Step Aside, I'm a Doctor

AP Photo/Rich Pedroncelli

Assemblywoman Toni Atkins, a Democrat from San Diego, urges lawmakers to approve a bill allowing nurse practitioners, certified nurse midwives, and physician's assistants to perform early-term abortions.

It’s hard to miss the fallout from the barrage of abortion restrictions that came out of state legislatures this year. Four abortion clinics in rural Texas announced plans to close after determining it would be too expensive to comply with a new state law imposing unnecessary medical standards. A clinic in Ohio, where similar laws have been passed, say they may also have to close. Iowa’s telemedicine abortion program—a creative workaround designed to bring first-trimester abortion to women in rural parts of the state—was recently shut down by the state medical board. In states nationwide, the hurdles to access safe, high-quality abortion care are getting higher and higher. 

But California is bucking the trend. A law that would allow advanced-practice clinicians—a technical term for nurse practitioners, physician’s assistants, and certified nurse midwives—to perform surgical first-trimester abortions passed in the California legislature in late August. If Governor Jerry Brown, a Democrat, signs the bill as expected, California will join Oregon, Montana, Vermont, and New Hampshire as the fifth state to allow clinicians to perform first-trimester abortions. Pro-life groups who oppose the law claim that allowing anyone other than a physician to perform abortions endangers women’s health. Their argument might have held more weight had it not been for a group of researchers at University of California, San Francisco (UCSF). 

Pro-choice advocates had been pushing to allow advanced-practice clinicians to perform surgical abortions—in which fetal tissue is vacuumed out of the uterus using a small tube attached to a pump—since 2003, when California began allowing these professionals to induce medication abortion. There was, however, little research to show whether women were equally safe if an advanced-practice clinician performed a surgical abortion rather than a physician. Frustrated by  the lack of medical evidence, a group of researchers at UCSF led by Tracy Weitz, an associate professor of obstetrics, gynecology, and reproductive sciences, designed a six-year study to find out whether the abortion opponents’ health arguments held water. Released in January 2013, the study proves clearly that surgical first-trimester abortions are just as safe when performed by advanced-practice clinicians. Advocates who helped push for the bill say the research was invaluable for allaying politicians’ concerns about the safety of the practice—and taking the wind out of opponents’ argument.

The success of bringing scientific research to bear on California’s abortion debate shows how much influence medical professors and physicians can wield when they decide to venture into the political sphere. As abortion restrictions grow tighter in states across the country, members of the medical community are venting their frustration about infringements on their ability to provide basic healthcare. After decades of silence on the issue, they are urging an end to restrictions on abortion access—not from an ideological perspective, but as a matter of public health. “What we’re trying to do is very simple,” Weitz says. “We want to end the unnecessary political limits on this procedure. It’s so strange to think that politicians, not doctors, should be making these decisions. We want abortion to be treated like every other kind of medicine.”

With the researchers’ help, the California bill has created some rare forward momentum for pro-choice advocates, who are struggling to hold the line on abortion in most states rather than working to increase availability. This development in the Golden State, a progressive stronghold with more than 500 of the nation’s roughly 1,800 abortion providers, might not seem especially groundbreaking, but the law will have a significant impact: Right now, nearly half of the state’s counties have no abortion provider. Allowing advanced-practice clinicians to perform first-trimester abortions will increase the number of clinics, especially in rural areas, that offer the procedure. Because the cost and risk of complications increase substantially when abortion is performed during the second trimester, the UCSF researchers say that making first-trimester abortion more easily available will also encourage women to have abortions earlier in their pregnancy. Expanding the range of providers is especially important for low-income women, who are disproportionately affected by barriers like cost.

Weitz is just one in a growing number of academics and medical professionals expressing dissatisfaction with the politicization of abortion. In late August, the American Journal of Obstetrics and Gynecology published a letter signed by 100 medical professors calling for more physicians to be trained to perform abortions, and for more abortion procedures to be conducted in hospitals, which would greatly expand access. In an op-ed for USA Today in 2012, two doctors and teachers at Harvard Medical School, Marcia Angell and Michael Greene, called on their fellow physicians to fight state-level abortion restrictions, arguing that these laws undermine the doctor-patient relationship. In states that require doctors to give patients medically inaccurate information about the link between abortion and breast cancer, Angell and Greene urged “civil disobedience.”

These are significant steps for physicians and other medical professionals, who sought to distance themselves from abortion providers in the years after Roe v. Wade. Before abortion was legalized, doctors who offered the procedure illegally had been painted as unethical quacks—an idea that persisted in the public imagination for decades. Rather than working to dispel the myth, mainstream doctors did everything they could to dissociate their work from the people who were now providing abortion legally. “The medical community has always been supportive of legal abortion in principle, but they allowed abortion providers to become isolated,” says Carole Joffe, a professor at UCSF’s Bixby Center for Global Reproductive Health. “Now, there's a lot of forceful and unprecedented speaking out from medical professionals who don’t necessary perform abortion themselves. It’s a huge change.”

Young doctors and medical students are also breaking the mold, demanding that they learn how to perform an abortion in medical school and looking for new ways to incorporate abortion into their practice. Nancy Stanwood, the chair of the board for Physicians for Reproductive Health and an associate professor of obstetrics and gynecology at the Yale School of Medicine, says that these young physicians are well-positioned to revive abortion access as a public-health issue, both in hospitals and the political realm.

But despite professors’ calls for more hospitals to perform abortions, doctors’ power is limited by a variety of factors, not least their employers. To take one example, there’s no medical reason why hospitals, which currently account for about 4 percent of the abortions performed in the U.S. today, shouldn’t start filling the void created by the new wave of abortion-clinic closures. Hospital-based abortions would, in many cases, heighten patient safety; Weitz points out that for low-income women who often have other serious health issues, a hospital is a better setting for any kind of medical procedure than an outpatient clinic. But the decision often isn’t up to doctors. Instead, that honor goes to controversy-averse hospital administrators. “People do not want the hassle,” says Joffe. “They don’t want demonstrators. They don’t want vendors saying, ‘I’m sorry, I’m not going to do your laundry anymore because I go to a pro-life church.’”

But as the California law shows, legislators in solidly Democratic states could be a sympathetic audience for doctors and advocates. Public-health arguments won’t appeal to legislators in states like Texas, where a recent report showed that despite much handwringing over the need to ramp up abortion-clinic safety, there was no evidence that conditions were hazardous enough to warrant a change in the law. But progressive states can also do more to widen the availability of abortion—and, perhaps most importantly, their legislators are willing to listen to medical evidence. "Even the most liberal states have abortion-access issues."“Even the most liberal states have abortion-access issues,” Stanwood says. “It’s an important health step forward, to make abortion more available for women, regardless of which state we’re talking about.”

Although proponents of the California bill say they’re waiting until the governor signs it into law before they think about exporting it to other states, Stanwood says it could easily become a model for other parts of the country. A handful of other left-leaning states, including Washington, Connecticut, New York, Massachusetts, and Maryland, currently allow advanced-practice clinicians to provide medical abortion, signaling that they might be receptive to laws like California’s. “Many states are in a defensive posture right now on reproductive health,” says Phyllida Burlingame, reproductive justice policy director for the American Civil Liberties Union of Northern California (ACLU-NC), which helped spearhead the bill. “In California, we tried to create a road map for other states to think about increasing access, not just blocking the next barrier.”  

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