The legal landscape for abortion is changing rapidly in Ohio, as it is in many states. Our governor recently signed into law a measure requiring as-yet-unspecified “viability testing” on women seeking abortions past 20 weeks. At least half a dozen other restrictive measures were recently passed or are on the horizon, including the “Heartbeat Bill,” which seeks to outlaw abortions as early as 6 weeks (before many women know they are pregnant). It’s unclear what this will all mean for clinics and for women. At my clinic, Preterm, the largest independent abortion provider in the state, women are calling us daily asking if abortion is still legal.
At the same time, Ohio clinics and our patients are now dealing with the effects of a restrictive law passed several years ago. Caught up in court challenges until last spring, this law dictates the way medication abortions—induced by a combination of mifepristone (mife), also known as RU-486, and misoprostol (miso)—must be performed in Ohio. It requires doctors to use an outdated FDA regimen, established during trials in the 1990s, instead of a lower-dose evidence-based regimen that has been used safely and effectively all over the U.S. for more than a decade.
Essentially, the FDA regimen shortens the time a medication abortion can be used from 63 days to 48 (or from 9 weeks of pregnancy to just under 7), triples the amount of mife used (and at $90 a pill that adds up!), and increases the required number of clinic visits from three to four, so that a doctor can watch the patient swallow the miso at the clinic rather than allowing her to dissolve it inside her cheek at home.
Our First Case
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The first medication abortion patient we saw at Preterm after the new regulations went into effect was exactly one day over the new legal limit for taking the combo of pills that is used to end an early pregnancy without surgical intervention. Denise had estimated that she was within the stipulated 48 days, but her ultrasound measured her at 49 days. “It took a lot of work for her to even get here,” explained Director of Counseling Samara Knox, “and she was really devastated when we told her she was too far.”
Denise had had a difficult time with her abortion decision. She was sure she could not keep the pregnancy, but she wrestled with the stigma, shame, and fear that so often surround abortion in our culture. She had decided that a medication abortion was the only kind of abortion she wanted. She wanted to pass the pregnancy at home, on her own terms and in her own space.
“She didn’t understand at first that we had to comply with the law,” Samara said.
“She thought it was just that it was less effective after 48 days, which is not true. We used to go to 63 days and it works just fine. She begged for us to fudge it, to just say she was 48 days. ‘I just want to try it,’ is what she kept saying, but we had to say no. It was terrible having to defend something I don’t believe.”
In the end, Denise chose to travel to another state where she could at least complete her abortion in the privacy of a hotel room, if not in her own home.
Since Denise, we’ve talked to dozens of women who are surprised, frustrated, and upset at the large increase in fees and the complicated rules that are putting a simple procedure out of their reach. The new regulations accomplish exactly what I assume was the unspoken intent of the people who wrote the law: to make the abortion process more burdensome for women and their doctors. It certainly does nothing to improve care or protect patients. Nor, ironically perhaps, does it change the numbers of abortions women are having.
More Hurdles, Same Number of Abortions
With the greater expense and scheduling difficulties, most Ohio women no longer have the option of a less invasive procedure and what some women perceive as a more private or somehow more natural or more self-directed abortion experience. Sure, if she has the privilege of early awareness of her pregnancy, financial resources, a flexible schedule, and a supportive partner or friend to drive her home on the day she takes her miso in the clinic, a woman can still have a medication abortion here.
But our typical patient doesn’t have those privileges. And even if she does, perhaps her flexible schedule isn’t quite flexible enough to make the exact clinic appointments we must offer her to comply with the law. Her first visit must be at least a day before the abortion, because of Ohio’s 24-hour waiting law. Then she has to be sure she can make the strict schedule for her next two appointments (the ones where she takes mife to alter the lining of her uterus and then returns exactly two days later to take the miso that causes her uterus to contract and expel the pregnancy) and be able to return 2 weeks after that for a follow-up exam. Or she may cease to find the option attractive when she learns that the FDA regimen might cause her more nausea or make her start cramping with contractions in the car before she even gets home.
For many women this amounts to an irritating inconvenience. They would have liked the medication, as increasing numbers of women across the country seem to, but they are fine with the surgical. An early surgical procedure is, after all, extremely safe and takes only a few minutes, and any discomfort involved is manageable with appropriate pain relief or relaxation.
Our clinic numbers attest to this. The number of medication abortions we perform has dropped steeply, but our overall number of abortions remains more or less the same.
But for some women the elimination of the medication option becomes a real burden. For a woman who has a history of sexual abuse or medical trauma, a surgical procedure might be particularly anxiety-producing. Other women have physical or medical issues that make a surgical procedure difficult. For instance, a woman might have large uterine fibroids or a stenotic cervix that is unusually narrow or almost closed. Normally, her doctor would have the latitude to recommend appropriate treatment based on clinical experience and expertise. Now the law dictates her treatment instead.
A Big Hassle and No Improvement of Care
From the clinic’s perspective, the law means that appointment center workers, patient counselors, and ultrasound technicians deal with more irritated or disappointed women. The 4-visit requirement makes staffing and scheduling more complicated. But more than anything, the law is a problem because it restricts our doctors from practicing according to their own professional training and experience.
According to Dr. Lisa Perreira, one of our doctors who is also on staff at a local hospital and in charge of training medical residents in reproductive health care, “This is the only area of medicine where the courts and politicians are regulating off-label use of medicines. Doctors use off-label meds all the time. We use beta-blockers for anxiety, and so on.”
“The FDA regimen works fine,” she continued. “But the evidence-based regimen is just as effective or even more effective, for less money, less medicine, less hassle. It doesn’t make any medical sense to go back to the old way of doing it, for nothing.”
Is There a Silver Lining?
There may be some unforeseen positives to this situation. For one, it is making some women angry without significantly restricting their access to abortion; some of them might be angry enough to become vocal pro-choice advocates. Beyond that, it is pushing some patients to be more honest with themselves about their abortions. This is a sensitive area, and not one that I would never say should be legislated, but it is useful to consider.
We know that some women perceive medication abortions to be different in meaning than surgical ones. Our patient advocates talk to women facing unplanned or other problematic pregnancies all day every day. They help them think through their options and help them make sure they are making the best decision for themselves at this point in their lives. One of patient advocates’ goals is to help women integrate their abortion experiences into their lives in a healthy and thoughtful way. This takes different forms for different women, of course, but we sometimes see women who are attracted to medication abortion because they believe it will mean they have had something “like a miscarriage” instead of being “the kind of woman who has an abortion.”
One woman we saw earlier this summer, I’ll call her Mary, came to her first appointment with a lot of complex emotions about her pregnancy and completely sure that she wanted only a medication abortion. During the ultrasound, the technician could find no evidence of pregnancy. This could have meant her dates were off and she was earlier than she thought or perhaps the pregnancy test was a false positive or it might have indicated a dangerous ectopic pregnancy. In any case, we had to reschedule her for another ultrasound later in the month to be clear about what was happening.
When Mary came back, the ultrasound showed her pregnancy, but now she was too far along to schedule her second and third appointments within the legal window. She was extremely upset and stormed out of the clinic with the angry declaration, “I will have this baby then. I don’t want it, but I am not having a surgical procedure!”
Mary went home and thought a lot about the situation she was in. She considered where she was in her own life and how she felt about the pregnancy and about the options before her. After a little more than a week, she came back and talked to the same patient advocate she yelled at the last time. Her advocate, Caitlin, recalled, “She’d had so much time to reprocess her decision and she had so much more clarity than she’d had before. She felt more optimistic, about the procedure itself and about what the abortion meant in her life. It was amazing.”
A few weeks after her abortion, Mary returned her follow-up questionnaire. She wrote about how the difficulty with the medication abortion seemed like it was almost meant to happen. The whole experience had been difficult but so eye opening, and she was grateful.
Don’t get me wrong. The new regulations are bad law and bad medicine. A woman should be able to choose a medication abortion for whatever reason she feels that she needs it. But on a larger cultural level, how much of her decision is influenced by the societal shame and stigma around abortion?
Maybe, just maybe, if we give them the right support, women who were playing into stigma by downplaying their abortions in their own minds will be pressed into doing the work they need to do to own and accept and integrate their abortions into their lives and sense of self, and perhaps they’ll feel stronger as a result. And maybe, just maybe, we’ll see some minute shift in how our society perceives abortion and the women who have them. This shift would be way too subtle for our anti-choice lawmakers to see but very gratifying for those of us who really care about women’s lives.