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Sunday, Nov 22, 2009
By the early '90s, only 12 percent of OB-GYN training programs routinely included abortion. A resident determined to master abortion techniques could volunteer at a clinic in her spare time -- after putting in 100 hours a week in the hospital. Not surprisingly, few bothered.
The paucity of training had a logical effect: Most OB-GYNs in practice today completed their education without so much as a half-hour lecture on terminating a pregnancy. As a practical matter, the omission is staggering, considering that roughly half the women in the U.S. will undergo an abortion in their lifetime. The corresponding political impact is palpable: The lapse has effectively and insidiously pushed abortion to the margins of healthcare.
"The message was, at best, that [abortion] isn't worthy of your time. At worst, it's that [abortion] is bad," said David Toub, a board-certified OB-GYN in Pennsylvania. "Ultimately that really harms women."
With a majority of doctors unable to terminate a pregnancy, women eventually lost all choice in abortion providers. These days, it's a big clinic or nothing. The scarcity of these clinics means that women typically must wait to get a clinic appointment, a serious problem given that the risk of complications doubles with every two weeks an abortion is delayed. Moreover, women outside big cities, especially in the South, the Midwest and the Rockies, must travel far to find a clinic where doctors perform abortions. And those clinics are no longer able to operate peacefully, as they did through the '70s. Patients must often dodge hostile protesters -- a cruel warm-up to a procedure that is rarely easy, regardless of the circumstances.
"The unspoken message is very powerful that abortion is so completely out of the norm that you have to drive 500 miles and bring cash," Stewart said. "The reality is, we're making women feel like they're on the run. They have to be ashamed and hide what they're doing. It undermines women's self-worth, I think, to feel like they have to go through a clandestine experience."
As abortion has been relegated to the periphery of medicine, the right to choose abortion has come under threat. Abortion clinics are not only highly visible targets for antiabortion groups but also outposts of controversy easily -- or conveniently -- ignored by anyone who isn't a patient, a provider or a protester. Certainly the medical profession hasn't provoked the violence against abortion doctors and their patients. But would the attacks have gotten so vicious if abortions were performed under the same roof as tonsillectomies or cardiac stress tests? Polls show that Americans largely support legal abortion. Might they have become fed up with antiabortion harassment long ago if the protests took place outside community hospitals or popular HMOs?
For a while, some medical experts predicted that abortion drugs such as mifepristone would at last shift early abortion from clinics into doctors' offices. But so far few doctors prescribe the drugs -- nearly all prescriptions are written at abortion clinics. The oft-cited explanation is that the Food and Drug Administration imposed conditions on the use of mifepristone that many private doctors cannot meet. But it was unrealistic to expect that OB-GYNs who had never learned the first thing about abortion would rush to try the latest technique for ending a pregnancy.
"What was very disheartening to me as a physician wasn't so much the potential threat from the general public opposed to [abortion], who are very militant in some cases," said Toub, who has worked in abortion clinics and performed the procedure in his private practice. "What bothered me more was the attitude of my own colleagues. They couldn't even use the word 'abortion.' They'd use all sort of euphemisms: VIP -- voluntary interruption of pregnancy. TAB -- therapeutic abortion."
Such attitudes and ignorance have infuriated abortion-rights and women's health groups. But it was the dwindling supply of abortion doctors that triggered efforts to require training. Activists lobbied on several fronts -- individual hospitals, accreditation bodies, medical school administrators. Many medical educators, too, recognized that abortion care -- once the model for minor surgery -- had been shoved, dangerously, to the fringe.
