Tracy A Weitz, PhD, MPA Director Advancing New Standard in Reproductive Health (ANSIRH) Bixby Center for Global Reproductive Health University of California, San Francisco January 25, 2010

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. Today’s 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
ACOG’s Committee
on Coding and
Nomenclature
LMP to
< 14 wks
14 -28 wks 28 wks +
Roe v Wade
LMP to
12 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 (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

5. 57.6%
20.3%
10.2%
6.2% 4.3%
1.5%
0%
10%
20%
30%
40%
50%
60%
70%
%ofabortions
<9 9-10 11-12 13-15 16-20 21+
Weeks
Source: Elam-Evans et al., 2002
(1999 data)
Abortions by Gestational Age
Almost 90% in the 1st
Trimester

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 => 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 (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

15. 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

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
 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.

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, 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

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 Kennedy’s dissent in
Carhart?
 Has science and evidence changed
 What is undue burden

26. 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

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 LMP
range [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 D&Es
 change who you allow in the procedure
room
 change the clinical technique for
performing D&Es

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 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.

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 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

39. 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?

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/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.

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 woman’s
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
 Women’s Option Center, San Francisco
General Hospital
Medical Director: Eleanor Drey, MD, EdM
 ACCESS/Women’s Rights Coalition
Executive Director: Parker Dockray, MSW

53. Women’s 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 >23
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

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
(n=236,000)

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 don’t take Medi-Cal at all

69. Acceptance of Medi-Cal by Second Trimester Abortion Providers (21-24 Weeks)
16 18 20 22 24
1
3
5
7
9
11
13
15
17
19
21
23
AbortionProviders(N=23)
Gestation (in weeks)
Medi-Cal
Accepted
Abortion
Peformed

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 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

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, 3/5/06;B01

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!