Commentary Abortion

How to Transform Future Health-Care Providers Into Abortion Rights Advocates

Michalina Drejza & Cecilia Espinoza

Medical students’ limited opportunities to train in abortion procedures are a major barrier to care. But as bad as the situation is in the United States for medical students, it’s actually much worse in many international settings—including our own home countries.

Medical students’ limited opportunities to train in abortion procedures are a major barrier to care in the United States. Many schools intentionally choose not to include abortion in the curriculum or only offer “opt-in” training. A national survey of medical schools in 2005 found that only 32 percent offered at least one abortion-related lecture during students’ third-year OB-GYN rotation, and only half of schools offered a fourth-year reproductive health elective that covered family planning and abortion.

Such restricted opportunities for abortion training are, of course, a result of institutionalized stigma, often forcing interested medical students to go above and beyond their school’s curriculum to learn abortion care clinical skills and reinforcing the shame surrounding this simple and common medical procedure.

But as bad as the situation is in the United States for medical students, it’s actually much worse in many international settings—including our own home countries. Michalina is in medical school in Poland, where abortion is not typically included in any OB-GYN class curricula. In fact, Poland’s government attempted to pass a total abortion ban just last year. Polish health-care providers who do manage to obtain training and offer safe abortions do so with great discretion; they risk being ostracized socially and professionally. And in Nicaragua, where Cecilia lived and worked until moving to the United States four years ago, a complete ban on abortion means medical schools offer zero training in this often lifesaving care.

Thanks to these kinds of policies, we have found that many medical students—from all parts of the globe—are in the dark about the fact that the procedure, when done safely and legally, has minimal risk of complications. Medical students without abortion training or knowledge go on to become doctors who cannot and will not perform the procedure, even in countries where it’s legal. Having internalized the stigma around abortion themselves, these doctors may refuse mid-career training on the procedure even if their community has a clear need for the service, and they may judge, scorn and turn away patients who seek safe abortions at health clinics—in turn giving people no other option than to seek unsafe, clandestine procedures.

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That’s why the International Federation of Medical Students’ Associations (IFMSA), one of the world’s oldest and largest student-run organizations, has partnered with Ipas, a global NGO dedicated to ending deaths and injuries from unsafe abortion, to develop a training for future health professionals on the importance of safe abortion access.

Our work together began in 2010 with a collaboration between Ipas Nigeria and the Nigerian Medical Students’ Association, which then evolved into a global-level partnership. IFMSA engages a network of more than one million medical students from 115 countries, and a total of approximately 4,000 students attend annual regional meetings held around the globe. To capitalize on the organization’s vast reach, together we created a training guide that IFMSA student leaders use at their regional meetings to offer a crash course on the public health issue of unsafe abortion and how health-care providers can be advocates for abortion access—regardless of whether they ever provide the service or where they work in the health system. Trainings began in 2013 at a regional meeting in Ethiopia, and Michalina, as a leader with IFMSA’s committee on sexual and reproductive health issues, has now helped facilitate six of these trainings in various regions.

Rather than offer clinical abortion skills training, we recognized that what many medical students need first is an opportunity to talk openly about the myths, misconceptions, and biases about abortion they’ve inherited from their respective cultures. Training participants explore how unsafe abortion affects women and societies and how practicing health professionals can reduce the many barriers to abortion care that patients face. A section of the training also demystifies clinical aspects of abortion care with an overview of safe procedure methods and the importance of patient-centered care. Finally, students learn strategies for advancing abortion rights and access, and practice skills like advocacy and peer education.

You can’t expect a roomful of strangers to instantly feel comfortable discussing such a stigmatized topic, so our training involves many participatory activities that allow students to clarify their own values and beliefs related to abortion and to challenge themselves by considering a variety of others’ perspectives—including those of fellow training participants, as well as people seeking abortions, their families, and the health professionals who provide them. One popular activity asks students to brainstorm all the many reasons why a person may want or need an abortion and then to discuss which reasons society deems more acceptable. The activity sparks conversations about differing cultural beliefs and the subconscious biases we all carry.

The “ah-ha!” moments that occur at these trainings are pretty remarkable. Students from the United States, carrying the burden of their country’s uniquely toxic political climate around abortion, are frequently shocked to discover the wide array of other students’ experiences. For example, students from Western Europe will note that immigrants in their countries struggle to access safe abortions due to factors like immigration status, language barriers, and lack of information, even though the procedure is legal and not highly stigmatized. Meanwhile students from some African nations all know of at least one woman whose life was claimed by unsafe, clandestine abortion—often obtained illegally.

Students are also regularly surprised to learn about the abortion laws in their own countries. Many simply assume tight legal restrictions on the procedure because of the way medical schools and health systems avoid the topic as if it’s forbidden. A group of students from Tunisia, for example, were shocked to learn in early 2015 that their country’s abortion law is quite progressive—and outraged that they had been uninformed. After participating in our training, they started a project to educate other Tunisian medical students about the abortion law and other policies that advance reproductive health and rights.

Perhaps the most rewarding part of these trainings—and we’ve seen it again and again—is when students begin our workshop staunchly opposed to abortion and leave committed to abortion rights advocacy and excited to educate their peers at home on the topic. We’ve been careful not to impose a particular view on abortion in the exercises that comprise our training, and we hear routinely from students that they didn’t feel pushed to adopt a particular outlook. Rather, they feel grateful for the opportunity to have open, honest dialogue—often for the first time. This dialogue, they say, allows them to dispel myths and better understand what their role might be in supporting access to safe, legal abortion in the future.

The first step to ending abortion stigma is education—and making people conscious of the problem. IFMSA regional meetings for the 2015-16 academic year kicked off in Rwanda in December, where we trained 13 medical students from across Africa. In January, we trained 42 students at the Americas regional meeting in Uruguay, and another ten students at the Eastern Mediterranean regional meeting in Jordan. We expect similarly robust and stimulating conversations in the trainings to come this spring. And we hope that region by region, year after year, we are laying the groundwork on a global scale for more pro-choice health systems with providers who advance, rather than restrict, women’s sexual and reproductive health and rights.

News Politics

Tim Kaine Changes Position on Federal Funding for Abortion Care

Ally Boguhn

The Obama administration, however, has not signaled support for rolling back the Hyde Amendment's ban on federal funding for abortion care.

Sen. Tim Kaine (D-VA), the Democratic Party’s vice presidential candidate, has promised to stand with nominee Hillary Clinton in opposing the Hyde Amendment, a ban on federal funding for abortion care.

Clinton’s campaign manager, Robby Mook, told CNN’s State of the Union Sunday that Kaine “has said that he will stand with Secretary Clinton to defend a woman’s right to choose, to repeal the Hyde amendment,” according to the network’s transcript.

“Voters can be 100 percent confident that Tim Kaine is going to fight to protect a woman’s right to choose,” Mook said.

The commitment to opposing Hyde was “made privately,” Clinton spokesperson Jesse Ferguson later clarified to CNN’s Edward Mejia Davis.

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Kaine’s stated support for ending the federal ban on abortion funding is a reversal on the issue for the Virginia senator. Kaine this month told the Weekly Standard  that he had not “been informed” that this year’s Democratic Party platform included a call for repealing the Hyde Amendment. He said he has “traditionally been a supporter of the Hyde amendment.”

Repealing the Hyde Amendment has been an issue for Democrats on the campaign trail this election cycle. Speaking at a campaign rally in New Hampshire in January, Clinton denounced Hyde, noting that it made it “harder for low-income women to exercise their full rights.”

Clinton called the federal ban on abortion funding “hard to justify” when asked about it later that month at the Brown and Black Presidential Forum, adding that “the full range of reproductive health rights that women should have includes access to safe and legal abortion.”

Clinton’s campaign told Rewire during her 2008 run for president that she “does not support the Hyde amendment.”

The Democratic Party on Monday codified its commitment to opposing Hyde, as well as the Helms Amendment’s ban on foreign assistance funds being used for abortion care. 

The Obama administration, however, has not signaled support for rolling back Hyde’s ban on federal funding for abortion care.

When asked about whether the president supported the repeal of Hyde during the White House press briefing Tuesday, Deputy Press Secretary Eric Schultz said he did not “believe we have changed our position on the Hyde Amendment.”

When pushed by a reporter to address if the administration is “not necessarily on board” with the Democratic platform’s call to repeal Hyde, Schultz said that the administration has “a longstanding view on this and I don’t have any changes in our position to announce today.”

News Law and Policy

Texas Lawmaker’s ‘Coerced Abortion’ Campaign ‘Wildly Divorced From Reality’

Teddy Wilson

Anti-choice groups and lawmakers in Texas are charging that coerced abortion has reached epidemic levels, citing bogus research published by researchers who oppose legal abortion care.

A Texas GOP lawmaker has teamed up with an anti-choice organization to raise awareness about the supposed prevalence of forced or coerced abortion, which critics say is “wildly divorced from reality.”

Rep. Molly White (R-Belton) during a press conference at the state capitol on July 13 announced an effort to raise awareness among public officials and law enforcement that forced abortion is illegal in Texas.

White said in a statement that she is proud to work alongside The Justice Foundation (TJF), an anti-choice group, in its efforts to tell law enforcement officers about their role in intervening when a pregnant person is being forced to terminate a pregnancy. 

“Because the law against forced abortions in Texas is not well known, The Justice Foundation is offering free training to police departments and child protective service offices throughout the State on the subject of forced abortion,” White said.

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White was joined at the press conference by Allan Parker, the president of The Justice Foundation, a “Christian faith-based organization” that represents clients in lawsuits related to conservative political causes.

Parker told Rewire that by partnering with White and anti-choice crisis pregnancy centers (CPCs), TJF hopes to reach a wider audience.

“We will partner with anyone interested in stopping forced abortions,” Parker said. “That’s why we’re expanding it to police, social workers, and in the fall we’re going to do school counselors.”

White only has a few months remaining in office, after being defeated in a closely contested Republican primary election in March. She leaves office after serving one term in the state GOP-dominated legislature, but her short time there was marked by controversy.

During the Texas Muslim Capitol Day, she directed her staff to “ask representatives from the Muslim community to renounce Islamic terrorist groups and publicly announce allegiance to America and our laws.”

Heather Busby, executive director of NARAL Pro-Choice Texas, said in an email to Rewire that White’s education initiative overstates the prevalence of coerced abortion. “Molly White’s so-called ‘forced abortion’ campaign is yet another example that shows she is wildly divorced from reality,” Busby said.

There is limited data on the how often people are forced or coerced to end a pregnancy, but Parker alleges that the majority of those who have abortions may be forced or coerced.

‘Extremely common but hidden’

“I would say that they are extremely common but hidden,” Parker said. “I would would say coerced or forced abortion range from 25 percent to 60 percent. But, it’s a little hard be to accurate at this point with our data.”

Parker said that if “a very conservative 10 percent” of the about 60,000 abortions that occur per year in Texas were due to coercion, that would mean there are about 6,000 women per year in the state that are forced to have an abortion. Parker believes that percentage is much higher.

“I believe the number is closer to 50 percent, in my opinion,” Parker said. 

There were 54,902 abortions in Texas in 2014, according to recently released statistics from the Texas Department of State Health Services (DSHS). The state does not collect data on the reasons people seek abortion care. 

White and Parker referenced an oft cited study on coerced abortion pushed by the anti-choice movement.

“According to one published study, sixty-four percent of American women who had abortions felt forced or unduly pressured by someone else to have an unwanted abortion,” White said in a statement.

This statistic is found in a 2004 study about abortion and traumatic stress that was co-authored by David Reardon, Vincent Rue, and Priscilla Coleman, all of whom are among the handful of doctors and scientists whose research is often promoted by anti-choice activists.

The study was cited in a report by the Elliot Institute for Social Sciences Research, an anti-choice organization founded by Reardon. 

Other research suggests far fewer pregnant people are coerced into having an abortion.

Less than 2 percent of women surveyed in 1987 and 2004 reported that a partner or parent wanting them to abort was the most important reason they sought the abortion, according to a report by the Guttmacher Institute.

That same report found that 24 percent of women surveyed in 1987 and 14 percent surveyed in 2004 listed “husband or partner wants me to have an abortion” as one of the reasons that “contributed to their decision to have an abortion.” Eight percent in 1987 and 6 percent in 2004 listed “parents want me to have an abortion” as a contributing factor.

‘Flawed research’ and ‘misinformation’  

Busby said that White used “flawed research” to lobby for legislation aimed at preventing coerced abortions in Texas.

“Since she filed her bogus coerced abortion bill—which did not pass—last year, she has repeatedly cited flawed research and now is partnering with the Justice Foundation, an organization known to disseminate misinformation and shameful materials to crisis pregnancy centers,” Busby said.  

White sponsored or co-sponsored dozens of bills during the 2015 legislative session, including several anti-choice bills. The bills she sponsored included proposals to increase requirements for abortion clinics, restrict minors’ access to abortion care, and ban health insurance coverage of abortion services.

White also sponsored HB 1648, which would have required a law enforcement officer to notify the Department of Family and Protective Services if they received information indicating that a person has coerced, forced, or attempted to coerce a pregnant minor to have or seek abortion care.

The bill was met by skepticism by both Republican lawmakers and anti-choice activists.

State affairs committee chairman Rep. Byron Cook (R-Corsicana) told White during a committee hearing the bill needed to be revised, reported the Texas Tribune.

“This committee has passed out a number of landmark pieces of legislation in this area, and the one thing I think we’ve learned is they have to be extremely well-crafted,” Cook said. “My suggestion is that you get some real legal folks to help engage on this, so if you can keep this moving forward you can potentially have the success others have had.”

‘Very small piece of the puzzle of a much larger problem’

White testified before the state affairs committee that there is a connection between women who are victims of domestic or sexual violence and women who are coerced to have an abortion. “Pregnant women are most frequently victims of domestic violence,” White said. “Their partners often threaten violence and abuse if the woman continues her pregnancy.”

There is research that suggests a connection between coerced abortion and domestic and sexual violence.

Dr. Elizabeth Miller, associate professor of pediatrics at the University of Pittsburgh, told the American Independent that coerced abortion cannot be removed from the discussion of reproductive coercion.

“Coerced abortion is a very small piece of the puzzle of a much larger problem, which is violence against women and the impact it has on her health,” Miller said. “To focus on the minutia of coerced abortion really takes away from the really broad problem of domestic violence.”

A 2010 study co-authored by Miller surveyed about 1,300 men and found that 33 percent reported having been involved in a pregnancy that ended in abortion; 8 percent reported having at one point sought to prevent a female partner from seeking abortion care; and 4 percent reported having “sought to compel” a female partner to seek an abortion.

Another study co-authored by Miller in 2010 found that among the 1,300 young women surveyed at reproductive health clinics in Northern California, about one in five said they had experienced pregnancy coercion; 15 percent of the survey respondents said they had experienced birth control sabotage.

‘Tactic to intimidate and coerce women into not choosing to have an abortion’

TJF’s so-called Center Against Forced Abortions claims to provide legal resources to pregnant people who are being forced or coerced into terminating a pregnancy. The website includes several documents available as “resources.”

One of the documents, a letter addressed to “father of your child in the womb,” states that that “you may not force, coerce, or unduly pressure the mother of your child in the womb to have an abortion,” and that you could face “criminal charge of fetal homicide.”

The letter states that any attempt to “force, unduly pressure, or coerce” a women to have an abortion could be subject to civil and criminal charges, including prosecution under the Federal Unborn Victims of Violence Act.

The document cites the 2007 case Lawrence v. State as an example of how one could be prosecuted under Texas law.

“What anti-choice activists are doing here is really egregious,” said Jessica Mason Pieklo, Rewire’s vice president of Law and the Courts. “They are using a case where a man intentionally shot his pregnant girlfriend and was charged with murder for both her death and the death of the fetus as an example of reproductive coercion. That’s not reproductive coercion. That is extreme domestic violence.”

“To use a horrific case of domestic violence that resulted in a woman’s murder as cover for yet another anti-abortion restriction is the very definition of callousness,” Mason Pieklo added.

Among the other resources that TJF provides is a document produced by Life Dynamics, a prominent anti-choice organization based in Denton, Texas.

Parker said a patient might go to a “pregnancy resource center,” fill out the document, and staff will “send that to all the abortionists in the area that they can find out about. Often that will stop an abortion. That’s about 98 percent successful, I would say.”

Reproductive rights advocates contend that the document is intended to mislead pregnant people into believing they have signed away their legal rights to abortion care.

Abortion providers around the country who are familiar with the document said it has been used for years to deceive and intimidate patients and providers by threatening them with legal action should they go through with obtaining or providing an abortion.

Vicki Saporta, president and CEO of the National Abortion Federation, previously told Rewire that abortion providers from across the country have reported receiving the forms.

“It’s just another tactic to intimidate and coerce women into not choosing to have an abortion—tricking women into thinking they have signed this and discouraging them from going through with their initial decision and inclination,” Saporta said.

Busby said that the types of tactics used by TFJ and other anti-choice organizations are a form of coercion.

“Everyone deserves to make decisions about abortion free of coercion, including not being coerced by crisis pregnancy centers,” Busby said. “Anyone’s decision to have an abortion should be free of shame and stigma, which crisis pregnancy centers and groups like the Justice Foundation perpetuate.”

“Law enforcement would be well advised to seek their own legal advice, rather than rely on this so-called ‘training,” Busby said.