Commentary Abortion

The Hidden Costs of Abortion Restrictions

Carole Joffe

The impact of targeted regulations on abortion providers extends beyond financial—it can also make it challenging to sustain a vision of quality "woman-centered" care.

“You walk into our surgery center and it’s so cold and scary. There’s no art. The lights are bright, the recovery rooms smell like bleach. All the staff are wearing gowns and head and foot covers and the patients have to wear the same thing … and there’s nothing comforting about it. The warmth is gone.”

As recent events in Texas have made clear, when it comes to abortion care, the worst outcome of the current onslaught of state-imposed targeted regulations of abortion providers (TRAP laws) is the forced closing of clinics. But even clinics in affected states that manage to stay open suffer costs. The words above were spoken to me by an administrator of an abortion clinic in Pennsylvania, one of 23 states that have passed legislation stipulating that abortion clinics must conform to the requirements of an ambulatory surgical center (ASC). ASC legislation, in essence, demands that clinics conform to the physical standards of hospitals, with regulations about such matters as hallway widths, heating and ventilation equipment, and janitor storage space. Moreover, as part of the ASC regime, clinics must adopt certain hospital-like policies, such as sterile environments, that are more stringent than those pertaining to other outpatient facilities. Although the Supreme Court temporarily blocked Texas from enforcing these ASC provisions, many of the state’s clinics have been facing the prospect of shuttering under the extreme financial burden of physically enacting the required changes.

Arguably, the aforementioned Pennsylvania clinic is one of the luckier ones. It has managed to remain open—after expenditures of several hundred thousand dollars to come into compliance with that state’s law. But as the opening quote from its administrator implies, there have been costs beyond the financial to clinics in affected states. In interviews I have been doing with abortion clinic staff in such heavily regulated states, I have heard how challenging it has been to sustain the vision of quality “woman-centered” abortion care that many in the field, particularly independent clinics affiliated with the Abortion Care Network, have developed over the past few decades. The necessity to have even first-trimester abortion procedures take place in a hospital-like environment has meant that the small touches developed over the years to comfort the patient—cozy fleece blankets, specially selected calming herbal teas, use of heating pads, journals where women could discuss their feelings about their procedures as well as write messages of support to other patients, and soothing art on the walls—have had to be abandoned in the name of sustaining a sterile environment. (As clinic staff explained to me, fleece blankets can’t be washed with bleach; tea could be spilled, heating pads and journals can convey germs of other users; art can collect dust.)

Though this can vary from state to state, some clinics operating under ASC regulations no longer can allow partners or friends to accompany patients in the procedure or recovery rooms, as was formerly the case. As one long-time clinic director said, reflecting on these changes, “What a tragedy … because the entire thing in medical care is nurturing—and if that is taken away from us, [the ASC regulation] is actually an even bigger crisis than we thought.”

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Veteran staff members are not only concerned about the consequences of the new regulations for their patients, but for younger co-workers as well. The more senior staff, beleaguered as they are, at least tend to have a political analysis of the restrictions afflicting abortion care: They view these measures as having nothing to do with patient safety and everything to do with the attempts of hostile legislators to shut clinics down. Such a belief is supported by a considerable body of evidence: Periodic studies done after the 1973 Roe v. Wade decision have consistently shown abortion procedures—about 90 percent of which occur in freestanding clinics—to be safer than childbirth. A study published in 2012 concluded that women were 14 times more likely to die during or after a birth than from an abortion. Various medical organizations, including the American Congress of Obstetricians and Gynecologists, have publicly criticized the ASC and other state-imposed restrictions as medically unjustified and ideologically motivated.

But newer staff can be bewildered and upset by the current, aggressive regulatory environment. For example, in some states, ASC laws permit unannounced inspections by health department officials. In one Southern facility, which was repeatedly subject to such inspections after complaints lodged by an extremist anti-abortion group, some recently hired staff members were confused by the constant presence of inspectors. As a veteran manager put it, the newer employees began to “internalize” the critiques of the clinic’s opponents, wondering if, indeed, “we were doing something wrong.” (In the clinic in question, all the complaints ultimately proved groundless.)

Patients, already subjected to the abortion stigma that permeates wider culture, also can get rattled by teams of inspectors entering a clinic, commandeering scarce space, and “coming off like FBI agents,” as the same manager said.

For senior staff in the clinics I visited, many of whom have been involved in abortion care since the Roe decision, perhaps the greatest threat of the climate of restrictions, beyond being forced to close altogether, is the loss of “institutional memory” of what quality care could be. As one veteran manager lamented, “As you make hires, and as they come in—every new nurse, every new medical assistant—they think that these ASC regulations are the actual standard of what abortion care should be: We can’t have that heating pad in the recovery room. So they have lost the thread, they have lost the history. They entirely practice to the regulation, without an understanding that we do that bullshit part because we have to.”

To be sure, there is an ironic aspect to this attempt to make clinics into mini-hospitals. It was the very reluctance of hospitals in the immediate aftermath of Roe to initiate abortion services that helped lead to the development of freestanding clinics. Accordingly, observers have argued that a major contributor to abortion stigma in the United States is the procedure’s separation from mainstream medicine. The various programs that, against considerable odds, have recently managed to increase abortion training and research in hospitals are unquestionably a positive development in an otherwise bleak abortion environment. In a sane world, of course, there would be recognition that abortions can be performed well in different kinds of environments, and that the freestanding clinics, as they have existed before ASC requirements, have achieved an exemplary safety record. To be sure, hospital-based abortion care is essential both for performing the procedure on sicker women and for serving as backup for the rare complications occurring in clinics. But policies governing abortion provision in America are anything but sane. Anti-choice politicians are currently doing their utmost to make abortion care as difficult as possible in both clinics and hospitals.

Meanwhile, staff in the affected clinics strive valiantly each day to not only remain open, but to somehow sustain the warmth.

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