Dr. Kelly Pfeifer flies from San Francisco, California to Overland Park, Kansas one weekend every month to perform abortions.
She says she donates her time for selfish reasons; she loves the work, people, and state. She even managed to catch a Katy Perry show after work once. Dr. Pfeifer likes to downplay her role and says she’s on a mini vacation, but her part-time work in Kansas is critical as there are only two full-time abortion doctors statewide.
When she’s not researching the opioid epidemic for a California health care foundation, Dr. Pfeifer performs abortions at a local Planned Parenthood in Kansas. She donates her services; the clinic only reimburses her for travel and stay.
Given the restrictive abortion laws in the state, it’s cumbersome to be a provider in Kansas compared to California, said Dr. Pfeifer. She added that it’s harder for the patients of course. In Kansas, a patient seeking an abortion needs to receive counseling and then wait 24 hours to get the procedure.
“In California, they could come and leave within an hour and here there are all these additional steps,” said Dr. Pfeifer. This is even more concerning for the patients who travel long distances due to the provider shortage, she added. Ninety-eight percent of Kansas counties have no abortion clinic.
“I live in a progressive state that allows me to be married to a woman — to lead a life without discrimination,” Dr. Pfeifer told ThinkProgress. “I am aware that a lot of people don’t have that privilege.”
Dr. Pfeifer is impressed by her colleagues caught in the political web. It can be dangerous to be an abortion provider in a conservative state. In fact, it was the murder of George Tiller, a Wichita abortion provider who was killed by an anti-abortion extremist in 2009, that galvanized Dr. Pfeifer to provide abortions in underserved areas. But unlike her Kansas colleagues, Dr. Pfeifer is able to fly home, leaving the politics behind.
A physician shortage
Access to abortion is based on income and ZIP code. While it’s necessary to understand restrictions from the patient perspective, it’s also important to understand that abortion access is dependent on physicians willing and able to provide the procedure.
More broadly, the country will soon face a serious doctor shortage. The demand for physicians is outgrowing the supply, and the Association of American Medical Colleges projects that by 2025, there will be a shortfall of somewhere between 61,700 and 94,700 physicians. There are already shortages in some specialties; almost half of all U.S. counties lack a single practicing obstetrician and gynecologist.
There are a host of reasons for this, including changing demographics and institutional inefficiency. But there are a few medical professions where stigma contributes to the shortage, like physicians who perform abortion.
While other medical professions try to remedy the shortage by incorporating mid-level practitioners or telemedicine, this cannot work for abortion doctors in some states — specifically those who administer medication abortion. Even though the World Health Organization has said physician assistants and advanced nurse practitioners can provide safe medication abortion, 34 states require it to be administered through a licensed physician. Similarly, research studies have said medicated abortions via telemedicine are safe, but 19 states outlawed such practice.
Physicians need to be trained and amenable to perform abortions. A recent study found that of the 1,800 practicing OB-GYNs surveyed, only 14 percent provided abortion services while 97 percent of them had patients sought the procedure. While the abortion rate is at the lowest level since Roe v. Wade, the demand for access is unwavering.
“She was 14 when her mother brought her in because she was pregnant and stated that ‘they’ already decided that she wanted to continue the pregnancy.”
The shortage of physicians who perform abortion is particularly acute in the midwest and south. Similar to Kansas, for example, there are about four full-time abortion doctors in Oklahoma. In neighboring Missouri, there are three abortion doctors. Just south of that in Arkansas, where over 1.5 million females live, there are three physicians who perform abortions. Only one performs surgical abortions and the other two perform medication abortions, where women take two drugs to terminate a pregnancy up to 10 weeks.
Earlier this year, when Dr. Stephanie Ho — one of the three abortion providers in Arkansas — needed to get a second physician to agree to handle any complications from medication abortions she provided in order to comply with a new state law (Act 577), she called almost 70 providers statewide and sent a follow-up letter to every OB-GYN. Every person she contacted either said no or didn’t reply, and ultimately, Dr. Ho was unable to find a back-up physician. Most of the people she contacted cited issues with abortion within their group practice or religious affiliated-hospital. (A court halted the law’s effect.)
The stigma doesn’t just affect physicians who are able to perform abortions — it can start at the very beginning, back when students in medical school are seeking the training they need.
Dr. Ho said she began facing hostility long before her work at Planned Parenthood. Rather, it began when she was a family medicine resident at the University of Arkansas Medical Sciences (UAMS).
Specifically, it started during her second year of residency. A patient she had seen for two years became pregnant. “I couldn’t be happy for her,” Dr. Ho said. “She was 14 when her mother brought her in because she was pregnant and stated that ‘they’ already decided that she wanted to continue the pregnancy.”
After seeing the consequences of unintended pregnancy, she realized she wanted to be a physician who provided the full range of reproductive health services, including abortion. But this training was not offered in the UAMS family planning residency program. Faculty never told Dr. Ho outright that she couldn’t talk about abortion, but she was criticized and discouraged from learning about abortion or talking about it with patients.
During her third year rotation, Dr. Ho sought training in Denver, Colorado, which would teach her how to provide surgical abortions up to 12 weeks. Reasonable request, she thought, given there were no programs or persons in Arkansas qualified to train her. But it was challenging to get the school to agree.
Eventually she was able to, but whenever she talked about her Colorado training afterwards, she felt she had to be discreet. When Dr. Ho was invited to speak about her training by phone to an advocacy group, she had to lie to her residency clinic and say she was heading to a doctor’s appointment instead.
“So, there I was, in my car – hiding behind the dark tint and window shades covering the front windshield” talking about the experience, she said. “All the while hoping no one noticed that my car was running with me inside – not at a doctor’s appointment.”
She eventually completed her residency program at UAMS in 2011. At 36 years old, she’s now the youngest abortion provider in Arkansas; her other two colleagues are approaching retirement age, including the only doctor that performs surgical abortions.
The obstacles in medical school
Dr. Ho graduated nearly six years ago, but the barriers she described then still persist today. Legislative obstacles remain; for instance, qualified physicians still cannot perform abortions at UAMS. Amendment 68 of the state constitution bans the use of public funds to pay for abortion, and UAMS receives state funding.
“Leadership at UAMS is afraid of the state legislature because we answer to the state government and know how conservative state politics are.”
The state legislature has passed the most restrictive abortion policy in the country in recent years, and local politics appear to have trickled down to UAMS, according to a handful of medical students ThinkProgress spoke to — be it through the culture or institutional policy. In short: if students want to learn about abortion, they have to take it upon themselves to learn. They can go to the only two clinics statewide: Planned Parenthood – Fayetteville Health Center or Little Rock Family Planning Services.
“It’s not to say the department is against teaching these sorts of things,” said one fourth-year medical student in Little Rock who has spoken to faculty about this issue and asked to remain anonymous as he’s currently applying to residency programs. “Their hands are tied quite a bit… it goes back to state funding.” State appropriations account for nearly 7 percent of the school’s budget.
While there are some pro-choice faculty members, they err on the side of caution because of the local politics, said the fourth-year medical student. The department head of obstetrics and gynecology told the student during a closed-door meeting that he would like UAMS to be part of the Ryan Program, a California-based initiative that offers nationwide residency programs the opportunity for more abortion and family planning resources. But given the abortion culture war currently playing out in the state legislature, it’s unlikely.
Abortion education in medical schools is limited. Residency programs, where soon-to-be doctors learn specialties by practice, can be too. The American Congress of Obstetricians and Gynecologists (ACOG) says there are three general approaches to abortion care training in residency programs: “opt out” where residents learn about the procedure unless they have religious or moral objections, “opt in” where training is available upon request, and programs where no training is provided. “Opt out” training results in greater exposure to abortion practices and complicated abortion techniques. But a 2013 national survey found that of 161 OB-GYN residency programs, only 54 percent of respondents said they received routine abortion training.
A 2011 study found that abortion training is uncommon in family planning residency. The RHEDI program offers financial and technical assistance to integrate abortion care into family planning residency. A fourth-year UAMS student who spoke to ThinkProgress on the condition of anonymity said she isn’t applying to any Arkansas family planning residency programs but is interviewing at a couple of RHEDI– affiliated residency programs out-of-state.
“It’s something that stands out to me as a strong part of the education there,” she said of programs affiliated with RHEDI — not just with abortion training but contraception, miscarriage management, and family planning overall.
UAMS has minimal abortion training, according to a handful of students who looked into the residency programs and spoke with ThinkProgress. UAMS Vice Chancellor for the Office of Communications & Marketing Leslie Taylor said OB-GYN residents need to opt in to receive it; ACOG says this approach can create a burden on trainees.
Emily Tharp is a first year medical student at UAMS who wants to be an abortion doctor. Residency is three years away, but she already has a plan: she’ll apply to an obstetrics and gynecology residency program because already one conservative state requires every abortion provider be OB-GYN-certified; given the politics, it’s not impossible that her home state Arkansas will be next.
“I don’t think I would have a good time having to do my residency — to learn about abortion in Little Rock. It’s been implied to me that I will encounter judgement if I run my mouth about it.”
Tharp wants to work in Arkansas given the shortage, but she won’t apply to the only OB-GYN residency program in the state, which is at UAMS.
UAMS is not affiliated with the Ryan program which, she says, ensures a more holistic reproductive health curriculum. And there’s only one provider in the state who can train her in surgical abortions, provided he doesn’t retire by then. And another caveat: stigma.
“Leadership at UAMS is afraid of the state legislature because we answer to the state government and know how conservative state politics are,” Tharp said. “You can find people at UAMS admin who are sympathetic… but they’re afraid of the political ramification.”
“I don’t think I would have a good time having to do my residency — to learn about abortion in Little Rock,” she said. “It’s been implied to me that I will encounter judgement if I run my mouth about it.”
While the stigma against abortion is pervasive in Arkansas, she still loves the state; she loves the color palette of the trees during the fall, the food (namely cheese dip), and her family. Her family of course will worry about her career choice as it can be dangerous and — as Tharp explained it: they care about “southern properness.”
“I’m already a lesbian — it doesn’t bother me,” said Tharp. “People who care about me the most, won’t care — won’t dislike me. I’ll be fine. I’m not worried about myself. I know they will be.”
Exposure to integrated abortion training is more prominent in Northeast and West Coast programs. These schools also tend to be more competitive, a point that worries Tharp. She hopes her tailored application helps her match with a residency program that provides comprehensive abortion training. Because after she graduates, she’ll be an abortion provider, not just a physician who provides abortion. That’s what often happens after providing abortion services. For example, Dr. Ho gave up her own private practice in Arkansas to provide abortions. Now she works at Planned Parenthood, where security and support is assured.
“I’m pretty much 100 percent fine with maybe not being a normal OB-GYN because of my abortion practices,” Tharp said. “That’s kind of what I’ve come to accept.”
Correction: An earlier version of this story said that a recent study of 1,800 practicing OB-GYNs found that 14 percent provided abortion services while 97 percent of patients sought the procedure. This has been corrected to note that 97 percent of the OB-GYNs surveyed encountered patients seeking abortion.