx 600 calls per month
  • Resources to help between 150-200 women
  • English and Spanish only
raising awareness
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


medi cal in california
Medi-Cal in California
  • Estimated 90,946 Medi-Cal funding induced abortions
  • Approx. 39% of all CA abortions (n=236,000)
the challenges for medi cal recipients
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

locating a medi cal abortion provider
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
acute provider shortage
Acute Provider Shortage
  • Of the 23 abortion providers who provide abortions past 20 weeks
    • only 3 accept Medi-Cal through 24 weeks
    • 10 don’t take Medi-Cal at all
not all medi cal is alike
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
survey of abortion providers
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
estimating cost v reimbursement
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
advocacy project
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”
second trimester abortion as a public health and human right

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

frances kissling cffc
Frances Kissling, CFFC

“a new era in prochoice advocacy—one 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

william saletan
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, 3/5/06;B01

other warning signs
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”
standing up
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
the illogic of it all
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