Commentary Abortion

Pivotal Positions: Transforming Abortion Provider Stigma

Stigma Shame and Sexuality Series

Few of us would sign up for a job that would pose risks to our personal safety and our family’s safety. Yet that is exactly what many—if not most—health-care providers sign up for when they decide to deliver abortion care in the United States.

This post is by Jennifer Coletti, and is part of Tsk Tsk: Stigma, Shame, and Sexuality, a series hosted by Gender Across Borders and cross-posted with Rewire in partnership with Ipas.

Few of us would sign up for a job that would pose risks to our personal safety and our family’s safety, threaten to stifle or derail our career, cause our community to ostracize us, and cause us to continually face judgment and stereotyping from people we see every day. Yet that is exactly what many—if not most—health-care providers sign up for when they decide to deliver abortion care in the United States. And it’s the same for providers in many countries around the world. 

The tentacles of social disapproval around abortion don’t end with women, but reach everyone—including family and community, all the way up to hospital administrators and lawmakers. Within this complex web of influences, abortion providers wage a daily battle to provide safe abortion care to women.

“Providers are not all on their own,” explains Anu Kumar, Ipas executive vice president. “They’ve got to relate to the health system, the legal system and the educational system, and they’ve got their bosses and their family. So it’s not so simple. When you walk into the provider’s office, you’re not getting just that person, you’re getting the institution behind that person.”

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Of course, abortion providers experience stigma in drastically different ways depending on their country and community. For example, in Uruguay abortion providers may be viewed as accomplices to murder due to deep-seated Catholic opposition to the procedure there. On the other hand, communities in Zambia tend to respect the professional judgment of abortion providers but severely disapprove of women who seek them. And provider experiences differ vastly even within the United States: Some physicians who work in more progressive urban settings face less discrimination and fewer social effects of stigma than their counterparts working in conservative rural communities.

Guts Has Nothing to Do with It

Given the complicated history of U.S. abortion politics, Americans often assume that physicians who provide abortion believe it’s morally acceptable and have the guts to go through with it, while those who do not are morally opposed and/or intimidated by society’s stigma. But in truth, who provides abortion in the United States often has little to do with moral or political resolve. For her book Willing and Unable: Doctors’ Constraints in Abortion Care, author and University of California, San Francisco researcher Lori Freedman interviewed physicians practicing obstetrics and gynecology nationwide and found many providers who were willing to perform abortions but unable to overcome the structural barriers that abortion stigma and U.S. politics create.

“While several of these physicians would have liked to continue to perform abortions after residency and even took steps toward it, they found that there would be significant professional and social costs in doing so—costs that they were not willing to bear,” Freedman writes. Professional obstacles cited by physicians included workplaces with an anti-abortion climate; the surprisingly widespread “no-abortion policies” that quietly exist in many private practices, HMOs, and hospitals across the country; the risk of being pigeonholed as just an abortion provider; and the risk of being ostracized by the local medical community and patient population. On a more personal level, some physicians worried that providing abortions would cause their families to suffer discrimination and even danger.

In addition, many providers are stigmatized by the very patients who come to them for abortions. Physicians who staff specialized abortion clinics report disheartening interactions with patients who ask “How do you do this on a regular basis?” or “Isn’t this really hard for you?” Even though these patients are willing to have abortions, they have absorbed society’s beliefs about abortion providers and convey that to their doctors.

Specialized Clinics: Separate but Not Equal

Separation is a hallmark of any stigmatized practice, and the fact that 93 percent of abortions are now performed at specialized clinics is no accident. Years of abortion prohibitions, threats and a professional medical culture that refuses to treat abortion inclusively has caused “multilevel, institutionalized buck-passing that marginalizes abortion practice,” Freedman writes.

While specialized abortion clinics are often able to cultivate a more positive environment for women in need of services, their complete separation from all other health-care facilities only perpetuates the idea that abortion is not a “normal” part of women’s reproductive health care. And now that abortion practice is firmly established as a very separate type of patient care, there are professional incentives for providers to stick with the model.

“If you’re going to do something that’s highly stigmatized in our culture, it’s not surprising that many people would like to do it in a setting where it’s not stigmatized, in a setting where everyone feels it’s normal and good, rather than in a setting where everyone is questioning what you’re doing,” Freedman tells Because.

The separation of abortion services from mainstream health care here in the United States is mirrored in many countries abroad thanks to U.S. foreign aid policy that strictly prohibits funding to any organization that provides abortion services.

“The he assessments of the impact of the global gag rule and the Helms Amendment shows that these policies have led to the isolation and separation of abortion, effectively delinking it from reproductive health and family planning,” explains Leila Hessini, Ipas director of community access.

Solution: Add More Settings and More Providers

To reduce the marginalization of abortion care in the United States and abroad, one solution is obvious: “If you simply diffuse abortion provision across many more sites and many more providers and many more contexts, then the clinics aren’t so targetable and aren’t so focused on by protestors and people who want to perpetuate violence,” Freedman tells Because.

“If there are more providers in more places,” Kumar agrees, “it will become more routine and less specialized.”

In addition to expanding the settings where abortion is provided, diversifying the types of providers performing abortion is also key. In the United States, only physicians are permitted to perform first-trimester aspiration abortions—except in a few states which have granted limited rights for some nurse practitioners, physician assistants and certified nurse midwives to perform the procedure.

“The diversification of this provider pool is so critical,” Kumar stresses. And many countries in which Ipas works are already doing this. “Ethiopia, Nepal, Ghana and South Africa all permit midlevel providers to provide abortion services,” she points out.

Researchers and advocates are working to make this a reality in the United States as well. The Primary Care Initiative (PCI)—a project of the University of California, San Francisco’s research group Advancing New Standards in Reproductive Health (ANSIRH)—is in the middle of a training and evaluation project for certified nurse midwives, physician assistants and nurse practitioners that seeks to prove the safety and effectiveness of allowing these types of providers to perform abortions, with the ultimate goal of affecting policy changes.

“With our study we’re looking to normalize abortion within women’s primary care and within reproductive health care, and so part of that is training more clinicians and health-care workers and teams of workers in providing safe abortion,” says PCI’s Principal Investigator Diana Taylor. Many states now allow midlevel providers to administer medical abortion pills, and this “is certainly normalizing the experience” for this abortion method, she adds.

Support for Providers = Support for Women’s Reproductive Rights

The complex tapestry of abortion stigma and its negative influences on providers, patients and society at large won’t unravel easily. But supporting abortion providers could be a critical first step.

“Providers are in a really pivotal position, and how we as a system and a society treat them translates into how we treat women,” Kumar explains. “So if we really hope to change how women experience abortion and to save women’s lives with safe abortion services, then we also really need to change the way we treat providers who perform these services.”

Jennifer Coletti is an editorial associate at Ipas, following several years spent training future journalists as a high school journalism teacher. This post is adapted from an article appearing in the Fall 2011 issue of Because, the Ipas magazine that connects U.S. readers to women around the world, highlighting reproductive health and rights and making connections between U.S. policy and global health. For a free subscription to Becauseclick here.

News Health Systems

Complaint: Citing Catholic Rules, Doctor Turns Away Bleeding Woman With Dislodged IUD

Amy Littlefield

“It felt heartbreaking,” said Melanie Jones. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

Melanie Jones arrived for her doctor’s appointment bleeding and in pain. Jones, 28, who lives in the Chicago area, had slipped in her bathroom, and suspected the fall had dislodged her copper intrauterine device (IUD).

Her doctor confirmed the IUD was dislodged and had to be removed. But the doctor said she would be unable to remove the IUD, citing Catholic restrictions followed by Mercy Hospital and Medical Center and providers within its system.

“I think my first feeling was shock,” Jones told Rewire in an interview. “I thought that eventually they were going to recognize that my health was the top priority.”

The doctor left Jones to confer with colleagues, before returning to confirm that her “hands [were] tied,” according to two complaints filed by the ACLU of Illinois. Not only could she not help her, the doctor said, but no one in Jones’ health insurance network could remove the IUD, because all of them followed similar restrictions. Mercy, like many Catholic providers, follows directives issued by the U.S. Conference of Catholic Bishops that restrict access to an array of services, including abortion care, tubal ligations, and contraception.

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Some Catholic providers may get around the rules by purporting to prescribe hormonal contraception for acne or heavy periods, rather than for birth control, but in the case of copper IUDs, there is no such pretext available.

“She told Ms. Jones that that process [of switching networks] would take her a month, and that she should feel fortunate because sometimes switching networks takes up to six months or even a year,” the ACLU of Illinois wrote in a pair of complaints filed in late June.

Jones hadn’t even realized her health-care network was Catholic.

Mercy has about nine off-site locations in the Chicago area, including the Dearborn Station office Jones visited, said Eric Rhodes, senior vice president of administrative and professional services. It is part of Trinity Health, one of the largest Catholic health systems in the country.

The ACLU and ACLU of Michigan sued Trinity last year for its “repeated and systematic failure to provide women suffering pregnancy complications with appropriate emergency abortions as required by federal law.” The lawsuit was dismissed but the ACLU has asked for reconsideration.

In a written statement to Rewire, Mercy said, “Generally, our protocol in caring for a woman with a dislodged or troublesome IUD is to offer to remove it.”

Rhodes said Mercy was reviewing its education process on Catholic directives for physicians and residents.

“That act [of removing an IUD] in itself does not violate the directives,” Marty Folan, Mercy’s director of mission integration, told Rewire.

The number of acute care hospitals that are Catholic owned or affiliated has grown by 22 percent over the past 15 years, according to MergerWatch, with one in every six acute care hospital beds now in a Catholic owned or affiliated facility. Women in such hospitals have been turned away while miscarrying and denied tubal ligations.

“We think that people should be aware that they may face limitations on the kind of care they can receive when they go to the doctor based on religious restrictions,” said Lorie Chaiten, director of the women’s and reproductive rights project of the ACLU of Illinois, in a phone interview with Rewire. “It’s really important that the public understand that this is going on and it is going on in a widespread fashion so that people can take whatever steps they need to do to protect themselves.”

Jones left her doctor’s office, still in pain and bleeding. Her options were limited. She couldn’t afford a $1,000 trip to the emergency room, and an urgent care facility was out of the question since her Blue Cross Blue Shield of Illinois insurance policy would only cover treatment within her network—and she had just been told that her entire network followed Catholic restrictions.

Jones, on the advice of a friend, contacted the ACLU of Illinois. Attorneys there advised Jones to call her insurance company and demand they expedite her network change. After five hours of phone calls, Jones was able to see a doctor who removed her IUD, five days after her initial appointment and almost two weeks after she fell in the bathroom.

Before the IUD was removed, Jones suffered from cramps she compared to those she felt after the IUD was first placed, severe enough that she medicated herself to cope with the pain.

She experienced another feeling after being turned away: stigma.

“It felt heartbreaking,” Jones told Rewire. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

The ACLU of Illinois has filed two complaints in Jones’ case: one before the Illinois Department of Human Rights and another with the U.S. Department of Health and Human Services Office for Civil Rights under the anti-discrimination provision of the Affordable Care Act. Chaiten said it’s clear Jones was discriminated against because of her gender.

“We don’t know what Mercy’s policies are, but I would find it hard to believe that if there were a man who was suffering complications from a vasectomy and came to the emergency room, that they would turn him away,” Chaiten said. “This the equivalent of that, right, this is a woman who had an IUD, and because they couldn’t pretend the purpose of the IUD was something other than pregnancy prevention, they told her, ‘We can’t help you.’”

News Law and Policy

Anti-Choice Group: End Clinic ‘Bubble Zones’ for Chicago Abortion Patients

Michelle D. Anderson

Chicago officials in October 2009 passed the "bubble zone" ordinance with nearly two-thirds of the city aldermen in support.

An anti-choice group has announced plans to file a lawsuit and launch a public protest over Chicago’s nearly seven-year-old “bubble zone” ordinance for patients seeking care at local abortion clinics.

The Pro-Life Action League, an anti-choice group based in Chicago, announced on its website that its lawyers at the Thomas More Society would file the lawsuit this week.

City officials in October 2009 passed the ordinance with nearly two-thirds of the city aldermen in support. The law makes it illegal to come within eight feet of someone walking toward an abortion clinic once that person is within 50 feet of the entrance, if the person did not give their consent.

Those found violating the ordinance could be fined up to $500.

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Harassment of people seeking abortion care has been well documented. A 2013 survey from the National Abortion Federation found that 92 percent of providers had a patient entering their facility express personal safety concerns.

The ordinance targets people seeking to pass a leaflet or handbill or engaging in “oral protest, education, or counseling with such other person in the public way.” The regulation bans the use of force, threat of force and physical obstruction to intentionally injure, intimidate or interfere any person entering or leaving any hospital, medical clinic or health-care facility.

The Pro-Life Action League lamented on its website that the law makes it difficult for anti-choice sidewalk counselors “to reach abortion-bound mothers.” The group suggested that lawmakers created the ordinance to create confusion and that police have repeatedly violated counselors’ First Amendment rights.

“Chicago police have been misapplying it from Day One, and it’s caused endless problems for our faithful sidewalk counselors,” the group said.

The League said it would protest and hold a press conference outside of the Planned Parenthood clinic in the city’s Old Town neighborhood.

Julie Lynn, a Planned Parenthood of Illinois spokesperson, told Rewire in an email that the health-care provider is preparing for the protest.

“We plan to have volunteer escorts at the health center to make sure all patients have safe access to the entrance,” Lynn said.

The anti-choice group has suggested that its lawsuit would be successful because of a 2014 U.S. Supreme Court decision that ruled a similar law in Massachusetts unconstitutional.

Pam Sutherland, vice president of public policy and education for Planned Parenthood of Illinois, told the Chicago Tribune back then that the health-care provider expected the city’s bubble zone to be challenged following the 2014 decision.

But in an effort to avoid legal challenges, Chicago city officials had based its bubble zone law on a Colorado law that created an eight-foot no-approach zone within 100 feet of all health-care facilities, according to the Tribune. Sidewalk counselor Leila Hill and others challenged that Colorado law, but the U.S. Supreme Court upheld it in 2000.

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