Pro-choice timidity in fighting shortage of abortion providers

But another 10 percent do not offer the training at all, and fully 40 percent only offer it on an “opt-in” basis, even though the American College of Obstetricians and Gynecologists has found, “The nature of elective or opt-in training places the burden to create a clinical experience on the residents, and prior data show that the majority of residents participate in training when it is integrated whereas a minority of residents participate when it is elective.”

A central obstacle to full enforcement of the ACGME’s abortion-training requirement is the Coats Amendment, named for Senator Dan Coats (R-Ind.), and passed by Congress as an amendment to the Public Health Service Act of 1996. The Coats Amendment states that governments at all levels “shall deem accredited” any residency program that would otherwise be in noncompliance with abortion-training requirements. In other words, the amendment overrides the ACGME’s ability to revoke the accreditation of a program that is not offering abortion training.

Despite the Coats Amendment, however, Dr. Douglas W. Laube, an ob-gyn who has been providing pregnancy terminations since 1970 and is board chair of Physicians for Reproductive Health, asserted that the ACGME has mechanisms of enforcement short of revocation of accreditation that it can utilize to put pressure on non-compliant residency programs. These include issuing citations to programs not following the rule, which could stir peer pressure from other programs to comply, and would flag the institution to potential residents who might consequently decline to go there. Coupled with citations for other problems, Laube said, citations related to abortion training could place a program in probationary status, which in turn could lead to more site visits by the ACGME. Such site visits — essentially audits that are time- and resource-intensive for residency programs to undergo — could, Laube said, encourage more programs to comply.

Mary Joyce Johnston, the executive director of the ACGME’s Obstetrics and Gynecology Review Committee, and of its Council of Review Committees, responded to Remapping Debate’s interview request by referring us to John H. Nylen, the ACGME’s senior vice president for administration. Nylen did not respond to our request for an interview, and did not answer emailed questions concerning what the ACGME is doing to enforce its abortion-training requirements.

Potential initiatives

One element of NAF’s training involves instruction on how to administer medical abortions using the medication mifepristone (the “abortion pill”). A medical abortion is available to women within the first nine weeks of a pregnancy, and is not a surgical procedure. As such, it has low complication rates. Because it is a medication, doctors are obliged to train in the pharmacology of and protocol for administering mifepristone, but there is no need for the more complex surgical instruction and practice that vacuum aspiration terminations require. Consequently, the medical method allows physicians to readily incorporate abortion into their existing practices. As of 2008, one quarter of all abortions were medical.

While NAF actively sought out doctors to train in mifepristone provision in the early 2000s, when the drug was first legalized in the U.S., Saporta, its president and CEO, said NAF has decreased these efforts in recent years. (Saporta said NAF hopes that mifepristone will be approved in Canada soon, and that when it is, her organization will be ready with updated outreach and education materials for doctors who want medical abortion training.)

Another approach to expanding the number of providers is to make available one-on-one mentors who can support new physicians in offering abortion care.

The UCSF-based Training in Early Abortion for Comprehensive Healthcare (TEACH) program is designed for residents in family medicine (doctors in family medicine practice can, with the proper training, provide abortions, just as ob-gyns do). Dr. Suzan Goodman, executive director of TEACH, said that new doctors just hired by a hospital or group medicine practice frequently find that their employer does not permit them to provide abortion services, even in their spare time. According to Goodman, the new doctors generally do not challenge the employer policy because they are often afraid of jeopardizing their newly acquired jobs — many have student loans, and have just started families and bought their first homes.

The TEACH program has developed a modest network of mentors who can be matched up with new doctors. These mentors can offer advice and strategies for how to introduce abortion services in the setting of a group practice or hospital otherwise resistant to doing so.

Mentors also work with new doctors who do give abortion care, but under stressful conditions, such as being the only provider in a geographical area. Mentors can offer advice on how the doctor can better cope psychologically and in practical terms, including how to build up a supportive nursing and office staff. “These mentoring relationships are so key,” said Goodman.

TEACH currently administers its mentorship program with fewer resources than Goodman would like. If TEACH had more funding, she said, it could hire one or more full-time employees to better facilitate the matching of new doctors and mentors, offer greater outreach to recruit mentors, and provide oversight to encourage doctors and mentors to continue to work with one another over time. She also said more money could be used to create resource centers to supply information, including legal advice, to new physicians who have been prevented by their employers from including abortion in their practices.

Lori Blewett, a communication and social studies professor at The Evergreen State College in Washington State, told Remapping Debate that established doctors who provide abortion services should be more vocal in encouraging their colleagues to do the same.