Texas Abortion Bill: Is There a Medical Case for More Regulation of Outpatient Clinics?

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Eric Gay / AP

A protester holds up their message on a hangar during a rally against new abortion legislation, July 1, 2013, in Austin, Texas.

Texas legislators want to require that abortions in the state be performed in ambulatory surgery centers rather than licensed doctors’ offices or clinics, but will that make them safer?

Doctors are performing more procedures, from liposuction, vision correction operations and even abortions in the comfort of their own offices or private clinics. Since 1999, the number of these so-called ambulatory surgery centers (ASCs) has doubled [PDF], from 2700 to nearly 5400 in 2011, according to the Ambulatory Surgery Center Association (ASCA). The organization says that about 65% of these centers are owned by physicians, but hospitals are increasingly forming partnerships with them or establishing their own facilities. And as the volume of these centers continues to grow, more insurers, legislators and patients are asking about whether they meet safety standards and provide quality care.

The Texas abortion bill would require that all abortions in the state be performed at an ambulatory surgery center, and not in clinics that the state currently regulates. That may simply be a matter of semantics, since some physicians argue they don’t need the accreditation to perform procedures, and some states view licensed and ASC clinics as equivalent, and equally safe. (Some states don’t even require licenses for facilities that provide certain outpatient procedures.) Critics of the proposed legislation also say that abortion is not surgery, but a procedure, and that legal abortion is considered safe, especially during the early stages.

(MORE: Meet the Woman Behind the Texas Abortion Filibuster)

But supporters of the Texas bill argue that the surgery centers would provide better medical care for patients, not only during the procedure but in the event that patients would require emergency care to treat complications as well. Currently, 43 states and Washington, DC require that ASCs be licensed. Certification by the Centers for Medicare and Medicaid Services (CMS), which is mandated if the facilities want to qualify for federal reimbursement for their services, and voluntary accreditation programs serve as additional ways to validate the quality of care that the facilities provide. CMS requires that certain infection control measures are in place, and that a nurse trained in the use of emergency equipment is present during every procedure. If complications develop, the ASC must also have a prior agreement with a nearby hospital for transferring patient for additional care.

Office-based surgery facilities that are licensed are not very different from these accredited surgery centers. But the latter is regulated by an outside accreditation association that conducts routine inspections, which some say tend to motivate facilities to maintain higher quality of care. Ambulatory surgery centers may also have more stringent rules when it comes to which medications are available, or whether or not there is an EKG machine on hand, in case an individual required more monitoring.

How do states determine which procedures can safely be performed in clinics, and which require the stricter oversight of ASCs? Again, the criteria vary widely, but typically, they look at the level of anesthesia involved. In general, procedures that require little or no anesthesia are more likely to be performed in licensed facilities, while those that involve light or moderate sedation tend to be done in ASCs.

As complicated and as piecemeal as the process seems, it emerged out of the need to protect patients while not over-regulating every dermatologist trying to remove a wart. Establishing standards is a well-established way of improving care, especially in an environment where more and more physicians are hanging up shingles to perform simple procedures. “Although there is added cost for the setup and accreditation of such facilities, it protects both physicians as well as patients, and thus creates standards for care and safety. Without strict regulation, oversight, and minimum standards, patients can be at risk for adverse outcomes,” says Dr. Robert Glatter, and emergency medicine physician at Lenox Hill Hospital in New York.

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Most reproductive specialists agree, although they admit that there is little evidence to support the idea that ASCs provide higher quality of care over clinics. The American Congress of Obstetricians and Gynecologists (ACOG) released a statement in response to the Texas bill stating:

The bills would require physicians who perform abortions to have admitting privileges at a hospital within 30 miles, allowing abortions only in surgical clinics and setting a higher standard than for other procedures with similar low risk such as colonoscopy. The fact is that abortion is one of the safest medical procedures. The risk of complications from abortion is minimal, with less than 0.5% of abortions involving major complications.

So should other procedures, not just abortions, that are currently performed at clinics (some of which are licensed, and some of which are not), also be regulated in the same way? In some states, the following operations can be performed at facilities that may not be either licensed or accredited:

Liposuction
While relatively safe, the procedure does carry potential risks, including bleeding and unpredictable reactions to anesthetics. The American Society of Plastic Surgeons and the American Society of Aesthetic Plastic Surgery require that if its member physicians operate in an outpatient or ambulatory surgery facility, that the center be accredited by an established facility accreditation organization or be licensed. Some centers possess a license issued by the state but are not recognized as an ambulatory surgery center. States like Idaho and Hawaii have no accreditation or license requirement.

Colposcopy
This procedure often involves taking a small tissue biopsy of the vulva, vagina or cervix, and while it carries a low risk of infection or bleeding it can be considered an invasive operation for an office visit. Still, some states do not require licensing or accreditation of facilities that provide this procedure.

Hernia repair
Once done in hospitals with at least an overnight stay, most of these surgeries are now done in an outpatient setting, since surgeons can reposition uncomfortable and bulging tissue in the abdomen using minimal incisions. Again, some states may offer only licensing or a mixture of the licensing and accreditation, but there are a handful that require neither.

If the bill passes, the new law would likely shut down the majority of abortion clinics in Texas since they won’t be able to finance the process of becoming an ASC. But regardless of the outcome of the vote, some medical experts see the debate as an opportunity to improve medical care. “The argument on one side is that people who are demanding licensing and accreditation are anti-abortion. Those who don’t want it, are pro-abortion. I don’t think that’s the issue,” says Dr. Geoffrey Keyes, the president of the American Association for Accreditation of Ambulatory Surgery Facilities. “There is nothing wrong with having standards to adhere to when you are performing procedures on patients.”

20 comments
Hermione
Hermione

As far as my views on abortion - the first trimester, yeah okay.  I think getting an abortion after 5 months is extreme, unless it is to save the life of the mother.

I do want to add this - I say fight fire with fire. Donate funds and time to clinics, like Planned Parenthood. There are no laws that state that private individuals cannot funds these women's clinics.   There are many women's clinics that provide access to birth control and healthcare WITHOUT providing abortions, so we should be willing to help poor women with their healthcare choices.  And that is something that both the anti-abortion and pro-choice groups can get together on.

ShirleyLRoy-Poche
ShirleyLRoy-Poche

No, outpatient procedures have Plenty of regulation and controls that were set by the Medical Community and Insurance Companies - what we don't need is ignorant Senators and Representatives using medical science and medical procedures to further their RELIGIOUS views. 

Separation of Church and State.  No other USA need exist.  Government has oversight within the medical community and that is where medical decisions of law should be dealt with on a federal or state level, with their medical advice.  

Men need to leave off of women's bodies or suffer the same type of attention onto themselves and their causes of consternation toward their given beliefs; lets say adultery or UNPLANNED PREGNANCY OF A WOMAN since it took a man for the woman to get pregnant and seek an abortion in the first place - "there is very little mention by or notoriety of the men that are fighting against these laws being passed, those men that did't plan for those pregnancies either and I wonder if that is the way it is, or the way of media's reporting). . . men don't medically "need the penis to pee" and the member does represent so many acts men perform that defy religious law and societal law. . . societal laws can be written as these men well know, and used to back up their Individual belief in a certain religion . . laws that are passed for these people to promote their religious beliefs will not be good law, as with these abortion law atrocities, but yes, fellows, do know that law can be written . . . and passed.  Hopefully, we can vote these idiots out of office, before any back-and-forth atrocious laws would have to battle in order for society to regain intellect and its regard for freedom and liberty.

ChynnaBlue
ChynnaBlue

As your article pointed out, most clinics simply could not afford the upgrade. Representative Sylvester Turner offered an amendment to the bill that would require the state to pay for the upgrades for these clinics, which provide health care (NOT just abortions, but basic health care) to countless women. If you belief that an ASC provides better health care, which is what the author of the bill says this is about, then that sounds like a win-win option. Better health care and safer abortions for women across Texas. Representative Jodie Laubenberg, the author of the bill, refused any amendments. This bill is not about better health care, it is about shutting down clinics across Texas. Lt Governor David Dewhurst said as much in a Tweet that showed a before and after map of Texas clinics and said that is why the bill must be passed. Laubenberg, the bill's 'author', was not educated on the bill, which was evident when she was questioned about it and did not even know that the Texas Hospital Association does not support her bill. Laubenberg's inability to intelligently discuss the bill is possibly due to the fact that she is the state representative for ALEC, the likely true author of the Texas bill and others like it across the country. Laubenberg is the woman who said that a rape kit "cleans a woman out" to "alleviate" the possibility of pregnancy after rape, which you recall from the recorded hearing from June. After she said that, she stopped answering any questions for the remaining hours of that hearing. This bill is not about the health and safety of women and it is not about science, something the bill's author seems to know precious little about. 

ChynnaBlue
ChynnaBlue

I've been present in the House and Senate for the abortion bill hearings since last month. In the most recent hearing, someone (from ACOG, I think) testified that ASC centers in Texas are inspected approximately 1-3 years (usually 3 because of staffing issues) and that abortion clinics are inspected every year. Representative Jodie Laubenberg was asked about several possible amendments to the bill, including one from Rep Sylvester Turner. The main issue for many is that this bill would close all but 5 clinics in Texas and leave none st all in west Texas, requiring some women to drive 600 miles to exercise a legal right. Turned offered an amendment that would require the state to finance the upgrades of the clinics to ASC centers, which would resolve that issue and, if you believe that ASC centers provide better health care for countless women

SwiftrightRight
SwiftrightRight

I know If my wife was getting an abortion I would want a licensed and trained staff who were required to maintain standards of cleanliness and training with access to basic lifesaving equipment in case of an emergency bleed or anaphylactic reaction.

As is abortion centers in most states have NO minimal standards other then the consciousness of the doctor running the show. If he decides its cheaper to defend against a law suit every few years then it is to pay to provide emergency meds equipment and training then guess what, if anything goes wrong your screwed.

And before anyone starts going on about med lawsuits being an economic force to provide good care most states cap med related lawsuits down to $60,000-$150,000. With a stocked Emergency cart costing about 45,000 + restocking costs and a qualified nurse who knows how to use it costing $36,000 to $60,000 per year many MDs opt to take their chances in court.

clarkadrummage
clarkadrummage

I don't really see the advantage of a law that just says if you want to murder a baby you have to do it in an approved location, when it's really really young...

vj1880
vj1880

To answer the question, "Is there a medical case...?" - yes. Here's something from the Gosnell trial. The following is quoted from the Washington Examiner website:

The grand jury noted that even after Gosnell's unqualified, unlicensed staff had (at his direction) given her a lethal overdose of local anesthetic, she might have still been saved but for the clinic's "cluttered," "narrow, twisted passageways" which "could not accommodate a stretcher" to get her out. Mongar still had a pulse when paramedics arrived, but they lost a critical 20 minutes just trying to get her out of the building.

The grand jury concluded that, had Gosnell's clinic been regulated like other "ambulatory surgical facilities" — say, your average plastic surgeon's office — then health inspectors "would have assured that the staff were all licensed, that the facility was clean and sanitary, that anesthesia protocols were followed, and that the building was properly equipped and could, at least, accommodate stretchers."

JudHanson
JudHanson

What is needed is more country-wide standards for clinics and hospitals. There are a variety of aspects of society where honoring states' rights create many more problems then benefits. Gun laws are another example but I digress. Requiring hospital privileges for abortion clinic doctors when the risk is so low compared to other "acceptable" procedures is clearly nothing more than an attempt ot circumvent Roe v. Wade.

rohit57
rohit57

I think that a limit of 20 weeks for elective abortions is completely reasonable as long as exceptions are allowed after that for emergencies.  Many countries, not afflicted with fundamentalism, still restrict elective abortions to 12 weeks.

At the same time, Texas ought to bite the bullet and accept that some abortions will remain legal and should not only be safe but also convenient.

RekkaRiley
RekkaRiley

@Hermione Most abortions that are done after five months are due to miscarriages.

After the first trimester, if the fetus miscarries, it is too big for the mother's body to expel on its own.  There might still be a very faint heartbeat left, but it is physically impossible to save it and the mother's body is already treating it as dead.  It's safer for the mother, and more humane for the fetus, to perform an abortion regardless of how far along the fetus is.  It could be 8 months along and nearly ready to pop, but if it starts to miscarry, it's a goner.  You may be able to try an emergency c-section at that point, but the most likely cause of the miscarriage is that the fetus is unhealthy or not genetically sound.  Nature itself has decided that it is not meant for this world, and it's usually best to LISTEN when Nature's trying to say something.

There was a recent case in Ireland where a woman started to miscarry just before that 5 month mark you mentioned, and the doctors couldn't save it.  The woman was in extreme pain and already feverish when she pleaded for an abortion to get it done and over with.

The doctors refused, saying that they were good Catholics and they could not perform an abortion as long as there was a detectable heartbeat.

The woman spent the next three days in excruciating pain, and sepsis set in and her body turned blue.  She slipped into a coma, with her husband begging the doctors to do the abortion.  This would've been their first child, but he would rather have his wife alive and well.  The doctors kept saying no, they could still find a fetal heartbeat.

She was dead the next day, and the child with her.

Abortion isn't pretty, but my stance is that it should be "safe, legal, and rare."  Stricter limits will not solve the problem.

What will solve the problem is better access to birth control, better education, ending the culture that tells women and young girls that they won't be valued unless they can make a man happy by giving him sex.

We need better parental leave, better resources for new mothers of all income levels, better genetic testing that allows us to tell when a fetus might not be healthy enough to bring to term.

That is what will stop abortions:  making women feel like they aren't backed into a corner by society and their economic environment.  Women who don't feel like they are going to risk their jobs, their ability to feed the children they already have, their marriages, their education, the reputation, etc.  are far more likely to choose to keep the child rather than have an abortion.

JoieTherese
JoieTherese

@Hermione Why does it have to be to save the life of the mother?  What if it is to end the suffering of a fetus, which does happen when pregnancies go wrong. 

Hermione
Hermione

Women should be empowering themselves by getting on birth control, and insisting that their partners do the same.  Tell the guys to "wrap it up" so to speak. 

As far as these holier-than-thou politicians, I will be happy to help vote them out of office, I would prefer my elected leaders be FISCALLY conservative, not socially conservative.

Hermione
Hermione

Of course it isn't about 'science', it is about stopping all these elective abortions.  But notice how these so-called bills NEVER address birth control, or providing for the well-being of unwanted children.  Just wait until the state of Texas has to foot the bill for all these mothers and their kids.

alice.c
alice.c

@SwiftrightRight Learn the facts before you spout off!  Abortion clinics in TX are already highly regulated, and clinics that perform later abortions already have to be licensed as ambulatory surgical centers.


Hermione
Hermione

Then I would assume that you are against this legislation, since this in itself is not necessarily going to stop abortions.  If anything, I am more convinced that abortion will become like illicit drugs and the billion-dollar black market industry that drives it.  But we can thank our worthless leaders for wasting billions of dollars on stupid marijuana plants.

Hollywooddeed
Hollywooddeed

@vj1880 Uh, huh.  Take away access and you'll create more Gosnells.  You know, that guy who was performing illegal abortions and preying on desperate women.  Not everyone is like you, cupcake.

JoieTherese
JoieTherese

@Hermione Why are you saying "women should be ... getting on birth control"?  Many are on birth control, and what the heck does that have to do with whether or not they have access to medical services and whether or not their constitutionally-protected rights are being infringed upon?  If a woman has an unplanned pregnancy and needs an abortion, it doesn't necessarily mean she was choosing to be irresponsible.  Stop blaming women.

JoieTherese
JoieTherese

@Hermione You should see how many mothers and kids live in homeless shelters in San Antonio.  JeSUS effing Christ, you should just see!  Texas is happy to let the CHURCHES and MINISTRIES foot the bill . . .

clarkadrummage
clarkadrummage

Yes. Let's not make something that's inherently evil illegal because people will still do it... like theft, or speeding, or any other crime that's 1000 times les offensive than baby murder...

Hollywooddeed
Hollywooddeed

@clarkadrummage  

If that's how you feel, then don't ever have an abortion.  In the meantime, keep your religion and pointy nose out of what is legal and personal and none of your business.