The Zika virus has presented a huge conundrum with far reaching consequences as well as problems right here in the ‘ol U.S. of A. Michelle Del Guercio pointed out the when Zika started spreading through Latin America earlier this year, a number of governments issued advisories recommending that women put off getting pregnant because the virus can cause severe birth defects. At the same time these countries kept in place strict laws that would prevent a woman from getting an abortion if she were already pregnant.
To Abigail Aiken — a health policy researcher at University of Texas, Austin — this felt like a “disconnect.” On one hand, authorities were saying Zika is such a major health threat and woman shouldn’t even get pregnant. On the other hand, they were implying that if a woman does become pregnant, Zika is not a serious enough health reason to consider an abortion.
That made Aiken wonder, “What are the impacts of these advisories and of Zika on what women want to do?” After all, she adds, even before the outbreak, millions of women in Latin America had been getting abortions illegally each year. Has the epidemic prompted more women to do so? Pinning down abortion rates in Latin America is notoriously difficult, notes Aiken. “It’s happening almost completely under the radar. So it’s very hard to collect data.”
But there was one source that seemed uniquely well placed to offer some. It’s a nonprofit called Women on Web that essentially offers an online portal through which women all over the world can log on and request abortion medication. Based in the Netherlands, Women on Web has a small team of doctors at its headquarters who review the requests and email back and forth with each woman to determine whether there are any health issues that would prevent safe use of the drug. If there are none, the doctor then authorizes a partner group in India to ship two drugs designed to induce abortion during early pregnancy. They’re mailed to the woman’s home.
How is this legal? Rebecca Gomperts, founder of Women on Web, says the group “really analyzed every country’s situation.” And in the countries they serve, “for the women to actually get the medication is not illegal. These are medicines on the list of essential medicines of the World Health Organizations.” (Indeed, the group says it does not send pills to women in the United States because it’s one of the few nations that specifically prohibit importation of the drugs involved.
Of course, Gomperts notes, when a woman actually takes the medication to induce an abortion she often is breaking the law. “But we inform them that if they have complications and they want to see a doctor that they can just say that they had a miscarriage. The symptoms are exactly the same, and the treatment is the same.” The group works with women in over 120 countries — including South and Central America. So Aiken and some other researchers teamed up with collaborators at Women on Web to run an analysis of every request for abortion pills that women in Latin America had made to the group over the last five years. “We had a very large sample. We had 28,670 requests in total over those five years,” says Aiken. Their findings were published Wednesday in the New England Journal of Medicine. In the countries where access to abortion is limited and the government had issued advisories about Zika, the number of requests for abortion pills skyrocketed after the virus hit. In Brazil, requests over a three-month period more than doubled, from the 582 Women on Web would typically see during that time frame to 1,210. Ecuador, Venezuela and Honduras saw increases above 70 percent. The increase was about 30 percent in Colombia, El Salvador and Costa Rica.
By contrast, the study did not see an increase in countries where governments had not issued Zika warnings — Mexico, Guatemala and Nicaragua, for example. “It seems as though as though women were responding not only to the threat of Zika but to the advisories issued by their governments,” says Aiken. Still, she concedes there’s a limit to how much you can conclude from the study.
It’s a caution echoed by other experts, including Gilda Sedgh, a researcher at the Guttmacher Institute and co-author of one of the most comprehensive studies on abortion rates in Latin America. For one thing, notes Sedgh, the abortions reported by Women on Web account for only a tiny fraction of the millions of the abortions that take place in Latin America each year — almost all of which are illegal.
Also, Women on Web clients are at least a bit more likely to live in cities and be better off than the average woman in Latin America. “These are women who have access to the Web,” says Sedgh. So when it comes to Zika’s impact on abortions, “we still really don’t know. I think it’s important that they’ve published this paper to give us a clue. But it’s not definitive.”
The question is how could this affect our country and why am I presenting this situation for consideration? Houston Public Media’s Carrie Feibel pointed out that every year, more than 100 new obstetrician-gynecologists graduate from a Texas residency program and enter the medical workforce. Theoretically, all have had the opportunity during their four years of residency to learn about what’s called “induced abortion” — named that to distinguish it from a miscarriage. But the closure of abortion clinics in Texas — more than 20 since 2013 — has made that training increasingly difficult. Realize that abortion is one of the more common procedures performed in the U.S., more common even than appendectomy. Texas has 18 residency programs in the field of obstetrics and gynecology, but only one allowed the author to observe how abortion is taught. Because of the political pressures facing abortion providers, NPR agreed not to reveal the doctors’ full names or the clinic’s location. The resident agreed to be identified by her middle name, Jane. Medical residents can opt out of abortion training for religious or moral reasons, but Jane felt a professional obligation to learn the procedure.
How difficult is the procedure you might ask? Medical school professors will tell you that it’s not difficult to teach the procedure. The technical procedure is the same, whether you are doing it for a miscarriage, or whether you’re doing it to terminate an ongoing pregnancy,” she said. That procedure is known as a dilation and curettage, or D and C. The cervix is dilated, and then a suction instrument is inserted to remove tissue from the uterus. D and C’s are also used to treat excessive bleeding, or to take a biopsy from inside the uterus. “I like to say that a D and C, a suction D and C even, is bread and butter gynecology,” she explained. OB-GYNs have always learned the D and C procedure. There’s nothing controversial about it, per se. But when it’s done because a woman chooses to end a pregnancy, it’s called an elective abortion, and to be able to perform the procedure in such a case, the doctor needs to have additional training.
Elective abortions are almost always done on an outpatient basis. To do them, doctors learn how to counsel the patients and manage their pain during the five-minute procedure. They also need to learn how to administer medical abortions — the ones that use pills. In addition, many states like Texas require doctors to perform extra steps, such as reading out loud a state-mandated script to the woman, or having her listen to the fetal heartbeat. OB-GYN residents can’t learn all that’s required without spending time at an outpatient clinic, which is where most abortions in Texas take place.
That worries Lori Freedman, a medical sociologist at the University of California, San Francisco. “How can you have abortion provision if you don’t have trained doctors?” Freedman said. “Especially the ones likely to stay in your state.”
“This is part of OB-GYN — it’s not an optional part, per se,” Jane said. “Women can choose if they want an abortion or not, but you as their doctor need to be able to provide them with all the choices available.”
Jane spent that morning performing ultrasounds on pregnant women, working alongside a senior doctor who supervised. Together, the two women examined a printout from a fetal ultrasound, and the senior doctor offered some feedback. “On this image here, you want it more of a plane, as if you were opening it like this, so that you have the hypothalamus in your picture,” the senior doctor advised Jane. “That’s going to give you a better measurement.” Doctors do ultrasounds before abortions in order to date the pregnancy, which helps determine which technique will be used to terminate it. In some states, including Texas, state law also mandates an ultrasound.
Jane spent about a month at this family planning clinic during the third year of her residency. Being able to perform the abortion is just one set of skills she learned. She also learned to counsel patients about abortion, contraception and sexually transmitted diseases, and learned techniques for pain management and dilation of the cervix.
The rotation taught her things that will be useful in other practice areas, Jane said. For instance, OB-GYNs use ultrasounds for many different reasons. “Before in residency, we were doing ultrasounds maybe once during a clinic afternoon, or a few ultrasounds in the OB triage area,” Jane said. “But here we do 30 ultrasounds in a morning, so it’s a lot of good learning about how to do ultrasounds.” It may be good learning, but in Texas this training happens quietly, almost in secret.
“Doctors working in these institutions are walking a very delicate line,” said Carole Joffe, a medical sociologist at the University of California, San Francisco. Joffe studies doctors who do abortions. “Some of them want very much to be able to train residents,” she said. “But they are fearful of the other sectors of the university coming down on them and saying, ‘You’re threatening our funding.’ ”
Academic medical centers in Texas receive tens of millions of dollars a year in state funding. Many of those centers sponsor residencies, which are the training programs that come after medical school. They last four or more years and allow doctors to focus on a specialty.
It’s understandable why an OB-GYN resident in Texas might think twice about providing abortions. Doctors who provide the service must think about security issues for themselves and their staff. They also have to deal with the scrutiny of state inspectors as well as anti-abortion protesters.
Last summer, hundreds demonstrated outside the Planned Parenthood affiliate in Houston after an anti-abortion group released a series of undercover videos purporting to shed light on problems with fetal tissue research. (Planned Parenthood maintains that the videos are deceptively edited and denies wrongdoing. Meanwhile, two people involved in making the videos have been indicted.)
“Aren’t you glad you’re from Texas, a pro-life state?” a man shouted into a microphone. “We’ve got great, pro-life leaders, like Sen. Ted Cruz,” he added, as the crowd burst into cheers. Later, they prayed and sang “The Battle Hymn of the Republic.”
Surveys and other research show that doctors who do abortions may have fewer job opportunities. That’s because many hospitals and group practices refuse to employ doctors who do abortions, even if they do so during evenings or weekends, on their own time.
A few years ago, 48 doctors in Texas did abortions, but a recent study shows it’s now down to 28. And some of the remaining doctors are nearing retirement.
Dr. Bernard Rosenfeld, 74, hasn’t been able to line up a successor to lead his medical practice. He says he understands — protesters have dogged him for years. “They’ve picketed my house where I live,” he said. “They put bullets in our parking lot.”
Rosenfeld has two medical offices but provides abortions at only one, a modest brick building in Houston’s museum district. He bought the clinic from other doctors in 1982, but now he can’t find anyone to buy it from him. “I’ve talked to some doctors, but none of them are interested in the political consequences of providing abortions,” he said.
As the number of doctors in Texas dwindles, medical educators have raised the alarm about the need to train the next generation.
To find out how much abortion training was going on, all 18 OB-GYN residency programs in Texas were contacted. Although abortion is legal, and these programs are expected to provide some access to abortion training, the queries were frequently met with fear, evasion or even outright hostility. Six of the programs, a third of the total, simply refused to answer questions about how the training takes place. “UT Health does not want to participate in that story,” said a spokeswoman for the University of Texas Health Science Center in Houston. “It’s not a story that benefits us.” UT Health sponsors two OB-GYN residency programs, both at Houston hospitals.
In the end, the author could only confirm that three out of the 18 programs in Texas had made arrangements for residents to spend time learning at an outpatient family planning clinic. Those types of clinics are where most abortions in Texas take place.
It’s unclear how some of the residency programs are handling the training requirement. Some directors point to the difficult fact that the nearest abortion clinic is now closed. Other directors may be providing some options for training but wouldn’t talk about it publicly.
One doctor who would was Dr. Robert Casanova, who was recently the residency director at Texas Tech University Health Sciences Center in Lubbock. The last clinic that provided abortions in Lubbock closed in 2013. “As of now, there’s really nothing in a close radius to us,” Casanova said. “Our patients will go to Albuquerque; they’ll go to Dallas; they’ll go to Denver.” Casanova was left in a similar bind, with no local clinic where the OB-GYN residents could learn. To compensate, Casanova created special seminars that cover elective abortion. He even arranged for guest speakers to fly down from Denver.
Since 1996, all OB-GYN programs in the U.S. must offer the residents at least the option to learn abortion techniques, even if the training happens elsewhere. If the residency programs don’t do so, it can affect their accreditation. In Texas, all 18 programs are currently accredited — even in places like Lubbock, where there are no longer any clinics that perform the procedure.
Given the political climate in Texas, and the dwindling number of such clinics, residency directors have had to scramble to find other ways to fulfill the curricular requirement. Dr. Tony Wen, the residency director at the University of Texas Medical Branch, in Galveston, said it’s one of the thorniest logistical problems he has encountered. His OB-GYN residency program is a large one, with slots for 32 residents. “We cannot teach them the procedure itself,” Wen said. “Can we teach them the concept, and describe the procedure and that sort of thing? Yes, we can do all that.”
Wen explained he is hampered by three factors:
- Like most hospitals in Texas, UTMB does not allow elective abortions. Doctors must obtain special approval to do abortions for other reasons, such as severe abnormalities in the fetus, or a threat to the mother’s life.
- Galveston does not have an outpatient abortion clinic. Wen has arranged for his residents to be able to travel for training to a clinic in Houston, an hour’s drive away, but almost none have gone.
- The faculty physicians at UTMB accept reimbursement from the Texas Women’s Health Program, a state-funded program for the medical treatment of low-income patients. The doctors cannot be paid if they perform elective abortions or affiliate with an organization that does. The upshot is that Wen and his colleagues cannot teach the procedure, even at an off-site clinic.
Most of his residents don’t seem bothered by the situation, Wen said. “If this part of the training is very important to them, more likely they will probably rank and choose another residency program to go to, instead of come to Texas,” he said.
Because getting an abortion has become more difficult in Texas, more patients may be purchasing abortion drugs in Mexico to try to induce a miscarriage, and those pills don’t always come with clear instructions.
The big question raising its ugly head is what are we all going to do with the increase in pregnancy complications seen with the Zika virus, i.e. microcephaly? Molly Walker wrote that increases in abortion on-demand requests ranged from 36% to 108% in countries with person-to-person Zika virus transmission compared with expected baseline requests, even in countries where abortion is legally restricted, according to data from a nonprofit Latin American women’s group. Not surprisingly, Brazil had the greatest increase in abortion requests compared with expected requests (+108%), followed closely by Ecuador (+107.7%) and Venezuela (+93.3%, P<0.001 for all).
But person-to-person transmission was only one part of the story. These countries also had both legally restricted abortion and national pregnancy advisories, where they provided information about the potentially devastating birth defects associated with Zika, reported Abigail R.A. Aiken, MD, of University of Texas at Austin, and colleagues.
“The virus will inevitably spread to other countries where access to safe abortion is restricted,” they wrote in a special correspondence in the New England Journal of Medicine. “Official information and advice about potential exposure to Zika virus should be accompanied by efforts to ensure that all reproductive choices are safe, legal and accessible.”
When asked what this could potentially mean for U.S. Ob/Gyns, as they prepare for potential local transmission of Zika virus, Laura Riley, MD, chair, American Congress of Obstetricians and Gynecologists immunization expert working group, said that pregnancy termination is more readily accessible in most of the U.S. compared to other countries. Especially, consider the impact of the up coming Olympic Games in Rio, their incidence of Zika, and the influx of travelers from all over the world possibly taking the virus back home.
“It’s quite unfortunate, because there is really nothing we can do for children once they are affected by Zika virus. The neurologic malformations and eye malformations may be quite devastating, so it’s not like we can offer parents any kind of meaningful improvement in the quality of their children’s lives,” she told MedPage Today. Riley was not involved with the research.
“All women, must have the legal right to abortion, unconstrained by harassment, unavailability of care, procedure bans, or other legislative or regulatory barriers,” said ACOG president Thomas Gellhaus, MD, in a statement. “The Zika crisis makes it impossible to ignore that women around the world do not have access to this basic health care need.”
In countries with restrictive abortion laws, information appeared to play a huge role in abortion requests. Countries with no national pregnancy advisory, such as Mexico, the Dominican Republic and Bolivia, found no significant differences in the amount of requested versus expected abortions, despite local Zika virus transmission.
A third group examined countries with restrictive abortion laws, but no person-to-person Zika virus transmission and found that Argentina and Peru experienced significant increases in abortion requests (+21.4%, P=0.004 and +20.5%, P=0.04, respectively). The authors explained that the increase in Peru might have been due to officials asking the government to declare a preemptive state of emergency.
Riley noted that there are parts of the U.S. where abortion laws, as I pointed out regarding Texas, are restricted as well, which could potentially make an Ob/Gyn’s job more difficult.
“It’s important for all of us clinicians to be able to at least be able to counsel patients about what their options are and help them to be able to make a decision that’s right for each family, and in that counseling, it’s also our responsibility to help them find access to that service if that’s what they believe is important for their families,” she said.
Riley stressed the importance of prevention for patients: birth control and bug repellent, as well as limiting travel to endemic areas for pregnant patients.
“All we have that is foolproof is prevention,” she noted. “Everything after that is essentially putting Band-Aids on a horrendous problem.”
So, protect yourselves this summer from the mosquitos, the Zika virus and enjoy the warm weather.