Course Authors

Nada L. Stotland, M.D., M.P.H.

Dr. Stotland is Professor of Psychiatry, Rush University, Chicago, Illinois.

Within the past 12 months, Dr. Stotland has no conflicts of interest relevant to this activity.

Albert Einstein College of Medicine, CCME staff, and interMDnet staff have nothing to disclose relevant to this activity.

Estimated course time: 1 hour(s).

Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 

Learning Objectives

Upon completion of this Cyberounds^®, you should be able to:

• Provide accurate information about reproductive rights to patients;

• Advocate for reproductive rights;

• Explain why reproductive rights are essential for women’s well-being.

 

Editor's Note: Dr. Stotland is the author/editor of several books on reproductive healthcare: Abortion: Facts and Feelings; Social Change and Women's Reproductive Health; Psychological Aspects of Women's Health Care: The Interface Between Psychiatry and Obstetrics and Gynecology and Psychiatric Aspects of Reproductive Technology. From 2008-2008, she was the president of the American Psychiatric Association. We invite your comments on this Cyberounds^® and will publish a representative sample.

Generally, rights in medical care are actions which care providers are obliged to provide to patients, such as securing informed consent for treatment or assuring the privacy of medical information. In reproductive health care, the problem is barriers to the right for medical care. Many countries impose restrictions on reproductive health care in particular.(12) The Guttmacher Institute (guttmacher.org) provides current information on laws and statistics around the world.

This Cyberounds^® focuses on the United States of America, where the barriers are many and increasing.(3) In no other area of medicine do laws (state and national) and institutional regulations intrude so deeply into the doctor-patient relationship and the provision of care.(4) The resulting absence, or scarcity, of care results in the dissemination of sexually transmitted diseases, stress on relationships because of fear of pregnancy, the disruption of lives by unplanned and unwanted pregnancies and efforts to terminate them, the birth of children into circumstances deleterious to their development and the diminution of resources available to other members of the family, particularly existing children, and complications of pregnancy and delivery up to and including maternal mortality.(5) In fact, grossly exaggerated claims about the numbers of abortions performed at Planned Parenthood centers have led to drastically reduced or eliminated funding for them, resulting in the loss of essential general health care for thousands of women.(6)

Legal Foundations

What are the underpinnings of women's reproductive rights? In the United States, it is illegal for one person to force physical contact, physical intrusion, on another person of legal age (the rights of children and criminal suspects are a separate issue). No matter how important to society, to the human race, an individual may be considered to be, no matter the threat to that person's life, no matter how small the intrusion, another individual may not legally be required to undergo a physical intrusion for another's benefit.

Though not even a drop of blood to save a life may be taken without consent (see the recent example in Utah where a nurse refused to allow a police officer to draw the blood of an unconscious crime victim),(35) pregnancy may threaten or erase that protection for a woman. Many laws and judicial decisions prioritize the well-being, real or supposed, of the embryo or fetus over the inviolability of the woman in whose uterus that embryo or fetus develops. According the fetus the rights of a person, and privileging those rights over those of the mother, has resulted in the arrest, prosecution and imprisonment of pregnant women whose behavior the government decides has harmed a fetus. Cases include those of a woman who attempted suicide and women accused of using alcohol or illegal substances, whether or not medical experts attribute any harm to the fetus to the maternal behavior.(7) (8)

U.S. Epidemiology

Nearly all women of reproductive age will face decisions about contraception, and nearly one-third of the women in the United States have an abortion at some time in their lives.(9) (In this Cyberounds^®, 'abortion' means induced, as opposed to spontaneous, abortion.) That is true regardless of expressed religious affiliation, and is, further, largely independent of ethnicity or geography.(10) A greater number will become pregnant and either miscarry, seek but be unable to obtain abortion services, or contemplate abortion but decide to carry the pregnancy. These decisions and experiences have profound effects on their physical and mental health and those of their families.

Political Perspectives

In Canada, and most of Western Europe, contraception and abortion are treated as essential components of medical care. Abortion as a controversial social or moral issue does not impact the elections of presidents or legislators, or the appointments of judges, government ministers and other government workers, even though these countries are otherwise similar to the United States in many other respects.

In the United States, abortion has become a major factor in all these governmental decisions. Nearly 1500 laws limiting abortion were passed by state legislators in the past five years.(11) The United States Supreme Court has ruled that a company cannot be required by law to include contraceptive care in the health insurance offerings for its employees (Burwell v. Hobby Lobby, 573 U.S. [2014])(34). Large Catholic and Evangelical health systems claim to offer comprehensive services without informing the public that any discussion of contraception and abortion is forbidden, regardless of the health needs of patients, up to and including life-and-death decisions in cases where the termination of pregnancy is not allowed even when the fetus has anomalies incompatible with extrauterine life and the pregnancy endangers the woman's life.(13)

Abortion Myths

There is much and significant misconception and misinformation not only in general circulation, but also embodied in proposed and enacted legislation.(14) Underpinning anti-abortion sentiment and legislation are myths, both acknowledged and unacknowledged:

• Abortion was universally forbidden until the United States Supreme Court decision in the case of Roe v. Wade in 1973. In fact, abortion was practiced in ancient Greece and has been practiced, in one form or another, throughout history and in all countries studied. (15) (16)

• Abortions are the result of the self-indulgent sexual behavior of women who rely on abortion rather than using contraception and who have no respect for motherhood. The realities are that many women are vulnerable to unwanted, unprotected sex in the context of exploitative and abusive relationships; that some women cannot afford or access contraceptive care; that contraceptives sometimes fail. Women have abortions because they respect motherhood too much to undertake it when circumstances will not permit them to adequately fulfill its demands.

• Women belonging to religious faiths opposed to abortion are less likely to have abortions than women who belong to more liberal faiths or who profess no religious faith. In fact, the distribution of religious affiliation among women having abortions is the same as the distribution of those faiths in the general population.(17)

Reproductive Rights: Opinions, Behaviors, Facts, Laws

Unfortunately, it appears that women's expressed opinions, and voting behaviors, with reference to abortion do not correlate with their actual decisions and behaviors(33) when faced with real-life pregnancy decisions. When a woman who opposes abortion in principle cannot countenance a pregnancy (or that of a daughter or other loved one) and the birth of a baby in her current or anticipated circumstances, she is likely to terminate that pregnancy — and continue to oppose abortion as a matter of public policy. If all the women who had abortions voted for the right to abortion, that right would not be curtailed.

In addition to general misinformation, several states mandate that physicians performing abortions provide medical misinformation to their patients: assertions that abortions cause breast cancer, suicide and substance abuse.(32) This is a unique imposition, an unprecedented intrusion into the doctor-patient relationship and a legal requirement that physicians violate their medical ethics by deliberately making statements that have been scientifically disproven and that are meant to discourage patients from receiving the care for which they came to the doctors.(18) Because the situation is fluid, with new laws being enacted and challenged all the time, clinicians will need to stay up-to-date on the laws governing their behavior, which are available, as mentioned above, from the Guttmacher Institute, and also from Planned Parenthood,The American Civil Liberties Union Reproductive Rights Project, National Advocates for Pregnant Women and similar on-line sources.

In addition to the empathy and concern essential to all care, medical decisions are driven by the best available empirical evidence. At this time, in the United States, some individuals elected and appointed to major health-policy-making positions have publicly expressed the conviction that contraceptives prevent neither sexually transmitted diseases nor pregnancy, that abortion causes breast cancer(29)[the American Cancer Society says there is no "cause-and-effect relationship"],(30) that pregnancy cannot result from rape,(31) and that no woman in the country lacks contraceptives because she cannot afford them.

Does Abortion Adversely Affect Women's Physical and Mental Health?

The conviction that abortion is detrimental to women's health has been enshrined in Supreme Court decisions and in national and state laws. What are the facts? An international panel of experts concluded that abortion does not cause breast cancer.(19) Decades of studies have demonstrated that abortion does not have negative mental health sequelae. (20) (21)This is true for adolescents as well as for adult women.(22) (23) Research has shown that anti-abortion demonstrators at abortion facilities have a negative impact on psychological well-being. (24)

The argument that girls below the age of majority lack the maturity to make abortion decisions underlies requirements for parental involvement or permission, exposing vulnerable girls to parental abuse or neglect.(25) The argument is decisively undermined by the fact that the very young woman deemed too immature to decide not to have a baby will, if prevented from terminating the pregnancy, within months be the mother of a newborn with full legal responsibility for and authority over her infant. The United States Supreme Court mandated that pregnant under-age girls who fear parental punishment or abandonment from these restrictions be allowed to seek permission for abortion from a judge. That is a daunting prospect for an adolescent.

Reviews of the abortion literature are complicated by the publication of methodologically flawed articles. The methodological flaws include conflating normal, self-resolving emotions (depressed feelings) with psychiatric illness (depression); meta-analysis of studies using widely varying/unacceptable methodology such as the absence of otherwise comparable control subjects; the lack of data on mental status before abortion; and the failure to address the reasons women choose to terminate pregnancies and the circumstances under which they do so.

High-risk Women

Women with ongoing psychiatric conditions, including alcohol and substance abuse, may decide that pregnancy is best delayed or avoided until the resolution of those conditions. They are also vulnerable to unprotected sex either in exchange for those substances or while under the influence of them. Women in abusive relationships are at risk for unwanted pregnancies and at greatly increased risk of psychiatric illnesses including depression and post-traumatic stress disorder.(26) Women who are abandoned by the men who impregnate them; women without social, financial, familial and economic supports are more likely to terminate pregnancies and to have psychiatric conditions. These flaws are ubiquitous in papers asserting psychiatric damage from abortion and entirely discredit their conclusions. Nevertheless, these discredited publications have been, and continue to be, used to justify state and national legislation and judicial decisions in the United States, to mandate inaccurate communications from doctor to patient, and in some other countries as well, that constitute barriers to abortion services.

Disingenuous concerns about safety have also delayed or prevented access to medical abortion methods. For example, a Texas law, HB2, mandates that all abortions, whether surgical or medical, be done in an ambulatory surgical facility. The law, headed for a final decision by the Supreme Court, is opposed by the American Medical Association and the American College of Obstetrics and Gynecology.(28)

Access to the Morning After Pill

The so-called 'morning after pill' can prevent unwanted pregnancies from happening. Its availability is compromised by barriers based on the assertion that it is an abortifacient. This argument is predicated on the belief that the fertilized egg itself is entitled to the protections legally afforded a human being. In medical terms, pregnancy does not begin until the fertilized egg is implanted in the uterine wall. Many women live in communities where the only pharmacy, or the only one to which they have ready access, does not stock the morning-after pill. Even where it does, the woman must reveal her request to the pharmacy staff, often within hearing of other staff members and other customers.

Geographic Barriers to Reproductive Rights

The state of Arizona passed a law mandating an outdated medical abortion regimen days before the improved regimen was promulgated.(27) An Indiana law bans abortion in cases of fetal anomaly, no matter how severe, and requires that the products of conception, at any stage, be treated like the body of a person who has died. This is despite the likelihood that some pregnancies are spontaneously aborted in very early stages and expelled with the menstrual flow.

Like the assertion that no women in the United States are deprived of contraceptive care because they lack the money to pay for it, many laws, whether willfully or negligently, fail to recognize the realities of women's lives. In many parts of the country, women must travel significant distances to obtain abortion services. Many states require waiting periods between the decision and the procedure, sometimes mandating two separate trips to an abortion facility. Few pregnant women find it easy to absent themselves from school, work and family for many hours or days. Travel is expensive. Women who anticipate negative reactions from family and community may have to feign reasons for their absences and expenditures.

Beyond Pregnancy

Reproductive rights are not limited to universal access to means to prevent and terminate pregnancies. Women should have an absolute right and access to the full range of prenatal, intranatal and postnatal care. Women seeking infertility treatment have a right to know the full range of their options and total transparency about the successes and failures of the facilities where they may seek treatment.

There are a number of potential rights which deserve public discussion and policy decisions. By what criteria should infertility care providers decide what categories of patients — marital status, sexual orientation, religion — they are obligated to serve? What are the rights of egg donors and so-called surrogate gestational agents? Women who donate eggs have a right, and the profession has an obligation, to the acquisition and provision of information about the long-term effects and to care for any adverse effects. They are currently denied those rights. The rights of women who serve as gestational surrogates, and their families, are in a legal quagmire. Do their existing children have protection against the effects of pregnancy, pregnancy complications and the surrendering of a child born to their mother to another family?

Men's Reproductive Rights

What about men and reproductive rights? There have been several attempts to require permission from the 'father' of the pregnancy or the women's husband before a woman could have an abortion. It is understandable that a man invested in a future son or daughter would feel it was unfair for the woman carrying the pregnancy to have the right to end that potential life. A man may not legally force a sexual partner to end a pregnancy, but of course there is a wide range of behaviors he may manifest in this regard, from unqualified support to abandonment and violence. This is one area where the courts have recognized the primacy of the rights of the woman.

Conflicts of Interests

Declarations of conflicts of interest are now, appropriately, required of scientific publications and presentations. These potential conflicts are directly or indirectly financial. Some readers may have concerns about conflicts or interests in this Cyberounds^®. The author has served on the Board of Trustees of Physicians for Reproductive Health and Choice and has testified against proposed or enacted legislation limiting reproductive rights in the United States Congress and several state courts. The author personally recognizes and respects religious, spiritual and personal objections to contraception and abortion but objects to the provision and dissemination of scientifically unfounded arguments against abortion. A moral argument against abortion or contraception ought to be presented as a moral argument rather than being cloaked in fictions about dangers to women's well-being. Women and their doctors should have the right to make and carry out reproductive decisions free from state interference.