Abortion Clinics

QUALITY OF ABORTION SERVICES

Clinical Policies Guidelines

The National Abortion Federation (NAF) is the professional association of abortion providers in the United States and Canada. A mission of the NAF is to promote and enhance the quality of abortion services. The organization has developed clinical policies guidelines to help assure safe, high quality abortion care.

The most recent edition of the NAF's Clinical Policy Guidelines is available at http://www.guidelines.gov and includes three types of policies: standards, recommendations, and options. Standards are applied rigidly and include directives such as, "Abortions must be performed by licensed physicians, or licensed/certified/registered midlevel clinicians trained in the provision of abortion care, in accordance with state law." Recommendations allow some flexibility in clinical management but must be justified when not followed. Recommendations include items such as, "Appropriate referrals should be available for patients who cannot be cared for at your facility." Options require no justification. For example, the option listed under the standard, "Accurate information must be provided regarding the risks and benefits of abortion," is: "This information may be provided either on an individual basis or in group sessions."

Satisfaction with Quality of Care

In May 1999 the Henry J. Kaiser Family Foundation (KFF) published "From the Patient's Perspective: Quality of Abortion Care" (http://www.kff.org/womenshealth/20010517d-index.cfm), the first large-scale study (and the most recent study available) about the quality of abortion care from the patients' perspective. The KFF commissioned the Picker Institute, a health care assessment and improvement research organization, to interview more than 2,200 abortion patients age eighteen and older from twelve abortion providers in a dozen states nationwide. The patients were "women who successfully located a provider, could afford the procedure, and were able to get to the clinic."

Of patients, three in five (60%) rated their care as excellent, and nearly two in five (38%) as very good or good. More than half of the patients indicated the information they received and the staff 's attention to their privacy were both excellent (56% and 55% respectively). The remaining patients rated these two aspects of their care as very good or good. Three-quarters (78%) of the patients felt "a lot" of confidence and trust in the staff who cared for them, and about one-fifth (18%) reported "some" confidence and trust. Almost all patients (96%) said they would recommend their abortion provider to family or friends.

The adequacy of information about the abortion was the most important issue to the patients. Almost all (98%) of the patients reported that the clinic staff explained the procedure, and 99% thought the explanation was clear. Nearly nine in ten (87%) stated they received all the information they wanted about what to expect during the procedure. More than nine in ten (93%) reported receiving information about emotional or physical reactions that might follow the abortion.

Satisfaction with Method of Abortion

In "Choice of and Satisfaction with Methods of Medical and Surgical Abortion among U.S. Clinic Patients" (Family Planning Perspectives, vol. 33, no. 5, September/October 2001), researchers S. Marie Harvey, Linda J. Beckman, and Sarah J. Satre evaluated the medical (nonsurgical) and surgical abortion experience for women. (See Table 1.1 in Chapter 1 for an explanation of these methods.) Among 304 women participating in the clinical trial, 186 received a medical abortion (methotrexate) and 118 were offered a medical abortion but chose to have a surgical abortion. The women completed questionnaires before the abortion procedure and then again during a follow-up visit.

The study participants revealed that both methods of abortion were highly acceptable. Almost half (48%) of the women undergoing a medical abortion reported being very satisfied with the methotrexate-induced method. Slightly more than one-third reported they were somewhat satisfied. Similarly, almost half (43%) of women who had a surgical abortion were very satisfied, and 39% were somewhat satisfied. Most of the women in both groups responded that they would recommend the method they had chosen to a friend, and most (89% of women who had medical abortions and 93% of the surgical group) said they would use the same method again if they terminated another pregnancy.

To determine what characteristics of a particular abortion method women valued most, the researchers asked the women to rate the importance of twenty-one attributes when choosing between the two abortion methods. Women who chose medical abortion differed greatly from the surgical abortion group in their ratings of fourteen of the twenty-one procedure characteristics. The surgical abortion group preferred several features: the procedure is over quickly; it does not have side effects (such as headache, nausea, and diarrhea); the patient does not see blood; it does not cause heavy bleeding or bleeding for longer than a week; it does not cause cramping for more than an hour; it is a technique that has been used for a long time; a doctor or nurse is present for the procedure; and the patient knows when and where the abortion is taking place.

The women who chose medical abortion gave four attributes much more importance than did the surgical abortion group. For the medical abortion group, it is important that the method does not involve surgery; it can take place in private (such as at home); it does not involve surgical instruments; and it is like a "natural miscarriage."

The researchers concluded that women consider numerous factors when deciding on abortion method. They note that abortion providers should supply women with enough information about the characteristics of abortion methods so that they can make informed decisions appropriate for their values and life circumstances.

ACTIONS AGAINST ABORTION CLINICS

Violence and Disruption

Since 1977 the NAF has tracked incidents of violence and disruption against abortion providers across the country. NAF members report incidents on an ongoing basis. Their reports are supplemented with information from newspaper reports, law enforcement agencies, and abortion provider organizations. A year-end survey is conducted to complete each year's presentation.

Over the years many abortion clinics throughout the nation have experienced violence. The most serious instances of clinic violence have been the murder and attempted murder of abortion doctors and clinic workers. The first clinic murder occurred in 1993: Michael Griffin shot and killed Dr. David Gunn in Pensacola, Florida. Four murders occurred the year after, and two happened in 1998. None have occurred since. There have been seventeen attempted murders since 1991.

From 2000 to 2004 there was a decrease in the total number of incidents of extreme violence against abortion providers, specifically bombings, arsons, and attempted bombings and arsons. (See Table 6.1.) The NAF credits the arrest and prosecution of Eric Rudolf, James Kopp, and Clayton Waagner, three antiabortion extremists, as key factors in the decline of severe forms of violence against abortion providers. "Vigorous enforcement of the law" by local, state, and federal officials and "effective vigilance, training, and dedication of clinic staff " also have contributed to the decline, according to the NAF. Overall, in 2004 there were 152 identified acts of violence, down from the record high of 795 in 2001. (The 2001 total was exceptionally high as a result of the 554 hoax anthrax threat letters recorded that year.)

As Table 6.1 shows, during the years 1990 to 2004, 1997 had the highest number of clinic bombings (six). During the same time span, 1992 had the highest number of arson-related fires (nineteen). In more recent years both types of incidents have decreased dramatically. There was one clinic bombing in 2001 and no bombings were reported from 2002 through July 2005. There was one arson-related fire in 2002, three in 2003, and two in 2004.

Incidents of vandalism have remained somewhat stable since 1998, fluctuating from a low of forty-six incidents to a high of sixty-three incidents. Death threats have remained low in recent years: three in 2002, seven in 2003, and four in 2004. There were no death threats to abortion providers between January and July 2005.

Figure 6.1 shows abortion clinic violence by state. The numbers include arsons, bombings, murders, shootings, and butyric acid attacks. (Butyric acid is a liquid with a vomit-like odor. Butyric acid can cause thousands of dollars of damage, requiring clinics to conduct extensive cleanups.) California, Florida, and Texas had the highest number of incidences in the years 1993 to 2004.

The NAF first collected data on stalking (the persistent following, threatening, and harassing of an abortion provider, staff member, or patient away from the clinic) in 1993, reporting a record high of 188 cases that year. Stalking cases dropped to about one-third of that amount through the mid-1990s. After 1997 the annual number of

stalking cases dropped again; in recent years they number in the teens. In 2004 there were fifteen cases of stalking reported. (See Table 6.1.)

After the passage of the Freedom of Access to Clinic Entrances Act in 1994 (FACE, PL 103-259; see later in this chapter), the number of clinic blockades dropped sharply, from twenty-five in 1994 to five in 1995. In general, there have been only a few clinic blockades each year since the mid-1990s (with the exception of 1997). However, clinic blockades increased to ten in 2003 and to thirty-four in 2004. (See Table 6.1.)

Picketing is by far the major activity of pro-life activists. The number of incidents of picketing has increased each year since 2000, peaking at 11,640 incidents in 2004. Picketing and various forms of harassment are becoming more intense, according to reports from abortion clinics.

Many protests at abortion clinics have been under the direction of Operation Save America (formerly Operation Rescue National), an organization that seeks to shut down clinics completely but denies promoting the use of violence. Operation Save America believes that the United States, in permitting abortion, has lost its morality. Demonstrators claim that they are not only saving the lives of the unborn but also preventing the judgment of God from being passed on the United States for murder committed through abortion.

FREEDOM OF ACCESS TO CLINIC ENTRANCES ACT (FACE)

The Freedom of Access to Clinic Entrances Act was signed into law on May 26, 1994, in response to increasing violence against abortion clinic workers and clients. FACE prohibits physical attacks on clinic employees and patient escorts, attempted arson of clinic facilities, blockades of clinic entrances by persons or vehicles, and threats of bodily harm to providers or recipients of services.

The legislation received support from both abortion proponents and opponents. Pro-life advocate Senator Harry Reid (D-NV) said that despite his conviction against abortion, FACE's aim was "not to restrict the rights of people to demonstrate but to protect the rights of people to be free from the fear of violence against them."

Some opponents of FACE, however, have challenged its constitutionality on a number of grounds. Some charge that FACE violates the freedom of speech and religion protections under the First Amendment, whereas others claim that Congress lacks the power to pass such a law under the commerce clause (to regulate interstate commerce) of the Constitution. However, the U.S. Supreme Court has affirmed the constitutionality of FACE by refusing to hear challenges to the law.

For more information on court cases regarding FACE and abortion clinic violence, see "Protesters at Abortion Clinics" in Chapter 2.

The Effectiveness of FACE

According to a 2003 report by NARAL Pro-Choice America, "FACE has proven to be an essential component of the effort to protect access to abortion services." Although violence continues, the frequency of some types of clinic violence has declined since 1994. The federal statute also has spurred enhanced clinic protection by law enforcement and has withstood numerous constitutional challenges. Incidents of extreme violence against abortion providers, however, continue to occur, with two murders and one attempted murder in the United States in 1998 and another attempted murder in 2000.

The U.S. Government Accountability Office (GAO), in "Abortion Clinics: Information on the Effectiveness of the Freedom of Access to Clinic Entrances Act" (Washington, DC: Government Accountability Office, 1998, http://www.gao.gov/archive/1999/gg99002.pdf), studied the occurrence of clinic incidents before and after FACE. The GAO surveyed forty-two clinics that experienced relatively high levels of incidents before FACE was enacted. Most of the clinics (thirty-four) reported experiencing fewer types of incidents during the two years after FACE than they had before FACE became law. Nonetheless, almost all clinics indicated no change in the occurrences of picketing, hate mail, and harassing phone calls before and after FACE. However, thirty-five respondents reported a decrease in the severity of the incidents, particularly of picketing. Overall, most respondents felt that FACE had deterred or reduced clinic incidents.

A survey on clinic violence conducted by the Feminist Majority Foundation (FMF) ("2002 National Clinic Violence Survey Report," http://www.feminist.org/research/cvsurveys/clinic_survey2002.pdf, March 2003) concurred that severe clinic violence decreased since FACE was enacted. Nonetheless, results of the survey revealed that in recent years severe clinic violence was rising; in both 1999 and 2000 it affected 20% of clinics while in 2002 it affected 23% of clinics. Bomb threats, stalking, death threats, and blockades were the most commonly reported types of severe violence in 2002. The number of clinics experiencing three or more forms of violence or harassment also increased—from 5% in 1999, to 11% in 2000, and to 14% in 2002.

CLINIC SATISFACTION WITH LAW ENFORCEMENT OF FACE

Most police departments surveyed by the GAO for its report "Abortion Clinics: Information on the Effectiveness of the Freedom of Access to Clinic Entrances Act" noted that they had taken steps to reduce and better respond to clinic incidents after FACE came into effect. These steps included increasing patrols at clinics during high-risk times (such as at the anniversary of Roe v. Wade or on Saturdays, when more protesters were present), training police officers about clinic incidents, and conducting outreach or education with clinic staff.

Most (thirty-five) clinic respondents to the GAO study generally were satisfied with the effectiveness of their local law enforcement in protecting their clinics during the two-year period after FACE; seven were dissatisfied. Five of the seven dissatisfied respondents cited officers' poor response (slow response or lack of response) to incidents.

Three-quarters (75%) of clinic respondents to the 2002 FMF survey rated the law enforcement response to clinic violence as good or excellent. These clinics were less likely than the remaining 25% of clinics to experience antiabortion violence or harassment. Of the clinics that had contact with state law enforcement, and of the clinics that had contact with federal law enforcement, 81% and 82%, respectively, rated their responses as good or excellent.

FACE and the Internet

In February 1999 a federal jury in Portland, Oregon, unanimously ruled that it is illegal for pro-life activists to threaten abortion providers through Wild West-style "wanted posters" and a Web site called the "Nuremberg Files." The "Nuremberg Files" listed the names of abortion doctors accused of committing "crimes against humanity." The list included the doctors' addresses and other family information. Murdered doctors were listed with lines drawn through their names.

The jury ordered the defendants (American Coalition of Life Activists, Advocates for Life Ministries, and twelve individuals) to pay the plaintiffs (Planned Parenthood, the Portland Feminist Women's Health Center, and four abortion doctors) more than $109 million in damages. The jury found all defendants guilty of violating or conspiring to violate FACE and all but two defendants of violating or conspiring to violate the Racketeer Influenced and Corrupt Organizations Act (RICO).

However, in March 2001 a three-judge panel of the Ninth Circuit Court of Appeals unanimously reversed the jury verdict and the injunction against continued publishing of the materials. Then in May 2002 an eleven-judge panel of the Ninth Circuit U.S. Court of Appeals upheld the 1999 trial verdict, stating that the Nuremberg Files Web site and the "wanted" posters amounted to threats and intimidation that violated FACE as well as other laws.