As red states push for more restrictions, California expands access to abortions

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."