Un-Doctored

Abortion Without Physicians

Doctors’ conscientious objection to abortion can be a major obstacle to women who want, or are compelled, to terminate a pregnancy. In some countriesItaly, for examplesuch a high proportion of physicians register official claims that their “principles of conscience” won’t allow them to take part in abortion that most women are unable to find abortion care in the public sector. In the US, federal law and regulations allow doctors and other health workers to refuse to participate in abortions (and other medical care to which they object) no matter the circumstances under which a woman requests one. In most states, public funds cannot be used to end a pregnancy. Consequently, many hospitals do not routinely provide abortions to their patients, even if they are not obligated to Catholic doctrine. 

 Medical abortion might have made safe terminations available to women all around the world, but some governments and religions opposed this development, and the potential of medical abortion for women’s selfhelp is only partially realized. 

With physicians and health systems around the world failing women, it’s no wonder that they contemplate “nonphysician” abortions, either by terminating pregnancies on their own or with the aid of nonmedical providers. The “selfhelp” abortion movement began in the US before legalization. In fact, the most common and effective method for abortion, manual uterine evacuation using a simple plastic syringe and tubing, was originally developed for the women’s “selfhelp movement” so that, with minimal training, women could help each other end pregnancies when physicians were prohibited or unwilling. A few years after the advent of this simple surgical approach, abortion became legal and American physicians adapted traditional surgical instruments, for example, sharp curettes and electric suction machines, for pregnancy terminations. The simple selfhelp devices were later refined for mass production and reintroduced worldwide through the family planning efforts of the US Agency for International Development (USAID). Later, the Hyde Amendment and gag rules prohibited federal involvement with abortion services or counseling, but the equipment and technique spread around the world, with abortion often provided by nonphysicians. 

Twenty years after the introduction of manual uterine aspiration (MUA), French biochemists and physicians developed “medical abortion, based on one of the components of birth control pills altered to occupy the receptor for the natural pregnancy-supporting hormone progesterone, so that the natural hormone could not continue the pregnancy. With the addition of a long-available drug to cause uterine contractions to expel the failed pregnancy (and, like the syringe, initially sponsored by the USAID family planning effort), a method of medical abortion was added to the MUA option for nonphysician abortion. Depending on the training and experience of their users, the two methods are about equally safe and effective and both are provided around the world by physicians and nonphysicians alike. In some places, Western Europe for example, the majority of abortions are medical, whereas in Asia, a higher proportion are surgical syringe aspirations. 

Medical abortion presented a better opportunity for nonphysician terminations and selfhelp than did MUA, because the two drugs—three tablets in a oneinch square foil packagecan be mailed with simple instructions and used by a woman on her own or she can buy them at a pharmacy. Medical help is required only if complications develop, and they are rare. Uterine evacuation, on the other hand, requires someone, but not necessarily a physician or nurse, who knows how to use the syringe, and has a speculum and light to identify the cervix for insertion of the sterile cannula into the uterus. Medical abortion might have made safe, inexpensive, unobtrusive terminations available to women all around the world, but some governments and religions opposed this development, and the potential of medical abortion for women’s selfhelp is only partially realized. 

Physicians have a long history of providing abortions, despite governmental and religious opposition, if the price is right, while they have often argued that others should notAorganizing principal of the American Medical Association was opposition to abortion, because it was done by poorly trained practitioners like lay midwives who competed with physicians for abortion services and patients. Physicians succeeded in restricting the practices of their competitors in part by persuading politicians to restrict abortion. A century later, obstetricians’ own experience with the gruesome complications of illegal abortion prompted many of them to call for legalization, with the caveat that only physicians be allowed to do them. Accordingly, as state and national governments changed their laws, they defined a “legal abortion as one done by a physician. Legalization meant that the nascent self-help movement using the hand-held syringe was superfluous because legal physician abortion would displace it. 

After Roe v. Wade in the US and legal changes in many other countries authorized physicians to do abortions, only a small proportion of doctors became “abortion providers.” Instead, abortion services in most countries were concentrated in specialized clinics. Their efficiency brought safe care at a low price, but most of them were in cities and only a few physicians did most of the abortions. In countries without many physicians and in rural areas abortion was not available, nor was abortion integrated into typical hospital care or into physician training programs. 

Even in places with high concentration of physicians, like California, the need for abortion in rural communities prompted reconsideration of laws that limited abortion to physicians. When the Food and Drug Administration (FDA) approved medical abortion, California changed its law to permit nurses to provide it. There was little physician opposition. A few years later, after a demonstration project showed that nurse practitioners and midwives could use the handheld syringe to do early abortions as safely as could physicians, the California law was further amended to permit “advance practice clinicians” to do surgical abortions. Other states, including, recently, Virginia, have followed. Opposition to these changes has come not from physicians, but from those opposed to abortion for religious and political reasons. Physicians recognize the value of collaborative practice to meet the need for abortion and other women’s care, including delivery by nurse-midwives. 

Over the years since legalization, physicians have not just tolerated abortion practice by other clinicians, but have endorsed it. In response, some politicians have tried to restrict access to abortion services with laws targeted at abortion clinics and by intruding into the clinician-patient relationship with requirements for untruthful consent, and unnecessary clinic visits, tests and waiting periods. All of these have decreased access to and increased costs of abortion in physicians’ clinics and offices. The drug developed for medical abortion might seem a way around these imposed obstructions to abortion care, but in the US the FDA requires that physicians registered with the manufacturer dispense it only in their clinics and offices, severely limiting access. Pharmacist provision is a way to increase access by allowing physicians and other clinicians to simply write a prescription for women who request abortion. That prescription could be filled inperson or by mail, as is the case for almost all other drugs, including those with much more serious side effects than abortion medications, which are very safe. An inperson examination is not required if woman is reasonably sure of the duration of her pregnancy, that is, the date of her last menstrual period, and eligibility and use of the drugs can be described on the phone or over the internet. 

Physicians support measures that allow easier access to medications for their patients, but politicians in several states have passed preemptive laws to ban pharmacist and mail distribution and even telephone discussion of medications for abortion. The critical abortion issue for most physicians is not conscientious objection or nonphysician provision, but rather political interference in the practice of medicine. 

Phillip D. Darney is distinguished professor, emeritus of obstetrics, gynecology, reproductive sciences and health policy, and director, Bixby Center for Global Reproductive Health, University of California, San Francisco, as well as codirector of the Fellowship in Family Planning at UCSF.

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