Abortion in Texas
One year after the Supreme Court decision we survey how hospitals and private citizens are responding to legalized abortion.
There are other options to an unwanted pregnancy, but none is so controversial. How available are abortions today, where are they done, and what has legalizing them meant?
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Officially, physicians who perform abortions have nothing to fear from their medical societies. Practically, the situation is different. A physician who flouts local convention by openly doing abortions can suddenly find that patients are no longer referred to him by other physicians; he may find that his privilege to practice in a hospital is endangered; one Dallas physician stopped working at a private abortion clinic for this reason. Doctors in San Antonio and Austin have been talked back into line by colleagues who do not approve of the way they conduct their practices.
Texas doctors who choose to do abortions must have more than a little courage. The situation is gradually changing, but there is an obvious philosophical gap between doctors who do large numbers of abortions and those who do them only for their own patients and then only rarely.
In Austin, for example, at the time of this writing, no more than three or four private doctors are routinely doing abortions; in El Paso, a social worker reports that only two physicians will perform abortions on any regular basis.
One Austin physician went, when the Texas case was on appeal, to New Mexico to learn the technique for vacuum aspiration, then a new procedure. (Other Austin physicians have gone to New York, California, and North Carolina for similar training.) After the decision. he found there was no vacuum suction equipment in town. Moreover, Brackenridge, the city general hospital, did not have money budgeted to buy the equipment. Finally a private donor—not the doctor himself—loaned the equipment to Brackenridge.
The Austin situation began to change—some private patients were able to obtain abortions from their doctors. But women with no private physician and women who were charity patients still could not get abortions in Austin. Doctors were afraid to do them or just didn’t want to. In a few cases, the doctor was willing but auxiliary personnel like anesthesiologists were unwilling to cooperate.
With the donated equipment, the private physician now does abortions without pay for charity patients at Brackenridge Hospital, using his own money to buy supplies. Other local physicians are learning the procedure. Eventually, this doctor hopes, enough trained physicians will be available in Austin to ensure that the women of the city can have safe, easily accessible abortions if they choose to do so.
He has met with some criticism from his peers. He feels that there may be a stigma attached to being thought of as an “abortionist”: “I haven’t had any direct pressure,” he says, “but I have felt the stigma at times. There are some doctors who will never accept abortion. But as more physicians begin doing them, the anger will diffuse.”
What makes a person give of his time, his income, and his knowledge for a cause which may make him unpopular among some of his peers? “I believe that there is an inevitability about abortion. If it is not done legally, it will be done illegally. If a patient is determined to have an abortion, I believe it behooves me to see that she gets quality medical care.” Slowly, very slowly, the situation seems to be changing.
Meanwhile, Austin doctors tell of seeing the results of illegal abortions which still are being done (by “the woman,” or “the nurse” in San Antonio or wherever), and of complications of abortions done in private clinics out of town which provide no follow-up or emergency care for the patient.
Dr. William McLean of Austin is president of the Texas Association of Obstetricians and Gynecologists (TAOG) , which is one of the specialty associations which sets standards for physicians who do abortions. The TAOG position is substantially similar to that of the TMA and the American College of Obstetrics and Gynecology (ACOG). Dr. McLean doesn’t feel that it is difficult for women who want an abortion to get one. He feels that abortion is accessible even for charity patients: “Sometimes charity patients get taken care of faster than private patients,” he says.
While many physicians see definite disadvantages to abortion clinics—the principal one being lack of emergency and follow-up care—Dr. McLean says that a well-run clinic can be quite satisfactory. He does see an occasional botched job from an illegal abortion, but he feels that women who seek illegal abortions do so because it is less expensive rather than because they cannot obtain a legal abortion. (Physicians experienced in abortion work say this is not necessarily true.)
Dr. McLean says that the technique of performing an abortion is not that hard to learn and that medical schools, while they haven’t specifically taught abortion techniques in the past, have taught procedures which are similar enough to those used in doing an abortion that they would enable the trained ob-gyn to do abortions without substantial additional training. In addition, since abortions have become legal, equipment which facilitates the procedure has been perfected. If abortions are ever declared illegal again, the process, even though it may not be done by a physician, may be safer because of the invention of new equipment.
Apparently, however, lay people who do illegal abortions in Texas haven’t kept up with the technological advances. One doctor reports seeing a patient whose uterus had been packed with gauze by a lay abortionist. The use of gauze packing can cause perforation of the uterus and bladder, and even death from infection or hemorrhage. Bits of gauze were found clinging to the patient’s uterine wall six weeks later. The woman was severely ill. She told her physician that she sought the illegal abortion out of desperation. The only physician she knew did abortions only on Tuesdays and Thursdays. The only days she could get off from work were Mondays and Wednesdays. The illegal abortionist was able to accommodate herself to the woman’s schedule.
THE HOSPITALS
Any abortion done after the 11th or 12th week of pregnancy must be done in a hospital, because procedures done after this time involve inducing labor and subsequent miscarriage of the fetus. Abortions done prior to the 12th week can be done in physicians’ offices or in hospitals on an outpatient basis, but few Texas hospitals we surveyed allow this sort of outpatient surgery.
All hospitals are governed by aboard of trustees or directors in conjunction with a medical staff. The medical staff of a hospital consists if private physicians who have “privileges” (meaning that they can admit and treat their patients at that hospital). Most Texas hospitals belong to the Texas Hospital Association (THA), but their internal policies are a matter of individual choice. No private hospital is required to allow abortions to be performed within its walls.
If the governing board of a hospital decides to allow abortions in its institution, guidelines are set up which dictate what kinds of procedures will be allowed, what kinds of consent and consultation are needed, and who will perform the procedure and when. If the hospital governing board and medical staff are opposed to abortion, they will either forbid its being done in that institution or make it difficult enough that patients will probably go elsewhere.
Hospitals can discourage abortions by requiring patients to stay overnight for what can be an outpatient procedure, thus making it more inconvenient and more expensive; by requiring consultation with several other physicians or social workers; by allowing only “therapeutic abortions”; by requiring consent forms from several persons other than the woman herself. It is impossible to determine how many Texas hospitals use these kinds of tactics and whether or not they are used specifically to make it difficult for the procedure to be performed in that institution.
Public hospitals are one example. There is or has been controversy in every Texas city over abortion policies of publicly supported hospitals. These hospitals are financed by tax money for the health care of all the people of the area, especially the indigent. Many who are on Medicaid or who are just above the poverty line use the public hospital as their sole source of health care. Public hospitals generally have outpatient clinics where patients can receive treatment for ailments which do not require hospitalization. Public outpatient facilities for abortion, however, are rare, if not non-existent.
The Austin city manager has refused to allocate money for abortion equipment despite endorsement of the request by the Brackenridge ob-gyn staff. In Houston, Jefferson Davis Hospital began providing abortion facilities for Medicaid patients in September 1973. At Dallas’ Parkland, one source says that fewer abortions are being performed now than were done before the Supreme Court decision. Fort Worth’s John Peter Smith Hospital allows abortions under certain conditions. Some groups are considering lawsuits against Texas public hospitals in an attempt to force them to provide abortions. State Representative Sarah Weddington says that several national suits are pending which may give courts precedent from which to work.
Meanwhile, hospitals across the state have policies which range from comparative permissiveness to complete prohibition. In general Texas hospitals which allow abortions at all require that it be done on an inpatient basis. Most ask for at least one consultation, and one prefers as many as four. All hospitals require the consent of the woman and of her husband (including common-law), or of her parent or guardian if she is under 18. On the other hand, only two responding hospitals stated that they require counseling.
THE CLINICS
The emergence of free-standing (not connected with a hospital) abortion clinics in Texas is a response to the fact that private doctors do not perform and hospitals do not accommodate significant numbers of abortion patients. In order to fill the need, clinics, which provide legal, reasonably safe abortions for large numbers of women, have begun to take hold in Texas.
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