Things are looking pretty bleak in the world of abortion care. A wave of states has already been disturbingly successful at shutting down abortion providers by passing medically unnecessary restrictions on clinics, despite the new laws frequently being blocked in court. In the past three years, 27 states have lost 54 clinics, and while not all closures were due to anti-abortion regulations, plenty were. Considering how few abortion clinics are left in the country—a count in January by The Daily Beast found only 724 left—this loss represents a dramatic decrease in abortion accessibility, especially in states like Texas and Arizona, where huge numbers of clinics shut their doors.
Because of this, pro-choice efforts to increase abortion availability have become all the more important. Luckily for pro-choicers, there is one advantage they have in the abortion arms race: In the first trimester, at least, abortion is incredibly safe and quite simple. Particularly in the era of the abortion pill, you don’t actually need expensive equipment, separate facilities, or even necessarily a medical doctor in order to provide one. As reproductive-rights advocates in the pre-Roe days understood, early abortion is safe and easy enough that even people who were previously not too familiar with the human body can be trained to do it. It’s this straightforwardness that has allowed pro-choice activists to come up with some innovative options to expand access.
The state of California, bucking the anti-choice trend in most legislatures at the moment, is about to pass a new law that would increase the number of people who can perform a legal abortion in the state. Recognizing that one doesn’t need high-level surgical skills to administer a pill or perform a one-minute vacuum-aspiration abortion, lawmakers in the state have passed a bill, which Gov. Jerry Brown is expected to sign, that would allow midwives, nurse practitioners, or physician assistants to perform first-trimester abortions after taking a training course in how to do them.
A move like this could not only increase the number of abortion providers available to women in California—and to women from neighboring states like Arizona, where clinics are rapidly being closed—but it opens up the possibility of integrating abortion into everyday health care, making it both more normalized and harder to attack with predatory regulations. While the abortion-clinic model of care initially arose to make women’s lives easier as a one-stop shop for a rare procedure, the existence of stand-alone clinics has made them sitting-duck targets for restrictive laws. Part of what “sells” the claim that abortion clinics need to meet ambulatory-surgical-center standards and have hospital-admitting privileges—two regulations that are being used to shut down clinics—is this widespread but utterly false belief that abortion is an intense and dangerous surgery. Allowing a nurse practitioner or a midwife to offer abortion services would drive home the reality that first-trimester abortion really is a relatively minor medical procedure that hardly merits the term “surgery,” especially in cases where it’s just a matter of taking a pill. This move could also help lower the price of an abortion, much in the same way these types of providers offer a bevy of more affordable care.
In general, the West Coast is trending toward decentralizing abortion and making it as widely available as possible. Oregon has no abortion restrictions—it treats abortion as it should be treated, as just another medical service—and Washington is now requiring all public hospitals to provide abortions. Unfortunately, the latter doesn’t do much to reduce the cost, but the move does help spread the message that there’s nothing about an abortion that requires it to happen only at a specialized abortion clinic.
Family doctors particularly are in a good place to incorporate first-trimester abortion into their practices. While many states have such onerous regulations that adding an abortion provision may not be affordable for some family doctors, for those in states that aren’t so harsh, it could help tremendously. As Emily Bazelon chronicled in her 2010 piece for The New York Times, “The New Abortion Providers,” groups like the Fellowship in Family Planning are not only recruiting young doctors to become abortion providers, but encouraging doctors who might not have otherwise considered it to become abortion providers.
States that are relatively liberal on abortion are already seeing a surge in patients from more conservative states, some of whom have traveled long distances to get an abortion. Maryland, a relatively liberal state, already has clinic workers reporting an uptick of patients from out of state. Maryland sits between Pennsylvania and Virginia, two states where right-wing attacks on clinics have made it much more difficult to get a safe, legal abortion. (The notorious Kermit Gosnell of Pennsylvania exploited this fact to provide unsafe, illegal abortions until his underground clinic was shut down.) In the past three years, nine clinics in the two states have shut down, and women seeking abortions have headed to Maryland instead. The state’s abortion rate is significantly higher than the national average, suggesting not just high demand within the state, but that plenty of patients are coming in from out of state—though it’s hard to track how many.
Of course, beefing up access in blue states to make up for the shortfall in red states isn’t enough—not everyone can afford to travel across state lines and not every red state is bordered by a more sexually liberated state. Doctors have been experimenting with one strategy to help for women in far-flung areas: prescribing the abortion pill remotely via phone or Internet and advising the patient on how to use it correctly.
This potential loophole, which would allow women all over the country to get a safe abortion, has anti-choicers in a panic. Eleven states have already passed laws requiring a doctor to be present when a woman takes the abortion pill, a measure clearly designed to keep doctors from using this strategy to help women in need. How enforceable these restrictions are, however, is still hard to determine. The laws are relatively new, and much of the traffic that’s going on is across state lines, and the laws on what even constitutes “telemedicine” are varied and hazy. Many laws are also tied up in the courts, so it could be years before their true impact is assessed.
The best solution for women, of course, would be for the needless restrictions on abortion to end and the current ones to be lifted, ensuring equal treatment for all women regardless of what state they live in. However, that day is a long way off; in the meantime, women will continue to need abortions and will often get desperate trying to find ways to get them. Having more liberal parts of the country step up and find new ways to expand abortion access can relieve part of the burden, and hopefully help redefine abortion care in ways that will secure a more pro-choice future for all.