Tracy A Weitz, PhD, MPA
Director
Advancing New Standard in Reproductive Health (ANSIRH)
Bixby Center for Global Reproductive Health
University of California, San Francisco
January 25, 2010
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In Trying to Find Common Ground, Do We Hurt Abortion Rights?
1. Access to Second Trimester Abortions:
A Public Health Perspective
Tracy Weitz, PhD, MPA
Director
Advancing New Standards in Reproductive Health (ANSIRH)
Bixby Center for Reproductive Health Research & Policy
University of California, San Francisco
2. Today’s Presentation
Overview of 2nd trimester abortion
Current barriers to provision
A recommitment to 2nd
trimester
abortion care
3. What is 2nd Trimester Abortion?
1st
Tri 2nd
Tri 3rd
Tri
ACOG’s Committee
on Coding and
Nomenclature
LMP to
< 14 wks
14 -28 wks 28 wks +
Roe v Wade
LMP to
12 wks
13-24 wks 25 wks +
4. 2nd
Trimester Abortion in Practice
Generally
Abortions between (14) and (24) weeks LMP
Involves use of Dilation and Extraction (D&E)
Can be done with medications as an induction
Providers vary on to what gestational limit
they do abortions
CPT Codes distinctions
59840: By D&C –Any trimester
59841: By D&E -- 14 weeks 0 days up to 20
weeks 0 days
59841-22: By D&E -- 20 weeks 0 days or more
6. Many Women Need Care
10% of 1.3 million is still a lot of women
130,000 procedures in the 2nd
Trimester
26,000 women over 21 weeks LMP
Women who need care
Access barriers
Social barriers
Diagnosis barriers
Life circumstances
Health care disparity and human rights
issue
7. Who Needs 2nd
Trimester Abortions
Greater likelihood for women who
are:
Low income
Non-Hispanic black
Geographically isolated
Young
8. What factors delay abortion
Funding needs
Only 17 states still allow for Medicaid
funding
Significant factor in use of 2nd
Ti
Late diagnosis of pregnancy
Late diagnosis of medical need
Logistics
Difficulty finding a provider
Referral from a prior clinic
10. Lack of Providers
Graying of the Abortion Provider
Concentration in High Volume Outpatient
Clinics not in Hospitals
Lack of Training
In Residencies
For the Practicing Physician
Inadequate Compensation
Out-of-Pocket Services
Medicaid Restrictions
Insurance Prohibitions
11. A More Complicated Story
# of providers is an inadequate
measure
MFM physicians may do procedures for
fetal abnormalities
Separating “Good” from “Bad” Abortions
Newer providers unwilling to do such
high volume
requirements are cost without
compensation => specialization
12. Increasing Federal and State
Regulation of 2nd
Trimester Abortion
“Partial Birth Abortion” Bans
“Fetal Pain” Consent Bills
Targeted Regulation of Abortion
Provider (TRAP) Laws
14. What is “PBA”
Not a medically recognized term
Introduced into the public after a 1992
presentation by Martin Haskell at the
National Abortion Federation (NAF)
meeting was leaked to anti-abortion
activists
Supposedly describes the dilation and
extraction (D&X) technique
where the fetal body is brought through the
cervix intact and then the skull is compressed
to safely move it through the cervix
There is no bright-line distinction between
D&E and D&X
most appropriately called intact D&E
15. Why Perform an Intact D&E?
Reduce instrumentation of the
uterus
Fetus presentation necessitates
Result of dialation of cervix with
laminaria or misoprostol or other
cervical preparation technique
Process of fetal loss
Preserve the fetus for post-
procedure examination
16. Early Efforts to Ban PBA
Federal legislation to ban PBA
passed by Congress in March 1996
and again in October 1997
President Bill Clinton vetod both bills
Override votes passed in the House of
Representative but failed in the Senate
Many states began to pass PBA
bans
17. State-based “PBA” Bans
26 states have bans on PBA that apply throughout pregnancy
18 bans have been specifically blocked by a court
7 bans remain unchallenged but are presumably unenforceable
under Stenberg because they lack health exceptions
Ohio’s ban has been challenged and upheld by a court
5 states have bans that apply after viability
Utah’s ban has been specifically blocked by a court because it
lacks a health exception
Montana’s ban remains unchallenged but is presumably
unenforceable under Stenberg because it lacks a health exception
3 bans are currently in effect
4 states have bans that include a health exception
2 states broadly allow the procedure to protect against physical or
mental impairment
2 states narrowly allow the procedure to protect only against
bodily harm
27 states have bans without a health exception
19 bans have been specifically blocked by a court.
8 bans remain unchallenged.
18. State-based PBA Bans
Found unconstitutional in Stenberg v Carhart
[2000]
Challenge to the state of Nebraska ban on so-
called “Partial Birth Abortion”
Found unconstitutional on 5-4 decision
Stevens, Breyer, Souter, Ginsburg, O’Connor:
Four separate dissenting opinions were filed:
Rehnquist, Scalia, Kennedy, Thomas
Must have a health exception
In spite of this- Congress passed a the 2003
Partial Birth Abortion Ban without a health
exception
20. What Does the Law Say
“An abortion in which the person
performing the abortion, deliberately and
intentionally vaginally delivers a living
fetus until, in the case of a head-first
presentation, the entire fetal head is
outside the body of the mother, or, in the
case of breech presentation, any part of
the fetal trunk past the navel is outside
the body of the mother, for the purpose
of performing an overt act that the
person knows will kill the partially
delivered living fetus; and performs the
overt act, other than completion of
delivery, that kills the partially delivered
living fetus.”
21. Immediately Challenged
3 Legal Challenges
Planned Parenthood v. Ashcroft
San Francisco
National Abortion Federation v. Ashcroft
New York
Carhart v. Ashcroft
Nebraska
Temporary Injunction
Who is covered?
22. Planned Parenthood v. Ashcroft/Gonzales
Challenged by Planned Parenthood, joined by the
City and County of San Francisco on behalf of San
Francisco General Hospital
Subpoena to obtain medical records
Federal District Judge Phyllis Hamilton struck
down the law on 3 grounds (6/1/04):
Because it places an 'undue burden' (i.e., "a
substantial obstacle in the path of a woman seeking
an abortion of a nonviable fetus") on women
seeking abortion
Because its language is unconstitutionally vague
Because it lacks constitutionally-required provisions
to preserve women's health
Upheld by 9th
Circuit (1/31/06)
23. NAF v. Ashcroft/Gonzales
Challenged by the ACLU Reproductive
Freedom Project on behalf of the National
Abortion Federation (NAF)
New York District Judge Richard C. Casey
(8/26/04)
found the Partial Birth Abortion Ban Act
unconstitutional
ruled that the act must contain exceptions to
protect a woman's health
Very inflammatory language reg the fetus
Upheld by 2nd Circuit (1/31/06)
24. Carhart v. Ashcroft/Gonzales
Challenged by the Center for
Reproductive Rights on behalf of a
Nebraska physician Carhart
U.S. District Judge Richard Kopf (9/8/04)
“The overwhelming weight of the trial evidence
proves that the banned procedure is safe and
medically necessary in order to preserve the
health of women under certain circumstances.
In the absence of an exception for the health
of a woman, banning the procedure constitutes
a significant health hazard to women."
Upheld by the 8th Circuit Court of Appeals
(7/8/05)
25. The Supreme Court
2 cases (Planned Parenthood &
Carhart) heard 11/8/06
Expect opinion at end of term
What do we expect
Will depend on Kennedy’s dissent in
Carhart?
Has science and evidence changed
What is undue burden
26. Kennedy’s Strong Opposition
states should be able to outlaw
“a procedure many decent and
civilized people find so abhorrent
as to be among the most serious
of crimes against human life”
dissent in Stenberg v Carhart, 2000
27. Implications of Reversal
Could ban all 2nd
trimester abortions
Impose criminal sentences on
physicians who violate the ban
Chilling effect on 2nd
tri provider
Fundamentally change the meaning
of abortion right articulated in Roe
Restrict abortion in states with more
liberal laws
28. What Will Providers Do?
Survey of 2nd
Trimester providers
attending the 2006 meeting of the
National Abortion Federation
N = 46 (US only)
Average gestation limit 21wks LMP
range [16-27+]
Median gestation limit 23 wks LMP
29. If PBA is upheld will you:?
alter the way you use misoprostol for
cervical ripening
use digoxin at earlier gestational ages*
reduce the gestational age to which you
perform abortions
stop performing intentionally intact D&Es
change who you allow in the procedure
room
change the clinical technique for
performing D&Es
30. Use Digoxin at Earlier Gestation Age?
What is Digoxin (“Dig”)
A feticide injected into the fetal heart to
stop fetal cardiac activity
Change clinical practice
Yes: 11 (24%)
No: 28 (61%)
No Answer: 7 (15%)
31. Why Isn’t Dixogin the Answer?
Scientific evidence demonstrates does not
increase safety or ease of procedure and
has medical risks
Drey, E. A., L. J. Thomas, N. L. Benowitz, N.
Goldschlager, and P. D. Darney. 2000. "Safety
of intra-amniotic digoxin administration before
late second-trimester abortion by dilation and
evacuation." Am J Obstet Gynecol 182:1063-6.
Jackson, R. A., V. L. Teplin, E. A. Drey, L. J.
Thomas, and P. D. Darney. 2001. "Digoxin to
facilitate late second-trimester abortion: a
randomized, masked, placebo-controlled trial."
Obstet Gynecol 97:471-6.
32. Other Complicating Factors
Increased difficulty
at reduced gestation age
with obesity
Cost
What is “fetal death”
How prove?
33. Where is the “Pro-Choice Movement”
Wavering support
Discomfort with the “techniques of abortion’
A desire to “not focus on the issue”
Belief that we lose when we discuss the issue
Belief that few women will be hurt by these
bans
Focus on “reframing” and terminology
rather than real understanding
34. Implications for Health Care Beyond
Abortion
Legislate a particular medical
technique
What does this mean to the
concepts of informed consent?
36. “Fetal Pain” Counseling Reqs.
Require a doctor performing an
abortion at 20 or more weeks to
read to the woman a statement
saying that the fetus may
experience pain and to offer to give
the fetus anesthesia
In place in 3 states and under
consideration in others
37. What is Pain
Pain is a feeling – a subjective
sensory experience – and as such,
an individual must possess some
level of consciousness or awareness
in order to perceive a stimulus as
unpleasant. To be conscious and
capable of experiencing pain, an
individual must have a functional
cerebral cortex.
38. Inconsistent with Science
Systematic review published in JAMA,
2005
Pain vs Movement
No “pain” prior to 29 wks gestation
“Wiring is in place but lights don’t come on”
Even if pain, no means for fetal anesthesia
Increased risk to the pregnant woman
Other concerns
Informed consent and notions of risk
Mandated physician speech
39. Shouldn’t Women Decide?
I can understand why we shouldn’t
require fetal analgesia/anesthesia
for all abortions, but why shouldn’t
we allow the woman to chose for
herself whether she wants fetal
analgesia/anesthesia during an
abortion?
40. How to Answer the Question
Patient autonomy is undoubtedly a consideration
of primary importance. However, there is no
known safe and effective fetal
analgesia/anesthesia to offer in the context of
abortion.
Additionally, patients should be advised that such
measures are unnecessary because science does
not support that fetuses feel pain before the third
trimester.
The goal of quality patient care is to inform
women of the most up-to-date scientific
information. Requiring that women be offered
care that is not needed nor demonstrated as safe
violates that goal.
42. What are TRAP laws?
Targeted Regulations of Abortion
Providers (TRAP)
TRAP laws = Purported health
facility regulations that apply only
to facilities in which abortions are
performed
43. TRAP laws often include:
Licensing and inspection provisions
Authorization for searches
Administrative requirements
Minimum training requirements for
staff
Physical plant specifications
44. TRAP laws are different than other
abortion laws
Other abortion specific laws attempt
to influence the pregnant woman’s
decision
premise to protect potential life
TRAP regulate the medical aspects
of the abortion procedure
premise is to promote health
45. How prevalent are TRAP laws?
Over half of all states have TRAP
laws, all deal with 2nd
Trimester care
Legal challenges have failed to
reverse TRAP laws
Before 1992, many TRAP laws were
struck down as unconstitutional
Since Casey when the Supreme Court
established the undue burden standard,
almost impossible to prove
46. Not regulated like similar care
Procedures with magnitude and risk
greater than abortions up to 20 wks that
are not regulated in the outpatient setting
hysteroscopy
surgical treatment of miscarriage
diagnostic dilation & curettage
endometrial biopsy
ovum retrieval
sigmoidoscopy
vasectomy
What about after 20 wks?
47. What are the implications of TRAP laws?
TRAP laws
segregate abortion from the general
practice of medicine
deter physicians from becoming
providers
unnecessarily raise the cost of
abortions
Results in reduced access to and
quality of abortion
increasing disparities particularly for
low-income & rural women
49. Clever TRAP Laws
Regulate clinic as an outpatient
surgical center
Requires that physician have
admitting privileges at the local
hospital
Physicians are flown in from out-of-
state
No hospitals would grant privileges
Essentially outlawed 2nd
Trimester
Abortion in Mississippi
50. “It is the women with resources who
continue to be able to get abortion.
And it is the low-income women,
people in marginalized populations,
people that live in rural areas, who
just don't have good access to legal
abortion and turn to very unhealthy
alternatives."
Jones, 2006
51. Despite This Reality
Very little attention by the
“Pro-Choice Movement”
Search of “Mississippi” and “Abortion”
focuses on the overt ban not the
convert ban
Failed legal challenge by the Center
for Reproductive Rights
Desperate need to study the effects
of this reality
52. Ensuring Access
Women’s Option Center, San Francisco
General Hospital
Medical Director: Eleanor Drey, MD, EdM
ACCESS/Women’s Rights Coalition
Executive Director: Parker Dockray, MSW
54. Serving the Most Acute Need
Primary referral site for medically
complicated patients
Only provider in Northern California
that accepts “emergency” Medi-Cal
after 20 weeks in pregnancy
Fee $1000 for 2nd
trimester
procedure
55. Turning Women Away
Caring for 23 wks patients first
Rescheduling 21-22 wk patients
1-2 patients a week
Turning away patients who are >23
weeks and one day
A new study to look at health outcomes
58. Mission
ACCESS exists to make reproductive
health and freedom a concrete reality -
not just a theoretical right - for ALL
women
ACCESS is a project of the Women's
Health Rights Coalition, founded in 1974
as the Coalition for the Medical Rights of
Women, a network of activists,
consumers and health care professionals
59. The ACCESS Hotline
Provides free and
confidential information,
referrals, peer
counseling and
consumer advocacy
about all aspects of
reproductive health
Connects women with
public insurance
programs
Refers to organizations
that help with other
issues such as IPV,
sexual assault, drug
addiction, homelessness,
or child-care
60. Practical Support Network
The Practical Support Network ensures
that women can obtain abortions and
other urgent reproductive health care
without isolation or delay
The network of over 125 volunteers
provides the transportation, overnight
housing, child-care and other support
women need to actually get to their
appointments
ACCESS can also pay for hotel rooms and
bus tickets when women must travel
great distances to find a provider
61. Meeting Only Some of the Need
Approx 600 calls per month
Resources to help between
150-200 women
English and Spanish only
62. Raising Awareness
“The Other Abortion Battle:
Abortion may be legal in California –
but that doesn't mean you can
actually get one”
Tali Woodward
The Bay Guardian
10/10/06
63.
64. Working Together to Ensure
Access and Care Provision
The Medi-Cal Reimbursement Project
65. Medi-Cal in California
Estimated 90,946 Medi-Cal funding
induced abortions
Approx. 39% of all CA abortions
(n=236,000)
66. The Challenges for Medi-Cal Recipients
Approximately 38% of reproductive aged
CA women are eligible for Medi-Cal
based on their income level
Only 20% of practicing CA Ob/Gyns
accept Medi-Cal
56% of Medi-Cal beneficiaries stated that
finding doctors in close proximity who
accepted Medi-Cal even for routine
medical care was difficult or very difficult
Medi-Cal Policy Institute. Speaking out: What beneficiaries have
to say about the Medi-Cal program. March 2006
67. Locating a Medi-Cal Abortion Provider
Review of the 148 publicly-
advertised CA abortion providers
defined as all providers listed under
abortion services in the yellow pages
53% accept Medi-Cal through the 1st
trimester
20% accept Medi-Cal into the mid-
second trimester (up to 20 weeks
gestation)
Only 4% accept Medi-Cal past 21
weeks
68. Acute Provider Shortage
Of the 23 abortion providers who
provide abortions past 20 weeks
only 3 accept Medi-Cal through 24
weeks
10 don’t take Medi-Cal at all
69. Acceptance of Medi-Cal by Second Trimester Abortion Providers (21-24 Weeks)
16 18 20 22 24
1
3
5
7
9
11
13
15
17
19
21
23
AbortionProviders(N=23)
Gestation (in weeks)
Medi-Cal
Accepted
Abortion
Peformed
70. Not All Medi-Cal is Alike
Medi-Cal Categories
Full Scope Fee-for-Service
Full Scope Managed Care
“Emergency” Pregnancy-related
Medi-Cal
May accept one and not the other
Impossible to acertain
71. Survey of Abortion Providers
A survey of abortion providers
who perform abortions through
24 weeks but no longer accept
Medi-Cal
Conducted by ACCESS
Revealed that reimbursement rates for
2nd
Trimester Abortions are too low to
cover the expenses associated with the
procedure
Accepting Medi-Cal seen as not
financially feasible
72. Estimating Cost v Reimbursement
Freestanding clinics that provide abortions past
20 weeks report
an average of $467 in total reimbursements from
Medi-Cal for the procedure, ultrasounds, tests, and
medications and supplies
providing these 2nd
trimester abortions costs a clinic
an average minimum of $637
leaving an estimated deficit of at least $170 per
procedure
For a hospital to perform the same procedure is
much more costly
the average 2nd
trimester abortion is reimbursed
$581
total related hospital costs are approximately
$1,860
leaving a deficit of $1,280 per 2nd
trimester abortion
73. Advocacy Project
California Coalition for Reproductive
Freedom
Proposal to State Office of Medi-Cal
Increase reimbursement for later
second trimester abortion
?--How deal with the
“We take Medi-Cal but not for that”
74. Second Trimester Abortion as a
Public Health and Human Right
Reverse the Provider Shortage
Provide Medically Appropriate Care
Ensure Access to Those Most in Need
Stand Up for 2nd
Trimester Care
75. Frances Kissling, CFFC
“a new era in prochoice advocacy—one that
combines a commitment to laws that affirm
and enhance the right of each woman to
decide whether to have an abortion or bear
and raise a child with an expressed
commitment to human values that include
respect for life, recognition of fetal life as
valuable and a concern for fostering a
society in which all life is valued”
Is There Life After Roe?: How to Think About the Fetus,
Conscience, Winter 2004-05
76. William Saletan
“Maybe that six-month window made
more sense in 1973 than it does
today. Maybe, if we spend the next
10 years helping women avoid
second-trimester abortions, we won't
have to spend the next 20 or 40
years defending them. Maybe the
best way to end the assault on Roe is
to make it irrelevant.”
Life After Roe, Washington Post, 3/5/06;B01
77. Other Warning Signs
NARAL Prochoice America refused
to oppose the Unborn Pain
Awareness Act
Many public opinion polls ask
questions only about 1st
trimester
abortion
Advocates warn about “bringing up
the fact that abortion is legal in the
2nd
trimester”
78. Standing Up
DO NOT sacrifice the human rights
of the women who need them most
in the name of “keeping abortion
legal for everyone”
DO NOT sacrifice the health of
women who need abortion care
simply because it is too difficult to
talk about that care
79. The Illogic of It All
Restricting 2nd
Trimester Abortion
Does not:
lead to increase prevention
make people not have sex
Does
Make people parents who do not want to
be
Medically risk the lives/health of women
Shift the burden to women of color, low
income women and geographically
isolated women
It is important to remember that few abortions occur in the late second trimester and beyond. Almost 90% of abortions are performed in the first trimester of pregnancy (in the first 12 weeks after the first day of the last menstrual period). More than half of abortions are performed before 9 weeks after the last menstrual period, or within 5 weeks of the first missed period. The proportion of abortions performed very early in pregnancy (at 6 weeks or before) increased from 14% in 1992 to 22% in 1999. Fewer than 2% of abortions are performed after 20 weeks. An estimated 0.08% of abortions are performed after 24 weeks, when the fetus may be viable
But data alone can not explain the political power of the PBA debate. This picture is worth a thousand words. Here the Republican leadership watches on as Bush signs the Ban into law. I ask you, who is making health care decisions for women.
So what can we expect if the ban is upheld. First it is likely that the ban would apply to all or most 2 nd trimester abortions. It would impose criminal sentences on physicians who violate the ban and thus is likely to create a serious chilling effect on 2 nd tri providers who are not likely to continue to offer services. More importantly a decision in favor of the ban would fundamentally change the meaning of abortion right articulated in Roe. It would also impose abortion restrictions nation-wide thereby limiting abortion even in states with more liberal abortion laws, i.e. California, NY.
Another law under consideration now is the Unborn Pain Awareness Act. This law, called “The Medical Intrusion Act” by its opponents, would require that Would require a doctor performing an abortion at 20 or more weeks to read to the woman a statement saying that Congress has determined that the fetus will experience pain and to offer to give the fetus anesthesia.
Although such a law on face value seems like a fair thing-we all want women to have more information it is medically and scientifically inaccurate. A systematic review of the state of the science was published in JAMA in 2005 concluding that no evidence supports the existence of pain in the fetus before the 29 th week, well into the 3 rd trimester and that use of anesthesia to address this nonexistent pain increases the medical risk for the woman with no known clinical benefit. What is hard for many people to grasp is that the fetus does move under stimulation from the abortion but that movement is not pain. A way to think about this is that the “Wiring is in place but lights don’t come on.” Opponents of the law are concerned that physicians will be mandated to tell patients things they do not believe are true and to offer care that they can not in good conscious consent their patients for.
Examples: Although the Health Department is empowered to license and regulate health clinics, that authority does not extend to "the residence, office, or clinic of a physician or association of physicians . . . unless ten or more abortions are performed in any one calendar week in such residence, office, or clinic." Neb. Rev. Stat. §§ 71-2017.01(9) "'[Health] Department inspectors shall have access to all properties and areas, objects, records and reports [of the abortion facility], and shall have the authority to make photocopies of those documents required in the course of inspections or investigations." S.C. Reg. 61-12 § 102-F Licensed facilities must establish and maintain a written "quality assurance program," run by a quality assurance committee of at least four staff members, who must meet at least quarterly. 25 Tex. Admin. Code § 139.8(a) "The abortion facility nursing service shall be under the direction of a legally and professionally qualified registered nurse." Missouri Min. Stds. of Operation for Abortion Facilities § 301.3 Abortion procedure and recovery rooms shall have a minimum of six air changes per hour, and "all air supplied to procedure rooms shall be delivered at or near the ceiling" and must pass through "a minimum of one filter bed with a minimum filter efficiency of 80 percent." 10 N.C. Admin. Code 3E.0206
Talk about abortion as having two essential aspects – the medical procedure aspect and the termination of potential life aspect Law like waiting periods and parental consent laws address potential life aspect of abortion Contrast with TRAP laws which address things like room dimensions or nurse’s degree etc
States with 1 st Tri – AL, AR, CA, CT, FL, KY, LA, MI, MS, MO, NE, OK, NC, PA, PR, RI, SC, TN, TX, WI States that have 2d tri TRAP schemes but not first tri – AK, GA, HI, IN, MN, NJ, SD, UT, VA (NOTE that some states that have first tri schemes also have an additional scheme applicable to 2d tri – these are AR, MS, NC, PA, RI)
Because TRAP laws impose general health standards that address things like staffing, physical facilities, administrative procedures, etc the question of comparability must also focus on these factors. Thus, if abortion is comparable to some other procedure with respect to the procedures’ needs regarding staffing, physical plant, administrative procedures, etc, then the procedures are comparable in all respects relevant to the law. Note, some of these procedures are comparable to first trimester abortion, some to abortions up to 20 weeks – I don’t have data on comparability for abortions past 20 weeks.
Segregation: contributes to problem of abortion not being integrated into provision of other health care services. It also creates an impression that abortion is not part of the practice of medicine and is not a medical procedure. Deterance: By subjecting abortion providers to civil and criminal penalties, exposing them to harassment, subjecting them to searches of their offices and records, micromanaging their practice of medicine instead of allowing them to exercise their professional judgment, etc – some physicians who would consider providing abortions within their medical practice will be deterred from doing so by the burdens of being regulated by TRAP laws. The small number of abortion providers in this country is already a public health problem as it reduces women’s access to the procedure. This lack of easy access to an abortion provider causes some women to delay their abortions until later in pregnancy when the procedure carries greater risks. TRAP laws impose requirements that are costly to comply with yet provide no corresponding health benefits – such requirements include requiring facilities to use licensed nurses instead of medical assistants, to install sophisticated air ventilation systems, etc. These costs get passed on to patients, some of whom face significant diffulties in raising those additional funds. Abortion price increases therefore cause some patients to delay abortions until later in pregnancy, when the risks of the procedure are greater.