Politics & Policy

Pro-Choicers Have a Problem

Telemedicine terminal in Des Moines, Iowa.
Iowa’s fight over telemed abortions underscores the increasing scarcity of providers.

Up until November, you’ll be able to get an abortion in Iowa via a Skype-like connection during the early stages of pregnancy. Then new standards recently approved by the Iowa Board of Medicine, which require that a physician meet a pregnant woman in person before prescribing pills to cause an abortion, will kick in.

When Iowa banned webcam abortions, it helped augment one of the biggest problems for the pro-choice movement. While we have the most pro-choice president (and, arguably, the most pro-choice Senate) in history, and while groups like EMILY’s List helped propel a significant number of pro-choice candidates into Congress last November, there’s a problem for the pro-choice movement that no number of votes can fix: It’s getting increasingly difficult to actually find someone to give you an abortion.#ad#

That’s why telemedicine abortions (often called telemed or webcam abortions) are so important to pro-choice advocates. The procedure itself could be out of The Jetsons: A pregnant woman has a teleconference from a local clinic with a remote physician, who types a command into a computer that opens a drawer in front of the woman containing pills. The woman takes one pill in the office and takes the second dose at home within a few days to expel the fetus.

Greg Hoversten, chairman of the Iowa board, defended its decision by explaining the process further: “The woman essentially goes home and labors and delivers a fetus,” he said. “It’s very bloody. It’s painful. There’s cramping, pelvic cramping.”

Supporters of the ban argue that it’s motivated by medical concerns, not pro-life politics. Mark Bowden, the board’s executive director, says it adopted the rule in good faith and doesn’t expect a court challenge. Telemed abortions present problems from a medical-standards perspective, he says; for example, most states have strict requirements about the necessity of having a physical examination before a doctor can write a prescription.

“You can’t call up a doctor and say, ‘You don’t know me, but I don’t feel well and I think I need these drugs, will you write my prescription?’” Bowden told me.

And Republican state representative Dawn Pettengill praised the board’s decision.

“I’m kind of proud of them, really, because they are looking at it more from what the actual practice is, and ignoring the too-political side,” she says. “They’re just looking at it from a stand of what’s best for the woman. And it’s not really a rule that says abortion’s good or bad; it’s a rule that says the way that it’s being done now is not safe.”

She still expects a court challenge.

“I can’t foresee what’s going to happen there,” she tells me. “Probably.”

Given the increasing scarcity of abortion providers, it’s hard to imagine abortion advocates in the Midwest not mounting a legal challenge. The Guttmacher Institute (originally part of Planned Parenthood) reports that as of 2008, eleven states had five abortion providers or fewer. Eighty-seven percent of American counties had no abortion provider, and 35 percent of American women live in those counties. The number of abortion providers peaked in 1982 and steadily decreased until 2005, a 37 percent drop.

Susan Hill, president of the National Women’s Health Foundation, told the Washington Post that the decrease in providers has many pro-choice advocates concerned. “We need young doctors, and we need them badly,” she said. “The situation is pretty grave, pretty dire.”

It’s not all bad news for abortion doctors, though. Pat Richards wrote on Abortion.com (a website that helps users find nearby abortion providers) that fewer providers means less competition for practitioners.

“I can say from the experience that there are a number of doctors or clinic owners who at times were not thrilled if another doctor moved into their neighborhood,” she wrote. “After all, this is — YES I’LL SAY IT — a profit making venture so who in their right minds would want someone to move in who will take away some of your business?”

At least one of the conventional explanations for the shrinking number of abortion providers is exaggerated — attacks targeted at abortion clinics don’t seem to deter medical students from entering the field. In a paper published in Perspectives on Sexual and Reproductive Health, a periodical put out by Guttmacher, researchers found that “several physicians mentioned the threat of violence as an obstacle to providing abortions, but few considered this the greatest deterrent.” The paper’s authors concluded that many medical practices choose not to provide abortions because of the “stigma and ideological contention” that surround it. But there’s probably more to the decrease than just that.#page#

An abortion provider who spoke with me on the condition of anonymity tells me that since it’s so controversial, most abortions happen at clinics rather than hospitals. That makes it less likely that med students will learn the procedure and, thus, less likely they’ll eventually incorporate it into their practices. If students aren’t immediately committed to learning how to provide abortions, they probably won’t ever do so.

And young med students are less likely to be passionate about abortion rights than the first generation of providers, she explains. Members of the “old guard,” as she calls it, remember treating botched illegal abortions before Roe v. Wade.#ad#

“Uniformly when you talk to them, and talk to them about why they provide abortions,” she tells me, “most of them will say something like, ‘It’s because of this case of this septic abortion that I took care of when I was in medical school, and I never want to see that happen again.’”

“I think people in my generation don’t have that same public-health reference to understand what a real lack of access is,” she adds.

Plus, performing abortions carries a strong social stigma. The abortion provider I spoke with works for a large hospital system and moonlights at a Planned Parenthood two hours away. Most of her hospital co-workers have no idea about her second gig. She says she’d face “social discomfort” if she was open about her work, especially given that she lives in a politically and religiously conservative area.

“I by no means offer up to these people, ‘Hey, I’m the abortion provider,’” she says. “I am very careful” about sharing that information.

She wouldn’t lie if someone asked her point-blank, she says, but she avoids the topic; she lives in a small community and has a three-year-old daughter.

Dr. John Bruchalski, an OB-GYN who performed abortions before returning to the Catholic Church, has a different perspective on the abortion-provider shortage. He tells me that he encourages pro-choice med students to learn how to perform the procedures.

“I’ve told people, ‘If you really believe that abortion is a loving, good choice, you damn well better do it,’” he says.

And taking his challenge often leaves students repulsed, he adds.

“It’s very hard to recruit people to do abortions,” he says, “because once they do it, even if you’re pro-choice, it’s — the words I hear are, ‘disgusting, revolting, brutal, but it has to be done. It’s very difficult to do, but someone has to do it.’ And so you’re finding that only the hardest-core are going into it, and that’s not many people.”

Bruchalski also sees another hurdle for those trying to recruit more abortion providers: Med students who want to deliver babies typically don’t want to perform abortions.

“It’s schizophrenic,” he says. “You go into the profession because you want to take care of two patients.”

— Betsy Woodruff is a William F. Buckley Fellow at the National Review Institute.

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