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Op-ed explores challenges, motivations for abortion providers in training

August 11, 2016 — In an opinion piece for Fusion, Alice Hines discusses the experiences of an abortion provider in Kalispell, Montana, to highlight the difficulties individuals face in trying to train as abortion providers and offer comprehensive reproductive health care services in a climate that is often hostile to abortion rights.

Spotlight on Kalispell, Mont.

According to Hines, Susan Cahill, a physician assistant at All Families clinic in Kalispell, "provid[ed] abortions and other primary health care services for four decades in Western Montana," outlasting both "an arson attack in 1994 and a state law in 1995 that sought to ban Physician's Assistants from performing abortions." After a lawsuit spanning four years, Cahill defeated the law. Cahill said, "Your conviction has to be stronger than the societal hassles you endure to have your conviction."

Hines writes that Cahill had hoped her practice would be taken over by Sam Avery, a former patient who later shadowed Cahill at All Families. However, the All Families clinic closed two years ago after an abortion-rights opponent vandalized the facility, and Avery herself decided not to pursue a career in abortion care, citing the hostile environment toward abortion rights. She said in the face of such violence and stigma, and despite her unwavering support for abortion rights, she "couldn't put [her] family in that position, or [her] future family."

According to Hines, the closure of All Families also affected Holly Carpenter, a nurse-midwife who had planned on training at the clinic and who ultimately is pursing abortion care training elsewhere. Citing the vandalism attack, Carpenter said, "If this is the reaction that women who are seeking autonomy over their bodies get from society, that inspires me to fight harder for them."

Future providers 'face an Everest of hurdles'

Hines explains, "Nationwide, and especially in rural areas, there is a shortage of clinicians willing and able to perform abortions." She cites research showing that the number of U.S. counties lacking an abortion provider increased from 77 percent in 1978 to 87 percent in 2005. Hines also pointed to a 2008 survey that found 64 percent of providers who offered first-trimester abortion care were over the age of 50, indicating many in the field are nearing retirement.

According to Hines, "Young people interested in entering the field face an Everest of hurdles." Not only does research show that just "about half of ob/gyn residency programs offer routine training in abortion -- [even] though 97% of ob/gyns will see a patient seeking one during his or her career" -- but targeted regulation of abortion provider laws have forced almost 30 percent of U.S. abortion clinics to close over the last five years. Moreover, "[a]bortion providers are routinely harassed and attacked," Hines writes, citing research showing a spike in antiabortion-rights violence in 2015.

Hines also points to a 2012 survey of 113 clinicians that found "54% of non-providers cited concerns from family members, or concerns about family members' safety, as a barrier to providing medical abortions." Twenty-one of the respondents in later interviews also cited "living in a 'region with a strong anti-abortion culture' as a deterrent," Hines writes.

Providers find motivation in hurdles

Conversely, citing the same survey, Hines notes that 22 respondents "cited 'self-motivation to overcome obstacles' as something that encouraged them to provide [abortion care]." Jody Steinauer, director of research for the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning, said, "In response to these extreme restrictions that are being passed, there seems to be really focused energy on doing this work as part of a service mission."

Separately, Cheryl Chastine, a family physician in Chicago and a faculty member at Medical Students for Choice (MSFC), discussed how many providers today are motivated by their support for abortion access in the face of antiabortion-rights restrictions. "The people who become providers now tend to be people who come in feeling very strongly about the necessity of abortion access," she said, adding, "They're committed to abortion access from a socio-political standpoint."

According to Hines, Chastine -- after being forced by her employer to choose between continuing work at a Chicago facility and traveling to provide abortion care in Wichita, Kansas -- opted to "quit her job in Chicago and ... trave[l] full-time to clinics around the Midwest to provide abortions." Chastine said, "If I allowed [antiabortion-rights] tactics to work, I [would be] allowing these people whose politics I found appalling to win."

Hines notes that "access to abortion training for ob-gyns is actually improving" in the United States, with the percentage of OB-GYN residency programs that provide abortion care training increasing from 12 percent in 1992 to 54 percent in 2010. Nonetheless, she notes that routine abortion care training remains sparse for family medicine residencies, at less than 10 percent, and advanced care practitioners programs, at just 21 percent.

Training, access vary widely by region

Hines notes that "improvements in access have been geographically uneven: Of the 16% of ob-gyn residencies that offered no training in abortion at all in 2010, 60% were located in Southern states." Further, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Pennsylvania, Ohio and Oklahoma "prohibit publicly-funded facilities or public employees (including medical or nursing school faculty) from providing abortions, which makes clinical training difficult," she writes. Discussing her own research, Hines explains that she was unable to visit MSFC chapters in Southern and Midwestern regions of the United States, largely because of "[t]he intense fear medical school PR departments and faculty displayed, simply for being publicly associated with abortion."

Hines writes that access to abortion care "varies widely by geography." She cited research showing that "women in urban areas with a mandatory 24-hour [delay] had a 2% chance of traveling more than 100 miles for abortion, while women in rural areas have a 24% chance of traveling that far." According to Hines, rural areas not only "tend to be more ideologically and legislatively hostile" toward abortion rights than urban areas, but "primary care providers -- who serve rural areas more so than specialists like ob/gyns -- are less likely to receive abortion training in school" (Hines, Fusion, 8/8).