in trying to find common ground, do we hurt abortion rights?

In trying to find

UCLA

In trying to find common ground,

do we hurtJanuary 25, 2010 do we hurt abortion rights?

Tracy A Weitz, PhD, MPADirectorAdvancing New Standard in Reproductive Health (ANSIRH)Bixby Center for Global Reproductive HealthUniversity of California, San Franciscoy

UCLACommon Ground and Abortion Rights

Today’s Talk

Weitz 1/25/10

�Define “common ground” approach to abortion

�Review its development�Discuss the implications of the p

search for common ground on abortion rights

�Offer an alternative approach

October 2009 |


Weitz 1/25/10

C G dCommon Ground

Reducing the Need for Abortion / Prevention FirstReducing the Need for Abortion / Prevention FirstMost major pro-choice social movement organizationsObama and the Democratic Leadership


Case Study: NARAL

Weitz 1/25/10 � NARAL, first formed in 1967 as the National Association for the Repeal of Abortion Laws

� With legalization changed its name to the National Abortion Rights Action League in 1973

� In 1993 NARAL changed its name to the National Abortion and Reproductive Rights Action League and launched the "Real Choices" campaign “to highlight thelaunched the Real Choices campaign to highlight the goals of its expanded mission: to preserve access to abortion while working to enact policies to make abortion less necessary”

� In 2003 changed its name to “NARAL Pro-Choice America” � NARAL became a word rather than an acronym,

i th d b ti f it ti lremoving the word abortion from its name entirely� In 2005 NARAL’s work prioritized a “prevention first

campaign” to reduce the need for abortion


Obama and Abortion

Weitz 1/25/10 � Internationally � Removal of Global Gag Rule� Appointment of Hilary Clinton as Sect of State� Appointment of Hilary Clinton as Sect. of State

� Domestically� The search for common ground� Acknowledging the importance of legality� No further expansion of abortion rights� Reducing the need for abortion� Bringing Pro-Choice and Anti-Abortion activists

together to identify places where they agree� Agree to disagree

October 2009 |


Obama’s Statement Commemorating Roe

Weitz 1/25/10"Today we recognize the 37th anniversary of the Supreme

Court decision in Roe v. Wade, which affirms every

fwoman’s fundamental constitutional right to choose

whether to have an abortion, as well as each American’s

right to privacy from government intrusion. I have, and

continue to, support these constitutional rights.”

“I also remain committed to working with people of good

will to prevent unintended pregnancies, support pregnant

women and families, and strengthen the adoption system.”

“T d d d t t i t th t ll“Today and every day, we must strive to ensure that all

women have limitless opportunities to fulfill their dreams.”

Obama, 2010Obama, 2010


Components of the new “Common Ground” agenda

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g

R d i t d d i� Reduce unintended pregnancies� 50 % of all pregnancies in the U.S. are unintended� ½ of all unintended pregnancies end in abortion

� Increase support for adoption� Data on adoptions is poor but somewhere between

1-5% of all unintended pregnancies� Increase support for families

� Low-income women and women of color have higher rates of abortion

� Goal: Reduce the need for abortion


The Underlying Assumptions

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� Decreasing the number of unintended pregnancies

will result in a significant decline in the number of

abortions

� Reducing the number of abortions will somehow g

reduce the social conflict over abortion

� Acknowledging that abortions should be used less� Acknowledging that abortions should be used less

frequently will demonstrate that we take abortion

seriously and thus enhance people’s support for y p p pp

abortion rights


Weitz 1/25/10 Women’s individual desires to avoid an unintended pregnancy is

lit ti l diff t fqualitatively different from a social goal of reducing the need for abortionfor abortion. Helping a woman achieve her reproductive desires is a laudablereproductive desires is a laudable goal, not because it reduces the need for abortion, but because it is what she wants for her life.


Weitz 1/25/10

A brief review of the how we got to th “ d” hthe “common ground” approach


1973: Abortion as a social positive

Weitz 1/25/10 � Roe decision articulated as a way for women to shape the course and destiny of their lives

� Seen as central to women’s equality in society� Synonymous with notions of modern feminism� Unqualified support for both the right to and use of

abortion� abortion on demand � abortion without apology


1980’s: Changing the Social Meaning of Abortion

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g

� 1970’s time of growing strength of the anti-abortion movementmovement

� Rise of single issue politics� Election of Ronald Reagan� Administrative restrictions on abortion� Changes in the composition of the Supreme Court

� The “Culture War”� Goal:

� To change the hearts and minds of the American� To change the hearts and minds of the American public

� To make abortion a non-normative practice unworthy of societal approval

� Tactics:� Humanizing the fetus� Vilifying women

Solidifying the relationship between religious� Solidifying the relationship between religious identification and abortion opposition


Understanding Abortion as Violent Social Conflict

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� Rise of direct action� Rise of direct action� Rescues

� Siege on Atlanta� Summer of Mercy� Summer of Mercy

� Clinic defense as a response� Extensive media coverage

� The violent wing� Direct targeting of abortion doctors and clinics� Murders and attempted murders

� Abortion is an angry hostile debate between two sides willing to win at all costs.


Longing for a way out of the war

Weitz 1/25/10 � The introduction of the mantra “abortion should be safe, legal and rare”

� Bill Clinton in 1992 presidential campaign� First day in office, reversed anti-abortion policies of

Reagan and Bush I with the affirmation that his vision was “an America where abortion is safe, legal and rare”rare

� Since introduction in 1990 almost every pro-choice politician has used the phrase� From the left and from the center/right� From the left and from the center/right

� Accepted as the middle ground � USA Today editorial, 2003

Abortion is a “right most Americans want preserved: reproductive choice that makes abortions safe, legal

d ”and rare.”


“Reducing the Need for Abortion” is Next Iteration

Weitz 1/25/10

� SLR is still used� Used in conjunction with “Reducing the Need,” which is

the implementation efforts of the sentiment� Core of the current common ground approach


Weitz 1/25/10

What’s so wrong about wanting to d th d f b ti ?reduce the need for abortion?

Discounts the role of abortion as a positive force inDiscounts the role of abortion as a positive force in women’s livesIncreases the stigma surrounding abortionProvides the fertile ground for the “abortion hurts women”Provides the fertile ground for the abortion hurts women message of the anti-abortion movementReduces access to careI di itiIncreases disparitiesDoes nothing to reduce the structural factors that produce larger social inequalities in which reproduction is imbedded


Produces a normative judgment about abortion

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� Suggest that abortion is happening more than it should� Separates the “good” and the “bad” abortions

� Those that could have been avoided


Understanding the Contradiction

Weitz 1/25/10Pastor Rick Warren challenge to Obama’s position on

abortion:

“Now, I don't understand the, the idea of it should be rare

and, and less. Well, either you believe it's life or you don't.

It--why would you believe it should be rare? Because if ifIt--why would you believe it should be rare? Because if, if

it's not--if a baby, a fetus is not a life, then why restrict it?”

Meet the Press Nov. 29, 2009,


Creates an understanding that women’s individual decision making

Weitz 1/25/10

gis the cause of social conflict

� Which women’s decisions are implicated? � African American women have 5x the abortion rate of

WhitWhite women� Latina women have women have 2x the abortion rate

of White womenW ith i l th 100% f th FPL h� Women with income less than 100% of the FPL have an abortion rate 3.2x as high as those at 200% of the FPL

� Rates for low-income and minority women are not� Rates for low income and minority women are not declining as fast as for higher-income and white women


Weitz 1/25/10

Increases stigma and creates theIncreases stigma and creates the fertile ground for acceptance of the new “Abortion Hurts Women” framenew Abortion Hurts Women frame of the Anti-Abortion Movement


Central Arguments

Weitz 1/25/10 � Women are victims of society, men and the abortion industry

� Promotion of restricted laws that prescribe the type and timing of information women receive related to abortion

� Focus is on telling women about the psychological risks of abortion

� Push for formal recognition of Post-Abortion Syndrome (currently not recognized by the American Psychiatric Association)


Weitz 1/25/10

Connecting g Personal experience Post-abortion recoveryy Social activism Religion


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Post-Abortion Recovery

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David Reardon

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� Architect of this approach� Founder of Women Exploited by

Abortion (WEBA) in 1982 toAbortion (WEBA) in 1982 to minister to the needs of aborted women and to help them heal their pain.A h f Ab d W Sil N� Author of Aborted Women Silent No More (1987)

� Founder of the Elliott Institute in Springfield IL 1988Springfield, IL, 1988

� Since 1987 –7 books and a dozen articles

UCLACommon Ground and Abortion Rights Goal is to replace Weitz 1/25/10 the fetus with the

guilt-ridden, grief-stricken images ofstricken images of women victimized by abortionby abortion

1996

1987

1996

1997

2002

1997


Using the Apparatus of the Gov’t

Weitz 1/25/10 Anti-abortion Surgeon General

tasked with investigating effects

fof abortion on women

1989 Koop finds insufficient data

to determine that abortion harms womento determine that abortion harms women

Koop’s Conclusion

“The pro-life movement always focused- rightly, I though-p y g y g

on the impact of abortion on the fetus. They lost their

bearings when the approached the issue on the grounds

f th h lth ff t th th ”of the health effect on the mother.”


Supported by the Science

Weitz 1/25/10 � 1990 American Psychological Association (APA) report published in Science:� Exhaustive review of literature� “Women tend to cope successfully and go on with

their lives”� Position of most professional medical associations

� American Psychological Association� American Psychiatric Association� American Public Health Association� American Public Health Association� American Pediatric Association


What do Women Experience?

Weitz 1/25/10 � Most feel relief� Some experience short-term feelings of:

� Anger regret guilt/sadness� Anger, regret, guilt/sadness� Natural emotions to big life decisions

� Rare cases of psychological problems� Best predictor of mental health after an abortion is

mental health before an abortion� No such entity as “post-abortion syndrome”� Conducting this research has many serious

methodological challenges


Significant methodological flaws to research finding harm

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g

� Using data not designed to answer the question� Incorrect comparison groups� Ignoring prior mental health statusg g p� Recall bias� Abortion underreporting� Conflation of association with causation� Conflation of association with causation


Gaining Traction

Weitz 1/25/10


Policy Change

Weitz 1/25/10 Texas Information Booklet: “A Woman’s Right to Know”

“You should know that women experience different emotions after an abortion. Some women may feel guilty,emotions after an abortion. Some women may feel guilty, sad, or empty, while others may feel relief that the procedure is over. Some women have reported serious psychological effects after their abortion, including d i i f i t l d lf t tdepression, grief, anxiety, lowered self-esteem, regret, suicidal thoughts and behavior, sexual dysfunction, avoidance of emotional attachment, flashbacks, and substance abuse. These emotions may appear substa ce abuse ese e ot o s ay appeaimmediately after an abortion, or gradually over a longer period of time. These feelings may recur or be felt stronger at the time of another abortion, or a normal birth, or on the

i f th b ti ”anniversary of the abortion”


Validation from the Supreme Court

Weitz 1/25/10“Respect for human life finds an ultimate expression in the

bond of love the mother has for her child....While we find

no reliable data to measure the phenomenon, it seems

unexceptionable to conclude some women come to regret

their choice to abort the infant life they once created and

sustained…Severe depression and loss of esteem can

follow.”

Gonzales v Carhart, 2007


But the Evidence is Still the Same

Weitz 1/25/10 � 2008 APA report� Critical review of recent literature (2006)� “Women who have abortions have no greater risk of� Women who have abortions have no greater risk of

mental-health problems than if they deliver the pregnancy.”

UCLACommon Ground and Abortion Rights But focusing on reducing the need Weitz 1/25/10 for abortion increases the

legitimacy of these arguments at a i t l l lsocietal level


Weitz 1/25/10

H #2 N N d f S iHarm #2: No Need for Services

Real implications for access to careReal implications for access to care


Abortion Services Today

Weitz 1/25/10 � Only 1,787 abortion providers (facilities) remained in 2005� Abortion clinics (>50% of patient visits are for abortion

services) provide 71% of all abortions� 87% of U.S. counties have no abortion provider

� 35% of women live in these counties� 97% of counties in nonmetropolitan areas have no

provider� Significant maldistribution across and within states


Declining Number of Abortion Providers

Weitz 1/25/10

41% of counties arenow without

an abortion provider

Guttmacher Institute

UCLACommon Ground and Abortion Rights Access in CaliforniaWeitz 1/25/10

Bay Guardian, 10/10/06, Front Cover


No Solution in Common Ground Approach

Weitz 1/25/10

pp

� Focus is reducing need not meeting access goals� Further negates mandates for routine training

� Currently less than 50% of Ob/Gyn residency y y yprograms offer routing training

� Only 11 of 480 Family Practice programs acknowledge abortion in the curriculum

� No NP/CNM/PA training programs incorporate

� Limits our ability to critique reductions in accessy q


Further legitimizes efforts to restrict use of abortion

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� 1989/1992 shift from abortion as a fundamental right to “ d b d ” th h lda new “undue burden” threshold

� States allowed to demonstrate a preference against abortion

W iti i d t l i l t d t� Waiting periods, parental involvement, mandatory information, scripted provider speech

� Allowances for misinformation� Breast cancer (6 states)� Breast cancer (6 states)� Fetal pain (8 states)� Mental health consequences (7 states)


South Dakota

Weitz 1/25/10Physician must tell the woman that the abortion will

“terminate the life of a whole, separate, unique, living

human being; that the pregnant woman has an existing

relationship with that unborn human being, and that the

relationship enjoys protection under the United States

Constitution and under the laws of South Dakota; and that

by having an abortion, her existing relationship and her

existing constitutional rights with regards to thatexisting constitutional rights with regards to that

relationship will be terminated.”


Proliferation of Policies to Reduce Use and Provision of Abortion Care

Weitz 1/25/10and Provision of Abortion Care

Targeting the Woman Targeting the ProviderTargeting the Woman

� State-mandated information

Targeting the Provider

� Public facilities and employees exclusionsinformation

� Waiting periods (usually 24-48 hours)

� Two visit minimums

employees exclusions� Broad refusal clauses� TRAP laws

� Two visit minimums� Parental involvement� Funding Restrictions

� Hospital admitting privileges

� Abortion procedure bans� Mandated ultrasound

provision and viewing� Reporting requirements


Impact of Reduced Access

Weitz 1/25/10 � Increases gestational age at which abortions are performed� Medical risk� Costs� Emotional consequences


Timing of Abortion Differences by Race/Ethnicity*

Weitz 1/25/10

y y

70%

50%

60%

70%

30%

40%

50%

BlackHispanic

10%

20%

30% HispanicWhite

0%

10%

<8 weeks 9-12 weeks >12 weeks

* Data does not include CA and 3 other states


Timing Differences by Age*

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70%

80%

50%

60%

70%

<1515-19

30%

40%

50% 15 1920-1425-29>30

10%

20%

30% 30

0%

10%

< 8 weeks 9-12 weeks 13-20 weeks >21 weeks

* Data does not include CA and 3 other states


Weitz 1/25/10

Two Other Components of the C G d A dCommon Ground Agenda

No federal fundingNo federal fundingAllowances for denials of care


Health Care Compromise

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“I want to clear up - under our plan, no federal dollars will

be used to fund abortions, and federal conscience laws will

remain in place”

(Obama, Joint Session of Congress

on Health Reform, 2009).


State Medicaid Coverage for Abortion

Weitz 1/25/10

17 states use state funds for all or most medically necessary abortions17 states use state funds for all or most medically necessary abortions

AK, AZ, CA, CT, HI, IL, MA, MD, MN, MT, NJ, NM, NY, OR, VT, WA, WV.• 4 of these states provide such funds voluntarily•13 of these states do so pursuant to a court order•13 of these states do so pursuant to a court order


North Carolina’s Natural ExperimentsWeitz 1/25/10

� Cook et al, 1999� Examined impact of episodic lack of state funds for

indigent women’s abortions between 1980-1993� Happened at different times of the yearF d d i b i d i i� Found a decrease in abortion rates and an increase in birthrates when funds were not available

� Conclude that 37% of women who obtained an abortion on Medicaid would have continued theabortion on Medicaid would have continued the pregnancy if funds were not available

� 10% more abortions among black women and 1% more among white womeng

� Morgan and Parnell, 2002 added additional administrative variables� Approx 3% of white women and 5% of black women pp

would have carried a pregnancy to term without funding


Weitz 1/25/10

Who pays the price f fi di “for finding “common ground”?g


Denials of Information, Referral and Services

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� Refusal clauses, often called “conscience clauses,” in which institutions and individuals are shielded from liability for failing to provide health services, counseling and/or referrals because the individual or institution has an objection to the service; j

� Institutional prohibitions in which institutions override physician-patient decision-making and prohibit the provision of certain services in their facilities, refuse to cover those services in their insurance products orcover those services in their insurance products, or otherwise restrict services that meet evidence-based standards of care; and

� Political restrictions including those laws and regulations� Political restrictions including those laws and regulations that are enacted based on political ideology or electoral politics and mandate how health care must be delivered, where and how it can be delivered, or what care is covered by health care payerscovered by health care payers.


An Exercise of “Conscience”

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Carla who lives in eastern Oklahoma thought she had the flu. Her family doctor referred her to an Ob/Gyn who discovered she was pregnant and that she had a largediscovered she was pregnant and that she had a large mass growing on her uterus. The Ob/Gyn refused to remove the mass because it would endanger the pregnancy. The anesthesiologist in the practice group refused to give her any drugs that would harm therefused to give her any drugs that would harm the pregnancy. At this point the mass was shutting off her colon and bladder. Eventually Carla found a doctor in another city who found that after substantial delay, he had to remo e her ter s a proced re that o ld ha e beento remove her uterus, a procedure that would have been unnecessary if the abortion had been performed earlier in her pregnancy.

Carla was uninsured. Her hospital bill forthe abortion and the hysterectomy was

$40 000over $40,000.


A Snapshot of Institutional Prohibitions on Care

Weitz 1/25/10

� 43 states allow health care institutions to refuse to provide services� Only 1 state (California) limits that refusal to religious

health care entitieshealth care entities� Federal level—The Weldon Amendment to the

FY 2005 Appropriations bill limits the ability of federal, state, and local laws to mandate abortion carestate, and local laws to mandate abortion care


Catholic-Owned HealthCare Facilities

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� Broadest religiously-based health care restrictions � Control > 16% of the U.S. hospital beds� Serve 1 in 6 patients in the U.S.

� Governed by the Ethical and Religious Directives for� Governed by the Ethical and Religious Directives for Catholic Health Care Services (ERDs)� Promulgated by the U.S. Conference of Catholic

Bishops� Prohibit abortion, sterilization, contraceptives and

most forms of assisted reproductive technology� Contain no exceptions

� Many patients who seek care or physicians who provide care do not adhere to the beliefs of the Catholic Hierarchy


Example: PROM

Weitz 1/25/10

� Premature Rupture of Membranes (PROM)� Amniotic membranes rupture pre-term� Risk: infection sepsis maternal mortality� Risk: infection, sepsis, maternal mortality� < 24 weeks: only 30% fetuses survive� ACOG and AAP standard of care:

balance risk to woman v potential for fetal survival� balance risk to woman v potential for fetal survival� Ob/Gy must counsel about risks and woman must

decide whether to abort or attempt to continue pregnancy


Weitz 1/25/10

“And at this point their personal decision-making runs afoul of their hospital’s policies Inducing labor afoul of their hospital s policies. Inducing labor before membranes have ruptured, or before there is a maternal indication such as infection, is technically an abortion This hospital like most hospitals in the an abortion. This hospital, like most hospitals in the metropolitan area in which they live, has a strict non-elective-abortion policy…”

“You might wonder, reading this vignette, how I happen to know so many details about this case, or even whether this is a fictional teaching care that so bedevils medical student. The unfortunate truth is that this is real life: I am the husband in this story ”

Ramesh Raghavan, MD, PhDJAMA, 4/4/07

that this is real life: I am the husband in this story.


Prohibits Willing Doctors from Providing Care

Weitz 1/25/10

“I’ll never forget this; it was awful—I had one of my hi i 19 k [P f] hpartners accept this patient at 19 weeks. [Part of] the

pregnancy was in the vagina. It was over…. And so he takes this patient and transferred her to [our] tertiary medical center, which I was just livid about, and, you know, “we’re going to save the pregnancy.” So of course, I’m on call when she gets septic and she’s septic to the point that I’m pushing pressors on labor and delivery trying to keep her blood pressure up and I have her on a cooling blanket because she’s 106 degrees. And I needed to get everything out. And so I put the ultrasound machine on and there was still a heartbeat and [the ethics committee] wouldn’t let me because there was still a heartbeat. This woman is dying before our eyes…She was so sick she was in the ICU for about ten days and very nearly died… “

Freedman, Landy, & Steinauer,, 2008


Low-Income and Minority Women More Vulnerable to Prohibitions

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� Less choice of care providers� Default enrollment� Less capacity to advocate for alternatives� Catholic-owned facilities more likely to be in low-income� Catholic owned facilities more likely to be in low income

communities� Historical providers of charity care


Weitz 1/25/10

Does The Frequency of Abortion E M tt ?Even Matter?


Examples to the Contrary

Weitz 1/25/10 � Dr. Tiller

� South Dakota� South Dakota

� California parental consent

� Perhaps the best argument for abortion is its commonness� 1.2 million abortions per year� 1 in 3 women by age 45


Weitz 1/25/10

So is there room for any “common d”?ground”?

Common ground is different from common purposeCommon ground is different from common purposeDone without the expectation that it will depolarize the abortion debate in this countryImportant goals in their own right and not because theyImportant goals in their own right and not because they offer us a solution to the abortion wars

i.e. reducing poverty, increasing self-efficacy, etc.H lth f d b t t ht i f l lHealth care reform debate taught us a painful lesson

Support for prevention did not translate unto support for abortion

Shifti th ti f b ti t UPShifting the stigma from abortion to UP


Alternative Approach

Weitz 1/25/10 � Acceptance that abortion is a polarizing issue in the U.S.

� Acceptance that abortion has and will always be part of the human condition� Internationally abortion is common even where it is

highly restricted� Difference is safety and social validation of the

decision� Engage in the hard conversations about abortion

� Moral status of life� Rights and autonomy of women� Right of the state to limit decisionsg� Role of religion in public life


What Do We Value?

Weitz 1/25/10 � Women deserve the legal right to abortion� Women deserve to have an abortion(s) without

judgment� Women deserve high quality accessible and culturally

appropriate abortion care

U f t t l th h fUnfortunately the search for common ground moves us further away from achieving each of these objectivesachieving each of these objectives.

in trying to find common ground, do we hurt abortion rights?

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