When Colleen McNicholas, MD, woke in a strange hotel room in the middle of the night with a mouthful of blood, her first thought was not for herself.
The day before, McNicholas had flown from St. Louis, Missouri, to Wichita, Kansas, to provide abortion care in a city where no local physicians were offering those services. She had recently had her tonsils removed, but deemed it safe to fly. The previous day in the clinic — dedicated to intake, patient prep, and consent procedures — went smoothly, and abortions for those women were scheduled for today.
McNicholas faced a dilemma. In Kansas, a woman must receive state-directed counseling that includes information designed to discourage her from having an abortion, then wait 24 hours before the procedure is conducted.
"In that moment, with blood gushing out of my mouth, all I could think about was, How am I going to get these patients taken care of?" the doctor recalled. "Some of these women were already at the gestational age limit for abortion in Kansas. I don't have any extra days. I don't have any extra people. There is no one else. This is our reality. It's crazy. It's just nuts."
Although precise numbers are hard to come by, the National Abortion Federation estimates that 50 to 60 US physicians live some version of that reality ― taking time off from their full-time jobs to fly across the country to provide abortion care in cities such as Wichita, or to help staff the only clinic offering abortions in an entire state, such as South Dakota.
Wichita was thrust into the center of the country's abortion debate 10 years ago when George Tiller, MD, was gunned down inside his home church. Tiller was revered by abortion rights advocates and hated in anti-abortion circles for providing late-term abortions. His killer was sentenced to life in prison. The risk to the personal safety of abortion providers was once again thrown into stark relief.
The reality for these physicians today means confronting hostile protesters and shrugging off personal threats. It means overcoming significant state-imposed constraints on their practice, including, in some cases, requirements to convey medically inaccurate information to their patients. Their reality means adding hectic travel days to an already lopsided work-life balancing act, because they are dedicated to enabling women to retain options in areas that are politically or socially hostile to abortion. And sometimes it means sitting with patients who feel completely alone and putting those patients first — even when you need medical attention yourself.
McNicholas went to a nearby emergency department for treatment and extended her stay to perform the abortions that had already been prepped. When she finally returned to St. Louis, she was satisfied that she'd helped preserve the reproductive rights of Wichita women.
Clinics Close in the Shifting Legal Landscape
McNicholas is one of 15 providers nationwide who work with Trust Women, a nonprofit organization that seeks to provide abortion care in underserved communities. The group was founded by Julie Burkhart after George Tiller was murdered; Burkhart had worked closely with Tiller. In the wake of new, highly restrictive state anti-abortion laws, Burkhart believes that Trust Women's mission is more important than ever.
"What we have," she said, "is a vast public health crisis."
From Missouri through the South, states have been passing "heartbeat bills" ― bans on very early (6- to 8-week) abortions, before the fetal heartbeat can be detected, said Burkhart. Almost 300 state abortion restrictions were enacted between 2011 and 2015.
According to a 2019 Pew Research Center poll, 61% of American adults believe that abortion should be legal in most cases. But without providers willing to travel to so-called abortion deserts, many woman would lack access to abortion. A 2014 Guttmacher Institute study found that 90% of US counties had no known abortion provider in 2014, and 39% of women lived in a county without a single clinic that provided abortion services.
More clinic closures are anticipated now that Planned Parenthood, the nation's largest provider of abortion services, chose to reject federal funds rather than comply with a new gag rule that forbids providers from counseling patients about or referring them to abortion services.
In Missouri, where McNicholas is medical director of the state's only abortion provider, the St. Louis Planned Parenthood Clinic, a recently passed law banning abortions after 8 weeks was overturned by a federal judge just a day before it was to take effect. If it goes forward, physicians who violate the 8-week rule could spend 5 to 15 years in prison.
Sarah Traxler, MD, chief medical officer of Planned Parenthood North Central States, sees a serious threat to the landmark Roe v Wade ruling. Although abortion would remain accessible in many states in which the ruling is overturned, 19 states have some kind of provision that would automatically make abortion illegal or otherwise heavily restrict access. In contrast, 13 states have laws to protect abortion access in the event that Roe v Wade is overturned.
An Unfriendly Work Environment
Trust Women currently runs clinics in three cities: Wichita, Oklahoma City, and Seattle. Physicians fly in monthly or quarterly, sometimes using their vacation days; the clinics typically provide abortion care only 2 days a week.
But recruiting physicians isn't easy. It took Burkhart 2 years to find a physician for the Wichita clinic, which opened in 2013. "Providers worry that if they come to Wichita (home to the national anti-abortion group Operation Rescue), they could be assassinated," said Burkhart, who lives in the heart of the anti-abortion movement. "People protest in front of my house, standing on my lawn with signs saying, 'Where is your church?' and 'Prepare to meet thy God.' They've handed out flyers to my neighbors saying things like, 'Bring Julie to Jesus,' " she said. "I've received death threats on social media — people saying they're going to track me down, drag me out of my car, and beat me to a bloody pulp."
Some of Trust Women's physicians have experienced harassment in their hometowns, and protesters outside the Wichita clinic write down the make, model, and license number of cars that are coming and going. The National Abortion Federation reports increased violence and harassment related to abortion care over the past several years, and providers are taking precautions.
"We're told not to engage with protesters, and it makes sense, but I want to yell at them," admitted one doctor who asked to remain anonymous. When traveling to provide abortion care, she tells no one why she's in town. She rents a car to avoid taxis and ride-shares. She watches TV and eats dinner alone in her hotel room. "Nobody knows who I am or what I'm doing," she said, adding that "the isolation and flying back and forth are exhausting."
McNicholas has a slightly different view on personal safety — that continuing to provide care is an important demonstration of the movement's resiliency and commitment. "You targeted one of our providers and murdered someone who was very important to the movement, but we are still going to show up and make sure the people of Kansas have access to abortion," she said.
Where Are the Local Providers?
Safety concerns aren't the only drivers of a shortage of local abortion providers. Some physicians or their staff have personal moral or religious objections or don't want to deal with the stigma of being an abortion provider. According to a 2017 Guttmacher study, fewer than 10% of US Ob/Gyns in private practice perform abortions, and about one third say they do not even provide referrals.
A lack of training opportunties also contributes to the current shortage. Even though the proportion of residency programs offering abortion education (64%) has risen in recent years, few provide actual clinical practice. Only 22% of residency program directors judged their graduates to be competent in performing dilatation and evacuation, the abortion method typically used in the second trimester of pregnancy.
Some physicians who would like to provide abortion services are discouraged by state restrictions on abortion. Erin King, MD, the executive director of Hope Clinics for Women in Granite City, Illinois, has seen this up close. Although she practices in pro-choice Illinois, which allows Medicaid coverage for abortions, her husband, David Eisenberg, MD, used to practice just across the state line in St. Louis, at the clinic now run by McNicholas.
"It was very interesting living in the same house as someone who is literally attacked by his state for providing legal healthcare," said King. "We worked within 10 miles of each other, seeing essentially the same patients, using the same instruments, and doing the same procedures. Yet Missouri has binders full of regulations telling doctors what they can and cannot do, when they can do it, what they can tell their patients, how they must say it, and how long the patient has to wait between getting the information and having the procedure."
Hurdles and Frustrations
In South Dakota, 4 or 5 providers rotate to allow the clinic to offer 2 days of abortion services every week. Flights are scheduled around the 72 hours that pregnant women must wait between being counseled about their medical options and going ahead with an abortion, explained Traxler. She takes an early flight out of Minneapolis–St. Paul with a security detail that also accompanies her when she's driven to the Sioux Falls clinic. She conducts ultrasounds, takes health histories, and reads the legally required consent information, which, she notes, contains scientifically inaccurate information, such as overstating the procedure's risks.
"On a good day when all of the flights work out, my day is about 12 hours," she said; 72 hours later, she does the same thing, returning to conduct the procedures. But travel doesn't always go as planned. Traxler once took an early morning flight. The plane encountered problems trying to land, and she didn't arrive at the Sioux Falls clinic until 1:00 PM. This meant that when she returned 3 days later, she couldn't begin any procedures until after 1:00 PM, when the full 72 hours had passed.
Midwestern winters don't always cooperate either, which means that if a physician can't make it back in time to perform the procedure, patients have to start the whole process over the following week, explained Traxler. Nearly one third of the Sioux Falls clinic's patients drive at least 150 miles to get there, and some inevitably won't be able to return.
For Traxler, perhaps the biggest frustration is not being able to practice medicine with the autonomy she brings to the rest of her practice. "The care I provide my general gynecology patients isn't under such scrutiny," she said. "It's a lot easier, and I don't have to say things that aren't true just to provide care. It's frustrating that my patient-physician relationship is being dictated by politicians instead of by my own medical expertise."
What keeps Traxler and like-minded physicians flying, however, is the belief that women "deserve access to the full spectrum of reproductive care, including abortions," as well as the rewards of meeting a desperate need, she said.
Traxler recalls a woman who had just been prepped for a procedure that was scheduled to take place the following day. She had confronted her boyfriend about cheating, and he kicked her out. With nowhere to go, she drove to the clinic in the middle of the night and slept in her car until the doors opened. After confirming that this woman still wanted an abortion, Traxler sat with her for a while.
"I reminded her, I am here with you, you are safe, and I'm going to take good care of you," Traxler said. "It gave her some solace to hear that she's not alone. There's so much stigma with abortion. They feel bad about what they're doing, even though they know it's the right decision for them. I view it as my job to let them know they're not alone."
Tara Haelle is an independent health and science journalist and book author. She specializes in reporting on vaccines, pediatrics, women's health, mental health, and medical research.
Medscape Medical News © 2019
Cite this: Death Threats and Abuse: Doctors Brave the 'Abortion Desert' - Medscape - Oct 14, 2019.