Category: Population

Related directly to population issues.

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Chastise Texas about its unsafe abortion law

Women’s March, 3 October 2021, in Durango, Colorado

There is no such thing as banning abortion, there is only banning safe abortion.

            Texas has just passed the country’s most draconian and restrictive law on abortion, which the Supreme Court initially refused to consider. What bothers me is not just the lack access to safe abortion services but also some aspects of the law.

            S.B.8 (nicknamed the “Texas Heartbeat Act”) prohibits a doctor from performing an abortion if a fetal heartbeat is present. Before performing an abortion, doctors must know if the fetal heartbeat can be seen by ultrasound. An abortion can only be performed with a heartbeat if there is a “medical emergency”, although that term is not defined. I assume that would include true medical emergencies (such as an infected pregnancy), or if the woman has a serious medical condition that might kill her if the pregnancy were to continue, such as a tubal pregnancy.

            The law empowers normal citizens to be abortion “vigilantes”. It says: “Any person… may bring a civil action against any person who….” Reasons for legal action include a doctor who performs an abortion with a heartbeat, a person who helps someone else get an abortion, or even a person who has the intention to help someone have an abortion. The penalties are dire, and include a bounty of not less than $10,000 for each abortion. The law has no exceptions for rape or incest.

            What is really remarkable is that the law prevents the usual enforcement, but rather encourages spying and snitching. It states: “…shall be enforced exclusively through the private civil actions….” This law allows anyone, in or outside of Texas, to attempt to grab the bounty on a doctor who performs an abortion beyond 6 weeks.

            The people who wrote this law knew that it would be challenged and that the challenge would probably go to the Supreme Court of the USA, so put in a remarkable clause: that no regard would be given to “a defendant’s belief that the requirements of this subchapter are unconstitutional….”

            Furthermore, the legislature has stopped using the correct medical term for an early pregnancy, “fetus”, but rather substituted “unborn child”. Although this might be satisfying for people who are against abortion, I hate to see legislators change medical terminology for their nefarious purposes. Isn’t there a law against lawyers practicing medicine? To make things worse, courts are playing legal pingpong with women’s reproductive rights, the law having been stayed by one court, then reinstated by another.

            What can we expect to see as a result of S.B.8? More women will travel outside of Texas for abortion care. One clinic in Oklahoma City already reports that two thirds of their patients come from Texas. More concerning is that there will be more unsafe abortions as women become desperate—as was the case before Roe v. Wade in 1973. We can expect an increase in maternal mortality in Texas, as has happened in states when they have enacted laws that decrease access to safe abortion services. Texas already has a higher-than-average number of women dying from pregnancy-related problems. 

            A brave Texas OB-GYN, Dr. Alan Braid, openly broke the law and wrote about it in the Washington Post. His patient, a 42-year-old mother of 4 young children, couldn’t leave them to go to another state. Braid wrote that during his training, before 1973, he saw 3 teenagers die from illegal abortions; this is part of his motivation for performing safe abortions. 

            What can be done? Studies in other countries have shown that home abortions with medications can be safe. Women can put away their hangers and knitting needles and safely purchase the medications needed on Internet. AidAccess is one source of information about the medications that can cause an abortion safely. For Texas women who live close to the border, misoprostol is available in Mexico and is a safe way to cause an abortion by following instructions at the International Women’s Health Coalition website.

            What is clear, according to a recent Economist survey, is that the majority of Americans favor access to safe, legal abortion services. Texans, don’t be bullied by religious fanatics!

© Richard Grossman MD, 2021

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Population

Liberate the Pill

            Do you think that a medication that kills more than 3000 people in the USA should be available without a prescription, even though it has health benefits? What about another medication that has many health benefits but doesn’t increase the risk of death?

            The first drug mentioned above is aspirin and can easily be bought without a prescription. The second is “the Pill”, or Oral Contraceptive Pills (OCPs), which need a prescription now. In the past women needed a yearly Pap smear which meant a visit to a doctor (or other health care provider) with the expense and embarrassment of a pelvic exam. As the amazing safety of the pill has been recognized, laws have been changed to allow women to purchase their OCPs in some states from a pharmacist with minimal hassle–and they can keep their clothes on!

            Perhaps you noticed that the first paragraph of this essay was making an unfair comparison. The people who die from aspirin are usually older than the women taking oral contraceptives. Furthermore, the study that found no increased mortality among women who had taken OCPs, found that there was an increase in deaths from breast cancer, but that was counterbalanced by a decrease in ovarian cancer and other causes of death.

            I had the unusual experience of getting a package OCPs for an elderly nun. Our Catholic hospital had a committee to consider requests for tubal ligations–usually women undergoing repeat Cesarean sections. The sister, a member of the committee, didn’t understand that a tubal ligation could be life-saving. Apparently, she wasn’t aware that women die from pregnancy complications. I showed the nun the insert accompanying every package of OCPs, which has information about the risks of dying with various contraceptive methods, or with none. The most dangerous was not using contraception, since every pregnancy carries a small risk of death. She was convinced of the importance of tubal ligations for women who desired no more children.

            When OCPs first became available 60 years ago they were quite different. Then the level of estrogen was more than twice what it is now. Over 50 years ago my wife and I visited a college classmate in the hospital where she had been diagnosed with a blood clot from OCPs. It took years to recognize that estrogen in OCPs increases the risk of clots–the more estrogen, the higher the risk. We now know that pills with less estrogen are safer, but still effective.

            Fortunately, there are already several ways OCPs can be bought without an examination. They include Planned Parenthood, where answering a questionnaire and blood pressure check are all that’s needed. In Colorado and some other states, a pharmacist can prescribe them. Also, there are Internet sites that provide prescriptions and sell OCPs inexpensively. Why not reduce the restrictions to make it easier and less expensive to get OCPs?

            Perhaps you remember a similar situation with Emergency Contraception Pills. It took years to convince the Food and Drug Administration of their safety. ECPs can now be bought in a pharmacy or even from Amazon without restrictions. Because ECPs are most effective in preventing pregnancy if they are taken within 12 hours after unprotected sex, it is suggested that people who are at risk keep a pack “just in case”.

The “Oral Contraceptives Over-the-Counter Working Group” advocates for OCPs to be available without prescription. They have worked for years to reduce hurdles for women. They have looked at pills’ safety record in other countries, where one can purchase OCPs without a prescription. Social scientists have been developing easy-to-understand wording to go with the pills since no provider will tell the woman how to take the medication.

Well, England has beat us to it! This month Progestin-Only Pills will be available without a prescription, after a brief consultation with a pharmacist. Since POPs have no estrogen, they are safer than the usual combined OCPs and can be used by many people who should not take estrogen.

Making contraception more available is not just a matter of convenience. Studies show that access to contraception increases young women’s chances of graduation from high school. Facilitating access to safe OCPs can help change teens’ lives for the better.

© Richard Grossman MD, 2021