On Jan. 22, NARAL Pro-Choice America held its annual legislative briefing on Capitol Hill.  The event was designed to give congressional staff an overview of upcoming priorities in 2010 regarding reproductive-health policy.  Melanie Zurek, Executive Director of AAP, was featured as the special guest speaker, providing detailed information about women's on-the-ground access to abortion care and connecting everyday access to the reproductive-health policies that Congress can advance.  

Zurek highlighted for Congressional staff three realities that stand out from AAP's work on the ground:

• Women and providers encounter systemic barriers that impede access at multiple points.  These barriers have a combined impact far greater than any individual policy could, or is even intended, to have.

• There have been significant and positive medical advances in the field of abortion, that are being prevented from reaching their full potential benefit.

• The barriers women and providers face act in a way that is self reinforcing; access will continue to worsen even if no new barriers are put into place.

"From working in these states, where women are misinformed, without support, and where there is only 1 or 2 providers, I can imagine no way that women aren't being denied their rights because of their inability to access abortion."

"For many clinicians providing abortion, doing so is an act of great compassion and conscience, and is received as such by women.  A magnificent contribution to them and to women could be made if you were to put in place these policies that recognize and protect this."

To read Melanie's full remarks, continue reading ...

Melanie Zurek, Executive Director

1.22.10 NARAL Pro-Choice America Legislative Briefing Remarks

Thank you all for being here.  I know there are many places you could be, and many demands on your time.  I am going to give you an on-the-ground look at the accessibility of abortion care, and talk about how we are seeing the work that happens here play out for individual doctors and women across the country. 

First, we see women and providers encounter systemic barriers that impede access at multiple points.  We see how these have a combined impact far greater than any individual policy could, or is even intended, to have.  When we look at access, we look at three things: the availability of care, women's ability to pay for the care, and women's comfort and ability to seek care.  Direct prohibitions and restrictions have contributed to a consistent decline in the availability of abortion since 1982.  How we see this play out on the ground is not as much a generalized or shared decrease but rather in the creating and deepening of wide geographic disparities in access.  For example, while a state like Massachusetts has for the most part retained multiple providers in a variety of settings across the state, in Kentucky there is one clinic with two sites between which the doctor travels, meaning each site is open only a couple days a week.   The Kentucky situation is no accident: it is fed by a series of laws that restrict where abortion can be provided, by whom and how, none with any medical cause behind them.  Worsened by the fact that in most states, neither federal or state dollars that support almost every other kind of health care are available to help ease the deep disparities that exist for abortion.

We have also, unfortunately, seen how violence is also a significant and devastating contributing factor to the availability of care.  George Tiller's murder left clinicians who we work with feeling scared, vulnerable, isolated and abandoned.  To give you some idea of what this looks like, imagine yet another year of meetings that open with a memorial service for a murdered colleague. We have also seen how these feelings of vulnerability, isolation and abandonment are reinforced when abortion is carved out and exempted in our discourse and our policies. 

Given this environment, it is not surprising that we have seen the voluntary opting out of abortion within mainstream healthcare - not because they oppose abortion, but because of the trouble one has to go through to provide it. This is encouraged by policies that favor those wishing to opt out over those wishing to opt -in, such as the Abortion Related Discrimination in Governmental Activities Act [1]which interferes with ability of the Accreditation Council for Graduate Medical Education to enforce its own standards regarding abortion training within Obstetrics and Gynecology.

We see in our work the sacrifices that women make to pay for abortion care and the great lengths that providers and others go through to assist them.  We see how the Hyde Amendment and other bans on federal funds deny women the assistance of their own taxpayer money when help is most needed.  And we see how these hardships would grow if private insurers were also to deny women coverage.  If laws and policies like restrictions on funding don't seem to matter that much, it is because of the extraordinary measures that people on the ground are taking.  But these measures have immediate and long term consequences: they burden women's ability to support existing or future children, and they burden providers which perpetuates the decline in availability and access.

Finally, in many parts of the country women are encountering substantial barriers as they seek care.  This includes being subject to intimidation and harassment, by clinic protestors but also in their communities, as exemplified by an Oklahoma church that posted pictures of women seen entering or leaving a clinic in the church foyer.  Women are also systematically being provided with deliberate misinformation about reproductive health and abortion by crisis pregnancy centers, in abstinence only education programs, and through biased counseling laws.  This directly interferes with a woman's ability to make informed choices and to access abortion care.  Finally, we see how information and support is unavailable to women because nurses, social workers and others who want to help don't have the ability to do so because resources and training are considered too politically risky by the systems and organizations in which they train and work.

From working in these states, where women are misinformed, without support, and where there is only 1 or 2 providers, I can imagine no way that women aren't being denied their rights because of their inability to access abortion.

Second, we have seen significant and positive medical advances in the field of abortion, but also see these being prevented from reaching their full potential benefit. 

Medication abortion using mifepristone was approved in 2000.  It is safe, effective and gives women a non-surgical abortion option.  Subsequent research has made it available to more patients, shortened the process, decreased the cost, and increased effectiveness while reducing side effects and complications. 

In last 10 years we have also seen increased interest and participation in providing abortion care outside of the Ob-Gyn community.  Studies have shown that abortion care provided by these professional groups including nurse practitioners and family medicine physicians is equal to that of ObGyn providers.  An increase in the number and type of providers can increase overall availability of abortion care.  This decreases distance traveled (and associated costs) and delays.  Fewer delays mean earlier procedures which are safer and less expensive.  An increase in the number and type of providers can also increase abortion's availability in settings that can meet diverse linguistic and cultural needs and can help ensure the sustained availability of safe abortion for future generations of women.

These improvements have meant that in some communities abortion is now offered as an integrated part of care in settings that can support a range of women's needs - for example, at Boston Medical Center 70% of patients come from underserved populations.  Because abortion care at BMC is part of a larger model of care, patients can receive counseling in 30 languages and have access to a comprehensive range of patient support services including transportation assistance, pastoral counseling, social work services and even anti-poverty programs.

Sadly, there are few sites in which this is true.  Physician-only laws prevent qualified clinicians from providing abortion.  This is also true of medical malpractice insurance providers who work against the public good by denying coverage for non Ob-Gyn physicians or charging cost-prohibitive rates for medication abortion only providers. There are also unique and medically irrelevant restrictions placed by the FDA on how mifepristone is made available and provided, that limit its use and benefit.  Laws that place medically-unnecessary requirements on facilities where abortions are provided  - commonly referred to as TRAP Laws - limit the availability of safe, lower-tech methods of abortion in accessible, primary care settings that want to provide abortion: the requirements these laws make are unnecessary and expensive and have a real and harmful impact.

This brings me to my final point, which is to show how these existing systemic barriers are self reinforcing and then to suggest a way forward.  Policies and other barriers that discourage provision mean a continued decrease in providers, further marginalization, greater stigma, less comfort, and less support which only leads to continued or growing barriers, fewer providers and more women without care.

From an on the ground perspective we at AAP see important improvements within the medical field being denied to women and a continued overall decline in access. This cycle will continue even if no new barriers are passed - the status quo on abortion policy works against women and against health care providers who want to provide abortion. 

From this perspective, there are two important things to be done.  As policy experts, each of you in this room will have better ideas than I about how to actually make these happen.  What I am here to tell you is that if you do make them happen, there will be immediate on the ground benefits to women and their families.  The first is to remove policies that constrain the provision abortion care and funding restrictions.  These laws work together at all levels in ways that magnify their impact far beyond, I will venture to guess, the intention of those who pass them with women's well being in mind.  If you make medical accuracy and full access to information the guiding principles of any program receiving government funds or describing itself as a health care provider, women will thank you.

Finally, the one I most want to emphasize is putting in place protections for clinicians and for health care settings that wish to provide abortion.  This means only applying the same standards applied to those opting out of abortion to those who wish to opt in.  It includes protections that secure access to training for those who want it: ObGyn residencies that don't meet their own professional accreditation requirements should not be protected by our government.  Providers also need protection from discriminatory insurance practices that deny them the coverage they need to practice, and protection from discriminatory institutional policies such as hospitals that do not allow doctors to provide abortion even on their own time in an outside setting.  Finally, we need policies that are serious about protecting clinicians who provide abortion and their staff from terroristic violence. 

I'll end my remarks with one, to me, most important thought. For many clinicians providing abortion, doing so is an act of great compassion and conscience, and is received as such by women.  A magnificent contribution to them and to women could be made if you were to put in place these policies that recognize and protect this.

Thank you.

[1] (42 USCA § 238; Title 42 The Public Health and Welfare bill, 2003?