Jeff Chiu/AP Photo
Dr. Jody Steinauer, director of the Bixby Center for Global Reproductive Health, is a national leader in the training of ob/gyns to provide the full range of reproductive care, including abortion.
The Dobbs decision of the Supreme Court is the culmination of half a century of insidiously successful efforts by anti-choice groups to add state restrictions that limit the right of women to get abortions. These rules are compounded by requirements that make it all but impossible for abortion clinics to function.
According to an ACLU report, “The Last Clinics Standing,” between 1992 and 2018, the number of clinics dwindled from 17 to 3 in Louisiana, 12 to 2 in Missouri, and 45 to 10 in Ohio, with similar declines in other states. Alabama’s three abortion clinics have stopped providing abortions entirely. Targeted regulation of abortion providers (TRAP) laws, which mandated facilities to have everything from hospital admitting privileges to certain-sized hallways, was the weapon of choice to winnow down clinics in anti-abortion states.
The campaign to stigmatize abortion affects reproductive rights in liberal states as well. As I reported in this piece, thousands of hospitals in states that allow abortions, as well as ones that restrict them, refuse to allow abortions on their premises. These hospital restrictions take on new importance in the aftermath of Dobbs.
As Dr. Jody Steinauer, director of the Bixby Center for Global Reproductive Health at UC San Francisco, points out, in states that restrict abortions, with most clinics having been put out of business and most hospitals not providing them, women who still have a right to an early elective abortion, or who require emergency care for a miscarriage or an ectopic pregnancy, literally have no place to turn. It is bizarre and dangerous to require a patient to travel to another state to get urgent care.
“More than ever, we need hospitals to be there in restrictive states, where clinics have closed,” Dr. Steinauer tells me. “Hospitals have to step up and care for people who qualify for legal abortions, or cases of emergency care such as miscarriages or ectopic pregnancies.”
A further ramification of Dobbs is that in states that restrict or ban abortion, ob/gyns in residency programs may not receive instruction in abortions at all, because it becomes literally unlawful to train residents to perform them.
Dr. Steinauer, who founded Medical Students for Choice in 1993, is also a national leader of the Kenneth J. Ryan Program in Abortion and Family Planning, named for a leader of the effort to expand access to abortion and needed medical training in the years following the Roe decision. The program was created in response to a mandate from the Accreditation Council for Graduate Medical Education (ACGME) for abortion and family planning training as part of ob/gyn residencies. Since 1999, 109 Ryan programs in 40 states have trained over 7,000 residents.
About 60 percent of ob/gyns get such training. However, as the effort to stigmatize abortion has gained ground, that progress is being reversed.
Many hospitals, in both liberal states and anti-choice states, are running scared. “Right now, I am not seeing a lot of leadership on the part of hospitals,” Dr. Steinauer adds. “They are talking to their lawyers for fear of being sued for helping someone. Well, what about the risk of being sued if someone dies? There are ethical imperatives to provide care, but how about just not wanting patients to die? That’s a pretty low bar. It would be bad for business if someone died.”
Ob/gyns in residency programs may not receive instruction in abortions at all, because it becomes literally unlawful to train residents to perform them.
The chief of obstetrics and gynecology at a leading teaching hospital that has a Ryan program tells me that at many teaching hospitals the requirement for training in abortion is nominally satisfied by a lecture or a video, but residents get no hands-on clinical experience in the procedure. The accrediting institution gives the residency a demerit, which is meaningless, and there are no further consequences.
In some residencies that do not provide hands-on instruction in abortion care, medical students are sent to Planned Parenthood clinics, to get practical supervised instruction. But the same states that severely restrict abortion also effectively prohibit hospitals from cooperating with the few clinics that remain, so no such training occurs.
President Biden’s executive order of July 11 made clear that states that restrict abortion rights may not prohibit emergency care in cases of ectopic pregnancy or other life-threatening conditions on the premise that these procedures can be construed as abortions. Biden said that the federal Emergency Medical Treatment and Active Labor Act (EMTALA) preempts state laws restricting abortion.
But Biden’s order is only as good as the practical right of a woman to get that care. And if the number of doctors trained to provide such care is dwindling, especially in restrictive states, the order is hollow.
As a student of political language, I note that the press coverage of these emergency situations routinely refers to “the life of the mother.” Excuse me, but a pregnant woman is not a mother until she chooses to carry a fetus to term and have the child. She is properly described as a woman. By routinely referring to pregnant women as “mothers,” the media mindlessly plays into the Orwellian language of the anti-choice lobby and its pleas to women who find themselves unwillingly pregnant not to “kill your baby.” That’s how insidious this crusade is.
Since teaching hospitals get federal funding, both direct and indirect, the HHS rules that Biden has requested by August 7 could also require teaching hospitals to provide instruction in the full range of reproductive care, including abortion. It’s yet another way that the administration, through HHS, can ensure lifesaving care for women and full access to reproductive health.
