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Contents: Current Commentary

Roe 2022

It's Not 1972

Darney, Philip D. MD, MSc; Landy, Uta PhD

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doi: 10.1097/AOG.0000000000004924
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The U.S. Supreme Court reversal of Roe v Wade will take many Americans back to 1972, when abortions were illegal in most states and complications from them accounted for 5–10% of maternal mortality.1 But a lot has changed in the past 50 years, with the introduction of abortion care, training, and evidence-based practice, so that abortions are accessible, safe, and integrated into medical education. It's not 1972; 50 years ago, abortion was illegal and not taught to residents. Residents learned, for example, to treat missed abortions and fetal demise in the first trimester with sharp curettage rather than suction and, later in pregnancy, to induce uterine contractions with high doses of oxytocin rather than use mifepristone and misoprostol followed by ultrasonographically guided surgical evacuation. Abortions were hazardous because they were done by various kinds of practitioners who did not know how to do them safely or were self-induced by desperate women. That changed on January 22, 1973, with the U.S. Supreme Court's decision in Roe v Wade that a Constitutional “right to privacy” provided a right to abortion as well as to contraception, which the Court had determined in Griswold v Connecticut in 1965, another signal precedent that the current politicized Court may contemplate overturning.

The year before Roe was decided, “100 professors of obstetrics” published a “Statement on abortion” that acknowledged the coming change in the status of abortion and the collective responsibility of obstetrician–gynecologists to provide abortions in teaching hospitals, where, they argued, a decrease in the complications of illegal abortions would free up space in hospital wards to provide safe abortions and time to train their residents to do them.2 They were right in predicting that about 1 million American women would seek abortions in that first year of legality and that doing these safely would substantially decrease U.S. maternal morbidity and mortality rates, but they were wrong about hospitals providing most of the abortions. Most hospitals were intimidated, had few physicians with abortion experience, and could not compete with the low-cost care of outpatient abortion clinics. Feminists had organized some of those clinics without physicians before Roe to provide illegal abortions using the new manual syringe and the flexible (Karman) cannula, but legality motivated physicians to establish clinics that accommodated referrals from hospitals. These clinics served patients well, but they rarely trained residents or published research. After passage of the Hyde Amendment in 1975, which eliminated federal funding for abortions, most public hospitals that had offered abortions no longer did so. Soon, most hospitals were referring patients to clinics, missing the 100 professors’ opportunities to teach and conduct research.

Some teaching hospitals followed the 100 professors’ council and opened abortion services where their obstetrics and gynecology residents could be trained. Among them were the Boston Lying-in Hospital, Johns Hopkins, Parkland, Washington Hospital Center, and the Medical University of South Carolina. To improve patient care, they sought advice from European colleagues experienced in providing abortion care and also initiated abortion research programs. Abortion training spread to other hospitals, sometimes using their associated outpatient clinics as training sites, and, in 1995, the Accreditation Council for Graduate Medical Education (ACGME) recognized abortion training as a required component of obstetrics and gynecology education. By 1999, the Ryan Program was launched to aid obstetrics and gynecology residencies in meeting this new ACGME requirement. The Ryan Program now includes more than 100 residencies in the United States and Canada and continues to expand despite the meddling of state legislatures in medical education.3

Some state governments reacted by restricting not only patients' access to abortion services but abortion training as well. In response, a second group of 100 professors, in the 40th year after the Roe decision, reiterated the obligation of teaching hospitals to provide and teach abortion and added advocacy for “evidence-based” abortion legislation and information.4 A glaring difference in this second group of 100 professors from the first group was that department chairs from several states that had passed restrictive legislation declined to participate, whereas, for the first statement in 1972, chairs from every state with a medical school signed onto the statement. Those who were invited to sign but demurred told the organizers of the effort that they declined not because they didn't agree that abortion was important for their patients' health, but because signing would invite the wrath of the state legislators who opposed abortion and controlled state budget decisions. They specifically mentioned the threat against Medicaid expansion through the Affordable Care Act, which legislatures in most of these states eventually refused to approve but which department chairs believed was essential to improve obstetric care in their states. In short, they wanted to sign the statement of support for abortion care, training, and evidence-based advocacy but felt threatened by their own state representatives, who held pregnant women hostage to their personal religious opinions about abortion and their own political ambitions.

In the 50 years between the first Supreme Court decision in support of abortion and the latest one against it, thousands of maternal deaths have been prevented, thousands of clinicians have been trained to provide safe abortion, and thousands of studies improving abortion care and supporting its positive effects on women's health have been published.3,5 The cancellation of the Constitutional right to abortion will deny nearly 40 million women in 28 states medical care. Abortion and family planning are proven essential to health.6 Half the nation's obstetrics and gynecology residents face being deprived of training in this key component of practice, recognized and mandated by the American Boards of Medical Specialties and Obstetrics and Gynecology, the ACGME, and the American College of Obstetricians and Gynecologists.7

Obstetricians must respond in support of our patients. We must continue to uphold educational mandates in residency and Complex Family Planning subspeciality training. We must find ways to protect physicians who will continue to provide abortions at the risk of imprisonment. We must expand research to include comparing reproductive health status after revocation of abortion rights with the progress made over the previous half century. The states where maternal (and child) morbidity and mortality are already highest are those where abortions will be restricted. Citizens of those states can ill afford this additional assault on their health that will, according to the National Academy of Medicine, worsen geographic inequities and widen the gap between women who can access safe abortion and those who cannot.8 Though the Supreme Court majority and legislators in many states did not consider the scientific evidence accumulated over the past 50 years, we have a continuing responsibility to document the effects of the Court's decision and ensuing state laws in the coming years. We must collaborate to provide the best care and training we can under the greatest challenge obstetrician–gynecologists have ever faced to evidence-based and patient-centered practice. We must ensure access to abortion care for our patients to avoid returning to the dark days of death from complications of unintended pregnancies and forced childbirth. Some of us may choose to defy laws that blatantly contradict scientific evidence and the tenets of the patient–physician relationship. For those, we must provide not only moral support but practical support as well, such as legal defense testimony and representation.

REFERENCES

1. Cates W, Rochat RW, Grimes DA, Tyler CW. Legalized abortion: effect on national trends in maternal mortality, 1940 through 1976. Am J Obstet Gynecol 1978;132:211–4. doi: 10.1016/0002-9378(78)90926-2
2. A statement on abortion by one hundred professors of obstetrics. Am J Obstet Gynecol 1972;112:992–8. doi: 10.1016/0002-9378(72)90826-5
3. Landy U, Darney PD, Steinauer J, editors. Advancing women's health through medical education: a systems approach in family planning and abortion, Cambridge University Press; 2021. p. 371.
4. One Hundred Professors of Obstetrics and Gynecology. A statement on abortion by 100 professors of obstetrics: 40 years later. Am J Obstet Gynecol 2013;209:193–9. doi: 10.1016/j.ajog.2013.03.007
5. National Academy of Medicine. The safety and quality of abortion care in the United States. National Academies Press (US); 2018.
6. Darney PD, Nakamura M, Regan L, Serur F, Thapa K. Maternal mortality in the United States compared with Ethiopia, Nepal, Brazil, and the United Kingdom: contrasts in reproductive health policies. Obstet Gynecol 2020;135:1362–6. doi: 10.1097/AOG.0000000000003870
7. Vinekar K, Karlapudi A, Nathan L, Turk J, Rible R, Steinauer J. Projected implications of overturning Roe v Wade on abortion training in U.S. obstetrics and gynecology residency programs. Obstet Gynecol 2022;140:146–9. doi: 10.1097/AOG.0000000000004832
8. Dazu V, National Academy of Medicine, President's press statement, New York Times, June 24, 2022.
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