Policy Trends and Research Updates on the 40th Anniversary of Roe v. Wade

On January 22, 1973, the Supreme Court of the United States decided the landmark case Roe v. Wade, which established the right to abortion.  Forty years later controversy still surrounds this decision and attempts to restrict and regulate abortion care have continued. In 2011 and 2012, the United States saw more regulation of abortion care and access at the state level than in the past 40 years, making it more and more difficult for women to exercise their rights.[1]

State lawmakers are continuing to find new avenues through which to restrict access to abortion; 2012 saw trends in proposed and passed legislation that restrict insurance coverage, require provision of unnecessary procedures or misleading information to women, target abortion providers, and seek to ban abortions at later gestational ages based on theories regarding fetal pain.

Eight states now have laws that require a doctor to perform an ultrasound and show her the image or offer to do so before a woman can receive an abortion.[2] Doctors already perform ultrasounds if they are needed to provide abortion care; enacting legislation to require the procedure and viewing of the image appears aimed solely at trying to dissuade women from choosing abortion. A 2012 study researching the effects of ultrasound viewing on women seeking abortion found that women can respond differently – some women felt dissuaded, some women experienced emotional difficulty, and some women reported a better ability to cope with their abortion. Given these varied outcomes, the authors suggest that the decision to view an ultrasound should be left to the doctor and patient.[3] The leaders of five well-regarded professional physician organizations agree. Responding in part to the ultrasound mandates, they published a commentary in 2012 voicing concerns over legislative interference with the patient-physician relationship; they assert that such legislative intervention undermines the ability of physicians to give, and patients to receive, the highest quality care and medical guidance.[4]

In a large number of states, a waiting period is required before receiving an abortion. In addition, doctors must provide mandatory counseling prior to abortion; in some states, specific language must be read, including information that is not supported by science regarding links between abortion and breast cancer and mental health risks. Not only do such mandates require physicians to provide misinformation, but a study conducted in June 2012 found that 87% of women are confident about their decision to make an abortion before visiting a clinic, suggesting that blanket regulations requiring counseling and waiting periods only interfere with a woman’s ability to receive personalized care.[5]

These misleading practices can be amplified by Crisis Pregnancy Centers (CPCs), which often give the impression that they offer abortion services, but in fact typically only offer pregnancy tests and ultrasounds and are usually established expressly to discourage abortion. In a recent study, researchers contacted 32 CPCs in North Carolina and seventeen (53%) provided at least one misleading or inaccurate piece of information, including inaccurate information about links between abortion and breast cancer, mental health hazards, and infertility.[6] Scholar Joanne Rosen also discussed the public health risks of CPCs in a 2012 commentary in Perspectives on Sexual and Reproductive Health, claiming that CPCs, which operate under the notion of informed consent, are actually, “contrary to the legal and ethical standards of informed consent”, given their practices of distributing misleading information.[7]

In 2012, three states (Arizona, Kansas and Missouri) enacted new “conscience provisions,” expanding the types of entities that can refuse to provide care or insurance to patients or employees.[8] Many states already have provisions in place that exempt individuals from providing these services on moral or ethical grounds, but new measures allow insurers to exclude coverage for contraception, abortion and sterilization.[9]  As Lisa Harris points out in a recent article in The New England Journal of Medicine, these measures allow for “conscience based refusals,” but there is little legal protection of “conscience based provision” of such services.[10]

In the past year, there has been an onslaught of legislation establishing targeted restrictions on abortion providers (referred to as TRAP laws). Bills were proposed in twelve states that would place burdensome restrictions on clinics through building regulation mandates and new employee requirements. Last month, Governor Rick Snyder of Michigan signed a bill which requires clinics that regularly perform abortions to meet the same building license requirements as surgical outpatient facilities. This bill and others like it will likely result in not only the closing of many existing clinics, but will make the building of new clinics more arduous.[11] Some women must already travel hundreds of miles to the nearest clinic, as this map demonstrates. These types of restrictions will make access even more difficult.

With the passage of the Affordable Care Act and the resulting creation of new state exchange programs, many legislatures have made efforts to curtail coverage for abortion. Four states in the past year passed bills which prohibit abortion coverage through their exchange programs, while a number of other states are working toward abortion care bans both within and beyond the exchange. In addition, many states continue to pursue a ban on abortion at earlier gestational ages. Eight states in the past year saw bills that proposed abortion bans as early as twenty weeks post fertilization, which precedes the current legal viability mark.[12] These bans likely impact the most vulnerable women; in a recent study, researchers found that patients seeking second trimester abortions were often younger (age 19 and below), Black, less-educated, lower-income, had experienced more disruptive life events, and were more likely to have been exposed to intimate partner violence.[13]

A major victory for women in the year 2012 was the passage of the Shaheen provision in the National Defense Authorization Act, which provides military servicewomen and military families the same abortion coverage as other federal employees. Previously, insurance for these women only covered abortions when a woman’s life was at risk, but the Shaheen provision allows for additional coverage in the case of rape or incest.[14] This change is especially welcome given the findings of a recent study which showed a number of challenges women in the military face when seeking contraception; one third reported that they were unable to access a method they might want for deployment, certain methods were reportedly discouraged or not available for some women (including intrauterine devices and sterilization), and 41% of women requiring refills found them difficult to obtain.[15]

Looking back on 2012, we can celebrate the reproductive justice achievement in the Shaheen provision, and applaud the successes that legislatures and reproductive justice advocates had halting the passage of proposed bills that would restrict access. However, some measures did pass which limit the ability of women to obtain supportive and quality reproductive care. As we move into 2013, there are promising ways to advance the rights articulated in Roe v. Wade. Such initiatives might include efforts to preserve insurance coverage and expand public funding for abortion care, expand sexual education, promote public awareness of issues related to reproductive justice and abortion, and increase women’s access to reproductive care.

[1] 2012 Saw Second-Highest Number of Abortion Restrictions Ever. New York: Guttmacher Institute, January 2, 2013.

[2] State Policies in Brief: Requirements for Ultrasound, New York: Guttmacher Institute; 2013.

[3] Kimport K., et al. Women’s Perspectives on Ultrasound Viewing in the Abortion Care Context.  Women’s Health Issues. 2012, 22(6): e513- e517.

[4] Weinberger SE, et al. Legislative Interference with the Patient-Physician Relationship. The New England Journal of Medicine. 2012, 367: 1557-1559.

[5] Foster DG, et al. Attitudes and Decision Making Among Women Seeking Abortions at One U.S. Clinic. Perspectives on Sexual and Reproductive Health. 2012, 44(2): 117- 124.

[6] Bryant A, Levi E. Abortion misinformation from crisis pregnancy centers in North Carolina.  Contraception. 2012, 86(6):752-756.

[7] Rosen JD. The Public Health Risks of Crisis Pregnancy Centers. Perspectives on Sexual and Reproductive Health. 2012, 44(3):201-205.

[8] 2012 Year-End Report. New York: Center for Reproductive Rights, 2013.

[9] State Policies in Brief: Restricting Insurance Coverage of Abortion, New York: Guttmacher Institute; 2013.

[10] Harris L. Recognizing Conscience in Abortion Provision. The New England Journal of Medicine. 2012, 367: 981-983.

[11] Marty R. “Michigan Governor Snyder Signs Abortion Superbill into Law”. RH Reality Check, 2012.

[12] 2012 Year-End Report.  New York: Center for Reproductive Rights, 2013.

[13] Jones RK, Finer B. Who has second-trimester abortions in the United States? Contraception. 2012, 85(6):544-551.

[14] Senate Votes to Ease Ban on Abortion Coverage for Military Servicewomen; Bill Now Moves to Conference Committee” New York: Center for Reproductive Rights, 2012.

[15] Grindlay K, Grossman D. Contraception access and use among US servicewomen during deployment. Contraception. 2012, 87(2): 162-169.

Disparities in Reproductive Care Among Urban and Rural Women

In Primary Care Physician’s Perceptions of Barriers To Preventive Reproductive Health Care in Rural Communities [PDF], published in Perspectives on Sexual and Reproductive Health, authors Cynthia H. Chuang, et al, sought to investigate the disparities in reproductive health care between urban and rural women.

Findings suggest that expanding access to preventive reproductive health services in rural areas may not be sufficient to improve use of contraceptive services and preconception care.  Raising public awareness of the importance of pregnancy planning and good preconception health is needed.

In 2010, authors conducted semistructured interviews with 19 rural primary care physicians in central Pennsylvania regarding their experiences in two domains of preventive reproductive health—contraceptive care and preconception care. Physicians perceived that they had a greater role in providing contraceptive care than did nonrural physicians and that contraceptives were widely accessible to patients in their communities; however, the scope of contraceptive services that were provided by each individual provider varied greatly.  Physicians also perceived rural community norms of unintended pregnancies, large families, and indifference toward career and educational goals for young women as the biggest barriers to both contraceptive and preconception care, as these issues predicted a lack of interest in family planning.

Study findings point to the importance of encouraging primary care physicians to take a more proactive role in promoting preventive reproductive health care.  This could be accomplished through continuing education programs and skills-building workshops to increase both provider knowledge about client self-efficacy for reproductive health counseling.

HIV Testing in Variety of Clinical Settings

In Supporting the Integration of HIV Testing into Primary Care Settings, published in The American Journal of Public Health, authors Janet J. Myers, et al, examined the efforts of the US network of AIDS Education and Training Centers (AETCs) to increase HIV testing capacity across a variety of clinical settings.

Authors utilized quantitative process data from 8 regional AETCs from 2008 and 2009, along with qualitative program descriptions to demonstrate how AETC education helped providers integrate HIV testing into routine clinical care with the goals of being able to diagnosis an infection as early as possible and providing treatment.

When compared with other AETC training, results indicated that HIV testing training was generally longer and utilized a broader variety of strategies to educate more providers per training.  It was also found that educational trainings did provide a platform for providers to master comprehension of their primary care responsibility to address public health concerns through HIV testing.  These AETC efforts illustrate not only how integration of the principles of primary care and public health can be promoted through professional training, but how integral these skills are to comprehensive and well-rounded clinical care practice.

How Educated are Medical Providers on Medical Abortion?

In Knowledge of Medication Abortion Among Adolescent Medical Providers, published in The Journal of Adolescent Health, authors Mandy S. Coles, et al, sought to understand whether providers caring for adolescents have the knowledge to counsel accurately on medication abortion, a suitable option for many teenagers seeking to terminate a pregnancy.

An online survey related to medication abortion was administered to U.S. providers in the Society for Adolescent Health and Medicine.  Authors evaluated the knowledge of medication abortion by reported adolescent medicine fellowship training, and to compare responses to specific knowledge questions by medication abortion counseling.  They also examined the relationship between providers’ self-assessed and actual knowledge.

Authors surveyed 797 total providers.  About 25% of respondents incorrectly believed that medication abortion was not very safe, 40% misidentified that it was < 95% effective, and 32% did not select the correct maximum recommended gestational age (7–9 weeks).  However, providers had difficulty identifying that serious complications of medication abortion are rare, and those who counseled on medication abortion had more accurate information in all knowledge categories, except for expected outcomes.  Medication abortion knowledge did not differ by adolescent medicine fellowship completion. In total, only thirty two percent of those surveyed were identified as having “very good knowledge.”

The authors concluded that knowledge regarding medication abortion safety, effectiveness, expected outcomes, and complications is suboptimal even among adolescent medicine fellowship trained physicians.  In order to ensure pregnant teenagers receive accurate counseling on all options, adolescent medicine providers need better education on medication abortion.

Obese Women Using Implanon May Have Lower Levels of Active Hormone

In Pharmacokinetics of the etonogestrel contraceptive implant in obese women, new research published in the American Journal of Obstetrics and Gynecology, author Sarah Momar and Section researchers examined serum levels of etonogestrel, the active hormone in Implanon, in a small cohort of obese women (BMI>30).

Researchers enrolled 13 obese (body mass index ≥30) women and 4 normal-weight (body mass index <25) women, who ensured comparability with historical controls. Etonogestrel concentrations were measured at 50-hour intervals through 300 hours postinsertion, then at 3 and 6 months to establish a pharmacokinetic curve.

All obese participants were African American, while all normal-weight participants were white. Across time, the plasma etonogestrel concentrations in obese women were lower than published values for normal-weight women and 31-63% lower than in the normal-weight study cohort, although these differences were not statistically significant. The implant device was found highly acceptable among obese women.

Although  this study finds that obese women have lower plasma etonogestrel concentration than normal-weight women in the first 6 months after implant insertion, authors comment that more research is needed to determine if this translates to decreased contraceptive effectiveness.

Abortion Training Initiative in New York City Hospitals

In The New York City Mayoral Abortion Training Initiative at Public Hospitals, published in Contraception, authors Maryam Guiahi, et al, set out to describe and understand the first-ever abortion training political initiative on the provision of abortion services and abortion residency training.

In 2002, NARAL/NY obtained the support of newly elected Mayor Michael Bloomberg to integrate residency training in abortion care into the eight New York City (NYC) public hospitals that have OB/GYN training programs. The authors completed in-depth interviews with 22 participants who have knowledge of abortion training and services in the NYC public hospital system before and/or after the initiative.

In these interviews, respondents identified strategies that helped achieve renovation of abortion facilities, updating of abortion services and protocols, and training of abortion providers. The initiative led to the introduction of several modern abortion methods including medication abortion and MVAs for first-trimester abortions and D&Es for second-trimester abortion. The initiative also expanded the provision of immediate postabortion contraception. Respondents also identified public health impacts including improvement of abortion services, empowerment of abortion providers, and legitimization of abortion training and services.

Authors concluded that this political initiative should be a model for other city governments to influence obstetrics and gynecology resident training and the provision of abortion services.