July 25, 2013 — Summary of "TRAP Laws Gain Political Traction While Abortion Clinics -- And the Women They Serve -- Pay the Price," Gold/Nash, Guttmacher Policy Review, Spring 2013.
After years of enacting additional obstacles for women seeking abortions -- such as mandatory ultrasounds and waiting periods -- abortion-rights opponents "recently have stepped up their efforts to block clinics from providing them," Rachel Benson Gold and Elizabeth Nash of the Guttmacher Institute write in a policy review.
The laws -- known as Targeted Regulation of Abortion Provider (TRAP) laws -- are in place in more than half of states. They include "onerous and irrelevant licensing requirements" that "have nothing to do with protecting women and everything to do with shutting down clinics," according to Gold and Nash.
Safety of Abortion
The rationale behind TRAP laws "is that abortion is inherently dangerous," when in fact it is "an extremely safe medical procedure," Gold and Nash write. Fewer than 0.3% of U.S. abortion patients experience a complication that results in hospitalization. The death risk from a first-trimester abortion is no more than four in one million -- which is about 14 times lower than the risk of dying in childbirth.
Nearly all abortions in the U.S. occur in non-hospital settings, and various studies spanning from the 1970s to more recent times have affirmed the strong safety record of the procedure, whether it is performed in a clinic, physician office or hospital. The American College of Obstetricians and Gynecologists has said that offering abortions in private practices is appropriate, as long as physicians are equipped to handle any emergencies, and the World Health Organization also has endorsed abortion access in outpatient clinics and physician offices.
Gold and Nash note that a reason abortion is so safe in the U.S. is that providers have developed evidence-based standards through the National Abortion Federation, which requires providers to adhere to the guidelines and undergo regular assessments as a condition of membership. The guidelines cover topics such as infection prevention, use of sedation, treating complications and emergency care.
Scope of State Regulations
In the years since the Supreme Court ruled in Roe v. Wade, states have imposed increasingly strict regulations on abortion providers that go "beyond those necessary to ensure patients' safety," Gold and Nash write. According to the review, beginning in the 1980s, states began trying to limit abortion access by "limiting public funding for abortions or requiring state-prescribed counseling and waiting periods." The heightened focus on clinics, as opposed to patients themselves, emerged in the 1990s and "has gained steam in the past few years," Gold and Nash explain.
Twenty-seven states now have TRAP laws in place, and 60% of reproductive-aged women live in those areas. According to Nash and Gold, the definition of an abortion clinic varies from state to state; 15 states apply the rules to private physicians, while 18 include facilities that only offer medication abortion and do not perform surgical procedures. Twenty-one states require abortion facilities or providers to have admitting privileges at a local hospital or some other arrangement to transfer patients in need of hospital treatment. Twelve states require specific room sizes and hallway widths in abortion facilities.
To date, only Mississippi has required abortion providers to be board-certified ob-gyns or eligible for certification -- a stipulation that "is clearly unnecessary, because abortion can safely be performed by a range of providers," Nash and Gold write. The Mississippi provision has been challenged in court.
Impact of Mandated Hospital Arrangements
Requiring abortion providers to have admitting privileges or other arrangements with local hospitals "does little to add to long-standing patient safeguards, but it can amount to granting hospitals effective veto power over whether an abortion provider can exist," according to Gold and Nash.
They explained that 10 states had five or fewer abortion providers in 2008 and that, currently, 97% of all nonmetropolitan counties do not have an abortion provider. While an abortion clinic would make mandated arrangements with hospitals close by, a woman likely would be at home if complications arose days after the procedure and would probably seek care near where she lives. Thus, as Patricia Gross of Planned Parenthood Arizona has noted, requiring hospital agreements "serves no useful purpose."
Regarding hospital admitting-privileges requirements, Gold and Nash note that such mandates are "very difficult, and in some cases impossible, for providers to meet." Hospitals often only grant the privileges to physicians who admit a certain number of patients per year. Because abortion providers rarely need to admit patients, they likely would be unable to meet the quotas.
"Nearly all TRAP laws dictate that abortions need to be performed at sites that are the functional equivalent of ambulatory surgical centers, or even, in a few cases, hospitals," the review notes.
The rules also can apply to entire buildings where abortion facilities are located -- demanding that other tenants unrelated to the abortion provider meet costly requirements. Planned Parenthood of Western Pennsylvania CEO Kimberlee Evert said, "[U]nless you own the building and you are the only tenant in it, you could easily get blocked," adding that the requirements "giv[e] the other tenants in a building veto power" over the abortion clinic.
"Promoting health and safety including in clinic settings and practices is a fundamental rationale for states having a role in licensing any health care facility," the authors write. However, the "true purpose" of TRAP laws is to close down clinics.
"[I]f these increasingly burdensome TRAP laws are allowed to stand, they may prove remarkably successful in accomplishing what decades of restrictions, protests and even outright violence failed to do" by effectively outlawing abortions, Gold and Nash argue.
In response to abortion-rights opponents who say that TRAP laws are "'common sense,'" Gold and Nash write that the laws "do seem to be increasingly common, but they only make sense if the goal is to make abortion less accessible."