Abortion access is endangered: We need to prepare for a post-Roe America

"Abortion deserts" abound in the U.S., and 21 states are at risk of banning abortion. But patients still need care

By Jody Steinauer
Published August 29, 2019 5:00PM (EDT)
Protesters for women's rights march to the Alabama Capitol to protest a law passed last week making abortion a felony in nearly all cases with no exceptions for cases of rape or incest, Sunday, May 19, 2019, in Montgomery, Ala.  (AP/Butch Dill)
Protesters for women's rights march to the Alabama Capitol to protest a law passed last week making abortion a felony in nearly all cases with no exceptions for cases of rape or incest, Sunday, May 19, 2019, in Montgomery, Ala. (AP/Butch Dill)

Like many Americans, I am saddened every time I see a headline about a state legislature stripping away access to abortion. The abortion restrictions sweeping the country in 2019 have reached new extremes — some outlaw abortion at six weeks, before most people even know they’re pregnant, and subject abortion providers to harsh criminal penalties. The anti-abortion movement is energized by a president who spouts dangerous lies about abortion with abandon, and a new conservative majority at the Supreme Court that could gut or overturn Roe v. Wade.

We need to prepare for a post-Roe landscape where 21 states are at high risk of banning abortion. But many people in the U.S. already live in that reality. Twenty-seven large cities are “abortion deserts” where people have to travel more than 100 miles each way to get an abortion. Six states have only one remaining abortion clinic, and their existence is often tenuous. The Trump administration’s changes to the Title X family planning program threaten reproductive health care for millions of low-income people.

As an abortion provider, educator and researcher, I am determined to ensure that patients can still access the care they need no matter where they live or how much money they make. We need to muster all of the will and ingenuity of the healthcare community to meet this moment. Earlier this year, the Bixby Center for Global Reproductive Health, a center I direct at the University of California, San Francisco, convened panels of reproductive health, rights and justice experts to explore how we can continue to meet the needs of patients post-Roe v. Wade.

Listen to those conversations on "Inflection Point":

One of the most critical things we can do is directly support patients in navigating the barriers to abortion care. Local abortion funds are filling the gaps that our system lets people fall through, and they need support.

At Zuckerberg San Francisco General Hospital, we see abortion patients who struggle to get to us from across the Bay, across the state, or even outside of California or the U.S. ACCESS Women’s Health Justice, California’s abortion fund, helps arrange everything from rides to housing to childcare so these patients can get the care they need. These funds are often volunteer-run and face much higher demand than they can accommodate.

Cities like New York and Austin have stepped up to provide city funds to facilitate access. Other states are joining California in providing state health coverage for abortions. This is essential as our research recently showed that about one quarter of women Medicaid-eligible pregnant women give birth instead of having an abortion because Medicaid does not cover abortion.

We also need to prepare for the likelihood that more people will manage their own abortions. People have a lot of reasons for choosing this option, most often cost and logistical barriers. As the Trump administration’s harsh immigration crackdowns scare undocumented people away from health facilities, this becomes even more critical.

Research shows that people can safely manage their own abortions with medication; the biggest threat they face is criminalization by an overzealous criminal justice system. People within the health care system must be prepared to treat people who have complications or questions after self-managed abortion. We must treat them with compassion, refrain from judgment, and understand we have no duty to report self-managed abortion to law enforcement.

We also need to build the abortion provider workforce, especially in areas that border hostile states. We need to incentive and support people to improve their skills so that more people can perform abortions and at a minimum, health care workers can provide supportive counseling and refer people to care. The education system must support that commitment — even now, more than one third of OB-GYN residency programs don’t offer routine abortion training. In addition to traditional medical training, there are creative ways to get this information to people in hostile environments, like our massive open online course on quality abortion care and public health.

It’s critical to expand who provides abortion care. Primary care providers including family medicine doctors can provide abortion as part of their practice. We demonstrated that it’s safe and positive for patients to have nurse practitioners, certified nurse-midwives and physician assistants to provide early abortion care. States can clear the way by eliminating physician-only laws that aren’t based in science and put up unnecessary barriers.

We also need to innovate on how we deliver care. Restrictions on the way we provide abortion are based on stigma and politics, not evidence. A group of determined students in California has put us on the path toward being the first state to require public campuses to provide medication abortion. Telemedicine could vastly cut down on travel time and childcare and transportation costs. We can’t let our thinking be bound by what the political system can support now—we need to push for better models and provide the evidence to make the case. Providing medication abortion over the counter, at the pharmacy or by mail could revolutionize access.

Abortion is necessary health care. Denying access is bad for people’s physical, mental and financial health. While we fight to maintain and expand legal rights and access, we must do everything we can to keep providing compassionate, patient-centered care to everyone who needs it in the face of aggressive attacks.

Jody Steinauer

Jody Steinauer, MD, MAS, is director of the Bixby Center for Global Reproductive Health at the University of California, San Francisco.

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