Increasing Access to Abortion Through Advanced Practice Clinicians: An Advocacy Agenda

Tracy Weitz

It is time to acknowledge that PAs, NPs and CNMs [collectively known as advanced practice clinicians (APCs)] are capable and qualified to provide abortion care services, but that current efforts to provide this care are thwarted by both the politics of health care and the politics of abortion.

This article originally appeared in the August edition of the journal Contraception.  It is co-authored by Tracy Weitz, Patricia Anderson, and Diana Taylor, all at the Bixby Center for GlobalReproductive Health at the
University of California, San Francisco (UCSF)
.  Bios and photos for Anderson and Taylor can be found by clicking on their names.

The
declining availability of abortion care has been the topic of many studies,
commentaries, conferences and advocacy initiatives over the last 20 years.
One of the ideas suggested to ameliorate this problem is to increase the number
of physician assistants (PAs), nurse practitioners (NPs), and certified nurse
midwives (CNMs) who perform first-trimester abortion.

While addressing access through
this strategy holds great promise, it is not simply a matter of access that
calls for more clinicians to participate in abortion care. Rather, as health
professionals, we should expect that professional scope of practice
determinations are based upon whether the “profession can provide this proposed
service in a safe and effective manner” and not solely on the lack of physicians available to provide the
service.

It is time to acknowledge that PAs, NPs and CNMs [collectively known
as advanced practice clinicians (APCs)] are capable and qualified to provide
abortion care services, but that current efforts to provide this care are
thwarted by both the politics of health care and the politics of abortion.
Outdated laws, restrictive
regulations, lack of clinical training opportunities, professional turf battles
and politically-motivated challenges impede APCs abilities to provide abortion
care. APCs, physicians, reproductive health and rights advocates and attorneys
must join together to promote the provision of abortion by APCs, thereby
protecting both women’s access to abortion care and practitioners’ rights to
provide essential care for their patients.

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APCs
have a long history of providing comprehensive reproductive health services
within primary care and family planning settings.  In 2004, APCs saw six times
as many women for publicly-funded family planning services as did physicians. Noteworthy is that APCs have been
providing abortions in some states since 1973 when abortion was nationally
legalized in the United States. There is a growing body of evidence that APCs are safe, efficacious
providers of abortion, via both medication and aspiration methods. Studies
published in 1986, 2004 and 2006, comparing abortions performed by physicians
to abortions performed by NPs and PAs found comparable rates of safety and
efficacy.

Despite
this evidence, many states have “physician-only” laws which prohibit the
performance of abortions by anyone other than licensed physicians. Some of
these laws were enacted around the time of Roe v. Wade in 1973 to protect women
from unsafe, unlicensed abortion providers. They predate the recognition of
APCs role in health care and the development of newer and simpler abortion
technologies.

These laws were never meant to prohibit the future evolving scope
of practice by APCs, but their presence “on the books” is a de facto
restrictive legacy. In recent years, abortion rights opponents have used
physician-only laws in Arizona, Missouri, North Dakota and Tennessee
specifically as a strategy to reduce access to abortion services by limiting
who can provide such care.
Usual
allies in opposition to abortion restrictions, such as regional offices of the
American College of Obstetricians and Gynecologists, fail to aggressively fight
these proposed restrictions in part due to their overall support for using the
political process to control the scope of practice of other health
professionals. Professional nursing and other allied health professionals also
fail to engage in challenging these laws, although their motivations stem more
from the desire to avoid the messy contested world of abortion politics.
Consequently, abortion opponents often find little resistance to their efforts
to restrict access to abortion through limiting scope of practice. This
editorial seeks to provide health care professionals with the tools for
engaging in these debates.
How is scope of
practice normally determined for APCs?

Scope
of practice can be understood as the activities that an individual health care
practitioner is permitted to perform within a specific profession and is
uniquely defined by the congruence between law and appropriate practice. The boundaries of scope of
practice are determined by clinical competence and skill, knowledge and
training, professional and institutional standards and legal-regulatory
requirements. Scope of practice evolves and changes over time due to community
needs and technology advancements, as well as health professional practice and
education standards, institutional policies and state laws or regulations.

Advancing scope of practice
requires evidence that a new skill or technique will facilitate access to safe
and effective health care services and that professional and educational
standards and competencies are consistent with a new area of practice.
Interpreting abortion to be
outside the scope of practice of CNMs, NPs and PAs, regardless of their
documented competence, runs directly counter to the normal manner is which
scope of practice assessments are made.

In
the United States, there are approximately 200,000 licensed CNMs, NPs and PAs
who today perform primary health care services once provided only by licensed
physicians. APCs specializing in reproductive health have acquired numerous
advanced skills that are now considered common practice, such as administering
paracervical anesthesia, performing ultrasounds, inserting intrauterine
contraception and conducting colposcopy and biopsies [as reflected in the numerous
educational programs offered to APCs by the Association of Reproductive Health
Professions (ARHP)].

Abortion care is a natural complement to these procedures
and practices. Integrating abortion into the care APCs provide holds the
potential to foster greater continuity of care, ensure earlier diagnosis and
termination of unintended pregnancy and promote women’s health and well-being.
Actions to support
including abortion in APC scope of practice
Advancing
abortion care within APC scope of practice depends on collaboration among
multiple stakeholders. Individual APCs, APC educators and employers, physician
allies as well as reproductive health advocates, professional organizations and
state regulatory groups must be part of the solution. Professional
organizations play a critical part with state licensing boards and legislatures
in developing, maintaining and advancing professional practice. The following
strategies highlight a few ways for APCs to participate in his/her professional
organization and to work with others in bringing the professional voice to
scope of practice conversations at the state and national level:

  • Become involved in your
    professional organization and take leadership in developing, maintaining, and advancing professional standards and responsibilities. If the professions fail to provide leadership, the licensing boardspan and legislatures will take the lead.
  • Become active in your national organization’s state chapters and practice committees; they play an important role in the implementation, review and revision of regulatory and credentialing documents. 
  • Build relationships with members of
    your state professional association before there is a scope of practice debate rather than waiting to act until a crisis presents itself.
    Read your state’s professional practice act and know how scope of practice is defined in statutes and regulations.
    Understand regulatory board functions, as well as the roles of board members, when advocating for change.
  • Check to see if your state regulatory
    board has developed guidelines for advancing scope of practice and know the
    procedures.
  • Get to know your nursing, medical
    and/or healing arts boards.
  • Volunteer to help your boards and
    serve on committees. Develop a better understanding of the issues or
    limitations that affect both the public and health professional groups.
  • Learn about board processes and the
    mechanisms used to regulate and advance scope of practice.
  • Attend a board public meeting to observe the process in action and get to know board members and colleagues from
    around the state.
  • Obtain the minutes from public
    meetings; in many states they are available online.
  • If you are a clinician, develop a
    professional portfolio that documents abortion care competencies and
    experience.
  • Describe your professional skills
    and profile your major accomplishments. All health professionals — whether APCs
    or physicians — are responsible for compiling essential documents and
    credentials that authorize them to practice.
  • As an educator or trainer, help develop
    abortion care education and training programs.
  • Serve as a resource to regulatory
    boards, which look to NP, CNM and PA educators for reproductive health
    standards and clinical competencies when assessing whether a procedure is
    within APC scope of practice.
  • Continue your dedication to
    high-quality education by aligning educational curriculum and core competencies
    in women’s and reproductive health with those for unintended pregnancy
    prevention, including abortion care.
  • Consider working closely with multi-disciplinary
    professional organizations that support linkages in education between all
    members of the health care team, such as the ARHP.
  • Educate legislators and
    policy-makers, testify before legislative committees and draft public
    statements in support of abortion care as part of the scope of practice for all
    health professionals who care for women at risk for unintended pregnancy.

APCs as abortion providers can make early abortion care more accessible, but their
practice in this arena is not simply a solution to the problem of access but a
natural advancement in scope of practice based on professional expertise. APCs,
their physician colleagues and reproductive health advocates need to actively
engage in the larger debates about scope of practice. Together we can ensure
that health policy decisions about who can provide abortions to whom and under
what circumstances are determined by evidence and not by the either the
politics of abortion or the politics of health care.

References used for this article include:

1.   
National
Abortion Federation. Who will provide abortions? Ensuring the availability of
qualified practitioners. Washington, DC: National Abortion Federation; 1991.

2.   
Darney
PD. Who will do the abortions?. Womens Health Issues. 1993; 3:
158–161.

3.   
Grimes
DA. Clinicians who provide abortions: the thinning ranks. Obstet Gynecol.
1992; 80: 719–723.

4.   
Joffe
C, Yanow S. Advanced practice clinicians as abortion providers: current
developments in the United States. Reprod Health Matters. 2004; 12 (24
Suppl): 198–206.

5.   
Samora
JB, Leslie N. The role of advanced practice clinicians in the availability of
abortion services in the United States. J Obstet Gynecol Neonatal Nurs.
2007; 36: 471–476.

6.   
Kruse
B. Advanced practice clinicians and medical abortion: increasing access to
care. J Am Med Womens Assoc. 2000; 55 (3 Suppl): 167–168.

7.   
Changes
in Healthcare Professions’ Scope of Practice: Legislative Considerations. https://www.ncsbn.org/ScopeofPractice.pdf
[Accessed April 14, 2009]: The Association of Social Work Boards, The
Federation of State Boards of Physical Therapy, The Federation of State Medical
Boards, The National Association of Boards of Pharmacy, The National Board for
Certification in Occupational Therapy, The National Council of State Boards of
Nursing, Inc.; 2007.

8.   
Taylor
D, Safriet B, Weitz T. When politics trumps evidence: legislative or regulatory
exclusion of abortion from advanced practice clinician scope of practice. J
Midwifery Womens Health
. 2009; 54: 4–7.

9.   
Frost
JJ, Frohwirth L. Family Planning Annual Report: 2004 Summary Part 1. Report to
the Office of Population Affairs, U.S. Department of Health and Human Services.
Washington DC: The Alan Guttmacher Institute; 2005.

10. Donovan P. Vermont physician
assistants perform abortions, train residents. Fam Plann Perspec.
1992; 24: 225.

11. Freedman MA, Jillson DA, Coffin RR,
Novick LF. Comparison of complication rates in first trimester abortions
performed by physician assistants and physicians. Am J Publ Health.
1986; 76: 550–554.

12. Goldman MB, Occhiuto JS, Peterson
LE, Zapka JG, Palmer RH. Physician assistants as providers of surgically
induced abortion services. Am J Publ Health. 2004; 94: 1352–1357.

13. Warriner IK, Meirik O, Hoffman M,
et al. Rates of complication in first-trimester manual vacuum aspiration
abortion done by doctors and mid-level providers in South Africa and Vietnam: a
randomised controlled equivalence trial. Lancet. 2006; 368: 1965–1972.

14. Safriet BJ. Closing the gap between
can and may in health-care providers’ scopes of practice: A primer for
policymakers. Yale J Regul. 2002; 19: 301–334.

15. Milstead JA. Health policy and
politics: a nurse’s guide. 3rd ed. Sudbury, MA: Jones and Bartlett Publishers;
2008.

16. Schuiling KD, Slager J. Scope of
practice: freedom within limits. J Midwifery Womens Health. 2000; 45:
465–471.

17. Taylor D, Safriet B, Dempsey G,
Kruse B, Jackson C. Providing abortion care: A professional toolkit for
nurse-midwives, nurse practitioners and physician assistants. San Francisco:
University of California, San Francisco; 2009.

 

 

Analysis Abortion

Data Shows Surge in Texans Traveling Out of State to Get an Abortion

Teddy Wilson

A Rewire analysis has found that while Texas data shows there has been a decline in the number of abortions in the state, data from other neighboring states suggests there has been a dramatic increase in the number of Texans traveling out of state to access abortion care since the passage of HB 2 in 2013.

Last week, the Texas Department of State Health Services (DSHS) was accused by the American Civil Liberties Union (ACLU) of Texas of deliberately attempting to conceal abortion statistics from 2014, the first full year provisions of the state’s omnibus abortion law were in effect.

DSHS has yet to respond to a letter from the ACLU of Texas demanding that the agency make those statistics available to the public.

The news comes as the Supreme Court is set to issue a ruling on Whole Woman’s Health v. Hellerstedt, which challenges provisions of the abortion law, HB 2, which lawyers of the abortion clinics argue place an undue burden on patients and providers in the state, impeding their ability to provide or access constitutionally protected health care.

DSHS officials finalized the statistics in March, according to the ACLU in a statement, but they have yet to release the full statistics to the public.

“The details are being reviewed for accuracy,” Carrie Williams, director of media relations for DSHS, told Rewire. “We did release the provisional total several months ago but can’t release the underlying details until they are final.”

Even without those details, a Rewire analysis has found that while DSHS data shows there has been a decline in the number of abortions in the state, data from other neighboring states suggests there has been a dramatic increase in the number of Texans traveling out of state to access abortion care since the passage of HB 2 in 2013.

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The number of abortions in Texas has been steadily decreasing since 2008, according to data from DSHS: Over the six-year period, the number has declined by nearly 22 percent. There were 81,591 abortions in 2008, 77,850 in 2009, 77,592 in 2010, 72,470 in 2011, 68,298 in 2012, and 63,849 in 2013.

Around that time, the number of Texans who traveled out of state to have abortions also steadily decreased, by nearly 57 percent from 2008 to 2012. There were 225 patients who had abortions out of state in 2008, 220 in 2009, 129 in 2010, 138 in 2011, and 97 in 2012, according to DSHS.

In 2013, the year Gov. Rick Perry (R) signed HB 2 into law, the number of Texans who traveled out of state to have an abortion increased to 681more than the previous four years combined. Prior to the implementation of HB 2, there were 41 facilities providing abortion services in the state, and 16 of those facilities had either closed or stopped providing abortion services by the end of 2013.

Trisha Trigilio, staff attorney at the ACLU of Texas, told Rewire that the statistics for out-of-state abortions for Texans are concerning. “This is more evidence of what was already proven in court: Texas’ onerous regulations unnecessarily block access to safe, legal abortion in our state,” Trigilio said in an email to Rewire.

Specifically, a study from the Texas Policy Evaluation Project showed the implementation of HB 2 has increased travel distances to clinics, out-of-pocket costs, and overnight stays.

At least 400 more patients traveled outside of Texas to have an abortion in 2014 than did in 2013, according to Rewire‘s analysis. Data collected by the state health departments of Arkansas, Kansas, Oklahoma, and Louisiana shows that at least 1,086 patients traveled to those states from Texas to obtain an abortion after portions of HB 2 took effect.

“Based on this [analysis from Rewire], it’s clear that this law doesn’t make women safer, it forces them to travel across the Texas border to get the care they need—and for women who can’t afford to leave the state, Texas law may prevent them from seeing a doctor at all,” Trigilio continued.

Texas Patients Seeking Out-of-State Abortions

In the wake of HB 2, more than half of the clinics that provide abortion services in Texas have been forced to close, leaving large swaths of the state without access to legal abortion care. The majority of the clinics that have remained open are located in major metropolitan areas: Austin, Dallas/Fort Worth, Houston, and San Antonio.

As clinics that once served rural areas have closed, patients have been forced to drive hundreds of miles away from their homes to one of the state’s major cities or cross the border into neighboring states. 

Arkansas has seen a slight increase since the passage of HB 2 in the number of patients from Texas seeking abortion care.

Arkansas’ Health Statistics Branch of the state health department tracks the number of patients from out of state who have abortions. There were 21 from Texas in 2012, 25 in 2013, 41 in 2014, and 33 in 2015.

Kansas has also seen a slight increase in the number of Texas patients seeking abortion care, according to statistics published by the Kansas Department of Health and Environment. There were two patients from Texas who traveled to Kansas to obtain an abortion during 2012, 13 in 2013,  23 in 2014, and 24 in 2015.

Oklahoma saw a noticeable increase in the number of patients from Texas seeking abortion care there after the passage of HB 2, according to data from the Oklahoma State Department of Health annual abortion surveillance report.

There were 21 patients from Texas who had an abortion during 2012 in Oklahoma, 59 in 2013, 136 in 2014, and 131 in 2015.

Based on Rewire‘s analysis, it seems as if no other state has seen a larger increase in patients from Texas seeking abortion care than Louisiana.

The Louisiana Department of Health and Hospitals (DHH) publishes data on abortions performed there collected by the State Center for Health Statistics (SCHS), but has typically not published data on the number of patients who live outside the state who have an abortion in Louisiana.

Preliminary SCHS figures for 2015 provided to Louisiana Right to Life, a state affiliate of the anti-choice organization National Right to Life Committee, included data on patients from out of state who obtained abortions in Louisiana.

There were 9,311 abortions performed in Louisiana during 2015, and patients from out of state accounted for 1,362 of all abortions performed in the state, according to DHH data published by Louisiana Right to Life.

The data did not include the states of residency for the patients from out of state, which the organization noted is “not available at this time.”

However, preliminary SCHS figures for 2014 provided to the Louisiana Right to Life did include details on the states of residency for patients who had an abortion in Louisiana. There were 10,211 abortions performed in Louisiana during 2014, and patients from out of state accounted for 1,432 of all abortions performed in the state.

Out of the 1,432 abortions had by residents from out of state, 886 were from Texas.

More and more pregnant people are traveling to New Mexico to access abortion care. About 20 percent of the roughly 4,500 abortions performed there in 2014 involved out-of-state patients, according to state health department data reported by the Albuquerque Journal.

Brittany Defeo, program manager with the aid group New Mexico Religious Coalition for Reproductive Choice, previously told Rewire that the people she assists represent a wide range of ages and backgrounds. “They’re ages 18 to 40. It’s all walks of life,” Defeo said.

Defeo estimates that approximately one third of those seeking abortion services in New Mexico from out of state are from Texas. If estimates are correct, that would suggest that approximately 300 patients traveled from Texas to New Mexico to obtain abortion care in 2014. 

Natalie St. Clair, who assists patients seeking abortion care with nonprofit Fund Texas Choice, told the Texas Observer that she helps about ten clients per month travel to New Mexico to access abortion care. St. Clair explained to the Observer that clients often express shock over the barriers in Texas to accessing  abortion care.

“I hear a lot of ‘I had no idea that the laws were this way. I have to go out of state?’ There’s a lot of shame and guilt because people think it’s their fault, or they weren’t prepared enough,” St. Clair said. “I explain that [Texas laws] are set up this way on purpose … [They’re] making abortion inaccessible on purpose.”

Trigilio told Rewire that this data shows that HB 2 was never about protecting patients’s health and safety as proponents have claimed. “When a woman makes the deeply personal decision to have an abortion, she needs access to safe medical care and respect for the decision she has made. HB 2 impedes that,” the ACLU of Texas staff attorney said.

Culture & Conversation Abortion

The Comic Book That Guided Women Through Abortion Months After ‘Roe’

Sam Meier

Abortion Eve used the stories of fictional girls and women to help real ones understand their options and the law. At the same time the comic explained how to access abortion, it also asserted that abortion was crucial to women's health and liberation.

“Can you picture a comic book on abortion on the stands next to Superman?”

In June 1973, Joyce Farmer and Lyn Chevli wrote to the National Organization for Women in Chicago, asking this question of their “dear sisters” and pushing them to envision a world where women’s experiences could be considered as valiant as the superhero’s adventures. They enclosed a copy of their new comic book, Abortion Eve.

Published mere months after the Supreme Court’s January 1973 Roe v. Wade ruling, Abortion Eve was intended to be a cheap, effective way to inform women about the realities of abortion. Like the few other contemporaneous comic books dealing with abortion, Abortion Eve‘s primary purpose was to educate. But for a comic dominated by technical information about surgical procedures and state laws, Abortion Eve nonetheless manages to be radical. Though abortion had so recently been illegal—and the stigma remained—the comic portrays abortion as a valid personal decision and women as moral agents fully capable of making that decision.

The comic follows five women, all named variations of “Eve,” as counselor Mary Multipary shepherds them through the process of obtaining abortions. Evelyn is an older white college professor, Eva a white dope-smoking hippie, Evie a white teenage Catholic, Eve a working Black woman, and Evita a Latina woman. Evelyn, Eve, and Evita are all married and mothers already.

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Their motivations for getting an abortion differ, too. Evita and Eve, for instance, wish to protect themselves and their loved ones by keeping their families smaller. Sixteen-year-old Evie is the poster child for sexual naiveté. Pregnant after her first time having sex, she spends most of the comic wrestling with guilt. “It’s all so ugly!” she exclaims. “I thought sex was supposed to be beautiful!”

Teenager Evie, one of the characters in the comic book Abortion Eve, breaks down as counselor Mary Multipary asks questions about her pregnancy. (Joyce Farmer)

Nonplussed, the older Eves talk her through her choices. As Eve reminds her, “Like it or not, you are a woman now, and you are going to have to decide.”

In an interview with Rewire, Farmer said that the plot of Abortion Eve was a direct outgrowth of her and Chevli’s experiences in the nascent women’s health movement. Both women had started working as birth control and “problem pregnancy” counselors at the Free Clinic in Laguna Beach, California, soon after it opened in 1970. Archival documents at Indiana University’s Kinsey Institute show that Chevli and Farmer visited Los Angeles abortion providers in December 1972, on a business trip for the Free Clinic. According to Farmer, one of the doctors they met approached the pair with the idea of doing a comic about abortion to publicize his clinic.

Earlier that year, the women had produced one of the first U.S. comic books written, drawn, and published by women, Tits & Clits alpha (the “alpha” distinguished the comic from subsequent issues). So they took the doctor’s idea and ran with it. They decided to use their newly founded comics publishing company, Nanny Goat Productions, to educate women, particularly teenagers, about abortion.

At the Free Clinic, Chevli and Farmer had seen all kinds of women in all kinds of situations, and Abortion Eve attempts to reflect this diversity. As Farmer noted in an interview, she and Chevli made sure that the Eves were all different races, ages, and socioeconomic backgrounds in order to demonstrate that all kinds of women get abortions.

Farmer had made the choice to get an abortion herself, when her IUD failed in 1970. The mother—of a 12-year-old son—who was putting herself through college at the University of California at Irvine, she decided that she couldn’t afford another child.

California had liberalized its abortion laws with the Therapeutic Abortion Act of 1967, but the law was still far from truly liberal. Before Roe, California women seeking abortions needed doctors (a gynecologist and two “specialists in the field”) to submit recommendations on their behalf to the hospital where the abortion would take place. Then, a committee of physicians approved or denied the application. Only women who could pay for therapeutic abortions—those needed for medical reasonscould get them.

For Farmer, as for so many others, the process was onerous. After an hour, the psychiatrist who had interviewed her announced that she would not be eligible, as she was mentally fit to be a mother. Stunned, Farmer told the doctor that if he denied her an abortion, she would do it herself. Taking this as a suicide threat, her doctor quickly changed his mind. She wrote later that this experience began her political radicalization: “I was astounded that I had to prove to the state that I was suicidal, when all I wanted was an abortion, clean and safe.”

Farmer and Chevli began work on Abortion Eve before Roe v. Wade, when abortion was still illegal in many states. After the Supreme Court’s decision, they added a page for “more info” on the ruling. Yet even as they celebrated Roe, the women weren’t yet sure what would come of it.

The comic reflects a general confusion regarding abortion rights post-Roe, as well as women’s righteous anger over the fight to gain those rights. On the day of her abortion, for example, Evita tells Eve that, at five months pregnant, she just “slipped in” the gestational limits during which women could have abortions.

Eve explains that women now have the right to an abortion during the first three to six months of a pregnancy, but that the matter is far from settled in the courts. After all, Roe v. Wade said that states did have some interest in regulating abortion, particularly in the third trimester.

“I get mad when they control my body by their laws!” Eve says. “Bring in a woman, an’ if the problem is below her belly button and it ain’t her appendix, man—you got judges an’ lawyers an’ priests an’ assorted greybeards sniffin’ an’ fussin’ an’ tellin’ that woman what she gonna do an’ how she gonna do it!”

Abortion Eve Dialogue

Abortion Eve confronts the reality that abortion is a necessity if women are to live full sexual lives. Writing to the underground sex magazine Screw in September 1973 to advertise the comic, Chevli noted, “Surely if [your readers] screw as much as we hope, they must have need for an occasional abortion—and our book tells all about it.”

Six months after they published the comic, in December 1973, Chevli and Farmer traveled to an Anaheim rally in support of Roe outside the American Medical Association conference. They were met by a much larger group of abortion opponents. Chevli described the scene in a letter to a friend:

300 to 8. We weren’t ready, but we were there. Bodies … acquiescing, vulnerable females, wanting to show our signs, wanting to be there, ready to learn. Oh, Christ. Did we learn. It was exhausting. It was exciting. We were enervated, draged [sic] around, brung up, made to feel like goddesses, depressed, enlightened … bunches of intangible things. I have rarely experienced HATE to such a massive extent. 

That wasn’t the last feedback that Chevli and Farmer received about their views on abortion. In fact, during the course of Nanny Goat’s publishing stint, the majority of complaints that the independent press received had to do with Abortion Eve. Several self-identified Catholics objected to the “blasphemous” back cover, which featured MAD Magazine‘s Alfred E. Neuman as a visibly pregnant Virgin Mary with the caption: “What me worry?”

As archival documents at the Kinsey Institute show, other critics castigated Chevli and Farmer for setting a bad example for young women, failing to teach them right from wrong. One woman wrote them a letter in 1978, saying “You have not only wasted your paper, time, money, but you’ve probably aided in the decision of young impressionable girls and women who went and aborted their babies.”

Farmer and Chevli responded to such charges by first thanking their critics and then explaining their reasons for creating Abortion Eve. In another response, also in the Kinsey archives, Chevli wrote, “Whether abortion is right or wrong is not our concern because we do not want to dictate moral values to others. What we do want to do is educate others to the fact that abortion is legal, safe, and presents women with a choice which they can make.”

Today, abortion opponents like Louisiana Rep. Mike Johnson (R) frame abortion as the “dismemberment” of unborn children, suggesting that women who seek abortions are, in essence, murderers. With Abortion Eve, Chevli and Farmer dared to suggest that abortion was and is an integral part of women’s social and sexual liberation. Abortion Eve is unapologetic in asserting that view. The idea that abortion could be a woman’s decision alone, made in consultation with herself, for the good of herself and of her loved ones, is as radical an idea today as it was in the 1970s.