Restricting abortion around the US to have ripple effects in the NW

The Texas law prohibiting most abortions is giving rise to a number of other states enacting more restrictions. Mark Nichols is a professor at Oregon Health Sciences University and a practicing physician who has been providing abortion services for 40 years. Anuj Khattar is a family practice doctor in Washington and travels out of state on a regular basis to provide abortions where access to the service is low. They join us to share their experience and tell us how policies in other states are likely to affect patients and providers in the Northwest.

This transcript was created by a computer and edited by a volunteer.

Dave Miller: From the Gert Boyle Studio at OPB. This is Think Out Loud. I’m Dave Miller. At the beginning of this month, the most restrictive anti-abortion law in the country went into effect in Texas. It bans abortions after about six weeks of gestation, earlier than when many people find out they’re pregnant and it lets anybody, anywhere bring lawsuits against people who provide or enable those abortions or even intend to. The U.S. Supreme Court refused to prevent the Texas law from going into effect despite the fact that it was specifically designed as a way to circumvent Roe v Wade and subsequent High Court precedents. That legal victory for anti abortion activists has encouraged lawmakers and governors in Idaho and other conservative states to consider similar laws. That hasn’t happened in Oregon, the only state without any state level abortion restrictions. But we were curious how this ongoing erosion of Constitutional protections could affect abortion providers and their patients in the Northwest. To answer that question and more, I’m joined by Mark Nichols, Professor of Obstetrics and Gynecology at OHSU. He was the Medical Director of Planned Parenthood of the Columbia-Willamette for almost 20 years, and Anuj Khattar joins us as well. He’s a Family Medicine Physician based in Washington State who travels to other states to provide Abortion Care. Welcome to Think Out Loud to both of you.

Nichols / Khattar: Thank you Dave, and thank you for having this topic on your show.

Miller : Dr. Khattar, first, how big a part of your medical practice is providing abortion services?

Anuj Khattar: Abortion care is, I’d say, the majority of my medical practice. I still do work as a Family Medicine Physician and I do continue to teach family medicine residents. But more than 50% of my time is spent in reproductive health care.

Miller: And that’s both in Washington State and in other states around the country, correct?

Khattar: Yes. Both in Washington State as well as Oklahoma, Texas and Tennessee where I do travel to provide care.

Miller: How often do you do that?

Khattar: On average, I travel once a month to these states to provide care. It’s not necessarily the same state every month, but I am traveling on average monthly.

Miller: And what are those visits like?

Khattar: Those visits are emotionally intense in some ways. Because of the stories I get to hear from patients and the volume of patients I’m seeing is often significantly higher than what I often see in Washington State. Challenges in the hurdles that patients have to go through to even get to clinics in states that have a lot of abortion restrictions can really be heart wrenching to hear.

Miller: You said the volume often is greater, meaning the number of patients you’re seeing on a given day?

Khattar: Correct.

Miller: How many might there be?

Khattar: I’d say the most patients I’ve seen in a single day is 70.

Miller: How is that possible? I mean, how is it physically possible?

Khattar: It’s hard, and I think one of the challenges in abortion care is that it doesn’t necessarily function like other medical clinics where there is a start and end time, you basically continue to do your work until you’ve seen everybody that needs to be seen.

Miller: What are some of the restrictions that the patients you’re seeing in those states? I imagine they vary even within those three states, but what are the kinds of restrictions the patients there have to deal with and that you as a Medical Provider have to deal with?

Khattar: I think the most frustrating one for myself and patients are waiting periods. In Oklahoma, there’s a 72 hour waiting period when somebody calls to make an appointment, to when they can actually be seen in clinic. In Texas, there’s a 24 hour waiting period from when the ultrasound is performed by the physician to when they can actually receive their abortion care. And in Tennessee, there’s a 48 hour waiting period from when a patient is seen in clinic and a consent that is mandated is read to them before they can receive their abortion care. And those waiting periods are really problematic for people because they have to take additional time off work. They sometimes travel far to come to these clinics. That means multiple trips to the clinic. They have to arrange childcare multiple times. The logistics of that can be really frustrating. And I’ve seen patients break down and cry out of frustration because of all these challenges and hoops and hurdles they have to jump through.

Miller: This is an issue that we’ve talked about before in the show, but it’s actually been a while and the legal landscape has shifted enough that it’s worth hearing this again. Why is it that there aren’t doctors in these states who can do this work? Why are you traveling 2,000 miles or 1,500 miles to do it?

Khattar: That’s a very complicated question. I think it depends on each state, but for example, in the state of Oklahoma there are restrictions on federal funding to go towards abortion training and access, which means that none of the Residency Programs in the state of Oklahoma can actually teach their residents how to provide abortion care. In Texas, patients who are using insurance to have their abortion care performed, can’t go to a physician that receives insurance coverage for other medical care. So doctors have to choose, am I going to see patients for abortion care or am I going to do a full spectrum of care? So really the systems are making it hard for doctors to actually provide the care that they want to give to patients.

Miller: Mark Nichols as I mentioned, is with us as well, a Professor of Obstetrics and Gynecology at OHSU and he was the Medical Director of Planned Parenthood for Columbia-Willamette Region for almost 20 years. You started at OHSU in the same decade that Roe v Wade was decided back in the seventies. At that point, how many physicians were providing abortions when you began at the hospital?

Mark Nichols: At that time there were very few physicians. When I joined the faculty I was essentially the only person providing abortions. Now, our faculty has grown dramatically and it’s about, I would say, 20 of us who provide abortion in some capacity. But what we’ve also been very successful at is training thousands of medical students and hundreds of Residents about providing abortion care and consequently, as opposed to Oklahoma and Texas, we have a large number of providers in the state who are ready and able and willing to provide. The other wrinkle that I would add to what Dr. Khattar said was the political environment and social environment here is so much more positive than it is in other states. We don’t face anywhere near the personal challenges that providers in other states face. And that makes it a lot easier.

Miller: If you look at a map of Oregon though, how would you describe access to abortion within the state as a whole?

Nichols: That is exactly the point of a concern that we have about possible changes in Idaho, legally, because east of the Cascades, there is one clinic and that’s the Planned Parenthood Clinic in Bend that provides abortion care. So for people in the Eastern part of the state, they have to travel hundreds of miles to be able to get the care that they seek. On the west side of the Cascades it’s not as much of a problem. There are individual physicians and providers in their clinics who may provide abortion to their patients. But in terms of recognizable clinic settings where patients can seek care, the Planned Parenthood Clinic in Bend is the only one east of the Cascades.

Miller: How common is it right now for people in say, Idaho or further away, in Montana or Utah to seek abortions in Oregon or in Washington?

Nichols: The Oregon Health Authority every year publishes data on the number of abortions provided in the state. The last data that was all finalized was from 2019 and there were 8,688 abortions in the state and about 10% of those were provided to out of state patients. And that 10% rate has been pretty consistent over time. I suspect that’s going to increase as you alluded to in your opening comments about restrictive laws in Idaho forcing women to travel out of state to come to Oregon or other places. We already see patients from other states, Northern California, Montana, Idaho of course. So we suspect that that’s going to increase.

Miller: Dr. Khattar, I mean this is obviously the opposite of you going to a state like Oklahoma or Tennessee or Texas. The idea instead is that some people seeking abortions would travel to a place where it’s either effectively legal or effectively available. But how many of the patients that you see don’t have that ability, whether because they can’t take time off from work or they don’t have the money to travel or their life circumstances just don’t enable them to go far away.

Khattar: That’s a wonderful question. And actually I saw a patient last week in Tennessee who was in a very similar situation. She was nine months postpartum; at four months, she had an implant placed for birth control, and she had waited the time that the provider had told her before having intercourse and she had gotten pregnant from that single time, and had surpassed the 20 week limit of Tennessee when I had performed her ultrasound. She unfortunately had to resign to the idea that she was going to continue this pregnancy because she didn’t have the resources at the time or the child care to seek care outside of her state. So people are going to be forced into pregnancies that they don’t want, in the situation even if there are funding platforms to help people seek abortion care in states that are more friendly to it. I think there’s a lot of social life situations and circumstances that will prevent people from actually following through with obtaining their abortion even if that’s what they want for their life.

Miller: I’m talking right now with Anuj Khattar, Family Medicine Physician based in Washington State who travels to other states, to Oklahoma, Texas and Tennessee to provide abortion care. And Mark Nichols is with us as well, a Professor of Obstetrics and Gynecology at OHSU. Mark Nichols, let’s turn to another important piece of this. Medication Abortion was approved by the FDA back in 2000. These are medicines that can terminate a pregnancy. According to the Guttmacher Institute, which studies abortion laws and abortion availability, they accounted medicines accounted for 39% of all abortions in the U. S. In 2017. But 32 states mandate that only an MD as opposed to say, a Physician Assistant or a Nurse Practitioner, can prescribe Abortion Inducing Medication. And 19 states including Texas effectively don’t allow telemedicine because patients have to take this medication in the presence of a doctor in those states. So what does all of that mean for access to this medicine, which the FDA has said is safe?

Nichols: That’s an excellent question and a very challenging situation. State by state, laws are being passed and signed by the Governors that restrict access to what has proven to be very, very safe medical care through these medications and the regimen that you described. There are teams of lawyers that are challenging these laws, state by state. And in many cases, there have been some victories, but it is a little bit like whack a mole. As soon as a set of laws are overturned, other ones pop up. So it’s a challenging legal issue. Fortunately here in Oregon, we are able to provide medication abortions via Telehealth. So patients get online, they have an interview with a provider, either physician or a nurse practitioner and they have their history reviewed carefully. They obtain an ultrasound, usually in some setting, for example in a hospital or other clinic, and then if there are no contraindications, and after a careful counseling process so that the patient really understands the details of the regimen that they’re going to go through, the medications are provided by the provider to the patient and often that’s by mail or they may pick it up at a local clinic or that sort of approach. A week or two afterwards, the patients either do their own home pregnancy test or they go in for a follow up ultrasound to confirm that the pregnancy has been terminated successfully. In Planned Parenthood in the Oregon Region, it’s about 50% or more now of patients who are under 10 weeks from the last menstrual period who opt for medication abortion. There are a lot of advantages to that particular approach, that has led to a steady increase in the percent of patients making that choice over a auction-aspiration procedure.

Miller: Anuj Khattar, as I mentioned, you mentioned the states that you go to, Oklahoma, Tennessee and Texas. Are you still going to Texas?

Khattar: I am scheduled to go to Texas in a couple of months, but I think a lot of it depends on the legal landscape at that time. It is a lot of resources for organizations to fly people like myself in to provide this care and if there aren’t enough patients to see, it may not be a great use of resources, right? There are local physicians that work in places like Texas that can provide this care and there are people who are continuing to provide this care to patients. I hope that I can continue to work in places like Texas in the future, but that all depends on how the legal landscape goes.

Miller: Doctor Khattar, before we say goodbye, I’m just curious how you made the decision yourself to have providing abortion services be the the largest part of your medical practice?

Khattar: I think that goes back to my time in medical school. So I actually attended medical school at OHSU. Between my 1st and 2nd year of medical school, I did an international rotation in Peru and spent some time in the emergency department and that was my first exposure with self-managed abortion. There was a patient who had come in with vaginal bleeding and I did the exam and there was some tissue coming out from her uterus and the attending [physician] just took that, put it on a gauze, and shoved it in the patient’s face and shamed her for what she had done. And that just did not seem right to me. That was my first exposure. Then, during my pediatrics rotation I saw so many patients admitted to the hospital for non-accidental trauma or child abuse. I was just confused about why people were hurting their own children and started to learn more about undesired pregnancies, access to contraception and access to abortion, and that led me down this field. I feel like it’s an important social justice part of medicine that is very meaningful to me and I feel like I’m changing people’s lives in a very short period of time and giving people back the power that they deserve to have to live the life that they want to live.

Miller: Anuj Khattar and Mark Nichols. Thanks very much for joining us.

Khattar / Nichols: Thank you for having us. Thanks for having us.

Miller: Mark Nichols was the Medical Director of Planned Parenthood of the Columbia-Willamette for nearly 20 years. He is a Professor of Obstetrics and Gynecology at OHSU. Anuj Khattar is a Family Medicine Physician based in Washington State who travels to other states to provide abortion care.

Contact “Think Out Loud®”

If you’d like to comment on any of the topics in this show or suggest a topic of your own, please get in touch with us on Facebook or Twitter, send an email to thinkoutloud@opb.org, or you can leave a voicemail for us at 503-293-1983. The call-in phone number during the noon hour is 888-665-5865.