FAYETTEVILLE -- Last year brought one of the toughest moments I'd ever faced as a family doctor. A woman had shown up for her appointment after a three-hour drive to one of our clinics in Arkansas, and we had to turn her away. A state restriction had gone into effect requiring that abortion providers contract with a physician who has hospital-admitting privileges. It works by weaponizing anti-abortion attitudes within the medical community.
My staff and I had been attempting to comply with the law since it was passed in 2015. We reached out to every OB/GYN we could find. Receptionists would hang up on us or refuse to take a message. The doctors who did answer said that while they might personally support a woman's right to choose, their colleagues did not. One told me that for him to sign on as a backup, he'd need permission not only from his hospital administrator but also from the Diocese of Little Rock--"and after that," he added, "the pope." We finally found a willing obstetrician in November.
This fear doesn't surprise me. Medication abortion--which involves taking a pill called mifepristone, followed by one called misoprostol--is one of the safest procedures out there; it's less risky than wisdom-tooth extraction (which requires anesthesia). But doctors and nurses in Arkansas are so afraid of abortions, and the attendant politics, that it's almost impossible to learn about them as a medical student, let alone administer them.
Where I grew up, in the River Valley of western Arkansas, nobody said the word "abortion" out loud. When I went to medical school at the University of Arkansas for Medical Sciences in Little Rock, that censorious silence didn't relent. Over four years, the most exposure we got to the topic was a half-hour guest lecture. (At that time, 17 percent offered no formal abortion education, according to a national survey published by the American Journal of Obstetrics and Gynecology.)
That implicit disapproval carried over to my residency in family medicine, which I began in 2008 at UAMS West in Fort Smith. Second-year residents gave presentations on a topic of their choice; mine, on abortion, was the most highly attended and contentious that year. A senior faculty member vocally disagreed with my description of abortion as a common medical service, interrupting every few sentences and quoting the Bible at me. Someone dubbed me the "abortion chick," and the nickname stuck.
Whenever a patient at the clinic wanted to learn more about terminating a pregnancy, the staff would call me in to talk her through her options, even when I wasn't scheduled on a shift. My fellow physicians didn't feel comfortable sharing information about abortions.
Third-year residents could pursue an elective rotation, and I was determined to learn how to perform an abortion. Because I was not aware of any local providers, I enrolled in a program at Planned Parenthood of the Rocky Mountains in Denver. The residency director said it was not an appropriate elective for a family medicine resident, and that he would have to talk about it with the other faculty physicians at Fort Smith. Then he said that the program didn't permit residents to rotate out of state.
I responded by citing the portion of the resident handbook that said we could travel for hard-to-find specialties and pointed out that another trainee had done so the previous year in a different sub-specialty. (Reached by an editor at The Washington Post, a UAMS spokesman declined to comment, saying that the residency program has since changed directors. The medical center did not return phone requests for comment.)
Then came the end of my residency. It was commonly known among residents that if you applied to work at our training medical center and had done a decent job, you were essentially a shoo-in. In my first interview, I was forthcoming about intending to provide abortions at some point in my career. I was not offered a second interview. I decided not to attend our graduation ceremony.
The only other hospital in the area was a Catholic institution, and I doubted that it would even consider hiring me. But I didn't want to leave: My house, family and patients were all in Fort Smith. My only option was to open my own practice, a highly unusual path for a newly minted doctor. So I took out loans and, in 2011, bought equipment from an out-of-state doctor closing her practice. Unlike most other providers, I did not cap how many Medicaid patients I saw. I lived paycheck to paycheck, paying my bills late and pouring every extra minute and dollar I had into keeping the practice afloat.
When I told my malpractice insurance company, SVMIC, that I wanted to provide the occasional medication abortion, it tripled my monthly premium from about $600 to $1,800, claiming that it didn't normally insure doctors who offer that service. (SVMIC also declined to comment for this piece, telling a Post editor, "We do not discuss our confidential insurance relationships.")
Although I could provide medication abortions, I didn't want to advertise the service and subject my staff to the scrutiny and harassment that would follow. So none of my patients asked me for an abortion. I started providing medication abortions only after Planned Parenthood's Fayetteville clinic asked me to fill in for a doctor there who'd fallen ill, first twice a month, then every week, then twice weekly.
At some point during my residency, a faculty member pulled me aside to ask, "Why do you even want to do this?" Then and now, my answer is: If I can, and I'm willing, then why wouldn't I? I was more hesitant about going public as an abortion provider. But as politicians continued to pile on restrictions, I saw how it affected my patients--and other doctors--and I realized that I couldn't do my work and keep quiet. It didn't feel right that my silence might hinder access to care by perpetuating the sense of shame around the procedure.
Today, I am one of four physicians regularly providing abortions in Arkansas, which is home to 1.5 million women. Who else is going to speak up for them?
In January 2016, the organizers of a reproductive-justice rally in Little Rock asked if I would speak, and I accepted. Before I did, I let my father know. He's an immigrant from Taiwan, always aware of how his children's actions reflect on him. To my surprise, he was completely fine with it. Some people need abortions, he said simply. It made sense to him that, as a doctor, I would help meet that need.
Not everyone was so supportive. After finding out about the rally, one local family wrote to me saying that, although I had provided them with excellent care, as Catholics (and as donors to a local crisis pregnancy center) they could no longer come to my practice in good conscience.
Yet the exodus of patients that I feared never came. After that, I was no longer afraid to say I provided abortions. I eventually closed my practice--ultimately, I couldn't make the finances work--and took a full-time position at Planned Parenthood Great Plains, where medication abortion was just one of many primary-care offerings, along with family planning, HIV care and transgender services.
Even so, the abortion work is hampered by a raft of medically unnecessary and insulting restrictions. Planned Parenthood clinics currently can't provide surgical abortions because Arkansas requires that our facilities be outfitted comparably to a hospital surgical center. I'm legally required to hand out pamphlets filled with falsehoods about how the mifepristone pill, which ends a pregnancy, can be "reversed." My patients sit through 48-hour waiting periods and mandatory follow-up visits, which impose costs--gas money, time off from work, overnight stays, child care--that many can barely afford.
The contracted-physician requirement was only the latest imposition; the state Legislature will consider passing two more bills restricting abortions when it reconvenes this week.
Reproductive rights depend in part on the medical community dispelling taboos. Abortion should be a topic of normal conversation, especially among medical professionals. It is, after all, a part of ordinary life, a routine medical procedure. When I first hosted a lunch for Arkansas medical students called Meet the Provider in 2017, I expected only a handful to attend. Instead, some 30 people came, and next time, we expect more.
The path to becoming an abortion provider can be extraordinarily frustrating in states like Arkansas, but younger doctors seem to be much more aware of inequity, stigma and other barriers to medical services. I'm hopeful that their sense of openness will ultimately mean better access for patients.
Stephanie Ho is the director of primary care for Planned Parenthood Great Plains.
Editorial on 01/13/2019