(Clarification appended: August 27, 2013)
There are many ways to pressure an institution into steering clear of providing abortion. In Toledo, Ohio, the last remaining abortion clinic may be forced to close next week after area hospitals refused to provide transfer agreements, citing a desire to remain “neutral” in the abortion debate. Earlier this month, the sole abortion doctor in Green Bay, Wis., agreed to stop providing the procedure after a local private hospital acquired his clinic. This comes as laws tightening regulations on abortion providers threaten to close clinics in at least five states, part of a Republican-led push that both pro-life and pro-choice activists say is designed to chip away access to abortion rights.
Now a group of medical professors is responding to the crackdown by urging hospitals to fill the void and reverse a decades-long trend that has isolated abortion providers from the mainstream medical community. The effort comes alongside a change in the kinds of professionals who work in women’s health. Ob-gyns are increasingly young and female doctors who, medical professors say, hold different attitudes toward abortion than their older male colleagues.
In a statement set to be published in the September issue of the American Journal of Obstetrics and Gynecology, 100 ob-gyns condemn new state restrictions on abortion as a “political regression.” The article, obtained by TIME, criticizes hospitals for relinquishing abortion to stand-alone clinics that are easily targeted by abortion activists, and calls on the medical community to integrate the procedure into women’s-health services and medical training.
“In our view, hospitals have disregarded the responsibility that our academic predecessors expected them to assume,” the professors write. “The savings in lives and money from legalization were soon forgotten and many hospitals now claim they cannot afford to provide abortions even if they wanted to …”
It’s a rare call to arms for the medical community, which tends to lay low when it comes to abortion. A 2011 study from the American College of Obstetricians and Gynecologists found that while 97% of ob-gyn doctors in the U.S. have met with a patient who wants an abortion, just 14% actually perform the procedure.
Hospitals provide just 4% of abortions in the U.S., according to the Guttmacher Institute, a nonprofit sexual-health-research organization, and many facilities limit the procedure to rare cases, like fetal abnormalities or when the life of the woman is at risk. The majority of hospitals perform fewer than 30 abortions per year. Others refuse to provide the procedure at all.
In their statement, the ob-gyn professors point out that the medical community has not always sought to marginalize abortion. In fact, an open letter written by a similar group of ob-gyn professors in 1972 predicted that freestanding clinics would be unnecessary if hospitals “cooperate in handling their proportionate share.”
This forecast never materialized. In the years following the 1973 Roe v. Wade Supreme Court ruling, federal court decisions and legislation — including the 1976 Hyde Amendment banning federal funding for abortions — marginalized the procedure in public hospitals and medical schools. Wary of the male-dominated health care industry, pro-choice activists opened their own low-cost clinics, which now perform 95% of abortions in the U.S.
“There are definitely instances of solidarity and courage where the medical community steps up and says that there are medical principles at stake,” says Donna Crane, policy director for NARAL Pro-Choice. “But by and large, this has been a fight waged by pro-choice communities.”
In the years since Roe v. Wade, political pressure and the promise of funding has been a powerful tool in preventing hospitals from performing abortions. The University of Arizona, for example, gave up its right to provide or teach abortions in 1974 in exchange for a $5.5 million football-stadium renovation. In Chicago, the Illinois Masonic Medical Center stopped performing abortions in 1991 in exchange for a deal to purchase land from the Chicago Catholic Archdiocese. Lawmakers in Arizona, Kansas and Texas have passed legislation barring state-funded institutions from providing abortion training to medical students, and seven other states ban abortion in public hospitals, according to the Guttmacher Institute.
“It’s generally not that hospitals don’t want to [perform abortions], but they feel tremendous pressure, either from laws that their legislators pass or from politics in general,” says Philip Darney, a professor of obstetrics and reproductive services at the University of California, San Francisco, and one of the lead authors behind the ob-gyn professors’ statement.
The marginalization of abortion within the medical community has made freestanding clinics an easy target for antiabortion activists, who picket, threaten and occasionally even kill abortion doctors. According to the Guttmacher Institute, an overwhelming majority (88%) of abortion clinics experienced some form of harassment — including protests, patient blocking, vandalism and bomb threats — in 2008, the most recent year for which data is available. In 2009, 67-year-old abortion provider George Tiller was shot and killed by an antiabortion activist while attending Sunday church services.
Many individual ob-gyns, including those who might want to provide abortions, are either unwilling or unable to provide the procedure. A 2010 survey of 30 ob-gyns found that of the 18 doctors who wished to provide abortions, only three were actually performing the service. The study also found that while some doctors expressed concern about violence, the majority were constrained by other professional factors, including hospital bans on the procedure, pressure from employers and other doctors in group practices, and a desire to get along with colleagues and nurses opposed to abortion.
In the end, many doctors are faced with the unsatisfying choice of either performing abortions, or becoming a practicing ob-gyn.
“I can train medical students and residents, but the question is, Where will they be allowed to practice this care?” says Nancy Stanwood, a professor at the Yale School of Medicine and board chair of Physicians for Reproductive Health. “And that comes down to the hospitals and other doctors in private practices, who might not be open to abortions.”
Despite these obstacles, however, pro-choice physicians say they have already made progress toward normalizing abortion in the medical community, most notably by expanding training through residency programs and family-planning fellowships. About 50% of the 200 ob-gyn residency programs in the U.S. now integrate abortion into training requirements, up from just 12% in 1992. Professors believe that a new generation of doctors will use their training to bring abortion back into hospitals and doctors’ offices. A 2011 study of ob-gyns found that female doctors and those ages 35 and younger were far more likely than their colleagues to perform abortions.
“It is very unusual for us to find new residents who don’t want to learn abortions,” Darney says. “They may find it difficult to practice, but we have a whole new generation of young women who are replacing the old men, and they have a very different view about their relationships with their patients. It’s very promising.”
Clarification: An earlier version of the doctors’ letter cited in the third paragraph of this piece was posted online March 18, 2013. On August 26, 2013, after the publication of TIME’s story, the American Journal of Obstetrics & Gynecology published the final version of the doctors’ letter online.