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.

News Politics

Clinton Campaign Announces Tim Kaine as Pick for Vice President

Ally Boguhn

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

The Clinton campaign announced Friday that Sen. Tim Kaine (R-VA) has been selected to join Hillary Clinton’s ticket as her vice presidential candidate.

“I’m thrilled to announce my running mate, @TimKaine, a man who’s devoted his life to fighting for others,” said Clinton in a tweet.

“.@TimKaine is a relentless optimist who believes no problem is unsolvable if you put in the work to solve it,” she added.

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

Kaine signed two letters this week calling for the regulations on banks to be eased, according to a Wednesday report published by the Huffington Post, thereby ”setting himself up as a figure willing to do battle with the progressive wing of the party.”

Charles Chamberlain, executive director of the progressive political action committee Democracy for America, told the New York Times that Kaine’s selection “could be disastrous for our efforts to defeat Donald Trump in the fall” given the senator’s apparent support of the Trans-Pacific Partnership (TPP). Just before Clinton’s campaign made the official announcement that Kaine had been selected, the senator praised the TPP during an interview with the Intercept, though he signaled he had ultimately not decided how he would vote on the matter.

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Kaine’s record on reproductive rights has also generated controversy as news began to circulate that he was being considered to join Clinton’s ticket. Though Kaine recently argued in favor of providing Planned Parenthood with access to funding to fight the Zika virus and signed on as a co-sponsor of the Women’s Health Protection Act—which would prohibit states and the federal government from enacting restrictions on abortion that aren’t applied to comparable medical services—he has also been vocal about his personal opposition to abortion.

In a June interview on NBC’s Meet the Press, Kaine told host Chuck Todd he was “personally” opposed to abortion. He went on, however, to affirm that he still believed “not just as a matter of politics, but even as a matter of morality, that matters about reproduction and intimacy and relationships and contraception are in the personal realm. They’re moral decisions for individuals to make for themselves. And the last thing we need is government intruding into those personal decisions.”

As Rewire has previously reported, though Kaine may have a 100 percent rating for his time in the Senate from Planned Parenthood Action Fund, the campaign website for his 2005 run for governor of Virginia promised he would “work in good faith to reduce abortions” by enforcing Virginia’s “restrictions on abortion and passing an enforceable ban on partial birth abortion that protects the life and health of the mother.”

As governor, Kaine did support some existing restrictions on abortion, including Virginia’s parental consent law and a so-called informed consent law. He also signed a 2009 measure that created “Choose Life” license plates in the state, and gave a percentage of the proceeds to a crisis pregnancy network.

Regardless of Clinton’s vice president pick, the “center of gravity in the Democratic Party has shifted in a bold, populist, progressive direction,” said Stephanie Taylor, co-founder of the Progressive Change Campaign Committee, in an emailed statement. “It’s now more important than ever that Hillary Clinton run an aggressive campaign on core economic ideas like expanding Social Security, debt-free college, Wall Street reform, and yes, stopping the TPP. It’s the best way to unite the Democratic Party, and stop Republicans from winning over swing voters on bread-and-butter issues.”

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.