Journalism in the Public Interest

California Poised to Broaden Access to Abortions

A state law could soon be signed to allow non-doctors to perform some abortions.

Pro-choice supporters and members of Planned Parenthood rally to mark the 35th anniversary of the Roe v. Wade decision legalizing abortion in Los Angeles in 2008 (David McNew/Getty Images)

Oct. 9: On Wednesday, California Gov. Jerry Brown signed two bills dramatically broadening access to early abortions in the state. Last week, we wrote about how researchers and lawmakers joined forces to pass the bills and how the legislation could influence abortion politics and access in other states.

When you read about abortion these days, the news is mostly about restrictions—new state laws, regulations, and court challenges that aim (depending on your point of view) either to make the procedure safer for women or to put providers out of business. But California is going in the opposite direction, with two bills that could lead to the one of the biggest expansions of access to abortion in the United States since the FDA approved mifepristone, aka the abortion pill, in 2000.

AB 154 would allow specially trained nurse practitioners, nurse midwives and physician assistants to perform first-trimester abortions without a doctor’s supervision. AB 980 would hold abortion clinics to the same building standards as other primary care facilities, instead of the stricter rules that some cities and counties would like to impose. Both are aimed at making the procedure more widely available in rural, largely conservative parts of the state where incomes are low, teen pregnancies are rampant, and finding an abortion provider often means taking the day off from work or school, getting on a bus, and traveling for hours or days.

Reaction has been predictably split. Margaret Crosby, the ACLU’s lead voice on reproductive issues in California, says one of the most significant things about the bills is that they “treat abortion like any other medical procedure. The fact that abortion is singled out for special consideration is a relic of the days when it was a felony,” she says. “It’s a reflection of where this country is politically rather than medically.”

That dismays Brian Johnston, director of the California Pro-Life Council, who sees what he calls the “minimization” and “casualization” of abortion as a terrible thing for women and girls. If the bills are signed, he says, “animals will have more dignity under the laws of California than human beings.”

Both sides do agree on one thing: The central role played by researchers in persuading lawmakers to pass the bills could change the terms of the whole debate.

Indeed, AB 154 would have gone nowhere but for a recent study out of the University of California–San Francisco that ranks as one of the largest examinations of abortion complication rates ever conducted. After monitoring more than 11,000 procedures over five years, researchers found very little difference in the rate of complications between first-trimester vacuum aspirations performed by experienced doctors and those done by skilled non-physicians.

“Other states that are adding restrictions and barriers are doing so purely out of politics,” says Kathy Kneer, president and CEO of Planned Parenthood Affiliates of California. “It’s not based on any medical evidence. The California study gives people a way to push back. It’s like a factual slap in the face.”

But first, some back story.

California’s support for abortion rights goes back to at least 1967, when Governor Ronald Reagan signed a law legalizing the procedure, six years before Roe v Wade. The state is also one of only a handful to have the right to privacy written into its Constitution. Courts have cited that right many times over the years to reject attempts by abortion opponents to impose restrictions.

As a result, unlike the vast majority of other states, California pays for abortions for low-income women and lets teenage girls end their pregnancies without having to tell their parents first. It has about 500 providers scattered throughout the state. These providers accounted for 18 percent of all the abortions performed in the U.S. in 2008, the Guttmacher Institute says. California “does not have” an access problem, insists Carol Hogan, director of pastoral projects and communications for the California Catholic Conference.

But abortion advocates look at the same picture and see many glaring gaps. Some 52 percent of counties—mainly in conservative areas like the vast agricultural Central Valley—either don’t have any providers or lack accessible providers, defined as clinics that perform abortions routinely for a fee that women can afford. Medi-Cal (the state’s version of Medicaid) may pay for the procedure, but it does so at 1985 levels—as much of a disincentive for many doctors and hospitals as noisy protesters and bomb threats.

Plus, California is enormous. Kern County, for example, at the southern end of the Central Valley, has one abortion clinic to serve an area larger than New Jersey.

 “Maybe there’s a clinic in their area but it only offers the [abortion] pill and that’s only good through the eighth week of pregnancy,” says Sierra Harris, associate director of ACCESS: Women’s Health Justice, a nonprofit organization in Oakland that helps women make arrangements and sometimes pays for their trips. “They have to arrange childcare, transportation.” The more onerous the logistics, the longer it takes to obtain care, and many women miss the first-trimester cutoff that most clinics impose, making it even harder to find a provider. “The delays lead to more delays. It becomes a cycle,” Harris says.

Then there’s the chronic nationwide shortage of doctors trained to perform abortions. New Hampshire, Vermont, Oregon and Montana have long permitted physician assistants and nurse practitioners to pick up the slack.

Abortion advocates have been trying for years to revamp the California statutes. A turning point came in 2002, when lawmakers enacted a new law that enshrined Roe. The law also gave the go-ahead for non-physicians to perform “medical” (pill) abortions.

Yet even pro-choice lawmakers remained reluctant to let non-doctors do “surgical” (vacuum aspiration) abortions—as of 2008, about 83 percent of first-trimester procedures in the U.S., Guttmacher says. They wanted proof that patients would not be harmed (and assurances that the medical establishment wouldn’t be hurt, either).

But the same political forces that have made it difficult to build new clinics and train doctors have also made it nearly impossible for researchers to study abortion the way they do other medical procedures.

Enter Tracy Weitz, an associate professor in the ob/gyn department at UCSF. A social scientist by training, she heads the Advancing New Standards in Reproductive Health project at the school’s Bixby Center for Global Reproductive Health, one of the very few programs in the U.S. doing clinical research on abortion and contraception.

Weitz and her team discovered a little-known mechanism in California law that lets health care professionals conduct pilot projects—for example, studying whether dental hygienists can be trained to safely fill cavities. After a two-year approval process, the researchers quietly embarked on a study the likes of which has never been done in this country.

First, non-physicians around the state—nurse practitioners, certified midwives, and physician assistants who specialized in women’s health and were already doing procedures like inserting IUDs and taking Pap smears—received training in how to perform vacuum aspirations. After they could show they were competent, they were allowed to do first-trimester procedures at some 22 sites run by Planned Parenthood or Kaiser Permanente, the state’s largest HMO.

Eventually Weitz and her team gathered data comparing 5,675 abortions performed by non-physicians to 5,812 performed by doctors with years of experience. Given that the non-physicians were such novices, Weitz was expecting their complication rate to be as high as 5 or 6 percent. But problems like incomplete abortions and infections were so infrequent that the study had to be extended a year to capture more patients, she says. In the end, the complication rate was .9 percent for doctors and 1.8 percent for non-doctors—figures that Weitz calls “enormously, incredibly safe.”

She credits the same kinds of improvements in technology that have made many other medical procedures easier and safer since the 1970s. The instruments used in vacuum aspirations are less apt to puncture tissue, ultrasounds make it possible to tell the age of the fetus, and antibiotics given before the procedure reduce the risk of infection. Abortion opponents point out the non-physicians still had twice as many complications as the doctors, but Weitz dismisses this as “disingenuous,” given that some critics have been claiming complication rates of 10 percent or higher.

The UCSF study, published on the American Journal of Public Health’s website, didn’t just sway Democrats to pass the non-physicians bill. AB 980, the bill dealing with building codes, also benefited from the fresh information. Governor Jerry Brown, apro-choice former Jesuit with a long history of supporting women’s issues, could sign the two bills any day, although his slowness is causing jitters in some camps and hope in others.(Also on his desk is a narrower abortion-related bill that would protect the privacy rights of young adults who receive insurance through their parents; earlier this month, Brown signed a fourth bill buttressing the rights of foster kids to reproductive health information and services.)

No one seems to expect that the California bills will have any domino effect in conservative regions of the country. Even in California, Johnston says, there could be pushback in the form of court challenges or voter initiatives. Indeed, while a brand-new poll by the Public Policy Institute of California found that 61 percent of those surveyed don’t want the government to interfere with abortion access, that figure is 10 points lower than in 2000. [PDF here]

But Kneer says the UCSF study could have a major impact in liberal states concerned about abortion access for low-income and rural women. “Places that have a progressive political environment now have a large study to back them up so they can also expand,” she says,

Meanwhile, Weitz predicts, the effects of any new law could also be felt border states like Arizona that have more restrictive abortion rules. “I do think it’s likely that some women will come to California for services,” she says. “It happened in the 1970s. There’s no reason to think… that the same thing wouldn’t happen now.”

Bruce J Fernandes

Sep. 30, 2013, 3:25 p.m.

So if women start dying as a result of botched abortion procedures performed by non-doctors….. will Obama blame Bush and will democrats blame the supposed war on women by the republican party?

If this is in the name of progressive politics I think people better start rethinking their definitions.  I will say this does appear to project the image of one political mindset completely focused on performing as many abortions as possible.

Why not allow tattoo parlors do abortions? They are more regulated than this bill stipulates. Or a veterinarian? More concern for animals than women in CA.

Oh, so the ACLU believes that abortion is “like any other medical procedure”?
No different than an appendectomy, cutting out a mole, or setting a broken ankle?

Anyone else see the irony in California broadening access to abortion on the one hand and restricting access to firearms on the other?

Hermann Helmholtz

Sep. 30, 2013, 7:02 p.m.

The use of the label “Pro-Abortion” and “Pro-life” is disingenuous.

Why is it that if a woman chooses to have an abortion is of any concern to Mike H, Marcus, Elise Healy or Bruce J Fernandes, who are write angrily about the planned California laws?

Or are they messengers of their God, fighting a war against the rest of humanity, which even the Vatican wisely set aside?

The equation of reducing the clinical requirements to carry a DNC procedure to the same level as that which is required when carrying out a neurosurgery seems quite reasonable. No?

Midwives deliver babies all over the world, using different techniques including aspiration, as stated in the proposed law. They are not strangers to the procedure, and do carry it out today!

This patent infringement of this basic human right of women is only an aspect of the continued relegation of women to a secondary position in our society today.

If Mike H, Marcus, Elise Healy, Bruce J Fernandes, or others who object to the California law feel so angry about the planned law, I would suggest they should boycott California and if any of them is a Californian he or she has the choice to vote next election, or even immigrate from this state.

Either way, Californians would not be at a great loss eve if they continued bad-mouthing the most populace state in the Union, and the source of more than 20% of the wealth of the USA.

It’s nice to see that California is addressing the medical needs of rural women as well as recognizing the abilities of competent health providers. It’s progress for citizen autonomy and quality medical care.

James M. Fitzsimmons

Oct. 1, 2013, 8:24 a.m.

“Planned Parenthood.”  How Orwellian.

Ryan Bomberger

Oct. 1, 2013, 8:38 a.m.

I commend ProPublica on providing more context than most mainstream media on the tragic issue of abortion. However, there are several key points left out that show how ridiculous the “lack of access” claim by Planned Parenthood, the nation’s largest abortion business with $1.5 billion in assets and a one billion dollar annual budget. Nowhere in the article is it mentioned that California aborts over 214,000 of its own children every single year, with nearly 90,000 paid for by Medi-Cal. It is the abortion capital of the nation. Nowhere is it mentioned that minors, of any age, can be taken off of school grounds to have an abortion, and it is illegal for a parent to even be notified let alone consent. Nowhere is it mentioned that California does not even regularly inspect its 522 abortion clinics, many of them squalid like (Philadelphia’s infamous) Gosnell’s. And now the state, in economic ruin, can’t understand how its baby bust happened??? When Reagan tragically signed the “Therapeutic Abortion Act” in 1967, there were a little over 600 abortions per year to “save the life of the mother”. A quarter million abortions per year in CA have nothing to do with saving any lives…just feeding a billion dollar industry that makes abortionists rich and has no regard for human life.

I’m a male who is all for safe, legal abortions.
I’m just wondering if there are any more safety issues here than there might be with a physician who presumably has more training.
Abortions are not midwifery.  To equate the two is not valid.
All that said, I do hope this new law will not create any problems or safety issues.

Miel D'Rodilique

Oct. 2, 2013, 11:50 a.m.

I, too, am struck by the biased labels; personally, I don’t know a single “abortion advocate.”  I’m astonished and disappointed that anybody in the business of disseminating information would use such charged, inaccurate terms.

This article is part of an ongoing investigation:
Sex and Gender

Sex and Gender

ProPublica's Nina Martin reporting on American systems and institutions that fail or mistreat people on the basis of their gender or sexuality.

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