Research Article related to abortion.

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24. Ministry of Healthcare and Nutri- tion. Overview of Maternal Mortality in Sri Lanka 2001---2005. Colombo, Sri Lanka: Family Health Bureau; 2009.

25. Family Health Bureau. Annual Re- port on Family Health Sri Lanka 2008--- 2009. Colombo, Sri Lanka: Ministry of Healthcare and Nutrition; 2010.

26. Family Health Bureau. National Strategic Plan on Maternal and Newborn Health (2012---2016). Colombo, Sri Lanka: Ministry of Health Sri Lanka; 2011.

27. WHO Guidelines for the Management of Postpartum Haemorrhage and Retained Placenta. Geneva, Switzerland: World Health Organization; 2009:1. Available at: http://whqlibdoc.who.int/publications/ 2009/9789241598514_eng.pdf. Ac- cessed September 13, 2012.

28. Berer M. Making abortions safe: a matter of good public health policy and practice. Bull World Health Organ. 2000; 78(5):580---592.

29. Senanayake L, Willatgamuwa S. Reducing the Burden of Unsafe Abortion in Sri Lanka. Colombo, Sri Lanka: Family Planning Association of Sri Lanka; 2009:21---31.

30. Senanayake H, Seneviratne SA, Kariyawasam V. Knowledge, attitudes, practices regarding postpartum contra- ception among 100 mother---father pairs leaving a Sri Lankan maternity hospital after childbirth. Ceylon Med J. 2006; 51(1):41.

31. Thalagala N. National Survey on Emerging Issues Among Adolescents in Sri Lanka. Colombo, Sri Lanka: United Na- tions Children’s Fund; 2004. Available at: http://www.unicef.org/srilanka/Full_ Report.pdf. Accessed September 13, 2012.

32. Safe Abortion: Technical and Policy Guidance for Health Systems. 2nd ed. Geneva, Switzerland: World Health Or- ganization; 2012:22---24.

33. Nathaniel C. Government to legalize abortion. Ceylon Today. January 29, 2012:5. Available at: http://www. ceylontoday.lk/e-paper.html. Accessed September 13, 2012.

34. Mudalige D. Catholic bishops on abortion law. Daily News. March 30, 2012. Available at: http://www. dailynews.lk/2012/03/30/news34.asp. Accessed September 13, 2012.

35. Jayasuriya L, Abeywardena M, Fernandopulle M. Don’t relax laws

preventing abortion in Sri Lanka. The Island. May 17, 2012. Available at: http://www.island.lk/index.php?page_ cat=article-details&page=article-details &code_title=52111. Accessed Septem- ber 13, 2012.

36. Mudugamuwa M. What others say about legalizing abortion. The Island. April 2, 2012. Available at: http://www. island.lk/index.php?page_cat=article- details&page=article-details&code_title= 48937. Accessed November 9, 2012.

37. Where the womb becomes the tomb. Daily Mirror. November 9, 2012. Available at: http://www.dailymirror.lk/ opinion/172-opinion/23345-where-the- womb-becomes-the-tomb-.html. Accessed December 12, 2012.

38. Jayawardana S. Abortion: women’s rights vs. child’s rights. The Nation. 2012; (February):26. Available at http://www. nation.lk/edition/component/k2/ item/3127-abortion-women%E2% 80%99s-rights-vs-child%E2%80% 99s-rights.html. Accessed September 13, 2012.

39. Center for Reproductive Rights. The world’s abortion laws map 2007. Publi- cations: maps and posters. July 2007. Available at: http://reproductiverights.

org/sites/crr.civicactions.net/files/ documents/Abortion%20Map_FA.pdf. Accessed September 14, 2012.

40. Asia Safe Abortion Partnership. Country profiles. Available at: http:// www.asap-asia.org/country-profiles.html. Accessed September 14, 2012.

41. Guttmacher Institute. Making Abortion Services Accessible in the Wake of Legal Reforms: A Framework and Six Case Studies. New York, NY: Guttmacher Institute; 2012. Available at: http:// www.guttmacher.org/pubs/abortion- services-laws.pdf. Accessed November 9, 2012.

42. Samandari G, Wolf M, Basnett I, Hyman A, Andersen K. Implementation of legal abortion in Nepal: a model for rapid scale-up of high-quality care. Reprod Health. 2012;9:7. Available at: http://www. reproductive-health-journal.com/content/ 9/1/7. Accessed November 9, 2012.

43. Berer M. National laws and unsafe abortion: the parameters of change. Reprod Health Matters. 2004;12(24, suppl):1---8.

Unintended Consequences: Abortion Training in the Years After Roe v Wade

The US Supreme Court’s

1973 Roe v Wade decision

had clear implications for

American women’s repro-

ductive rights and physician

ability to carry out patient

choices. Its effect on physi-

cian abortion training was

less apparent.

In an effort to increase

patient access to abortions

after Roe, provision shifted

from hospitals to nonhos-

pitalclinics.However,these

procedures and patients

were taken out of the med-

icaleducationrealm,andphy-

sicians became vulnerable

to intimidation. The conse-

quent provider shortage

created an unexpected bar-

rier to abortion access.

Medical Students for

Choice was founded in 1993

to increase abortion-training

opportunities for medical

students and residents. Its

mission ensures that mo-

tivated medical students

will learn and a growing

number of physicians will

commit to comprehensive

abortion provision. (Am J

Public Health. 2013;103:404–

407. doi:10.2105/AJPH.2012.

301152)

Sarp Aksel, Lydia Fein, MS, Em Ketterer, Emily Young, MPH, MA, and Lois Backus, MPH

THE 1973 US SUPREME COURT

decision on Roe v Wade had far- reaching implications for the training and acceptability of abor- tion practice among physicians in the United States. Almost over- night, there was a shift in abortion provision from hospital centers to nonhospital clinics. Following Roe, the percentage of abortions performed in nonhospital clinics rose from 51% in early 1974 to 61% in 19761 and reached 95%

in 2008.2 Although the shift of abortion provision out of hospitals increased the number of sites where women could access abortion and other critical family planning services, it unintention- ally took the procedure, relevant reproductive health care topics, and the patients out of the realm of hospital-based medical education accessible to medical students and residents. Training in family planning became uncommon in

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404 | Safeguarding Abortion Globally | Peer Reviewed | Aksel et al. American Journal of Public Health | March 2013, Vol 103, No. 3

residency programs, and by the early 1990s, only 12% of obstet- rics and gynecology (OB/GYN) programs offered training in abor- tion care.3

The exodus of abortion provi- sion away from the safe haven of hospital medical centers and into specialized clinics also produced a shift in the focus of anti-abortion activists toward individual physi- cians and their clinics.4 Eventu- ally, harassment previously re- served for clinic sidewalks moved to target the private homes of physician providers. Anti-abortion activists strove to intimidate and make pariahs of these health care professionals on a very personal level. In early 1993, thousands of medical students across the coun- try were mailed a vulgar and menacing pamphlet of jokes by an anti-abortion group in Texas entitled, “Bottom Feeder: The Abortionists’ Jokebook.” One in- clusion from the pamphlet read, “Q: What would you do if you found yourself in a room with Hitler, Mussolini and an abortion- ist, and you had a gun with only two bullets? A: Shoot the abor- tionist twice.”5(p9) Later that same month, David Gunn, an abortion provider in Pensacola, Florida, was shot and killed in front of the clinic at which he worked. He was the first of many physicians, clinic staff, and volunteers to fall prey to the violent tactics of ex- treme anti-choice activists.

The anti-abortion movement’s violence against physicians and attempts to influence medical stu- dents’ opinions on abortion met resistance from an unexpected, rising leader. Infuriated by anti- abortion tactics, Jody Steinauer, then a first-year medical student at the University of California, San Francisco, decided to take a year’s hiatus from school to counter these attacks on current and future

physicians. Her attention became centered on the lack of abortion- related education and training within medical school curricula.6

Working as an intern at the National Abortion Federation, Steinauer began contacting like- minded medical students and quickly uncovered a burgeoning pro-choice medical student com- munity yet to be organized. What started as a small gathering of medical students at the 1994 National Abortion Federation an- nual meeting quickly grew into a cohesive national community of pro-choice advocates. These stu- dents joined together to form a new organization named Medi- cal Students for Choice (MSFC).

In an environment that is often resistant to change and contro- versy, medical student activists of MSFC have worked steadily for almost two decades to reinstate abortion training in their medical education and to reverse the steady decline in the number of US abortion providers. Program- ming efforts have been at the heart of this work, including innovative

medical-school curriculum reform strategies and clinical training op- portunities including the Repro- ductive Health Externship, which provides financial and administra- tive support for medical students to gain exposure to abortion counseling and procedures. Although impressive inroads have been made, there remains a lack of comprehensive reproductive health education in medical school curricula nationwide.7 The loss of hospital-based abortion experi- ences for medical students and residents following the Roe deci- sion has unfortunately made ac- cess to training more difficult for these students. Hence, it has po- tentially added to the lack of ac- cess to safe abortion care.

Countless studies over the past decade have highlighted the ne- cessity of comprehensive abortion training and reproductive health education for medical students. In a 2005 study, Espey et al. found that almost a quarter of medical schools provided no formal education on abortion in the third-year OB/GYN clerkship.8

A subsequent 2008 study showed that the majority of medical stu- dents view abortion education as an appropriate and valuable ex- perience that they would recom- mend to others.9 Perhaps of most importance, increased exposure to abortion care has not only been shown to correlate with improved attitudes toward abortion among medical students,10 but also with more medical students consider- ing abortion provision in their future careers.11

The impact of the lack of abor- tion education and training on access has been profound. A re- cent study of practicing obstetri- cians and gynecologists in the United States shows that those who graduated from medical school between 1990 and 2000 have the lowest rate of abortion provision.12 In turn, these years correspond with the years of steepest decline in access. The most striking recent data show that 87% of US counties, home to one third of all women of re- productive age, have no abortion providers.13 Lack of abortion

TABLE 1—Alumni Survey Results for Abortion Provision, by Medical Specialty: Medical

Students for Choice, 2011

Medical Specialty Total Response, %

Respondents Providing Abortion

Services, No. (%)

Obstetrics and gynecology (n = 98) 31.5 65 (66.3)

Family medicine (n = 74) 23.8 24 (32.4)

Internal medicine (n = 34) 10.9 0 (0)

Emergency medicine (n = 22) 7.1 1 (4.5)

Pediatrics (n = 21) 6.8 1 (4.8)

Psychiatry (n = 18) 5.8 0 (0)

Othera (n = 44) 14.1 3 (6.8)

Total (n = 311) 100 94 (30.2)

Note. Total surveys mailed = 670. Response rate = 46.6%. The estimated response rate by specialty: obstetrics and gynecology, 47.1%; family medicine, 53.6%; internal medicine, 45.9%; emergency medicine, 50.0%; pediatrics, 24.1%; psychiatry, 52.9%; other, 51.8%. a Other specialties included adolescent medicine, allergy/immunology, anesthesiology, colorectal surgery, critical care, dermatology, endocrinology, general surgery, geriatrics, infectious disease, neurology, obstetric anesthesia, ophthalmology, orthopedic surgery, pathology, pediatric dermatology, pediatric emergency medicine, pediatrics, physical medicine and rehabilitation, preventative medicine, pulmonary, radiology, rheumatology, sports medicine, transplant surgery, urology, and vascular surgery.

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March 2013, Vol 103, No. 3 | American Journal of Public Health Aksel et al. | Peer Reviewed | Safeguarding Abortion Globally | 405

training is directly related to this provider shortage and causes a decreased access to options for patients.

Since its inception, MSFC’s mis- sion has been to increase medical student and resident exposure to and training in abortion pro- cedures. This aim includes edu- cating future obstetricians and gynecologists, family practitioners, emergency medicine physicians, pediatricians, and any other type of physician wishing to gain knowledge or skills in abortion provision. Ensuring adequate ac- cess for all women to safe and legal abortions requires a collabo- rative effort from physicians across the various specialties. In MSFC’s 2011 Alumni Survey, re- sults showed that more than two thirds of OB/GYN alumni and one fourth of family medicine alumni provide abortions, and an array of physician alumni practicing pe- diatrics, internal medicine, and emergency medicine also provide abortion services to their patients (Table 1).

As medical students, we are entering our profession at a time when national hostility toward abortion and reproductive health is once again at near-fever pitch. For the first time in decades, more Americans identify as “pro-life” than “pro-choice.”14 In 2011 alone, 67 abortion-restricting laws were enacted, in addition to a flurry of budget restrictions placed on family planning funding and re- productive health care facilities.15

In only the first six months of 2012, 39 more anti-abortion regulations have gone into effect to limit pa- tient access. A majority of these new restrictions specifically and intentionally target abortion pro- viders and their ability to practice.16

Almost half of all American women will seek an abortion in their lifetime,17 and thus the lack

of training for physicians may have profound public health im- plications. The decades of unre- lenting harassment of physicians have ensured that abortion is still a procedure that most doctors will perform only under the guise of anonymity for fear of professional and personal consequences. Even more troubling is that many phy- sicians who support women’s ac- cess to abortion are reluctant to advocate for their patients within this hostile environment, inadver- tently adding to abortion’s stigma with their silence.18 Even those physicians who complete abortion training note the challenge of finding a practice or hospital that will accept them for affiliation if they choose to provide abortions.

This current shortage of trained physicians means a lack of will- ing teachers who can provide train- ing for medical students on a full range of reproductive health care topics. Although 97% of practic- ing obstetricians and gynecologists report that they have encountered patients seeking abortions, only 14% provide this service.12 Lack of training remains the most com- monly cited reason by MSFC alumni for not providing abor- tions, including practicing OB/ GYN alumni. Also cited frequently as a barrier were institutional pol- icies prohibiting abortion training and provision by residents and physicians. In addition, many medical students attend schools that are openly against abortion, and these students will likely never even hear the procedure mentioned in their four years of training outside of a possible dis- cussion on its ethics.

Yet, amid continued attacks from the anti-abortion movement, there are some positive signs of progress. For the first time since the early 1980s, there was no significant decline in the number

of abortion-providing facilities be- tween 2005 and 2008.13 Even more encouraging is the finding that obstetricians and gynecolo- gists younger than 35 years are the most likely age group to pro- vide abortions in their practice. With the majority of abortions in the United States currently being provided by physicians older than 50 years,2 this younger generation ensures many years of future provision, and that is what MSFC cultivates through its student membership.13 Lastly, it has been found that exposure to abortion education while in medical school and subsequent development of an intention to provide abortions are the most powerful predictors of future abortion provision.11 This fact reinforces the importance of MSFC’s continued commitment to increasing exposure and train- ing opportunities for the new generation of pro-choice medical students and resident physicians.

Forty years ago, a woman’s constitutional right to privacy when making personal reproduc- tive health decisions was affirmed. Twenty years later, a group of medical students set out to ensure that this right could be exercised through the creation of caring, educated, and well-trained physi- cians. On this important anniver- sary of Roe v Wade, we honor the passion and fortitude of the Roe- era abortion providers and former medical students such as Steinauer who paved our way forward. Today, in the face of increasing adversity, we also renew our own commitment to the patient’s right to make informed medical deci- sions about her own body. We recognize the challenges women continue to face when seeking an abortion, including the barriers of stigma, cost, and lack of access, all of which continue to unjustly af- flict our country’s most vulnerable

populations. We will always re- member the countless women who lost their lives seeking the chance to build their families on their own terms before Roe, and unfortunately even after.19 We also honor the many sacrifices of the outstanding and courageous physicians who have ensured the right of women to have agency over their futures through their willingness to act. Without these physicians, there would be no “choice.” This ability to make pri- vate reproductive health decisions has been hard won, and it cannot exist without competent and compassionate abortion pro- viders and pro-choice physicians— precisely the doctors that MSFC strives to create. j

About the Authors All authors are with Medical Students for Choice, Philadelphia, PA. Sarp Aksel is also with the Albert Einstein College of Medicine, Bronx, NY. Lydia Fein is also with the University of Miami Leonard M. Miller School of Medicine, Miami, FL. Em Ketterer is also with the Wayne State University School of Medicine, Detroit, MI. Emily Young is also with Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, FL. Correspondence should be sent to Sarp

Aksel, 1925Eastchester Rd, Apt28B,Bronx, NY 10461 (e-mail: [email protected]). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link.

This commentary was accepted November 8, 2012.

Contributors S. Aksel and L. Fein conceptualized and drafted the article. S. Aksel led revision of the article with critical contributions from all authors.

Acknowledgments The authors would like to thank Erica Seaborne and Monica Dragoman, MD, for their invaluable input and thought- ful comments throughout the writing process.

References 1. Forrest JD, Tietze C, Sullivan E. Abortion in the United States, 1976--- 1977. Fam Plann Perspect. 1978;10 (5):271---279.

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2. Jones RK, Zolna MRS, Henshaw SK, Finer LB. Abortion in the United States: incidence and access to services, 2005. Perspect Sex Reprod Health. 2008;40 (1):6---16.

3. MacKay HT, MacKay AP. Abortion training in obstetrics and gynecology res- idency programs in the United States, 1991---1992. Fam Plann Perspect. 1995; 27(3):112---115.

4. Sonfield A. Abortion clinics and contraceptive services: opportunities and challenges. Guttmacher Policy Rev. 2011; 14(2):1---7.

5. Bottom Feeder: The Abortionists’ Jokebook. Lewisville, TX: Life Dynamics Inc; 1993:1---16.

6. Steinauer J, LaRochelle F, Rowh M, Backus L, Sandahl Y, Foster A. First impressions: what are preclinical medical students in the US and Canada learning about sexual and reproductive health? Contraception. 2009;80(1):74---80.

7. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 424: Abortion access and training. Obstet Gynecol. 2009;113(1): 247---250.

8. Espey E, Ogburn T, Chavez A, Qualls C, Leyba M. Abortion education in medical schools: a national survey. Am J Obstet Gynecol. 2005;192(2):640---643.

9. Espey E, Ogburn T, Leeman L, Nguyen T, Gill G. Abortion education in the medical curriculum: a survey of stu- dent attitudes. Contraception. 2008;77 (3):205---208.

10. Espey E, Ogburn T, Dorman F. Student attitudes about a clinical experi- ence in abortion care during the obstetrics and gynecology clerkship. Acad Med. 2004;79(1):96---100.

11. Steinauer J, Landy U, Filippone H, Laube D, Darney P, Jackson R. Predictors of abortion provision among practicing obstetrician gynecologists: a national sur- vey. Am J Obstet Gynecol. 2008;198(1):39. e1---39.e6.

12. Stulberg DB, Dude AM, Dahlquist I, Curlin FA. Abortion provision among practicing obstetrician gynecologists. Obstet Gynecol. 2011;118(3):609---614.

13. Jones RK, Kooistra K. Abortion in- cidence and access to services in the United States, 2008. Perspect Sex Reprod Health. 2011;43(1):41---50.

14. Saad L. “Pro-choice” Americans at record-low 41%. Gallup Politics. 2012. Available at: http://www.gallup.com/poll/ 154838/Pro-Choice-Americans-Record- Low.aspx. Accessed July 23, 2012.

15. Who Decides? The Status of Women’s Reproductive Rights in the United States. NARAL Pro-Choice America Foundation. 2012. Available at: http://www.

prochoiceamerica.org/assets/download- files/2011-who-decides.pdf. Accessed September 12, 2012.

16. State Legislative Trends at Midyear 2012. Guttmacher Institute. 2012. Available at: http://www.guttmacher. org/media/inthenews/2012/07/10/ index.html. Accessed July 23, 2012.

17. Jones RK, Kavanaugh ML. Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstet Gynecol. 2011;117(6):1358---1366.

18. Kumar A, Hessini L, Mitchell EMH. Conceptualising abortion stigma. Cult Health Sex. 2009;11(6):625---639.

19. Saultes TA, Devita D, Heiner JD. The back alley revisited: sepsis after attempted self-induced abortion. West J Emerg Med. 2009;10(4):278---280.

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