Obstacles to Abortion and
Comprehensive
Reproductive Health Care
Martin Donohoe, MD, FACP
Fertility


Without contraception, the chance for a
successful pregnancy is:
 25% within the first month
 85% by the end of the first year
At least 1/5 pregnancies ends in miscarriage
 Usually in first trimester
 Primarily due to sporadic chromosomal
abnormalities
Contraception in the United
States

Whether they are married or not, 79% of
women are sexually active by their early 20s
 75% of Evangelicals
 86% of mainline Protestants
 89% of Catholics
Contraception in the United
States

89% of U.S. women have used birth
control (89% of Catholic women, 90% of
mainline Protestants, and 81% of
Evangelicals who are not currently trying
to conceive use birth control)
 68%, 73%, and 74%, respectively, use
hormonal methods, the IUD, or
sterilization
Abortion in the U.S.
30 million women have had abortions since
legalization (1973)
 3 million unintended pregnancies per year
in the U.S.
 1.2 million abortions in 2008 (↓ from 1.6
million in 1990, ↓27% since 1980)

Abortion in the U.S.
17 abortions/1,000 fertile women/year
 Lowest rate since 1973
Decline due to availability of
contraception
 9/10 abortions are in first 12 weeks
 9/10 abortions surgical
 236 induced abortions/1,000 live births
 Over 1/3 decline since early 1980s

Abortion in the U.S.

51% of all pregnancies are unintended,
including more than 31% within marriage
 Half of these end in abortion
 IUD insertion post abortion is the best
reversible method of contraception to
prevent another unintended pregnancy
Abortion in the U.S.

Patients:
 48% over age 25
 14% married (67% never married)
 56% have children
 43% Protestant, 27% Catholic, 8% other, 22% no
religion
 Catholics, mainline Protestants, and Evangelicals
all have similarly high rates of contraceptive use
(compared with other religions)
Abortion in the U.S.
 Patients:
 59%
white
 African-Americans and Hispanics more
likely to have abortions than Caucasians, in
part due to:
 Higher
levels of poverty/lower SES
 Higher rates of unintended pregnancy
 Greater proportion of conceptions that end in
abortion
Most Important Reason Given for Terminating an
Unwanted Pregnancy




Inadequate finances - 21% (40% contributing
factor)
Not ready for responsibility - 21%
Woman’s life would be changed too much 16%
Problems with relationship; unmarried - 12%

½ of babies born today are to unwed mothers (1/5
in 1980)
Most Important Reason Given for
Terminating an Unwanted Pregnancy







Too young; not mature enough - 11%
Children are grown; woman has all she wants 8%
Fetus has possible health problem - 3%
Woman has health problem
- 3%
Pregnancy caused by rape, incest - 1%
Other
- 4%
Average number of reasons given = 3.7
Abortion in the U.S.
 When
abortion was illegal, 1 million
were still performed annually
 By age 45, the average female will have
had 1.4 unintended pregnancies
 By age 45, 35% of US women will have
had an induced abortion
Abortion in the U.S.
54% of women with unintended pregnancies get
pregnant while using birth control
 Optimum one year contraceptive failure rates:
 periodic abstinence -21%
 OCPs – 7%
 IUD - 1-2%

Rape and Pregnancy


Noninvasive prenatal genetic testing through
amplification of fetal alleles from maternal blood very
accurate for identifying father
 Can be performed at 8-14 weeks gestation
 vs. amniocentesis and chorionic villus sampling (1015 weeks, risks to mother and fetus)
 May assist mother’s decision to carry vs. terminate
pregnancy
IPV more common in women seeking pregnancy
termination
Abortion in the U.S.:
Public Opinion Split
2009: 42% consider themselves more “prochoice,” 51% more “pro-life” (was
44%/50% in 2008)
 Men 46% “pro-choice,” women 51%
“pro-choice”
 2010: 45% “pro-choice,” 47% “pro-life”
 2010: Abortion should be “generally
available” (36%), “available under strict
limits” (39%), “not permitted” (2%)

Abortion in the U.S.:
Public Opinion Split

2011: 41% “pro-choice”; 50% “pro-life”

2011: Abortion should be legal in all cases
(25%); illegal in all cases (20%); legal under
certain circumstances (52%)
Abortion in the U.S.:
Politics

Republicans less supportive than
Democrats

25-30% of members of both parties would
not vote for a candidate who did not share
their views on abortion
Abortion in the U.S.:
Public Opinion
25-30% of American women think
abortion should be legal and available in all
circumstances
 17-19% think abortion should be illegal
under all circumstances
 The remainder would restrict abortion to
cases of rape, incest, or to save a woman’s
life

Abortion in the U.S.:
Public Opinion



Top priorities for the women’s movement
 Reducing domestic violence and sexual assault 92%
 Equal pay for equal work 90%
 Keeping abortion legal 41%
2/3 believe the Supreme Court will not overturn Roe v
Wade
 Center for the Advancement of Women surveys,
2001-2003
Are we taking Roe v Wade for granted?
Abortion Worldwide
 44
million/year
 28/1,000/yr
 23 million unsafe (98% of these in
developing countries)
 Percent increase from 1995 (44%) to
2008 (49%)
Abortion Worldwide
 Cost
of treating women for complications
of botched abortions = $19 million/yr (vs.
$4.8 million to provide contraception)
 Countries
with more liberal abortion laws
have lower abortion rates
Abortion Worldwide
70,000 annual deaths (7/hour)
 13% of all maternal deaths (i.e., 13% of
585,000) each year
1/4 - 1/2 of maternal deaths in Latin
America
 7 million require hospitalization or treatment at
health care facility annually
 30 infections/injuries for every one abortion
death

Abortion Worldwide

220,000 children orphaned each year by
poorly performed abortions

Legal restrictions have no effect on
abortion incidence
Non-physicians performing
abortions

Use of mid-level providers can decrease
deaths
 No difference in complication rates
 CA allows NPs, CNMs, and PAs with
special training to perform
Maternal Mortality

1/3800 in U.S.



1/39 in sub-Saharan Africa; 1/290 in SE Asia
287,000 maternal deaths worldwide each year
(most avoidable)


3X higher in black than white women
Death rate decreasing
Cause: Lack of access to comprehensive
reproductive health care/obstetrical care
Common Grounds on Which
Abortion is Permitted Worldwide







To save woman’s life – 98%
To preserve physical health – 63%
To preserve mental health – 62%
Rape or incest – 43%
Fetal impairment – 39%
Economic or social reasons – 33%
On request – 27%
Worldwide, every minute





380 women become pregnant
190 women face unplanned or unwanted
pregnancies
110 women experience pregnancy-related
complications
40 women have unsafe abortions
1 woman dies
Historical and Contemporary
Methods of Unsafe Abortion


Many used for millennia
Examples:
Toxic solutions taken orally or intra-vaginally: e.g.,
turpentine, bleach, mercury, acid, detergents, etc.
 Uterine stimulant drugs
 Foreign bodies placed in the cervix/uterus – e.g.,
sticks, wires, coat hangers, air blown from pump
 Direct/indirect trauma

Teenage Sexual Activity


47%/44% of teenage boys/girls have had sexual
intercourse (decreasing)
Teen birth rate (2014) = 26/1,000/yr
 Lowest since mid 1940s
 Down from high of 96/1,000/yr in 1957)
 Hispanics and African-Americans = 2X
higher than Whites = 2X higher than Asians
Teen Pregnancy
80% of teen pregnancies unintended
 Teen pregnancy has decreased 57% since
1991
 But still higher than in many other
developed countries

Teenage Sexual Activity


50% of pregnant teens were not using any form
of contraception
 31% of these did not believe they could get
pregnant
Contraception use among teens increasing
 80% condom with first intercourse
 16% in combination with hormonal
method
Teenage Sexual Activity


STD rates high, testing/treatment/followup
poor, long-term risks include PID, infertility
HPV vaccine uptake low


No increased sexual activity with HPV
Inadequate sex education and limited access to
reproductive health care likely increases
morbidity, mortality
Barriers to Abortion:
Misconceptions about Sex and Contraception



Common among adolescents and physicians
40% of children age 13-17 who had intercourse
did so before any parental discussion of STDs
and birth control
Duration of oral contraceptive use not a factor
Barriers to Abortion:
Misconceptions about Sex and Contraception
20% of 18-29 yr olds say they never had
school-based sex education
 1/3 of U.S. adolescents get no sexual
counseling during their annual doctor visits

Barriers to Abortion:
Misconceptions about Sex and Contraception
63% acknowledge “little to no knowledge”
about contraception pills
 30% for condoms
 28% of men think wearing two condoms at once
better (actually promotes condom breakage)
- National Campaign to Prevent Teen Pregnancy,
2009

Common misconceptions about
OCPs




They cause weight gain (reality = 30% gain 12kg from fluid retention)
They cause acne and hirsutism (reality = less
acne, no hirsutism)
They cause breast cancer (reality = minimal, if
any, effect)
They impair future reproduction (reality = not
true)
Common misconceptions about OCPs: Lack
of awareness of benefits re …




Decreased risk of ovarian and endometrial
cancer
Regulation of cycles, prevention of
dysmenorrhea and iron deficiency anemia
Decreased prevalence of PID and ensuing
salpingitis and infertility
Increased bone density
Barriers to Abortion:
Availability of Contraception


Limited access to health care and lack of
coverage
2012: Only 28 states require health insurance
policies that cover other prescription drugs to
include contraceptives

Until recently, Oregon Medicaid covered Viagra but
not oral contraceptives
Barriers to Abortion:
Availability of Contraception

PPACA (ObamaCare) requires insurers to
pay full cost of contraception (including
EC)
 But SCOTUS allows religious exceptions
in Hobby Lobby case (2014), citing
Religious Freedom Restoration Act of
1993
Barriers to Abortion:
Availability of Contraception

2012: 40% of school-based health centers are
allow to dispense contraception


Requirements for parental consent vary
When free contraceptives offered for 3 yrs,
abortion rates fell by 70% (and teen pregnancies
dropped dramatically) [Obst and Gynecol
10/4/12]
Barriers to Abortion:
Availability of Contraception


Congresspersons trying to get HHS to cover 1
yr prescription without out of pocket costs
 Dispensing one year supply much more
effective at decreasing unwanted pregnancies
and abortions than dispensing one or three
month supply
Worldwide contraceptive use averts almost 230
million births each year
Barriers to Abortion:
Availability of Contraception

OTC status for OCPs would improve access, is
considered safe
 Would not increase sexual risk-taking
behavior
 ACOG and AAP support (regardless of age)
 IOM considers contraception preventive care
 CA (2015, no age restrictions) and OR (2016,
18 and over) legalize OTC hormonal
contraception
Barriers to Abortion:
Availability of Contraception

1 year failure rates of contraceptives with typical use (women
overestimate effectiveness):
 Condoms - 20%
 OCPs – 9%
 IUD – 0.05% (recommended first line option, ACOG)
 No increased risk of PID
 No effect on later fertility
 Higher up front costs, but greater net savings (lasts 10 yrs)
 Nearly 100% effective in preventing pregnancy when
placed within 5 days of unprotected sex
Barriers to Abortion:
Availability of Contraception

Savings (from averted pregnancy-related costs)
for various methods of contraception, per $1
spent (2007 study):
Contraceptive implant/IUD: $7.00
 Injectable contraceptives: $5.60
 Oral contraceptives: $4.07
 Contraceptive patch: $2.99
 Vaginal ring: $2.55
 Barrier methods: $1.34

Barriers to Abortion:
Availability of Contraception


Sterilization (tubal ligation) effective
 Most common birth control method in developing
world
Project Prevention:
 Pays women $300 to get a tubal ligation or IUD,
implant or Depo-Provera shots
 Pays men for vasectomies
 4,097 individuals “treated” by mid 2012; 72 men
 Controversial
Barriers to Abortion:
Legal Viability


Roe vs. Wade (1973): Abortion legalized up to
“point of viability” (currently 24 weeks)
 After viability, states can ban abortion except
when necessary to protect the woman’s life or
health
Gestational limits (fetus < 500g or < 20 weeks
gestational age)
 Survival very rare before 24 weeks
Barriers to Abortion:
Cost

Cost: approx. $350-$450 (1st trimester); $750-$1800 (2nd
trimester)




¾ of patients pay out of pocket
only 1/3 of patients have private insurance coverage; only
1/3 of private insurance companies cover (after deductible
met)
5 states restrict abortion coverage by private insurance plans
(ID, KY, MO, ND, OK)
most insured patients reluctant to file due to confidentiality
concerns
Barriers to Abortion:
Coverage

Medicaid:
 Hyde Amendment (1978) prohibits federal
Medicaid dollars from being spent on
abortion, except to preserve the woman’s life
or in cases of rape or incest
 But, 17 states allocate Medicaid funding to
cover most abortions
Barriers to Abortion:
Coverage

Medicaid:
 Between 18% and 35% of Medicaideligible women who would have had
abortions instead continue their
pregnancies if public funding is
unavailable
Barriers to Abortion:
Coverage

Medicare:
 Hyde Amendment applied to Medicare in
1998
 Bans federal funding for abortions for
disabled women except in cases of life
endangerment, rape, or incest
 No state funding of Medicare to make up the
gap
Barriers to Abortion:
Coverage

Title X Family Planning Clinics:
 Cover women from low income households
at over 4500 family planning clinics
 Ethnic minority women disproportionately
represented
 Funding has not kept up with inflation
 Prohibited from using federal and non-federal
funds for all abortions
 “Gag rule” – 1981 to 1993
Barriers to Abortion:
Coverage
 Indian
Health Service:
 Covers 1.5 million American Indians
and Alaska Natives
 Subject to Hyde Amendment
restrictions
Barriers to Abortion:
Coverage

Military Personnel:
 TRICARE (funded by Defense Dept.) covers
8.3 million uniformed personnel and their
families
 Permanent ban on abortion except where the
life of the women is endangered (Senate
Armed Services Committee voted to lift ban
in mid 2010, bill pending)
Barriers to Abortion:
Military Hospital Abortions Ban

Military women serving abroad, and their dependents,
are prohibited from obtaining abortions at military
hospitals, even if they pay with personal funds
 EC not available at all military treatment facilities
 Alternatives:
 Travel long distances for abortion – expensive
and requires permission from commander to take
leave
 Have abortion locally – unsafe in certain
countries (e.g., in Middle East)
Barriers to Abortion:
Coverage

Federal Employees Health Benefits Program
(FEHBP)
 Covers over 8.5 million federal employees,
their dependents, and retirees; 45% women
 Since 1983 (except for 1994), abortion
coverage permitted only in cases of life
endangerment, rape, or incest
Barriers to Abortion:
Coverage
 Peace
Corps
 7300 volunteers; 61% women
 Funds cannot be used for abortions,
even when the woman’s life is
endangered
Barriers to Abortion:
Coverage

Federal Prisons
 13,763 women
 From 1987-present (except for 1994),
ban on funding abortions except when
woman’s life endangered or the
pregnancy the result of rape
Obama Health Care Plan



Executive Order states that federal funds cannot
be used for abortion (except in cases of rape or
incest or when the life of the woman is
endangered)
Prohibits discrimination against health care
facilities and providers because of unwillingness
to provide or refer for abortions
Religious hospitals must provide contraception
through third parties
Obama Health Care Plan

Bans tax credits and federal subsidies for people
required to purchase private insurance from
being used to pay for abortion (except in cases
of rape or incest or when the life of the woman
is endangered)
Consequences of PPACA
Abortion Coverage Restrictions



Most policies will require two separate monthly
premiums
Will discourage plans from offering abortion
 23 states have banned abortion coverage from
insurance plans sold via health insurance
exchanges
Will exclude poor
Barriers to Abortion:
Funding Cuts

Under Bush II, U.S. opposed language in the
Cairo Action Plan, such as “reproductive health
care,” stating that this is a proxy for abortion

This halted U.S. participation in global efforts to
prevent unintended pregnancies and control the
spread of STDs, including HIV
Barriers to Abortion:
Funding Cuts

Domestic family planning budget cuts
under Bush II
 Every $1 invested in family planning
averts $4 in Medicaid expenditures
Barriers to Abortion:
Limits on Availability of Emergency Contraception


EC available in 102 countries
 Available OTC in parts of Canada and in S. Africa, UK,
France, other European countries
Cost: $25-$50
 Less expensive options involving OCPs
 $1.43 cost savings (from averted pregnancy-related costs) for
every $1 spent
 2009 Utah study demonstrates association between increasing
rates of EC use and decreasing abortion rates
Barriers to Abortion:
Limits on Availability of Emergency Contraception

French study showed that only 15% of EC
pill use instances were reported by women
using no contraception (in 45% of cases,
women had been taking OCPs; in 35% of
cases, partner(s) had been wearing
condoms)
Barriers to Abortion:
Previous Limits on Availability of Emergency
Contraception
17 states mandate that emergency
contraception be available to rape victims
 9 states allow pharmacists to directly
prescribe emergency contraception
 Other states considering

Barriers to Abortion:
Emergency Contraception in Oregon ERs, 2003


61% of Oregon hospitals routinely offer EC to
rape patients
 Catholic hospitals = non-Catholic hospitals
46% of Oregon ERs discourage prescribing EC
to non-rape patients
 Catholic hospitals < non-Catholic hospitals
Barriers to Abortion:
Emergency Contraception in Oregon ERs, 2003


70% of all pharmacists surveyed reported that
their pharmacy stocked emergency
contraception.
Of those pharmacists who do not stock
emergency contraception, 30% will not fill a
prescription for the medication due a moral
objection.
Barriers to Abortion:
Limits on Availability of Emergency Contraception
National Study, 2005



Surveyed all 597 Catholic hospitals and 615 (17%) of nonCatholic hospitals
½ of staff said they do not dispense EC, even in the case of
sexual assault
 Similar for both types of hospital
 Other data show only ¼ of Catholic hospitals would provide
EC in cases of rape
Phone number for alternate facility provided in about 50% of
calls
 Many unreachable, wrong
Barriers to Abortion:
Limits on Availability of Emergency Contraception



Public awareness low:
 ¾ of reproductive-age women have not heard of
EC, only 12-15% of teenage girls have used (2006-10
data)/11% of women aged 15-44 (2011)
Advance access to EC does not promote risky sexual
behavior
Congress has considered bills to prohibit the use of
federal funds to prescribe, distribute, or provide
emergency contraception to minors in elementary and
secondary schools
Barriers to Abortion:
Limits on Availability of Emergency Contraception





“Conscience Clauses” common
Laws in Arkansas, Mississippi, Georgia, and South
Dakota explicitly protect pharmacists who refuse to
dispense EC
Other states are considering similar legislation
Wal-Mart offered EC as of 3/06, but does not require
pharmacists to dispense it (guns, ammo, on the other
hand…)
Military clinics not required to stock EC
Barriers to Abortion:
Limits on Availability of Emergency Contraception


2009: FDA allows Plan B OTC for those 17 and
older (younger women require a prescription) in
response to US District Court ruling
 Supported by ACOG, AAFP, AAP
2010: FDA approves ulipristal (Ella)
 effective for EC for up to 5 days post-coitus
 Up to twice as effective as levonorgestrol
 More effective in obese women
Barriers to Abortion:
Limits on Availability of Emergency Contraception




2011: HHS Secretary Sebelius instructs FDA not to
approve Plan B for OTC sale
2012: AAP recommends physicians prescribe EC to all
females age 16 and over (in advance of need)
2013: FDA approves OTC EC for girls 15 and older
2013: Federal judge orders FDA to make EC available
to all adolescent girls and women without a prescription
Prophylaxis for Adult Victims of
Sexual Assault
Prevention of Pregnancy
 Most
effective oral regimen: 1 dose of 30 mg
ulipristal or 1.5 mg levonorgestrel within 120
hours of unprotected intercourse (ulipristal
twice as effective; 0.9% pregnancy rate vs
1.7%)
Prophylaxis for Adult Victims of
Sexual Assault
Prevention of Pregnancy

Alternate regimen: 2 doses of 100 mcg ethinyl
estradiol plus 0.5 mg levonorgestrel taken 12
hours apart (plus prn antiemetic)


Less effective than ulipristal and levonorgestrel
Most effective: copper IUD implanted within 5
days
Nearly 100% effective
 Preferred for obese women

Prophylaxis for Adult Victims of
Sexual Assault
Prevention of Pregnancy



Clinical exam/pregnancy testing not required
before EC
Women with contraindications to conventional
oral contraceptives may receive any EC regimen
Even within the same menstrual cycle, EC can
be used more than once
Barriers to Abortion:
Mifepristone

Bush supported re-evaluation of FDA approval
of mifepristone (RU-486, the “abortion pill”)
 Approved for medical termination of
pregnancies 49 days or less from LMP
 Used in 25% of first trimester abortions
 Cost approx. $500
 Has been used by over 30 million women
worldwide
Barriers to Abortion:
Mifepristone




Medicaid funding for mifepristone restricted to
cases of rape, incest, or to preserve the pregnant
woman’s life
Sold only directly to providers
Proposed state and federal legislation to curtail
availability of mifepristone and limit the number
of doctors who can prescribe it
Alternative = Methotrexate termination, cost
approx. $450
Misoprostol (Cytotec)
95%-99% effective in conjunction with
mifepristone; 85% effective alone
 Safe: Less than 1% suffer serious side
effect (bleeding or infection)
 Buccal administration (vs vaginal
administration) with routine provision of
antibiotics decreases risks of serious
infections dramatically

Misoprostol (Cytotec)
$2 per pill on black market
 Use increasingly common among low
income immigrants
 Americans who cannot afford abortion
crossing into Mexico to buy cheap
misoprostol
 Self-induced abortion illegal in 39 states

Barriers to Abortion:
Provider Availability
 87%
of counties have no abortion
provider
 35% of women live in these areas
 30% of metropolitan areas have no
provider
 AK, ND, SD, and MS have only one
surgical abortion clinic each
Barriers to Abortion:
Provider Availability
 1800
facilities provide abortion services (↓
from 2900 in 1982)
57% of providers are aged 50 and older
Family physicians facing denial of
coverage, huge malpractice premium
increases
Barriers to Abortion:
Provider Availability

Medical school training:
 17% no formal education
 Clinical years:
 23% no formal education
 32% lecture
 45% third-year clinical experience (participation
low)
 ½ fourth-year reproductive health elective
(participation low)
Barriers to Abortion:
Provider Availability

Provider training
 51% of Ob/Gyn residency programs houve
routine training; 39% optional training

Only ½ of those trained end up performing abortions
 California

law now requires all ob/gyn residency
programs to comply with ACGME requirements,
including training in abortion (with opt-out
provision for conscientious objectors)
40 states bar non-physicians from performing
abortions
Barriers to Abortion:
Harassment of Patients and Providers
55%-86% of providers harassed
 80,000 acts of violence and/or disruption at
clinics in U.S. and Canada since 1977:
 Including 8 murders, 17 attempted
murders, 41 bombings, 643 bomb threats,
175 arsons, 184 assaults, 100 acid attacks,
661 anthrax threats (487 since
9/11/2001)

Barriers to Abortion:
Harassment of Patients and Providers
Abortioncam.com
 Army of God
 Nuremberg Files website (closed)
 Links with extremist groups/militias

Barriers to Abortion:
Harassment of Patients and Providers


Scheidler v. National Organization for Women U.S.
Supreme Court, 2/06)
 Federal extortion and racketeering laws cannot be
used to stop anti-choice extremists from obstructing
access to clinics, trespassing on or damaging clinic
property, or using violence or threats of violence
against clinics, their employees, or their patients
2007: Massachusetts enacts toughest restrictions in US
on protestors at abortion clinics

Buffer zone = 35 feet
Barriers to Abortion:
Harassment of Patients and Providers

Federal Freedom of Access to Clinic
Entrances Law
 Passed 1994
 Somewhat effective
Barriers to Abortion:
Harassment of Patients and Providers

15 states and D.C. prohibit certain specified
actions aimed at patients and providers
11 states and D.C. prohibit blocking entrance and
exit from facilities
 5 states and D.C. prohibit threatening of
intimidating staff
 3 states have “bubble zones” to protect patients
from protestors

Barriers to Abortion:
Inflammatory Oratory


President Bush, declaring January 20, 2002 (20th
anniversary of Roe v. Wade) “National Sanctity
of Life Day,” likened abortion to terrorism:
“On September 11, we clearly saw that evil
exists in this world, and that it does not value
life. Now we are engaged in a fight against
evil and tyranny to preserve and protect life.”
Inflammatory political ads continue around
election times
Barriers to Abortion:
Inflammatory Oratory

Ad campaigns supporting proposed Georgia
abortion ban claims to protect AfricanAmericans and Asian Americans from
“coerced” race- and sex-selection abortions

“Black children are an endangered species” because
of abortion
Barriers to Abortion:
Inflammatory Oratory
Virginia State Legislator Bob Marshall, speaking in
opposition to state funding for Planned Parenthood
(stating that according to the Old Testament, being
forced to bear a disabled child is punishment for the
mother’s having earlier aborted her first-born):
 “(W)hen you abort the first-born…nature takes its
vengeance on the subsequent children.”
 The organization ought to call itself “Planned
Barrenhood.”
- Richmond News Leader, 2/22/10 (he later apologized)

Barriers to Abortion:
Inflammatory Oratory



MO Congressman Todd Akin: “If it’s a legitimate rape,
the female body has ways to try to shut that whole
thing down” (i.e., prevent pregnancy)
Presidential candidate Rick Santorum: “Back in my
days, they’d use Bayer aspirin for contraceptives. The
gals put it between their knees, and it wasn’t that
costly.”
Radio host Rush Limbaugh called law student and
women’s rights activist Sandra Fluke a “slut”
Point-Counterpoint
Barriers to Abortion
 Religious
“Right’s” unscientific
polemics →
Barriers to Abortion:
Religious Hospitals

Religious hospitals
 15% of US hospitals
 ½ of twenty largest health systems in US
are Catholic, as measured by patient
revenue
Barriers to Abortion:
Religious Hospitals
 Religious
hospitals
 Granted special exemptions by federal
government to use religious doctrine to
guide patient care yet still retain
government funding
 Catholic hospitals prohibit provision of
abortion services, as well as contraception,
sterilization, and infertility services
Barriers to Abortion:
Religious Hospitals

Catholic hospitals deny approval of uterine evacuation
while fetal heart tones present, forcing physicians to
delay care or transport miscarrying patients to nonCatholic-owned facilities


Some physicians violated protocol to avoid compromising
patient safety
2010: Pope Benedict gives tacit approval to condom
use for sex with prostitutes to decrease AIDS risk

2012: In several major US cities, carrying 3 or more condoms
used as evidence of engaging in prostitution
Christian Science Pharmacist Refuses To
Fill Any Prescription
Barriers to Abortion:
Legal



Spousal Notification Laws
Parental Consent and Notification Laws for
Teen Abortions
Mandated waiting periods
 25 states
 Most have 24 hour waiting period
 South Dakota -72h, mandates counseling at
CPC
Parental Consent and Notification
Laws for Teen Abortions
 20 states require parental consent
 11 states require parental notification
 4 states requires both
 16 states do not require parental
permission
Parental Consent and Notification Laws
for Teen Abortions

All states have a judicial bypass procedure

2006: CA and OR ballot measures to
require parental consent failed
Parental Consent and Notification
Laws for Teen Abortions
Notification dangerous if pregnancy
resulted from incest or if home situation
abusive or otherwise unstable
 U.S. Supreme Court struck down a
Nebraska statute because it did not have an
exception to save a pregnant woman’s life
or health and returned a similar New
Hampshire law to the lower courts

Parental Consent and Notification
Laws for Teen Abortions
 National
survey of female adolescents
 Laws would likely increase risky or
unsafe sexual behavior and, in turn,
the incidence of STDs and adolescent
pregnancy
- JAMA 2005;293:340-8
Parental Consent and Notification
Laws for Teen Abortions
Studies show can prevent up to half of
teens from utilizing Planned Parenthood
services, including contraception
 Could cause only 1% of teens to stop
having sex

- JAMA 2002;288:710-4.
Potential Annual Costs of Parental Consent and Law
Enforcement Reporting Requirements For Texas

$43.6 million for girls younger than 18
currently using publicly funded services
 Based on projected number of additional
pregnancies, births, abortions, and
untreated STDs and resulting cases of
PID
-Arch Ped Adol Med 2004;158:1140-6.
Texas Parental Notification Law


Enactment associated with a decline of 11-20%
in abortion rates among minors from ages 15-17
Enactment associated with increased birth rates
and rates of abortion during the second
trimester among a subgroup of minors who
were 17.50-17.75 years old at time of conception
NEJM 2006;354:1031-8
Barriers to Abortion:
Biased Counseling Laws



More than 20 states
Often deceptively labeled “Mandated Informed
Consent” or “Women’s Right to Know” Laws
Scare tactics re safety of abortion
 Women read a lengthy list of possible but very rare
complications from abortion (but not list of benefits
of abortion)
 Many require providers to state, falsely, that abortion
can cause breast cancer and “post-abortion
syndrome”
Barriers to Abortion:
Publicly-Funded “Crisis Pregnancy Centers”




Over 4500 nationwide, some receive state
funding
Outnumber abortion clinics (816)
Listed in phone book under “pregnancy
services” or “abortion services”
48% of college health clinics routinely refer
women who might be pregnant to CPCs

81% routinely refer to full-service health clinics
Barriers to Abortion:
Publicly-Funded “Crisis Pregnancy Centers”
Staff try to dissuade clients from having
abortions through misinformation
exaggeration of risks, myths, and fetal
photos/body scans
 Stop Deceptive Advertising for Women’s
Services Act died in House Committee
 2011: NYC, Austin (TX), SFO pass “truth
in advertising laws” related to CPCs

Barriers to Abortion:
Scare Tactics, Misinformation, and Pseudoscience

Scare tactics re safety of abortion, contraception,
and STD prevention:
 E.g., Cardinal Alfonso Lopez Trujillo (the
Vatican’s spokesperson on family affairs):
“Relying on condoms is like betting on your
own death...They [the WHO] are wrong about
that [condoms are a highly efficient means of
preventing the spread of HIV]”
Barriers to Abortion:
Scare Tactics, Misinformation, and Pseudoscience

Adults questioned re first trimester abortion
(90% of all abortions) – 2013:
45% think it is more dangerous than giving birth
(30% less dangerous)
 37% think it increases risk of serious mental health
problem (32% unsure)
 15% think it can increase risk of breast cancer (50%
unsure)
 27% think future fertility impaired (28% not sure)

Facts re Abortion




One of the safest and most common medical
procedures available
Risk of death from legal abortion less than that
from a shot of penicillin
40 times safer than a colonoscopy
10-30 times more dangerous to carry a fetus to
term than to undergo a legal abortion
Risks Associated with Abortion

Risk of death:
 1/1 million up to 8 weeks
 1/29,000 at 16-18 weeks
 1/11,000 at 21 or more weeks
 1/11,000 for carrying full-term
pregnancy
Risks Associated with Abortion

Complication rates
 Medical abortion – 2.1%
 First trimester aspiration abortion – 1.3%
 Second trimester or later abortion – 1.5%
 Complication requiring hospitalization – 0.3%
Facts re Abortion

No long-term emotional or psychological
sequelae
 Women denied abortions often
experience resentment and distrust
 Their children may face social and
occupational deficiencies
Barriers to Abortion:
Scare Tactics, Misinformation, and Pseudoscience


No increase subsequent risk of ectopic pregnancy,
spontaeous abortion, preterm birth, or low birth weight
with less than 3 lifetime medical or surgical abortions
 Unintended pregnancy associated with reduced
prenatal care, lower breast feeding rates, and poor
maternal and neonatal outcomes
With 3 or more lifetime abortions, higher risk for
subsequent prematurity, low birth weight
Barriers to Abortion:
Scare Tactics, Misinformation, and Pseudoscience


No overall effect on the risk of breast cancer
 NCI removed information re abortion and breast
cancer from website; later posted unsupported “data
controversial” statement
 C.f., NIH and CDCP websites removal of
information about the effectiveness of
condoms and sex education curricula
Even so, 5 states require that women seeking an
abortion be counseled that doing so will increase their
risk of breast cancer
Sex Education
77% of Americans have had sexual
intercourse by age 20
 Average number of sex partners over
lifetime:
 Wealthy country = 10
 Poor country = 6

Abstinence-Only Education

Only 22 states mandate sex education in public
schools


Only 13 of these require comprehensive sex ed
Federal government spends $180 million/yr onb
comprehensive sex ed, $50 million/yr on
abstinence-only education
Abstinence-Only Education

2% of school districts in 1988; 23% in 1999



2006-8: 53% (teenage boys) and 65% (teenage girls) receiving
comprehensive sex ed
Over 80% of curricula, used by 2/3 of grantees, contain
false, misleading, or distorted information about
reproductive health
Does not decrease sexual activity, STD rates, teen
pregnancies; does not increase use of condoms and
contraceptives
Abstinence-Only Education

c.f. “Virginity Pledges”
 88% violated
 Pledgers have identical STD rates to nonpledgers
 Pledgers are less likely than other to use
condoms and to be tested and diagnosed with
STDs
- J Adol Hlth 2005;36:271-8
Abstinence-Only Education




Attempts to instill guilt, fear and shame into students
Places responsibility for refusing sexual advances on
women
Blurs science and religion
Treats stereotypes about boys and girls as scientific fact
 Stereotypes undermine girls’ achievment, claim that
girls are weak and need protection, and reinforce
male sexual aggressiveness
Abstinence-Only Education



Prohibits any discussion of contraceptives
beyond failure rates
Presents worst case scenarios of abortions and
STDs
Since 2001, success defined as “completion of a
course,” rather than by actual outcomes
Abstinence-Only Education


Programs have used funds to buy bibles,
subsidize crisis pregnancy centers
New Jersey program funded “Free Teens USA,”
connected to the Sun Myung Moon’s
Unification Church

Moon has described homosexuals as “dung-eating
dogs” and American women as “a line of
prostitutes”
Abstinence Only Education:
Examples

Bizarre scare tactics:


“Today being an adult means being able to …
participate in any and all types of perverse activities
that depraved minds can imagine.”
Errors:

“Studies show that five to ten percent of women will
never again be pregnant after having a legal
abortion.”
Abstinence Only Education:
Examples

Sexism/Sex Stereotypes:
 “Deep inside every man is a kinght in
shining armor, ready to rescue a maiden
and slay a dragon.”
 “Females have the uncanny ability to
remember the most insignificant details
about past experiences.”
Abstinence Only Education:
Examples

Sexism/Sex Stereotypes:
 “Men tend to be more tuned in to what
is happening today and what needs to be
done for a secure future.”
 “Girls will feel “dirty and cheap” when
they “lose” their boyfriends after having
sex
Abstinence-Only Education

24 states rejected abstinence-only funding
in 2008

Total $1.5 billion spent on abstinence-only
education between 1996 and 2010
Comprehensive sex education programs
 Delay
onset of intercourse
 Reduce
the frequency of intercourse
 Reduce
numbers of sexual partners
Comprehensive sex education programs
 Increase
condom and contraceptive
use
 Reduce numbers of unwanted
pregnancies
 Supported by large majority of
Americans
Barriers to Abortion:
TRAP Laws

Targeted Regulation of Abortion Providers
Laws


2013: 2 dozen states enacted 70 measures
Regulate hallway corridor and door frame width,
temperature of operating rooms, numbers of
hours of training each staff member much
receive, increase licensing fees, impose
burdensome documentation requirements,
require hospital admitting privileges, etc.
Barriers to Abortion:
TRAP Laws
Not applicable to other ambulatory health
centers
 Increase retrofitting, design and training
costs; put some clinics out of business
 Zoning ordinances – some clinics forced to
relocate; others shut down

Barriers to Abortion:
TRAP Laws
Effect: decreased access to and increased
costs of abortion
 Restrictions on providing medical
abortions skewing those who elect this
option toward women who are white,
educated, and insured

Barriers to Abortion:
State Laws

Very few states have both pro-choice
legislatures and a pro-choice governor
Barriers to Abortion:
State Laws

2012: Many states have laws that encourage or require
the use of ultrasound
 Unnecessary, rape when transvaginal (transabdominal US does not capture images prior to 10
weeks)
 Patients often required to bear cost ($50 - $200)
 99% of women go ahead with abortion after
voluntarily viewing an ultrasound
Barriers to Abortion:
State Laws

As of 2012, >10 states require ultrasounds prior
to abortion (AL, AZ, KS, KS, LA, MS, TX)
 2012: Federal appeals court allows TX
requirement for women seeking abortion to
undergo ultrasound and view pictures or have
doctor describe them
Barriers to Abortion:
State Laws Banning Abortion

In 2005, a Michigan anti-abortion law
passed, prohibiting physicians from
performing most abortions, even when the
mother’s health or life is endangered
 It is currently held up in federal court
Barriers to Abortion:
State Laws Banning Abortion

2006 – South Dakota voters reject measure to ban
abortion





No exception for rape, incest or to protect woman’s health;
contains inadequate and poorly-worded exception for “life
endangerment”
Violation is a felony
2008 ballot initiative to outlaw “partial birth abortion” also
failed
2011 bill would classify the crime of a man killing a provider
aborting his female partner’s fetus as justifiable homicide
Similar bills have been introduced in Alabama, Georgia,
Indiana, Kentucky, Ohio, Mississippi, Rhode Island,
South Carolina, Tennessee, and West Virginia
South Dakota’s “Informed Consent”
Law
 Passed
in 2005
 Planned Parenthood sought and
received injunction to suspend Law
 6/08: Eighth Circuit Court of Appeals
(Planned Parenthood Minnesota v.
Rounds) lifted injunction
South Dakota’s “Informed Consent”
Law: Requirements


Physician must give pregnant women a description of
scientifically-unsupported “risks of abortion”
Women must be told that they have an “existing
relationship with fetus that enjoys protection under the
U.S. Constitution and under the laws of South Dakota,”
and that abortion terminates that relationship
terminates that relationship along with “her existing
constitutional rights with regards to that relationship”

Neither the Constitution nor SD laws explicitly mention such
a relationship
South Dakota’s “Informed Consent”
Law: Requirements



Disclosures must be made in writing, and
women must sign each page of the state-crafted
script
Physicians who do not satisfy statute subject to
license suspension or revocation and may be
charged with a class 2 misdemeanor
Physicians thus must violate Hippocratic Oath
and lie to patients or violate SD law and face
sanctions and possible prosecution
Barriers to Abortion:
State Laws


2005 – Cook County judge ruled that parents of a
frozen embryo accidentally destroyed by a Chicago
fertility clinic could file a wrongful death lawsuit
Many states have introduced “fetal personhood laws”



Could affect fertility clinics
2015: 12 states ban abortions after 20 weeks
State laws requiring doctor to be present for admission
of abortion-inducing drugs

Hits rural states hardest
Barriers to Abortion:
State Laws



2011: Ohio “heartbeat bill” – would ban abortions if
detectable heartbeat (happens at 6 wks embryonic
development, long before many women realize they are
pregnant)
2013: Arkansas legislature overrides governor’s veto to
pass “Human Heartbeat Protection Act,” banning
abortions after 12 weeks
2013: Judge blocks similar law in ND banning
abortions after 6 weeks
Barriers to Abortion:
State Laws

2011: Utah legislature passes bill criminalizing
women who have indued miscarriages or
miscarriages that occur due to “reckless
behavior”
Miscarriages common, especially in first trimester
 Most miscarriages caused by chromosomal
abnormalities
 Due to mass opposition, Republican governor does
not sign

Barriers to Abortion:
State Laws


Colorado’s Human Life Amendment, which
would have given full legal rights to fertilized
eggs, defeated 3-1 (2008)
2010: OK law prevents women who give birth
to disabled child from suing doctor who misled
or outright lied about health of fetus during
pregnancy

Protects doctors against violation of ethical mandate
to tell truth
Barriers to Abortion:
State Laws



22 states have “Choose Life” laws, allowing motorists
to purchase “Choose Life” license plates
 Proceeds support “Crisis Pregnancy Centers” and
anti-choice organizations in 12 states, adoption in 14
states
2013: NC passes TRAP Law as part of a bill outlawing
Islamic Sharia law
2014: TX TRAP law put on hold by SCOTUS; AL law
struck down by judge
Barriers to Abortion:
State Laws


2013: Proposed North Dakota ballot measure to
define life as beginning at conception
 State already bans abortion on the basis of
any genetic disease or defect
2013: 8 states define life as beginning at
conception
 AZ law dates pregnancy back to LMP
Barriers to Abortion:
State Laws

7 states ban abortion providers (e.g.,
Planned Parenthood) from receiving state
money (2012)
 Federal Appeals Court overturns TX ban
(2012)
“Fetal Research Rights”
 Under
Bush II, Mission of Advisory
Committee on Human Research
Protection – which oversees the safety
of human research volunteers –
expanded to include embryos
Insuring Fetuses
 Bush
II administration pushed “adopt
the unborn” campaign, extending State
Children’s Health Insurance Program
(SCHIP) to fetuses
 But full prenatal care not extended
to all women
Barriers to Abortion:
“Partial Birth Abortion” Ban

Criminalizes intact dilatation and extraction
 0.17%

Many states have such bans


of all abortions
Some have exceptions for health of woman
Similar 2000 Nebraska state law found
unconstitutional by U.S. Supreme Court (Stenberg
v. Carhart)

Despite this, 17 states since enforcing ban
Barriers to Abortion:
“Partial Birth Abortion” Ban

Lawsuits filed to overturn
 SF Appeals Court blocked
administration enforcement of act
against Planned Parenthood Clinics and
their doctors, who perform roughly ½ of
the nation’s abortions
Barriers to Abortion:
“Partial Birth Abortion” Ban

2007: US Supreme Court upholds ban
(Gonzales v. Carhart)
 Physicians
subject to 2 years in prison, fine of
up to $250,000, and monetary damages for
psychological injury to the husband or parents
of the pregnant woman

2012: Federal appeals court blocks AZ lateterm abortion ban
Barriers to Abortion:
Legal

“Unborn Victims of Violence Law”
 Criminalizes harming fetus; e.g., conviction in Texas
(6-05)
 Supposedly will “help protect victims from domestic
violence”
 Irony: Domestic violence programs in U.S.
woefully under-funded
 Could limit women’s freedom to work in certain
settings/at certain jobs
 2010: 37 states have “attempted feticide” laws
Barriers to Abortion



“Born Alive Infants Protection Act”
DHHS using BAIPA in enforcing EMTALA
(Emergency Medical Treatment and Active
Labor Act)
Will cause conflicts relevant to desire for
palliation vs treatment
Barriers to Abortion


2014: TN law allows prosecution of women who
intentionally, knowingly, or recklessly cause
bodily injury to eggs, embryos, or fetuses as part
of an unlawful act or unlawful omission
Some states require reporting of drug (including
marijuana and alcohol) use by pregnant women
Legal Barriers to Abortion:
The “Teen Endangerment Act”

Part I: “Child Custody Protection Act”:
 Would make it a federal crime for anyone other than
a parent, including other relatives and religious
counselors, from accompanying a young woman
across state lines for an abortion, without complying
with the home state’s parental involvement statutes
 Would delay abortion, increasing cost and
physical/emotional health risks to teenager
Legal Barriers to Abortion:
The “Teen Endangerment Act”

Part II: “Child Interstate Abortion Notification Act”:
 Would make it a federal crime to provide an abortion to a
teenager outside of her home state unless the physician has
notified a parent at least 24 hrs. in advance.
 No exception when abortion necessary to protect the
teenager’s health
 Requires 24 hr. waiting period and written notification even if
a parent accompanies teen to an out-of-state abortion
provider
Legal Barriers to Abortion:
The “Teen Endangerment Act”
 Passed
by the U.S. House of
Representatives in 2005
 Senate currently considering a similar
bill, but without interstate abortion
notification procedures
Barriers to Abortion:
Legal

Unborn Child Pain Awareness Act
 Mandates that women seeking abortion
after 20 weeks be provided specific
information regarding fetal pain during
abortion, and that they sign a form
accepting or refusing “pain medications
for the unborn fetus”
“Fetal Pain” Counseling
Required for all women in 6 states
 Required after 20-22 weeks in 4 states


Sensory structures to feel pain don’t
develop until after 23 weeks
Barriers to Abortion:
Legal

Proposed Congressional legislation would:
Allow hospitals to let a pregnant woman die rather
than perform a life-saving abortion
 Effectively prevent women from using their own
money to purchase insurance that includes abortion
coverage in the new insurance exchanges
 Tax small businesses that pay for health plans that
cover abortion (and people who pay for abortions)
 Permanently ban federal spending on abortion

Barriers to Abortion:
Legal – The Courts
 Nominations
 ?Supreme
 ?Overturn
of anti-choice judges
Court nomination(s)?
Roe vs. Wade?
Bush Nominates First-Trimester Fetus
To Supreme Court – The Onion, 9/05
Barriers to Abortion:
Legal

Unsuccessful attempt to subpoena medical
records from family planning clinic
(violating patient confidentiality)
 Storm Lake, Iowa – resisted by Jill June,
one of Ms. Magazine’s 2002 Women of
the Year
Barriers to Abortion:
Legal

Maine Rep. Brian Duprey submitted bill to
state legislature to make it a crime to abort
an unborn child if that child is determined
to be carrying the “homosexual gene”
 Such a gene is not known to exist
 Duprey got idea for bill “from Rush
Limbaugh”
Barriers to Abortion:
Bush Political Appointments

Political appointments to government
scientific organizations/committees based
on ideology, not knowledge and experience
 E.g., Drs. David Hager, Susan Crockett
and Joseph Stanford appointed to the
FDA’s Reproductive Health Drugs
Advisory Committee
Barriers to Abortion:
Bush Political Appointments

Example: Ob/Gyn Hager
 Author of “As Jesus Cared for Women”
 Has advocated Scripture reading and
prayer for PMS and reportedly refuses to
provide contraceptives to unmarried
women
 Accused by wife of “serial anal rape”
Barriers to Abortion:
Bush Political Appointments


Erik Keroack (head of “crisis pregnancy center,”
anti-birth control, anti-sex education) appointed
Deputy Asst Scty. For Population Affairs in
DHHS – later resigned
FDA Representative Dr. Janet Woodcock:
 Selling Plan B OTC would transform it into
an “urban legend” that would tempt
adolescents to create “sex-based cults”
Church Amendment
 Protects
those who choose to
participate and those who choose not
to participate in abortion at federally
funded public health institutions
Coats Amendment



Passed 1996
Maintains federal funding and legal status of
medical institutions that do not offer abortion
training or provide referrals for individuals
seeking abortion training at another institution
Prohibits discrimination against institutions and
individuals who refuse to provide abortion
training
Barriers to Abortion:
The Weldon Federal Refusal Clause




Signed by President Bush in 12/04
Allows federally-funded health care entities to
deny women information on abortion services,
even if state laws mandate that such information
be given upon request
46 states have similar conscience clauses
Obama overturns, but allows individual
conscientious objection protections
Barriers to Abortion:
The Weldon Federal Refusal Clause


Opposing lawsuit filed December, 2004, by the
National Family Planning and Reproductive
Health Association
Lawsuit by state of California rejected by federal
judge (2008)
Barriers to Abortion:
Refusal Clauses

46 states enacted shortly after Roe v. Wade

14 states allow some health care providers
to refuse to provide contraceptive services

18 states allow some health care providers
to provide sterilization services
Barriers to Abortion:
Refusal Clauses



Permit certain medical personnel, health
facilities, and/or institutions to refuse to
participate in abortion
DHHS regulations (9/08) allow health care
workers and institutions to refuse on religious
grounds to perform or refer patients for
abortions
“Conscience Clauses” protect only consciencebased refusal of care, not conscientious
provision of care
Effects of Refusal Clauses



Employers can refuse to provide contraceptive
coverage in their health plans
Pharmacists can refuse to dispense, or provide
referrals for, lawfully-prescribed OCPs
Health care professionals can deny patients
information on, or referral for, family planning
services, regardless of the patient’s health care
needs
ACOG Position

Doctors whose personal beliefs require them to
deviate from standard practices such as
providing abortion, sterilization, or
contraceptives should:
Give patients prior notice
 Offer timely referral
 Provide medically-indicated services in an emergency
 Practice close to physicians who will provide legal
serivces or ensure that referral processes are in place
so that patient access is not impeded

Barriers to Abortion:
Global “Gag Rule”
 First
adopted by Reagan Administration
in 1984
aka Mexico city policy
 Rescinded by President Clinton in 1993
 Reinstated by Bush in 2001
 Overturned by Obama in 2009
Barriers to Abortion:
Global “Gag Rule”

After Global Gag Rule reinstated by Bush
Administration in 2001
 430 organizations in 50 countries stopped
performing abortions or speaking about abortion
laws in order to qualify for U.S. funding
 1/16 women in sub-Saharan Africa die during
pregnancy or childbirth
 Did not cover condoms procured with HIV/AIDS
funds
Barriers to Abortion:
Domestic “Gag Rule”
 Adopted
by Reagan administration in
1988
 Overturned
by Clinton in 1992
The Good News



Parents very accepting of idea of sexually
transmitted disease vaccination for their
adolescent children
- Arch Ped Adol Med 2005;159:132-7
States and U.S. Congress introducing bills to
improve sex education and affirm women’s right
to choose “Freedom of Choice” bills
The European Court of Human Rights has
declined to extend full human rights to fetuses
BUT

Obama administration has done little to stem
erosion of reproductive rights

2014: Republicans control Congress – what is
next?
Barriers to Abortion: Worldwide
 Abortion
broadly legal in 60% of
countries
6% of developing countries
 1/3 of developing world lives where
abortion is prohibited or allowed only in
cases of rape or incest or to save the
mother’s life
Barriers to Abortion: Worldwide

Lack of access to contraception
 Average number of lifetime abortions: Russia
(9), Romania (18 - pre-fall of communism)
 215 million women have an unmet need for
contraception
 Catholic Church opposes contraception (even
condoms)
Barriers to Abortion: Worldwide

Under Bush II, U.S. cut $34 million in funding
for U.N. Population Fund and withdrew support
from a population control program that stressed
access to reproductive health care and education
 Based on unsubstantiated argument that the
program supports China’s coercive
population control policy
 However, selective abortion of female infants
common (119F/100M born in China)
Barriers to Abortion: Worldwide
 U.N.
Population Fund
 Obama re-instated funding ($50
million) in 2009 budget
$35 million in 2013 budget
Barriers to Abortion: Worldwide

Education:
 More years of education translates to greater likelihood of
contraceptive use, decreased childbearing, higher salaries,
improved status of women and families, and better education
for their children
 Average number of children based on mother’s years of
education:
 No school: 4.5
 Few years primary school: 3
 One or two years of secondary school: 1.9
 One or two years of college: 1.7
Barriers to Abortion: U.S. Pressure on
World Health Organization

WHO expert committee recommended
that mifepristone and misoprostol should
be added to its Essential Medicines list

WHO has failed to act, possibly in
response to pressure from the U.S. Dept.
of Health and Human Services
Perspective:
Poverty and Priorities


Amount of money needed each year ( in
addition to current expenditures) to provide
reproductive health care for all women in
developing countries = $12 billion
Amount of money spent annually on perfumes
in Europe and the U.S. = $12 billion
Conclusions
Restrictions on access to abortion and
other reproductive health services
increased dramatically under the Bush
administration
 Backed by inflammatory/hostile rhetoric
and pseudoscience
 Obama: ?change?

Conclusions
 Vigilance
and legislative efforts at
federal and state level and in the
courts necessary to preserve and
protect women’s right to choose
References


Donohoe MT. “Teen Pregnancy: A call for sound science and
public policy,” in Current Controversies in Teen Pregnancy and
Parenting, Lisa Frick, Ed. (Farmington Hills, MI: Greenhaven
Press/Thomson Gale, 2006). [Reprinted from Z Magazine 2003
(April);16(4):14-16. Available at
http://zmagsite.zmag.org/Apr2003/donohoe0403.html]
Donohoe MT. Increase in obstacles to abortion: The American
perspective in 2004. J Am Med Women’s Assn
2005;60(1)(Winter):16-25. Available at http://www.amwadoc.org/index.cfm?objectid=1B138032-D567-0B2557EE86AC69902184
References


Adams KE, Donohoe MT. Reproductive Rights –
Commentary: Provider willingness to prescribe
emergency contraception. American Medical
Association Virtual Mentor 2004 (Sept.);6(9). Available
at http://www.amaassn.org/ama/pub/category/12783.html
Donohoe MT. Obstacles to abortion in the United
States. Medscape Ob/Gyn and Women’s Health
2005;10(2):posted 7/7/05. Available at
http://www.medscape.com/viewarticle/507404
References


Donohoe MT. Parental notification and consent
laws for teen abortions: overview and 2006
ballot measures. Medscape Ob/Gyn and
Women’s Health 2007. Posted 2/9/07.
Available at
http://www.medscape.com/viewarticle/549316.
Guttmacher Institute:
http://www.guttmacher.org/
Contact Information
Public Health and Social Justice Website
http://www.phsj.org
martindonohoe@phsj.org