Jill Clements was 37 and living in downtown Wichita when she found herself unexpectedly pregnant for the second time in her life. Her first abortion, three years earlier, in 2010, had been a disaster: Alone and broke, Clements had driven 250 miles through a blizzard to get to a Planned Parenthood. Not wanting to relive the experience, she reached out to her primary care doctor with the hope he could refer her to a local ob-gyn to terminate her pregnancy, then only six weeks along.
Wichita was—and still is—politically conservative. In 2009 an antiabortion extremist assassinated one of Wichita's most prominent abortion doctors, George Tiller, while he attended church just a few blocks from Clements’ apartment. Still, she was hopeful that she'd be able to find someone competent and close to home to perform her procedure. Her primary care doctor referred her to an ob-gyn nearby, but only after saying, “Maybe this baby is God's plan for your life,” according to Clements.
At the ob-gyn appointment, things took a turn for the worse. After performing an ultrasound and a pelvic exam, the doctor left the room and returned with a nurse who presented her with a stack of pamphlets. “We understand you are considering adoption,” he said.
At first Clements was too stunned to speak. “I hadn't breathed a word about adoption to anyone, and that wasn't at all what I was considering,” she says. “But they were acting like it was the only option I had.”
Clements left the office quickly and started researching, eventually finding a female doctor who she hoped would understand. But when she showed up for her appointment a few days later, she was again disappointed. “She sympathized with me and she listened, but then she shook her head and told me she couldn't help,” Clements says. The doctor also wouldn’t refer her to another doctor in the area who would perform the abortion, she adds: “Looking back, I think she was scared. It had only been a few years since Dr. Tiller's murder, and I can't imagine that it wasn't on her mind. She seemed like she wanted to help me, but in the end she didn't.” Sobbing, Clements left her office and went home.
A Common Problem
Across the country patients like Clements request abortion services from their ob-gyns and are routinely denied. In a recent survey from the journal Obstetrics & Gynecology, researchers found that although the majority of ob-gyns have encountered patients seeking an abortion, only 24 percent of them actually perform the procedure themselves.
A major contributing factor: They aren’t being trained. One 2013 survey found that out of 161 physician residency programs across the United States, only half provided abortion training as part of their standard curriculum. (Some programs have “opt-in” abortion training.)
In some cases doctors are outright barred from learning or performing the procedure. A 2016 report from the ACLU found that one in six U.S. hospital beds fall under the rule of directives from Catholic hospitals, which “prohibit a range of reproductive health services, including contraception, sterilization, many infertility treatments, and abortion, even when a woman’s life or health is jeopardized by a pregnancy.” In some states more than 40 percent of hospitals have to abide by these rules.
That’s part of a deeper issue: Abortion care is often viewed as separate from mainstream medicine, a view that’s been percolating since abortion was legalized in 1973, says Lori Freedman, a researcher studying reproductive health care access at the University of California, San Francisco (UCSF), and author of Willing and Unable: Doctors’ Constraints in Abortion Care.
Even with the proper training, there is still a troubling lack of physicians willing or able to provide abortions. The “incredible hostility toward abortion in our country,” in particular, Freedman says, matters. “[Ob-gyns] are taking on a lot of professional and personal risk if they decide to provide abortions—most work in a private medical context and are worried about losing business if there are protestors or a community backlash.” Not to mention the threat of physical violence. To date, 11 people have been killed by antiabortion terrorism in the United States, and incidents of harassment at clinics are on the rise.
The result? Many ob-gyns, even in progressive areas, can’t or won’t provide abortions—whether they support a woman’s right to the procedure or not.
Gagged
Of course, it’s not just a matter of training or personal choice for physicians: Many doctors who want to provide abortions find themselves facing legal hurdles. Earlier this month Alabama’s governor signed into law one of the strictest abortion bans in the country. If allowed to go into effect, it would make getting or performing an abortion (with few exceptions) a felony, punishable by prison time. “These regulations and threats of criminalization prevent doctors from providing the health care they want to—and are trained to—provide,” says Carley Zeal, an ob-gyn in Missouri and a fellow with Physicians for Reproductive Health.
Outside of criminalization, there are gag rules, which prohibit providers who receive federal funding from even discussing abortion with their patients. “The people I serve rely on me to be honest with them and present them with all of their options, and these gag rules prevent me from being an objective provider,” Zeal says. Many practitioners in Missouri have had to refer patients out to specialists for “second opinions” even when the patient is clear they want an abortion, she adds: “These providers fear the consequences of direct referrals to family planning clinics, so the patient instead has another unnecessary consultation instead of getting the health care they are seeking where and when they need it.”
Other states allow abortion but make the procedure harder to access via targeted restrictions on abortion providers, or TRAP laws—extraneous rules like the size of the room in which the abortion is performed or the width of the corridors in the building. Despite the fact that they often have no medical basis, TRAP laws keep doctors from providing care, says ob-gyn Carrie Cwiak, director of Family Planning at Emory University in Atlanta. “There is no medical reason abortion needs to be marginalized,” she says. “It’s a common procedure, it’s a safe procedure to do in office, and it’s restricted because of political reasons, not safety ones.”
Other methods of gagging doctors are less straightforward: “Sometimes within a practice group," says ob-gyn Daniel Grossman, a medical researcher and professor of obstetrics and gynecology at UCSF, "there might be senior physicians who say that nobody can provide this service. Other times there are restrictions related to the lease where the office building is located, especially if it's a medical office building associated with a religiously affiliated association.”
Victoria Barrett, then 39, came up against this restriction when she found herself faced with the decision to abort a much-wanted pregnancy in 2013. At 14 weeks she learned that the fetus carried a chromosomal abnormality called trisomy 13, which causes severe intellectual and physical birth defects. Most infants born with trisomy 13 die within the first few weeks. Her ob-gyn was kind and compassionate but was unable to provide the abortion herself because of her affiliation with a large Catholic hospital in their area. “I think she regretted that she wasn't able to help me through it,” Barrett says. Instead the ob-gyn referred her to a male doctor in the area who could perform the abortion in a public hospital in Indianapolis, not far from where she lived.
Barrett has no regrets about the procedure, completed at 15 weeks, but it's one she still wishes her own doctor could have performed. “I would have never voluntarily gone to a male ob-gyn given the choice," she says. "But to my knowledge he was the only one available for a second-trimester procedure.” On top of that, she found herself having to navigate an unfamiliar hospital system and to transfer her medical files to the public hospital in the midst of her grief. Glancing at one of the pages, she accidentally discovered the sex of the fetus—information she had not wanted to know. “I would have had more preparation and more agency in each step of my care had I been with my regular providers,” she says. “It would have been so different.”
Finding Care
So what can women in need of an abortion do to get care? “Patients might not have the option, but if you can, switch [providers],” Cwiak says. “You deserve someone who listens to you and values your choices.” She recommends calling reputable organizations, such as Planned Parenthood, the National Abortion Federation, or the National Network of Abortion Funds, who can help find abortion clinics local to your area (and provide financial assistance). If your doctor won’t perform the procedure, “understand it has nothing to do with your value as a person,” Cwiak says. “You are valuable regardless of your doctor’s decision.”
For two weeks after her second ob-gyn visit, Clements wavered between aborting the pregnancy and carrying it to term. “You could say that I took the time to decide, but really it was the treatment I got from the local ob-gyns that caused me to doubt my original decision and delay it,” Clements says. In the end, she decided termination was best.
“It makes me angry, looking back,” she says. “I would have had a termination at six weeks, if I'd had access.” Instead, Clements was just one day shy of 14 weeks and visibly pregnant when she had her abortion at a Planned Parenthood—the same one she had driven three hours through a blizzard to access in 2010. “I went through everything again: the six-hour round-trip drive, the hotel rental, the meals out, the days off work,” she says. And thanks to the delay in treatment, her abortion was riskier too: For each additional week an abortion is delayed after the first two months, the risk of complications increases by 38 percent.
The experience left Clements distrustful. “I really believed that an ob-gyn would be someone I could approach who could at least tell me all of my options,” she says. “I thought it was a safe place, and I don't feel like that anymore.”
When she and her husband decided to carry a pregnancy to term in 2016, she made sure to find a provider who offered the whole spectrum of reproductive care—prenatal, delivery, and abortion. “I wanted to know that if I did end up needing to terminate—God forbid—that they would respect my decision and that they'd help me,” says Clements. “If I hadn't found someone like that, to be honest, I don't think I would have trusted them to touch me.”
Sarah Watts is a writer in Chicago covering health and science. Follow her at @swattswrites.
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