It’s doctors – not the FDA – standing between miscarrying mothers and medical best practices

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Like so many people who encountered the recent NPR piece on mothers suffering through miscarriage, my heart broke for the patients forced through the agony of waiting after using a less effective drug to end the pregnancy when there was a far quicker and more successful option available. However, that sorrow was overshadowed by the furious anger I felt for the doctors managing their care – because it is them, not the FDA – who are standing in the way of patients getting the mifepristone that would end their suffering faster.

As NPR reported, mifepristone is highly regulated, meaning a doctor does need to go through additional protocols in order to have it stocked in their office. But the actual requirements aren’t onerous at all, especially not for an OB-Gyn or other doctor doing pregnancy related or reproductive healthcare. All that is needed is for the provider to have a medical license, as well as the medical knowledge and ability to refer a miscarrying patient for a D&C should the medication fail.

Not even perform a D&C. Just refer.

Just like having Rhogam shots in the office to provide for a patient who is RH negative, or methotrexate if a patient has an ectopic pregnancy, mifepristone could easily be stocked in offices to have a supply on hand. The cost of mifepristone is the same as a Rhogam shot- nothing exorbitant! Unlike these other medications, though, mifepristone carries the stigma of being thought of as an “abortion drug,” and the added issue of drawing the attention of rabid anti-abortion activists who would rather watch women suffer and put their health in jeopardy through a drawn out miscarriage than risk the possibility that even one unwanted pregnancy might be ended with secretly in the process.

There is absolutely no reason for a hospital or doctor not to be stocking mifepristone other than complacency and cowardice in our profession. Mifepristone has been used to accelerate the process of pregnancy loss in non-viable pregnancies for two decades, with repeated studies showing that the process is both safer and more efficient. Yet every month I see patients coming in to have D&Cs after weeks of undergoing multiple rounds of misoprostol-only miscarriage management from doctors who simply don’t understand how the process works, or care enough about the physical and emotional well being of a patient who is suffering a drawn out loss of a wanted pregnancy. Patients who after waiting for a failing pregnancy to end eventually end up in a hospital surgical center with huge deductibles due for a D&C when she could have already been done and potentially trying once more to get pregnant again.

Make no mistake about it – doctors, led by abortion opponents, are letting miscarrying mothers suffer in order to punish abortion patients.

It doesn’t have to be this way. Doctors, whose first responsibility is to help their patients and provide the best care possible, could easily stock mifepristone and help any current and future mother undergoing a miscarriage – but only if they are brave enough to break the stigma around this safe, legal, efficient medication regime and stock it in their practices all across the nation. Instead, they’ve refused and tried to pin the blame on the FDA and NPR let them pass the buck.

The question is, are you going to let them pass the buck, too?

Arizona Reporting Rules: Ending Abortion Through a Thousand Paper Cuts

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For the last decade the right has chipped away at abortion access by making it more expensive, closing clinics, increasing waiting periods and decreasing gestational limits. But for 2019 Arizona abortion opponents are literally enacting a “death by a thousand paper cuts” agenda against legal abortion through their new paperwork and reporting requirements for doctors performing abortions. None of them are medically necessary, not a single question will provide any benefit to public health, and each one will dramatically raise the amount of resources a clinic uses per patient.

What these rules will do, on the other hand, is systematically aid anti-abortion activists in their quest to harass their way to the end of accessible legal abortion.

The Arizona legislature has instituted a full range of new reporting requirements that are only applicable to those who perform abortions, all of which just went into effect.. The state wants to see any complication from an abortion no matter how insignificant that issue may be, even including each instance where a medication abortion does not completely terminate the pregnancy (ironic, since under other circumstances they consider this not only not an abortion complication, but a potential “reversed abortion” and a win for their side). Since abortion – early abortion in particular – has so few medical incidents, their goal is to try to amplify any small complication to booster their vendetta of proving abortion is actually “dangerous” despite its longstanding history of safety, especially compared to all other medical procedures. Could you imagine if the state required reporting on each incidence of induced labor or every time an episiotomy is used during a vaginal delivery? Live births are frequently one medical intervention after another, and OB/Gyns would protest en mass if similar reporting requirements were demanded, knowing they had no bearing on public safety and would cripple them with extra burden.

These reports will slow us down, hurting providers financially as we are forced to hire people to deal with the onslaught of new forms and questions. But they will hurt other medical professionals just as much. The requirement that we list those doctors who refer patients to us has no sound medical reasoning behind it. Instead, it is obviously meant to create a catalog of those who are open to the idea of helping their patients access care when they choose to end their pregnancies, a listing of doctors and other caregivers who could be harassed if their names every were accidentally or intentionally made public. The new rule that we must cite the specialty of each medical provider on staff is clearly meant to offer ammunition for future TRAP (Targeted Regulation of Abortion Providers) laws, like ridiculous demands that only board certified OBs be allowed to dispense abortion pills.

And of course these rules will also hurt patients. While we can all cheer for the small victory that abortion providers will no longer be mandated to report a crime to the police anytime a patient asks for an abortion and says she was impregnated due to sexual assault, that does little to address the root issue of asking any pregnant person why they want to end the pregnancy. There is no more or less valid reason for seeking an abortion – the only answer that matters is that the patient, for whatever reason, does not wish to remain pregnant or give birth. To force that person to explain their reasoning is an attempt to undermine the professional relationship between doctor and patient, and adds no value to the medical process or to public health.

The new law reporting requirements – which were crafted in part by the anti-abortion Center for Arizona Policy, not even the Health Department – have clearly been created simply to harass patients and clinics. Do men get questioned by the state about why they want ANY medical care? Or women for any procedures other than an abortion?

If Obstetricians had to ask every pregnant patient why they wanted to have a baby, or every patient seeking contraception why they wanted birth control, and had to figure out a way to gather this information, record it, then enter the mass of data on the health dept website, or even hire staff to do this – heads would roll. Imagine any doctor or office tolerating this invasion into personal decision making? It would never stand.

Despite reports that show the number of abortions is decreasing across the country, in clinics like my own we are seeing an opposite trend. Regardless of continuing abortion restrictions across the state the number of people seeking out our services continues to grow, with as many as 20 percent more people coming to us in 2018 than in the year before. It is not unheard of to have as many as 25 unscheduled walk-ins arrive on a given day, wanting to complete the first day of their 24 hour mandatory wait prior to a termination. We are already overextended as we try to meet this growing need for our services. And now the state wants to double our paperwork over each and every patient, overburdening our resources not out of medical necessity but for political gains.

The Arizona legislature is quite literally trying to end abortion access though one thousand paper cuts, and while it may not have the media glamor of a full abortion ban or mass clinic closures, it very well may be the one attack that succeeds.

Yes, a “heartbeat” abortion ban is really a full abortion ban

The state of Ohio is currently voting on a ban that would ban abortion from the point in which a “heartbeat” can be detected. South Carolina pre-filed a ban, too. Even Missouri is in on the action, planning to ban abortion when a heartbeat can be found on a “heartbeat detection device” – whatever it is they mean by that.

These far-right politicians claim that a heartbeat should be used as the new point of viability to rule when abortion should no longer be legal. But as any reputable medical practitioner would tell you, a heartbeat in utero doesn’t mean the pregnancy is necessarily viable – and it definitely doesn’t equal “life.”

That “heartbeat” that antis will tell you starts as early as “21 days post conception!” is really just cardiac electrical impulses. The heart itself is only just beginning to form at six week after your last period (or four weeks after fertilization), and doesn’t develop all four chambers until at least the 8th week. New research suggests that heart development now continues on until the 20th week of pregnancy. To tie “viability” to this first point of impulses isn’t any different than saying abortion should be banned at the point which a fetus develops ears, or bendable elbows. Early cardiac activity is just one minuscule component of an entire plethora of extensive and ongoing embryonic development, all of which at that point is occurring in a form that is no larger than a grain of rice.

Meanwhile, even once this so-called “heartbeat” is found, there is no guarantee that the pregnancy is a viable one. An estimated 10 to 30% of pregnancies are found to be nonviable even after cardiac activity has been detected on an ultrasound, making it clear that the “heartbeat =viability” talking point is nothing but the fantasy of the anti-abortion movement.

The gynoticians introducing these bills pretend that they aren’t actually proposing total abortion bans – after all, they argue, you can still get an abortion prior to a detectable “heartbeat.” But in practice, that’s nearly impossible to do. Most clinics won’t even perform an abortion before there are signs of an intrauterine pregnancy (a fetal pole, or at least a yolk sac) – and that already doesn’t occur until nearly 20 days post conception as it is.

In my own clinic, a patient who wants an abortion would need to contact me the moment that they have a positive pregnancy test, and that patient would need to be seen within the next day or two from that phone call. We would need to confirm that pregnancy with either a blood or urine test or both, and if using a blood test would need to quantify how much pregnancy hormone (HGC) is in the blood to make a best guess about if that pregnancy is healthy, ectopic, or even a miscarriage or blighted ovum (a fertilized egg that doesn’t develop into an embryo). Because it would be too early to see much at all on even a vaginal ultrasound (possibly a gestational sac, but little more) we would perform a termination (either with medication or aspiration) but would then need have the patient return a week later to ensure that the abortion was successful, there was no ectopic pregnancy, and that the pregnancy did not continue.

Getting an abortion at all would be a fraught procedure where time is of the essence. The only people who would even be able to manage the process would be those who are utterly certain of their cycles to the point where they would be immediately aware that their periods were late. Those who have longer or irregular cycles will probably miss that window all together.

If “heartbeat ban” proponents succeed, the only way to obtain a legal abortion would be to take a test every day starting a week after sex, just to be completely positive you aren’t pregnant and be able to get into an abortion clinic immediately if you ever get a positive result. Is that really how Republicans expect women to live?

“Heartbeat” may be a politically hot word for abortion opponents, but medically it means nothing – at least, not when it comes to an embryo. The heartbeats that really matter are the hearts of the people who come into clinics every day looking to end pregnancy they are unable or unwilling to continue. These patients feel and think and have rich full lives that conservative politicians only too eager to cast aside in order to ensure that every fertilized egg is carried to term.

When will their heartbeats matter?

 

Women, it’s time to walk out on your doctors

24458315652_8c56cae219_zThe last week brought us a stark look at what we as a country will be facing in the next few years. A week of testimony from Dr. Christine Blasey Ford and potential Supreme Court Justice Brett Kavanaugh showed us clearly that the Republican Party has absolutely no interest in the health and safety of the women of the United States. Nominee Brett Kavanaugh showed his true colors earlier when previously blocked documents from his time as a lawyer for the Bush administration were leaked, proving that this potential new justice doesn’t believe Roe is actually “settled law.” His later reference to some forms of birth control as “abortion-inducing drugs” also was a red flag that we aren’t just looking at the end of abortion, but a curtailing of access to contraception, too. 

Then, when faced with accusations of sexual assault and other offenses while drinking in high school and college, he dodged, dissembled and even lied repeatedly under oath, in some cases belittling the female senators asking him straight questions. 

Despite it all, there were positive moments during proceedings. Nearly two hundred activists were arrested and physically removed from the building for disrupting the testimony. Sexual assault survivors followed Republican senators through the halls, demanding that their experiences not be ignored. Activists even knew that this was the last, slim chance to stop the Supreme Court from decimating decades of civil rights gains in our nation, and while it was a long shot prospect to stop these sham hearings it might be the only remaining hope. At the very least, they showed us all that even if it meant arrest, they wouldn’t give up without a fight. 

Those moments of civil disobedience were a true inspiration, and a reminder that we all have the ability to act out to affect change no matter how hopeless the situation may seem. Each individual can pledge to take one large step to keep our reproductive freedoms intact, even if the courts eventually try to strip them from us, and we can act now to get started. 

Ladies, let’s walk out on our doctors. 

It was nearly 20 years ago, but I still clearly remember a talk I had with Dr. Tamos, a colleague of mine who provided abortions for many years here in Phoenix. Abortion was already starting to be restricted in Arizona – not legally, yet, but by doctors who were eliminating it from their practices, cutting off even the option of it as a part of full spectrum reproductive health care services 

“You know, women should just walk out,” he told me. “Just walk right out of their offices. If your doctor won’t talk about abortion, won’t discuss referrals or even consider the procedure, they should just step right out and find a new one.” 

If every patient did that, he argued, doctors would be forced to make abortion a general part of their practice. With no patients left to serve, these physicians would have to face the fact that abortion is an indispensible part of patient care, and not simply something they can opt to include or reject on a whim. 

Today it is even more important than ever to know if your doctor is pro or anti-choice. It is imperative that as the right to birth control and abortion is restricted that you know beyond a doubt if your family physician or Ob-gyn is trained in all medical procedures, is willing to refer for abortion care if the situation arises, even where he or she stands on allegedly non-controversial topics like birth control and tubal ligations.  

I cannot count the number of times that I have spoken with patients in my clinic who arrived after claiming they had been “abandoned” by their primary provider, who either could not or would not offer a termination if a pregnancy became too medically complicated to continue or a miscarriage was pending. I’ve seen women turned down for tubal ligations because their doctors rejected them because they were too young, or had only one or two children – one even was told no because she had only given birth to girls and her doctor was convinced some day she would want a boy. 

One time, I saw a patient seeking a new provider because she no longer could get birth control from her regular physician. The doctor – a devout Catholic – decided that she would give up prescribing hormonal birth control pills for Lent. With no warning, her patients were cut off from prescription renewals and left in the lurch with no means of contraception. 

These are not one off accounts – these are the people that I see every day, denied and rejected by practitioners and health professionals who all took vows to do no harm. 

So how can you make sure now that your reproductive health isn’t in the hands of a secretly anti-choice physician who doesn’t truly respect your autonomy? The easiest thing to do? Just ask. Ask your doctor if they provide medication or non-medication abortions, or if at the very least they would refer you to someone who does if you need it. Ask where they stand on birth control, and if they believe it should be offered to anyone who asks, regardless of their age or marital status. Ask them if they have any particular rules when it comes to sterilization procedures, and if that is available to any person who chooses that option even if they are unmarried or have no children at all. Plus, if you are in a state like Arizona, where doctors are protected from lawsuit if they fail to disclose fetal anomalies or any issue during a pregnancy that could cause a patient to consider an abortion, ask your doctor if they will promise to always tell you the truth about the potential outcome of any prenatal testing, and ask long before you get pregnant in the first place. 

They very well may say no, and if they do, be prepared to walk away and seek out a new doctor. Your life may very well depend on it. 

If we all agree to do this one simple act, we can strike out against physicians that refuse to offer full spectrum reproductive health care. If we all stand together, we may finally have a chance to control our bodies – regardless of what the courts eventually decide. 

Take inspiration from those who challenged power during these Kavanaugh hearings: from Christine Blasey Ford, from abortion rights activists, from the survivors of sexual assault. The GOP may get the Supreme Court justice they want, but if we work together we will be the ones to get justice in the end. 

When Roe Ends, Be Prepared for the Rippling Life or Death Consequences

abortionishealthcareWhen I was a new physician, my mentor taught me not only medical techniques, but also the stories of those who sought abortions before they became legal. He told me about the hospital wards that filled with pregnancy and abortion complications, and the relief the physicians felt once they could terminate a pregnancy without fear of being thrown in jail.

Dr. Stimmell would be horrified to see us facing this again just a few decades later.

As one of the few abortion providers in the conservative state of Arizona, I’ve already gotten a glimpse of what a post-Roe America will look like. Heightened restrictions on performing abortions, a hostile environment for doctors that perform them and political and financial pressures on medical schools that train physicians have created an environment where fewer medical professionals have the ability to end a pregnancy even if it becomes medically necessary.

The medical consequences of anti-abortion politics already have life or death consequences in the U.S., even for those who find themselves needing a medically indicated termination under today’s current abortion laws. Doctors who now have to seek out additional training to perform any abortions, much less later terminations, combined with hospitals fearful of the potential wrath of anti-abortion protesters and politicians, are responsible for a deepening void in women’s health care that will only grow worse if Roe is overturned.

Just recently a colleague shared a story of a patient hospitalized in a large urban hospital in Phoenix for an impending miscarriage. She was in the second trimester, still well over a month before even the cusp of fetal viability, and rapidly bleeding out. A D&E procedure could have quickly ended her ordeal, but was a procedure no one currently on staff at the hospital could perform. Instead, they induced labor, giving her blood transfusion after blood transfusion as the process continued for hours. Throughout the entire process, the patient begged the staff not to let her die.

She survived, but her life never should have been at risk. Never.

But it was put at risk, all because a growing portion of the medical community is placing women’s lives at stake by not training to do life-saving essential surgical or medical interventions. They’ve chosen not to make waves, determining that it’s too politically fraught to learn to end a pregnancy in(THE) safest way possible and in medically appropriate situations. And that number will grow even larger should Roe v. Wade be overturned.

The end of Roe doesn’t just mean an end to legal abortion in certain states across the nation. It means the end of training of local medical students to allow them to assist in medical emergencies. It means the elimination of medical best practices when it comes to dealing with pregnancy complications for areas that already have some of the worst health care access and maternal outcomes in the nation.

It means more women, lying in hospital beds, begging not to die.

When Dr. Stimmell trained me to follow in his footsteps, these were not the footsteps I wanted to walk in.  We can never go back to those overflowing hospital beds.

Dr. Gabrielle Goodrick is the owner and medical director of Camelback Family Planning, one of only four private abortion clinics left in Arizona. She also serves on the board of NARAL Pro-Choice Arizona.

 

When Roe Ends, It’s Abortion Opponents Who Will Miss It The Most

32089528650_07135abe89_h.jpgPresident Donald Trump announced a new conservative justice to serve on the Supreme Court – one who is virtually guaranteed to overturn Roe v. Wade. As one of the few abortion providers in the state of Arizona I’m already well versed in what a post-Roe America will look like. Thanks to an onslaught of state laws that restrict when and how I am allowed to end a pregnancy, and political and financial pressures that have limited the number of medical professionals willing to learn how to perform abortions, terminating a pregnancy for any reason is already extremely difficult here. Removing that last fig leaf of legality may not have much impact on those who are marginalized already by race, geography or economics. But it will be a wake-up call on those who long claim to oppose abortion, yet still demand it be accessible for themselves when the time comes that they are the ones who need it.

Make no doubt about it  – a significant number of those who come through the doors of my clinic consider themselves ”pro-life.” They explain to my staff in great detail how they oppose the right to choose, even as they themselves are making that very same personal choice. They sneer at the other patients around them, believing that their own cases are completely different because the other women are avoiding responsibility whereas they just can’t be pregnant right now. They insult my colleagues for doing their jobs, they malign my clinic because it is a place that exists just to perform abortions, they tell us they would prefer to be in a hospital or a doctors office or anywhere that separates them from the rest of the people doing exactly what they are doing – ending an unwanted pregnancy.

And yet they get the abortion. Every time. And then they leave and still they consider themselves “pro-life.”

Just like before Roe, making abortion illegal will not end these abortions, not even for those who will have voted for just such policy. A politician looking for an abortion for his mistress will find a doctor who will do it secretly. That well-connected Christian family who doesn’t want their pregnant daughter to lose her chance at a good future will find a physician willing to terminate her pregnancy just this once. The GOP business owner who thought she was done having children until that one surprise showed up will be able to find a way to take care of that through a contact if she looks hard enough.

But as for the others – the ones who oppose abortion in every circumstance except their own? They are the ones most likely to feel the impact of Roe when it falls.

Some would say they brought it on themselves. They would argue that this is what the right deserves for taking away a person’s legal right to bodily autonomy. But as a physician – and as a person who believes that carrying a pregnancy is something that cannot be forced on another human being against that person’s will – I will never support taking away any person’s right to terminate a pregnancy.

No, not even for the people who advocated to take it away themselves.

Dr. Gabrielle Goodrick is the owner and medical director of Camelback Family Planning, one of only four private abortion clinics left in Arizona. She also serves on the board of NARAL Pro-Choice Arizona.

An Open Letter to Doctors – Safe Abortion Is In Your Hands Now, Are You Ready to Step Up?

cropped-cbfp-gabrielle-goodrick-mdRoe v. Wade is in immediate jeopardy and we are now staring into the face of a country without legal abortion, and regardless of where you stand on the issue it is imperative that you understand that it is you who are now in professional jeopardy. As an abortion provider from Arizona, a state with some of the most conservative abortion laws in the nation, let me tell you what you can expect if abortion becomes illegal either in your state, or across the nation as a whole.

Expect every medical decision to be questioned. Do you have a patient who needs a D&C to finalize a missed miscarriage? Misoprostol to expel the remains of an embryo? It is not unreasonable to expect that your files will be subject to scrutiny if all abortion is banned. Anti-abortion officials will be checking to ensure no physician is attempting to slip in a clandestine abortion by calling it miscarriage management. A missing piece of documentation, a lost ultrasound proving fetal demise prior to follow up, anything suspect could land you in jail or get your medical license revoked.

Expect more pregnancy complications in your offices. The inability to access abortion care means patients who continue unwanted pregnancies without adequate prenatal care, or without full recovery from a prior birth. It means patients with weak hearts, high blood pressure, previous complications from prior births or other risk factors who are forced to put their health in jeopardy because abortion will only be available for those whose lives are at immediate risk.

Expect patients with incomplete medical histories. When abortion becomes illegal, those who have them or attempt them will hide them from you out of fear of prosecution, or because they worry you will not provide your best care if you know what they have done. Never again will you be able to simply take a patient at their word about their medical pasts. Their history will be guesswork and assumptions, and you will be forced to fly blind.

Expect to be the last generation to know full spectrum women’s reproductive healthcare. For those of you who have been trained to terminate a pregnancy, you well may be some of the last to do so. For those of you who haven’t – because you believe your faith would oppose it, because it was too difficult to access it in med school, or because your current hospitals won’t let you and it is more important that you stay in your financially secure job and not make any waves – understand that you are the ones who opened this door for good. No surgeon would be allowed to say, “I just don’t believe in removing gallbladders” and still be allowed to practice. Yet when it comes to abortion, you’ve now set the standard. You’ve allowed a procedure that is conducted more than any other in the nation to be moved to the fringes. You’ve encouraged medical schools to make it elective, and to cave to political pressures to block training and end fellowships teaching the skill.

Expect to be forced to encounter abortion face to face in the hospitals. For decades, those of you who do not perform abortions have been able to keep abortion in the distance and out of your practices. You’ve referred your patients to me and to clinics like mine and kept your offices free of it. Even in the rare case where an abortion was medically indicated and they preferred an office or a hospital, you sent them away for the procedure so you didn’t have to be involved. These patients will be yours, now. There will be no one else to provide it. It will now be in your hands. You will no longer be able to pretend it doesn’t exist.

Expect to fight your own hospital administration when eventually one of your patients does need care. When abortion is returned to the medical wards, it will be the hospital, not you, who will eventually decide what is in your patient’s best interest. They will be the one to decide if is it best to let a pregnant patient bleed out while labor is induced, rather than do a direct abortion and more quickly save her life. Decisions won’t be made based on medical best practices. They will be made based on hospital policy, political fear and financial interests. And as a result, more of your patients may die.

This is the landscape you will see if Roe is overturned and if abortion returns to being illegal. It’s the choice you physicians made when you refused to learn even simple abortion procedures, assuming providers like me would always be there if your patient really was in need. It’s the choice the hospitals made when they accepted that partnering with religious organizations was worth losing full spectrum reproductive healthcare like terminations, sterilizations and emergency contraception after a sexual assault as long as there was enough money involved in the partnership. And it’s the choice that medical schools and universities made when they chose to cower in the face of pressure from the right over abortion training fellowships or internships at reproductive health clinics, afraid of the financial consequences of losing donations or public funds.

This is the new normal unless you finally say “Enough is enough” and demand to treat each and every patient with whatever medical service she may need. You must stand up against it now – as this may very well be our last chance to save our profession.