The 25th anniversary of Roe v. Wade in January of1998 was a bittersweet celebration. While pro-choice organizations were publiclypaying tribute to a quarter-century of legal abortion, they were privatelyworried that the alarming decline in the number of abortion providers would soonstrip reproductive rights of their meaning. After all, what good is the right toan abortion if there are no doctors left to perform the procedure? Abortionclinics, like other medical facilities, tend to cluster in urban areas; yet in1996, one-third of American cities had no abortion services. Women in rural areaswho choose to terminate their pregnancy often have to travel hundreds of miles orcross state lines to find a doctor willing to perform a perfectly legal operation.
The New York Times Magazine commemorated Roe's birthday in1998 with a cover story on North Dakota's only remaining abortion doctor, a60-year-old physician who also commuted to clinics in Minnesota, Wisconsin, andIndiana in his six-seat plane. A majority of the nation's abortion doctors aremore than 65 years old, and access to abortion is getting scarcer with everyretirement. Between 1992 and 1996, the number of active abortion providers fellin every state but two--North Dakota and South Dakota, which each had a singleprovider in both of those years. As of 1996, only 14 percent of U.S. counties hadone (compared with 48 percent with a practicing obstetrician gynecologist).
Now, the situation is slowly beginning to change--after nearly a decade ofactivism centered in medical schools and hospital residency programs. Considerthe typical student who entered medical school in 1990. By his or her third year,the first chapter of Medical Students for Choice (MSFC), which now boasts7,000 members on more than 100 campuses, had been formed. Since then, MSFChas been instrumental in reintroducing abortion as a medical procedure and amatter of public health into the curricula of the nation's medical schools. Andby early 1996, when our newly minted M.D. might have been starting a residency inobstetrics and gynecology, the Accreditation Council for Graduate MedicalEducation (ACGME) had adopted new guidelines requiring that all OB-GYNprograms offer instruction in abortion procedures.
Anti-Anti-Abortion
The National Abortion Federation (NAF) first called attention to thecrisis in abortion access in 1990, when it organized a conference (co-sponsoredby the American College of Obstetricians and Gynecologists) entitled, simply,"Who Will Provide Abortions?" One of the biggest concerns at the symposium washow to change attitudes toward abortion in the medical profession. Doctors whopracticed in the late 1970s and early 1980s still carried with them vividmemories of treating the victims of back-alley abortions gone wrong; they werecommitted to the idea that offering safe abortions in a clinic or hospitalsetting helped to save women's lives. But by 1990, the right to an abortion hadbeen a reality for almost two decades, and new physicians felt little motivationto provide a service that carried with it personal and political risks.
Young doctors now completing their residencies constitute a third generationof potential providers. While they are even further removed from the history ofcoat-hanger abortions, they are witness to another form of violence: clinickillings. In 1993 the murder of Dr. Michael Gunn, an abortion provider inFlorida, set off an escalating campaign of harassment at facilities around thecountry. The number of reported death threats on clinic workers shot up fromeight in 1992 to 78 in 1993.
That year, the anti-abortion movement not only targeted clinics and doctorsbut also peppered medical schools with mass mailings. The gruesome pictures andinflammatory rhetoric was intended to turn future doctors' stomachs and thusdiscourage them from performing abortions. A particularly egregious pamphletheadlined "Bottom Feeder," which among other affronts compared abortion doctorsto Hitler, was sent to students at the University of California at San FranciscoSchool of Medicine--and had precisely the opposite effect. Incensed by what shesaw as a personal attack, second-year student Jody Steinauer called the NationalAbortion Federation and asked what she could do to fight back. A few months later,Steinauer became an intern in NAF's office in Washington, D.C., and startedcontacting medical students around the country to gauge their interest inabortion issues. "It quickly became clear to me that a movement was erupting,"she now recalls. While the first post-Roe generation of abortion providers wasstaunchly pro-choice and the second was more or less indifferent, this thirdwave--newly energized by the violence and propaganda of the anti-abortionmovement--could be called anti-anti-abortion. They didn't want moralists orreligious zealots determining what they could or couldn't learn in medicalschool, and they started questioning the silence on their campuses and in theircurricula. During the phone calls she made as an intern, Steinauer identified afew fellow activists and they soon founded Medical Students for Choice.
The first members of MSFC had their work cut out for them.Despite the fact that surgical abortion is the most common outpatient procedurefor women in the United States, it was hardly mentioned in medical-schoolclassrooms in 1993. Nor was it a regular part of third- or fourth-year clinicalrotations in gynecology. Even more surprising, a majority of OB-GYN residencyprograms did not require basic instruction on how to provide abortions orcounsel women with unintended pregnancies.
Since Roe, there has been a steady decline in the number ofOB-GYN programs that teach resident physicians how to perform abortions. In1976, 93 percent offered residents instruction in first-trimester abortions; by1991, only 70 percent did. And these figures massively overstate the percentage ofresidents who are actually being trained: An increasing majority of the trainingtakes place during "opt-in" elective rotations, while the number of programs thatconsider abortion a routine part of the curriculum continues to drop. As of 1991,only 12 percent of OB-GYN programs required instruction in abortion. (Ofcourse, residents with religious or moral objections have always been allowed toopt out of this cycle.)
Relegating abortion to the status of an elective is effectively not to teachit at all. Resident doctors in hospitals often work more than 80 hours a week.Only the most devoted pro-choicers are likely to add an abortion class orrotation to their already packed schedule voluntarily. Logistics pose anotherproblem: OB-GYNs are trained in hospitals, whereas by the early 1990s, 70percent of abortions were performed in freestanding clinics. Hospitals are morelikely to provide difficult second-trimester abortions for women with a severemedical condition, and then only rarely. "Residents typically train in hospitals,but hospitals do few abortions," says Susan Yanow, the executive director of theAbortion Access Project in Cambridge, Massachusetts. "Say a program has sixresidents. Each resident would have to perform 50 to 60 procedures in order to befully trained, but the average hospital only does 30 abortions a year. Add it up:That's not training."
As its first national action, Medical Students for Choice collected more than3,000 signatures to petition the Accreditation Council for Graduate MedicalEducation to reconsider its residency requirements for OB-GYN programs. InFebruary 1995, the ACGME issued a new set of carefully worded curriculumguidelines that, for the first time, explicitly required training in abortionprocedures. "Access to experience with induced abortion," the document read,"must be part of residency education." The rules included an exception forindividual residents or residency programs with religious or moral objections."We knew that using the A-word would be a red flag," a doctor who was involved inissuing the new guidelines explained, "so we led with the exception."
The "A-word" did indeed raise a red flag--in the U.S. Congress. Indiana'sconservative Republican Senator Dan Coats (a fundamentalist who has sinceretired) countered the ACGME's requirements with the deceptively titledMedical Training Nondiscrimination Act. Wrapping his bill in the rhetoric ofconscientious objection, Coats vilified the new rules by implying that they wouldcoerce residents with personal objections into performing abortions. Congressdoes not have the power to overturn guidelines issued by privatemedical-licensing bodies like the ACGME, but it does have substantialleverage over medical schools in the form of federal research grants. Coats'slegislation, which passed in 1996, ensures that any residency program that losesits accreditation over its abortion policy will continue to receive federalfunding.
Yet despite Coats's best efforts, recent evidence suggests that the new ruleshave been relatively successful in reintroducing abortion into OB-GYNtraining schedules. A survey by the National Abortion Federation published lastyear in the peer-reviewed journal Family Planning Perspectives found that 81percent of OB-GYN residency programs now offer some form of training infirst-trimester abortions (up from 70 percent in 1991). Even more significant isthe fact that 46 percent of programs include routine training--a threefold jumpin less than a decade.
The survey's authors were cautious in interpreting the results and noted thatthe response rate was a low 69 percent (compared with 87 percent in earlierstudies). Perhaps, they speculated, uncooperative programs were wary of beingcaught ignoring the new ACGME standards. And some activists, like Yanow ofthe Abortion Access Project, are skeptical of the study's methodology. "If youcall the residency program you get one set of answers, and if you ask residentsthemselves you get another," she claims, adding that a bit of subterfuge isnecessary in such politically sensitive research. In her group's surveys ofMassachusetts hospitals, she says, "we have women call and ask for information onabortions, saying that they are pregnant, and see how the hospitals respond."
Even if the numbers are a bit rough, there are other signs thatresidency-training opportunities are increasing. Vicki Saporta, the executivedirector of the National Abortion Federation, believes that the "ACGMEtraining requirements have made a difference" in spite of Congress's threats."We've been getting calls regularly from programs that need help implementing anew reproductive-health curriculum," she notes. NAF has since developed atextbook (A Clinician's Guide to Medical and Surgical Abortion) and atraining packet on medical abortion, complete with computer-graphicspresentations and a study guide on CD-ROM. The organization recently helpedto coordinate eight partnerships between hospital-based residency programs andlocal clinics and, according to Saporta, plans to establish eight more over thenext few years.
Basic Training
Dr. Maureen Paul, a professor at the University of Massachusetts Schoolof Medicine and the staff physician for the Planned Parenthood League ofMassachusetts, is one of the leaders in the effort to create institutionalpartnerships between hospitals and local clinics. In the past few years, shehelped design a 10-week rotation for residents at Baystate Medical Center inwestern Massachusetts to work at the Planned Parenthood clinic in Springfield. Asimilar association between the University of Massachusetts School of Medicine inWorcester and a nearby Planned Parenthood clinic will start in 2002.
But Paul is quick to point out that discussion of abortion--one of thenation's most common medical procedures--shouldn't be left up to specialists.All medical students learn about cancer, whether or not they are planning to bean oncologist. Similarly, she says, "not every M.D. will end up providingabortions, but it's important for any doctor who works in women's health care tobe able to counsel women with unintended pregnancies, to tell women who chooseabortion about the different methods out there, and then to make the appropriatereferrals." Basic training, Paul believes, should begin in medical school, beforeprospective doctors branch off into their isolated specialties. "Medical studentsshould hear about the public-health aspects of abortion," she says. "They shouldlearn how to take a good patient history, to counsel women who are consideringtheir options, and, of course, to consider the ethical questions and think abouthow their own opinions might affect their professional role as futurephysicians."
Medical schools vary widely in how they present information on abortion--ifthey mention the procedure at all. Harvard Medical School is known as a leader inreproductive health, but even there training can be hit-or-miss. According toDebbie Stulberg, a fourth-year student at Harvard who is currently the NewEngland regional coordinator of Medical Students for Choice, abortion is includedin first-year classes on reproductive biology and pharmacology entirely because ofstudent efforts. "Six years ago, students went to the professor of thereproductive-biology class and expressed their interest in learning somethingabout abortion," she says. The professor responded by offering an optionallecture. Today, after another round of student activism, the lecture is arequired part of the course.
Students usually spend the third and fourth years of medical school completinghospital clerkships that allow them to observe working physicians in action. AtHarvard, says Stulberg, getting clinical exposure to abortion depends on which ofthe four area teaching hospitals a student is assigned to for rotation duty. "Ifyou do your OB-GYN rotation at a hospital like Brigham and Women's, where theprocedure is fairly common, it is easy to observe an abortion. But even then, itis not required. It has to take place during elective time, on a day when you'renot expected to be on the floor somewhere else." Students who train at a hospitalthat doesn't offer abortions, says Stulberg, "would have to ask specifically andmake a special arrangement to observe at a clinic."
Tony Charuvastra, a fourth-year student at Brown University's Medical School,observes in an e-mail response to my inquiry that opportunities for training areavailable--but are certainly not required. "Students can go down the street tothe Planned Parenthood to watch first- and second-trimester abortions if they sochoose," he says. "Probably 25 percent of the class does this. But no one talksabout it, at least not openly. The problem at Brown," he adds, "is that studentsaren't interested. Particularly, male students are unaware of how prevalentabortion is, ... [and] it's seen as a problem that happens to 'other people.'"
As patchy as the training may be at places like Harvard and Brown,instruction is nearly nonexistent at southern and midwestern medical schools.According to e-mailed comments from Binit Shah, a student at Northeastern OhioUniversities College of Medicine (NEOUCOM) near Akron, the NEOUCOMcurriculum has a "paucity of information about reproductive procedures." So far,the only mention of abortion has been three short sentences on RU-486 (theabortion pill known generically as mifepristone) in his pharmacology coursematerials. "At best," he says,"it could give us name recognition of such anoption, but not nearly enough knowledge to answer questions or advise ourpatients about it." Noting that "43 percent of women will receive an abortion intheir lives," Shah wonders how this omission can "possibly do justice to medicaltraining," and adds: "Much less than 43 percent of the population will have heartattacks, but we have been forced to learn about cardiac disease ad nauseam."
As Medical Students for Choice continues to grow, chapters areforming in unlikely schools around the country--including NEOUCOM, where Shah isthe school's coordinator. There are now five chapters in Texas and one in Indiana,Dan Coats's home state. Catherine Direen, the executive director of theorganization's national headquarters in Berkeley, California, estimates thatgroup members "have made substantial changes in at least one-third of the medicalschools in the country." The extent of the changes, of course, depends on theschool's location and institutional affiliation; Catholic schools and schools inconservative areas are much less likely to introduce information about abortionin the classroom. On one end of the spectrum, Direen points to the StanfordUniversity School of Medicine, where MSFC members designed and implemented a10-week class on reproductive health with information on medical and surgicalabortions, contraception, and adoption. Last year, 50 students took the class."In schools that aren't as supportive," she says, "the main work is just finding aneutral faculty member who is willing to introduce some mention of abortion intoa class on anything from pharmacology to family medicine or, of course, in anOB-GYN course." At some conservative schools, the MSFC chapters don't dare to use"Choice" in their name but instead call themselves Medical Students forReproductive Health.
Even in a supportive environment, curriculum reform can be held hostageby recalcitrant professors or slowed down by multiple layers of bureaucracy.Loren Roth, a first-year student at the Tufts University School of Medicine,recalls that when her biochemistry professor introduced the class tomethotrexate, a drug used in chemotherapy, he neglected to mention that it is nowbeing prescribed for medical abortions. "It was a glaring omission," she says."At this point, I associate methotrexate very explicitly with abortions. So Iapproached him after class and asked him why he didn't mention methotrexate'sother use. He balked and gave me excuses, saying that he doesn't have time tobring it up." Eventually, Roth adds, after a five-minute exchange, her professorconceded her point.
Vicki Saporta of NAF is optimistic that MSFC's efforts to reformcurricula at medical schools and residency programs will eventually solve theshortage in abortion providers. "If only half of the students in MSFC addabortion to the services they provide when they graduate," she says, "that couldalmost double the number of providers in the United States." Indeed, half of thestudents I spoke with who are active in MSFC plan to provide abortions.("Whatever specialty I go into," says one third-year student at Tufts whorequested anonymity for fear of being personally targeted by anti-abortionextremists, "it's important that I provide because so few doctors will actuallydo it.") The other half are preparing for careers in fields like psychiatry andpediatrics, but they emphasize their commitment to ending abortion's confinementto the margins of medicine.
Because the vast majority of abortions in this country are performed infreestanding clinics, many doctors now think of the procedure as something doneby "other people." The word abortionist still has a pre-Roe taint ofclandestine greed and incompetence. And the more that mainstream physicians shyaway from abortion, the more the procedure is shunted to the fringe of theprofession. Ultimately, MSFC's most important legacy may not be members whoone day actually provide abortions but its work to rehabilitate abortion's imageso that it's no longer seen as an act of political defiance but as a basic medicalprocedure that should be readily available to all women.
