Wednesday, July 30, 2008
By Grace Hammond
Jackson Hole, Wyo.- On a cloudless December night in a small town in South Dakota, Julie was curled in a ball in a snowdrift, her gloves and hat littered across the parking lot. She had emptied one whiskey bottle and was working through the second - enough, she hoped, to end her pregnancy. If it didn’t, she’d have to try something else.
Julie, which is not her real name, agreed to tell her story but declined to reveal her identity in order to protect her privacy.
Julie, 21, was single, in debt from the birth of her first son, and working a desk job at $5.65 an hour. She knew that if she asked for time off - either to have an abortion or to take care of a newborn - that she would lose her job.
“I couldn’t feed the son I already had,” she said. “So I did what I could do.”
By her estimates, getting to Sioux Falls - some 300 miles away - for a “doctor abortion” would have cost her $660, including $100 for gas, $60 for a hotel and $500 for the procedure itself. She would have needed a car, which she didn’t have, and two days off of work to wait out the state-mandated, 24-hour waiting period. Time and money were resources she simply had no access to.
Her friend bought the whiskey for her, and Julie took it to the high school parking lot after putting her 2-year-old to bed.
“I drank [the pregnancy] to death under the basketball hoop,” she said. “I nearly drank me dead, too. I had to find that balance between it dying and me dying, you know?”
Her friend took her to the hospital for alcohol poisoning once the whiskey - and, they figured, the pregnancy - was gone.
“It worked,” Julie said about the incident, now nearly two years behind her. “I’ve told a few girls it works.”
Julie is one of a growing number of women living in the West without an abortion provider within 100 miles.
Since 1982, the number of abortion providers in the United States has fallen by 37 percent. Of the remaining practitioners, 57 percent are older than 50 and are expected to retire within the next decade, according to Medical Students for Choice, a group founded in 1993 on the belief that “one of the greatest obstacles to safe abortion today is the absence of trained providers.”
The ‘graying of the profession’ is already affecting the West, which struggles with attracting and keeping physicians in its rural areas and has seen dramatic declines in abortion providers over the past two decades.
At the height of abortion services in the state of Wyoming, from 1981 to 1985, there were eight providers, according to the Guttmacher Institute, a nonprofit organization for sexual and reproductive health research. About 1,000 abortions a year were performed in Wyoming during that time.
After 1985, provider numbers began to drop as doctors retired but were not replaced. By 1988, a study found that the majority of women were leaving Wyoming to procure abortions. This report from the Center for Disease Control and Prevention showed that while only 188 abortions were performed in the state that year, 902 women who identified themselves as Wyoming residents had obtained abortions somewhere in the country.
By 2005, two abortion providers remained in Wyoming, and 70 abortions were recorded in the state. Now, a single advertised abortion provider is left: Dr. Brent Blue, a family practitioner at Emerg-A-Care in Jackson Hole. There may be other Wyoming providers, however, who don’t advertise their abortion services and limit them to their own patients.
A class of its own
The retiring generation of abortion providers is largely comprised of general and family practice physicians who were studying or practicing medicine both before and after Roe v. Wade made abortion legal in the U.S. in 1973.
Many doctors of this era do not consider themselves activists. Rather, they call themselves ‘community doctors,’ and they consider abortion a small but integral part of providing full-service medical care.
“As far as I’m concerned, it’s part of a family practice,” Blue said. “It’s part of medicine. It’s no different from vasectomy services and no different than delivery services. … It is not a political issue.”
Blue’s clinic in Jackson Hole was bombed in 1995 by Richard Thomas Andrews, an anti-abortion activist who later pleaded guilty to bombing abortion clinics in California, Montana and Idaho. Still, Blue said that he pays “very little attention” to opposition.
Edward Boas, one of the few remaining family practice physicians to provide abortions in Boise, Idaho, said he is not an upstart by any means.
“I’m not gonna go marchin’,” he said. “I have done surgery all my life and this is a minor little surgical procedure. … It’s part of the medical world and somebody’s got to do it.”
The toll of travel
Even though an estimated 35 percent of U.S. women will have at least one abortion by age 45, about 87 percent of the nation’s counties currently have no provider, according to the Guttmacher Institute.
In the Western census region, where Wyoming is located, 18 percent of women having abortions in 2005 reported traveling more than 50 miles and 5 percent traveled more than 100 miles.
In other Western states, some women report traveling 300 miles or more.
Planned Parenthood’s Wyoming Abortion Fund has provided more than 200 women with financial assistance, paid directly to the provider, since its creation in October 2004. The fund will assist Wyoming residents with lodging, day care, and travel to other states, as is often necessary. Another fund, called Women for Women, also helps Wyoming residents.
An abortion at Emerg-A-Care in Jackson Hole costs $1,045, cash only, and insurance is not accepted. The abortion funds in the state may provide $500 in total toward this cost.
Boas, in Idaho, charges $450 for the procedure.
The Hyde Amendment denies federal Medicaid funding for abortions except in cases of rape, incest or life endangerment.
Boas, like many Western family practice doctors, believes that no one will take his place performing safe, legal abortions when he retires. Just recently, there were three providers in Idaho. But one retired last year, Boas is retiring in December and the final provider “is not really that into doing it,” he said.
Unless there are abortion providers working under the radar in Idaho - which Boas doubts, based on the cost of ultrasound and other equipment - it could be the end of an era for the state.
New medical school graduates don’t want “that bad connotation” of providing abortion services, he said, and that’s why there isn’t anyone replacing the retiring generation - yet.
“Guys like me, I started doing it when I was about 50,” Boas said. By then, he was established in the community and unconcerned about losing business by providing abortions to women who wanted them.
Doctors who are just graduating from medical school and creating their practices may more worried about what people think, he said.
One Western abortion provider, who asked not to be named, said that state legal restrictions saddle the procedure with so many regulations that some doctors are wary to become involved, even if they have no qualms about abortion itself.
“There is also the issue of reporting terminations,” the doctor said. “New graduates are going to be more worried about the laws than maybe us old doctors are. They think of the law as bigger than it is.”
Wyoming has parental notification laws that require that the parent of a minor consent before an abortion can be provided. There have also been repeated attempts in the Legislature to create a state-written script that doctors must recite to a patient before performing the procedure. The script included phrases medical professionals called “insulting, patronizing and unscientific,” such as linking abortions to breast cancer. The bill was most recently defeated in 2007.
Blue just smiled at the idea of a mandated script. “What I say to a patient is no one’s business but mine and the patient’s,” he said.
Other doctors are afraid that if they provide abortions they will be pigeonholed as “abortion doctors” rather than doctors providing a full range of services. Some doctors are concerned about being stigmatized within the medical community, said Sharon Breitweiser of NARAL Pro-Choice Wyoming.
Other doctors, say anti-abortion groups, simply think it’s wrong.
Lack of medical school training
Even if medical students want to be trained in surgical abortion procedures, some have little opportunity. Between 1978 and 1995, the number of medical programs providing routine abortion training to residents dropped from 26 percent to 12 percent, according to Guttmacher data.
“Medical schools across the country just are not teaching the service, so when people are presenting at emergency rooms … they’re not providing abortion services,” said Katie Groke, a field manager at Planned Parenthood of the Rocky Mountains. “They don’t know how.”
It is possible that surgical abortions will decrease as surgical training opportunities flounder but that medical abortions with RU-486, the so-called “abortion pill,” will increase in the future, some medical professionals said.
Medical Students for Choice was formed in the 1990s to address the dearth of training, but it has “had trouble catching on in the West,” where most doctors are “funneled” to the University of Washington Medical School to complete their residencies and where abortion training is “severely lacking,” said a member of the group.
Officials at the medical school did not return calls for comment.
Boas is connected to the organization. “I go to these meetings that are nationwide, and you get about 12 to 15 of these kids in training,” he said. “They’re different now than we are. Most of them are girls.”
He would be happy to pass his knowledge along to another Idaho doctor.
“Hell, I could teach somebody to do one in two days,” he said. “It’s not brain surgery.”
Few ‘abortion clinics’
As these providers retire, their services are rarely replaced by ‘abortion clinics’ in the West, which are defined as clinics where abortions make up more than 50 percent of provided services.
Abortion clinics are typically established in city centers with dense populations, which the West lacks. Further, Planned Parenthood officials said the pool of abortion providers in some Western states is too small to provide enough doctors to operate a clinic.
A few clinics operate without local doctors. South Dakota’s single abortion clinic, on the far eastern side of the state in Sioux Falls, flies doctors in to provide abortions a few hours a week.
The doctors “have security from the moment they step into South Dakota until the moment they leave,” said Kathi Di Nicola, Director of Media Relations for the Planned Parenthood clinic. “They just have to.”
Three out of four doctors are “seasoned,” said Di Nicola, and one provider, identified in the media as Dr. Miriam McCreary from Minneapolis, came out of retirement just to provide termination services in a state where none of its own doctors are willing to do so.
One of the biggest challenges is what to do next if any of these doctors retire from the clinic, Di Nicola said. “They won’t be easy to replace.”
Planned Parenthood’s abortion clinics aren’t attractive options to medical professionals like Boas, who defines himself as a generalist and a community doctor rather than ‘an abortion doctor.’
“They tried to recruit me to come to Spokane … but I turned it down,” Boas said. “That’s itinerant medicine. I don’t really like it.”
The end of an era
Boas said he believes “we’re seeing the last days of Roe v. Wade.”
Even if abortion remains legal, it could become inaccessible, he said. If there are enough barriers placed between a woman and a doctor, like in Julie’s case, the two may never connect.
“These anti-abortionists, they’ll chip away at it until it will eventually collapse,” Boas said. “Finally the providers are going to say, ‘I’ve had enough of this and I can’t do it anymore.’ I guess I’m glad I’m retiring.”