TRAPping Abortion Providers

Acronyms are rarely perfect, but when it comes to TRAP, short for Targeted Regulation of Abortion Providers, the word says it all.

Anti-abortion zealots have long contended that abortion is unsafe and have pushed state legislatures to impose burdensome requirements on providers. These requirements, in effect in nearly half the country, are more stringent than those imposed on other outpatient medical practices.

Critics say that the laws are essentially a game of gotcha and have done little to improve patient care or reduce surgical risk. Instead, since abortion is safe–only 0.3 percent of abortion patients require hospitalization for post-operative complications–they argue that the laws have less to do with protecting women’s health and more to do with limiting reproductive choices. Statistics from the Guttmacher Institute bear this out: The number of abortion providers in the U.S. dropped from 2900 in 1982 to 1787 in 2005, at least in part because of TRAP laws.

"The anti’s strategy has been to allow abortion to remain legal, but to make it unavailable," says Bonnie Scott Jones, Deputy Director of Domestic Programs at the New York-based Center for Reproductive Rights. "Their goal is to make abortion so difficult to obtain it’s not really an option. They’ve also worked to make it more difficult to be an abortion provider than any other kind of doctor. TRAP laws work as a disincentive to becoming part of, or remaining in, the abortion field."

The laws fall into three categories: Licensing, hospitalization, and staffing/patient care. And they run the gamut, from the common-sensical to the illogical and impractical.

Take South Carolina where the law requires six air changes per hour in the recovery room and mandates that there be no grass or weeds near clinics or medical offices where pregnancies are terminated. Arizona requires MDs performing abortions to do gonorrhea and Chlamydia tests on every patient, a practice, providers say, that usurps a physician’s ability to judge what measures are necessary. It also drives abortion fees up by $30-$40 per procedure.

In Missouri, a presently-enjoined law requires doctors who perform five or more first-trimester terminations a month to convert their offices into ambulatory surgery centers. Among the requirements: Hallways must be six feet wide, doorways must be 44 inches across, and the recovery room must have at least four beds.

These restrictions, if upheld, will put Dr. Allen Palmer, the only private physician performing abortions in the Show Me state, out of business. "Dr. Palmer does a full range of gynecological services," says attorney Bonnie Scott Jones. "He works out of a regular doctor’s office. It would cost him in excess of $1 million to turn it into a surgical center. If we lose the case he will retire because abortions are enough of his business that without them he has no practice. This is a man, a family gynecologist, who sees the daughters of patients he treated 20 years ago."

In addition to the law’s singling out of abortion providers, and not, say, those performing gastric bypasses or liposuction, Jones is further incensed that there is no grandfather clause built into the Missouri law. "You can’t increase hall widths in existing buildings," she says. "Most laws that change zoning or construction standards only apply to new construction or massive renovations and wave in facilities that already exist. Laws like the Americans with Disabilities Act don’t apply retroactively."

Texas is an example of what happens without grandfathering protections. When TRAP laws were passed to require clinics performing abortions after 16 weeks to become ambulatory surgery centers, the availability of care plummeted. "In 2003 there were more than 20 providers doing abortions at or after 16 weeks," Jones reports. "After the law took effect in 2004 there were none." While the number of licensed second trimester providers has begun to creep up — Jones says there were four in 2007 — in a state the size of Texas the unmet need is likely enormous.

TRAP laws have also impacted the way Diane Derzis, owner of New Woman All Women Health Care — a Birmingham, Alabama, clinic that was bombed by Eric Robert Rudolph in 1998 — does business. After a nurse at Birmingham’s Summit Medical Center erred in determining the gestational age of a fetus in 2006, newly-passed TRAP laws gave the state greater power to regulate abortion. Although Summit was subsequently closed, Health inspectors increased surveillance of the state’s six remaining providers. "We had investigators come to the clinic four times in 2007," Derzis says. "All visits are unannounced and they always barge in when patients are inside. They take charts out of the clinic and copy them, which they have an absolute right, under the law, to do."

You pick your battles, Derzis shrugs. Nonetheless, she becomes irate when she speaks about inspectors observing abortions. "We’ve had to ask patients, ‘Do you have a problem with a Department of Health observer in the OR?’ Most say ‘no,’ but I still don’t think inspectors have any business in surgical procedure rooms."

June Ayers, owner and Director of Reproductive Health services in Montgomery has, like Derzis, been on the receiving end of the Alabama Health Department’s probing. "For about five years we had a verbal agreement with an emergency physician," she begins. "When the Health Department called him he said he could no longer do back-up for us because he did not want to be bothered by the Health Department. The inspectors closed us down immediately, suspending our license for six weeks. We’d never had a deficiency before in 28 years of operation. I made arrangements with another physician to provide back-up within two weeks but they refused to re-open the clinic. It wasn’t just that we couldn’t do abortions. We couldn’t do pregnancy tests, give out contraceptives, or even do paperwork. We’re a small clinic, seeing about 1200 women a year. From a clinical and monetary standpoint, the whole thing was a nightmare."

Worse, at meetings to discuss re-opening, the state attorney told Ayers that since new regulations were about to be promulgated she needed to agree, in advance, that RHS would abide by them. If Ayers refused she understood that the clinic would remain shuttered.

"The new standards of care require our doctors to be certified by a disinterested physician saying that he or she is qualified to perform abortions," Ayers says. "These are already licensed MDs who have to find someone to stick his or her neck out and do this unnecessary paperwork once a year."

In addition, a "Did You Know?" bill presently requires Alabama clinics to provide a resource guide to all abortion patients. The booklet lists services for women, children and families, including information about adoption and abortion alternatives. "The law says that the only people who can hand the brochure to patients are licensed psychologists, sociologists, RNs, or MDs. My counselor, who has worked at the clinic for 10 years, is not qualified to distribute it," says an exasperated Ayers.

"These laws are supposed to provide a higher standard of care," she continues. "But that’s not what happens. TRAP laws do not elevate care or help patients. They’re punitive, forcing clinics to provide services under adverse conditions. It’s why Alabama is down from 10 clinics to six. When it becomes too difficult to provide services, clinics close."

That, says CRR’s Bonnie Scott Jones, is the point. Since the 1992 Supreme Court decision in Planned Parenthood of Southeastern Pennsylvania v. Casey, which weakened the test of unconstitutionality for abortion law to "undue burden," "the antis have been testing the limits to see how onerous regulations can be and still be upheld by the courts."

Onerous, of course, is subjective, but clinicians and pro-choice activists call TRAP regulations unnecessary, even galling. "There was a horrific death of an abortion patient in Arizona in 1998, a clear example of criminal medical malpractice," Jones says. "But like in Alabama, because the incident was abortion related, it provided the impetus to pass really bad TRAP laws. Malpractice happens and it always needs to be addressed, but TRAP laws just add fuel to the fire of anti-abortion activism."

The National Abortion Federation, a professional association for providers, agrees. According to their website, "TRAP bills stigmatize and burden abortion providers…By implying that abortion clinics are dangerous and in need of special regulation, such bills promote an unfounded fear that abortion is unsafe. Abortion has an outstanding safety record. These regulations create a burden for small outpatient clinics."

You can almost hear the antis cheering.

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  • invalid-0

    Exactly what are the dire consequences of all this? Hm? I’m still seeing women dying from the nice, safe, legal abortions that don’t need to be regulated, but there’s no pandemic of coathanger-impaled women strewn across the front lawns of America.

    Is it about the women’s actual well-being, or just about abortion being the easiest procedure available in any given community, regardless of how much or little enthusiasm the women of that community may have for abortion?

  • invalid-0

    women dying from the nice, safe, legal abortions that don’t need to be regulated?
    I’m not sure what you mean by this but please do cite unbiased, medical sources for your claim. Legal abortion is one of the safest medical procedures available – much safer than childbirth, actually. Women rarely every die from legal abortion. It’s unsafe, illegal abortion that kills women.

    Here are the facts compiled by The Guttmacher Institute from unbiased, medical/public health resources:

    I’m not sure how many abortion clinics, hospitals that provide abortions or private practices that provide abortions you’ve visited or spent time researching but these are all "regulated" as they are health care providers. Health care provision in the United States is heavily regulated hence a health care system that, while outrageously inequitable and expensive, is quite safe and high-quality.

    You have every right not to have an abortion or stand in opposition to abortion but opposing legal abortion is a stance that places women in harm’s way, prevents women and their families from making the choices they believe are best for their health & lives and tells physicians that you know more about medical provision than they do.

    Amie Newman

    Managing Editor, RH Reality Check

  • invalid-0

    “You can’t increase hall widths in existing buildings,”

    So the EMTs can just manage to get the stretcher in?

    If you do the math: 0.3% abortions need hospitalization for post-operative complications. An abortion clinic that performs one abortion a day will, on average, send a patient to the hospital every year. One that performs five a day will send five a year. One that performs twenty a day, twenty a year. Etc.

  • invalid-0

    I don’t understand why anyone would object to safety standards for any type of clinic. Second trimester abortions are surgery – why shouldn’t they be done in surgery centers? Sexually active women are getting tested for STDs that can cause future sterility – why is that a problem?

  • invalid-0

    Most of the regulations are ridiculous and all of them are aimed specifically at abortion providers and not any other kind of surgery. And, while STD/STI tests are an important part of reproductive health, they have nothing to do with abortion and making them mandatory only dries up the cost. Not to mention that it would be arbtitrary and discriminatory to force them only on women seeking abortion and not just sexually-active women in general.

  • invalid-0

    I’m confused as to what point you’re trying to make. EMTs bring stretchers into all kinds of places, such as other places that provide surgery (dental offices, plastic surgery, etc.) and homes, right? And if you read more carefully, you’d notice that the quote you cited said that those 0.3% of complications requiring hospitalization were post-operative. That could mean any time during recovery, couldn’t it? It doesn’t necessarily mean they would still be in the clinic at the time.

  • invalid-0

    Thank you so much for providing specific examples of exactly how absurd these TRAP laws are. I had no idea! Your article was very informative.

  • invalid-0

    This is the future of abortion rights in the United States.

    Unfortunately, Roe will not be overturned. I say unfortunately, because if Roe were overturned, the backlash of a pro-choice nation would quickly correct this in an election cycle or two. Instead, abortion will remain legal, but unavailable.

    If Roe were challenged today, I predict that Alito and Roberts will join Anthony Kennedy in a compromise opinion. States will not be allowed to criminalize abortion, but they will be able to restrict it however they want. “Rational basis scrutiny” will be applied to laws restricting abortion.

    What this means is that states will have free reign to come up with any clinic regulations that have any possible connection to public health. Likewise, they will be able to make women and doctors jump through as many hoops and over as many obstacles as they can dream up. However, since abortion will still remain legal, the pro-choice majority will not be shocked awake by these changes.

  • invalid-0

    to unnecessarily stringent and harsh laws like this, there would be screams of outrage coming from every corner of the country. But hardly anyone makes a peep when abortion providers are singled out, and the clueless MSM doesn’t bother to put anti-abortion politicians on the spot when they claim these laws are “reasonable restrictions”. Journalists need to get off their dead butts and expose the ridiculous nature of these laws-plus the hatred and spite that inspired them.

    By the way, why aren’t CPCs required to have wide hallsways and doorways “in case of an emergency”? Talk about a double standard.

  • invalid-0

    Bringing in stretchers is a lot easier in some places than others. Like, in clinics that have suitably wide corridors.

    And the abortion clinics are sending out women who will need hospitalization? That’s why they need to have the recovery beds. So that the women can recover there and not collapse on the way home. And the woman who collapses at the clinic even now is exactly the one for whom every second the EMTs need to get her out is a matter of life and death.

  • invalid-0

    What happened to my comment? It takes 10 hours to post? Okay, I’ll rewrite and I apologize if the other shows up.

    Sayna, chlamydia is the most frequently reported STD, and symptoms can be mild or absent. Women undergoing abortion have a higher than average incidene of chlamydia. Having an untreated STD at the time of abortion increases risk of pelvic inflammatory disease. PID can lead to chronic pelvic pain, higher rates of tubal pregnancy and infertility. So why would you call this testing “ridiculous” rather than reasonble and prudent?

    Regarding the now closed Summit Medical Center, which is briefly mentioned above as the impetus for TRAP laws after fetal age was misdetermined – there’s way more to that story. A woman was diagnosed using ultrasound as having a six week pregnancy when in fact she was almost full term, and given RU-486 even though she was dangerously hypertensive. One of the physicians at the clinic had his license suspended by the Medical Licensure Committee, citing “gross malpractice” and that his conduct was “immoral, unprofessional or dishonorable.” The Alabama Department of Health cited numerous violation of state health rules.

    Everything I’ve written above can be sourced through AP and medical articles. I provided links in my missing comment – is that why it wasn’t approved? In any case, I suggest to all readers of this article that they do their own research, educated themselves, and come to their own conclusions. Some TRAP laws are implemented to save women’s lives, despite what Eleanor Bader would have you believe.

    • invalid-0

      Actually there is no indication that std’s, sti’s, etc. have any higher incidence in women seeking abortion than other women. Alabama requires each woman having an abortion be tested for gonorrhea (again, no basis)and delay her care till test results return or be provided antibiotics approved by the health dept. to treat this undiagnosed gonorrhea- if the woman proceeds with abortion care before test results are in.
      The TRAP regulations in Alabama did not and will not do anything to prevent another instance like the Summitt experienced- in violating existing state law with other than a licensed physician providing abortion care. It is unfortunate that with the history of a physician losing his license there previously, that facility was not being monitored more closely. Common sense would require that, don’t you agree? As usual, it’s best to write what you know the most about and avoid mixing reports or confusing your readers.

  • invalid-0

    Funny, the EMT’s managed to get a stretcher in to my Dad’s house, and he lives in a travel trailer.
    And more women die worldwide every *year* from childbearing and childbirth than legal abortions. I personally ended up in the hospital twice in the first trimester with my daughter. Without hospitalization, I might not have survived to give birth to her.

  • invalid-0

    Dears abortion is what it is. It’s just that simple; pro-choice ideals are so easy to defeat! Try a dose of intellectual honesty, it doesn’t taste bad.

  • mellankelly1

    Dears abortion is what it is.  It’s just that simple;

    Yes, of course… abortion is the termination of a pregnancy.  It is just that simple.  It is.

     pro-choice ideals are so easy to defeat! Try a dose of intellectual honesty, it doesn’t taste bad.

    Ah yes, little things such as bodily autonomy (including moral independence), freedom from religion, privacy, equality, the right to medically accurate information not to mention the right to decide if/when and under what circumstances to have a child.  Lets see… Roe v. Wade was 1973 right… wow, you’d think if those "ideals" were so easy to defeat, it would have happened by now… go figure, huh?  Seems that after a good ole’ dose of intellectual honesty that whole anti-choice crowd doesn’t have a leg to stand on.

    • invalid-0

      blah blah blah like you’re the only one who has the intellectual capacity to make reasoned arguments defending her/his position. If the pro-choice viewpoint was the only one comprised of “intellectual honesty,” then the debate would be over. Both sides have convincing arguments – may the best team win.

      If you are a person of faith (as your personal blog suggests), would it not be fair for me to question your pro-choice views as being at least partially derived from that spirituality? Faith is spirituality is religion is deityworshipping, and I want freedom from ALL of them.

  • invalid-0

    First let me just say this is such a great post I just had to comment. I will be back often so keep up the good work.

    Second I would like to offer more health info, news and fun at my health blog medical & health articles

    I am not for or against abortion I feel it is or should be your own choice.