Opposition to Requirements for Hospital Admitting Privileges and Transfer Agreements for Abortion Providers

  • Date: Nov 03 2015
  • Policy Number: 20151

Key Words: Abortion, Access To Health Care, Reproductive And Sexual Health, Womens Health

Abstract

Between 2011 and August 2015, nine states enacted “hospital admitting privilege” laws that require clinicians offering abortion services to obtain the right to admit patients to a local hospital in order to legally provide abortions in their private practice or clinic setting; seven states have similar, facility-level “hospital transfer agreement” laws. These stringent, medically unnecessary laws, a form of targeted regulation of abortion providers (TRAP), restrict the availability of abortion services and disproportionately decrease abortion access among women of color and rural and low-income women. Abortion is a very safe procedure, and there is no evidence to support the claim that hospital admitting privilege laws protect or improve women’s safety. This policy statement urges federal and state policymakers to reject TRAP policies and adopt practices designed to ensure that abortion services remain safe and accessible to all women, irrespective of external political forces or personal beliefs; it also urges hospital officials to adopt admitting privilege policies and practices that facilitate the inclusion of all reproductive health providers. Specifically, this policy recognizes that legislation limiting access to safe abortion has critical public health implications and, therefore, aims to represent APHA’s position against hospital admitting privilege and restrictive transfer agreement mandates, which are not evidence based or informed by best practices for patient care.

Relationship to Existing APHA Policy Statements

Since 1967, the American Public Health Association has recognized access to comprehensive, safe abortion services as a critical reproductive and public health issue for the physical, mental, and economic well-being of women and their families. To that end, APHA has implemented the following policies that address issues related to women’s reproductive health and safety in obtaining health services, including abortion, pregnancy, and maternal mortality:

  • APHA Policy Statement 200318: Safe Motherhood in the United States: Reducing Maternal
  • Mortality and Morbidity
  • APHA Policy Statement 201114: Reducing US Maternal Mortality as a Human Right
  • APHA Policy Statement 6803: Abortion
  • APHA Policy Statement 8104: Opposition to Constitutional Amendments or Statutes to Prohibit Abortion
  • APHA Policy Statement 8901: Safeguarding the Right to Abortion as a Reproductive Choice
  • APHA Policy Statement 200314: Support for Sexual and Reproductive Health and Rights in the
  • United States and Abroad
  • APHA Policy Statement 20083: Need for State Legislation Protecting and Enhancing Women’s
  • Ability to Obtain Safe, Legal Abortion Services Without Delay or Government Interference
  • APHA Policy Statement 7704: Access to Comprehensive Fertility Related Services
  • While each of these policies broadly addresses the importance of access to abortion as a critical component of comprehensive health care for women, this policy statement specifically addresses the problem of restrictions on abortion service delivery and providers in the context of how and where safe abortion procedures are performed.

Problem Statement

Abortion is a critical component of comprehensive health care for women[1]; at least half of American women will experience an unintended pregnancy by the age of 45 years,[2] and an estimated one in three women will have an abortion within their lifetime.[3] In 2011, 1.06 million abortions were performed in the United States, 94% of which occurred in a clinic setting.[4] Because the overwhelming majority of abortions occur in a clinic setting, laws that target these sites of service provision warrant attention from the public health community, as they have the potential to limit patients’ access to integral reproductive health services. Indeed, in its November 2014 opinion statement, the Committee on Health Care for Underserved Women of the American College of Obstetricians and Gynecologists (ACOG) identified abortion as a necessary component of women’s health care and noted that “[l]egislative restrictions fundamentally interfere with the patient-provider relationship and decrease access to abortion for all women, and particularly low-income women and those living long distances from health care providers.”[1]

Since 2011, nine states (Alabama, Kansas, Louisiana, Mississippi, North Dakota, Oklahoma,Tennessee, Texas, and Wisconsin) have enacted “hospital admitting privilege” laws requiring clinicians who offer abortion services to gain and maintain the right to admit patients to a local hospital in order to legally provide abortions in their private practice or clinic setting under the pretense of patient safety.[5,6] (For example, the US Court of Appeals for the 5th Circuit upheld an admitting privileges requirement in Texas [HB 2], while a different panel of judges in the same circuit blocked an admitting privileges law from Mississippi [HB 1390]. Meanwhile, the US Court of Appeals for the 7th Circuit has stayed an admitting privileges law in Wisconsin [SB 206] while lower courts consider the measure.) Hospital admitting privilege laws, a form of targeted regulation of abortion providers (TRAP), impose onerous restrictions on clinics and clinicians providing abortions, restrictions not faced by other medical practices.[6] TRAP laws go beyond what is necessary for patient safety, as abortion is already a very safe procedure with few complications and low mortality and, by law, no hospital can refuse to provide a patient with emergency care when needed.[7] Both the aims and the consequences of TRAP laws are to isolate abortion care from other routine health care services and limit access to abortion, a common—and sometimes life-saving—procedure for women.

While hospital admitting privilege laws for abortion providers have existed in the United States for nearly three decades, there has been a considerable and rapid uptick in admitting privilege legislation since 2010.[5] Before 2011, two states, Missouri and Utah, had hospital admitting privilege laws on their books, dating back to 1986 and 1998, respectively. As of July 2015, four states—Missouri, North Dakota, Tennessee, and Utah—had admitting privilege laws in effect, while seven states (Alabama, Kansas, Louisiana, Oklahoma, Mississippi, Texas, and Wisconsin) have laws that are enjoined or are pending an implementation or effective date.[5]

Likewise, seven states (Kentucky, Michigan, Nebraska, Ohio, Pennsylvania, Virginia, and Wisconsin) had “transfer agreement” requirements for abortion-providing facilities as of 2015. Similar to hospital admitting privilege requirements, transfer agreements are a form of TRAP legislation requiring abortion providers to have a contractual arrangement with a local hospital to transfer patients in the case of an abortion complication.[5] While admitting privileges must be obtained by each individual abortion provider and dictate continuity of care by the overseeing medical provider, transfer agreements are facility-level contracts that apply only to the transfer of patients between the facility in which the services originated and the hospital receiving the patient. Therefore, although transfer agreements apply to health facilities more broadly and may be easier to obtain than admitting privileges—because they require a contractual agreement with the facility to cover all of its affiliated health care providers rather than an agreement with each individual provider—neither transfer agreements nor hospital admitting privilege requirements for abortion providers are grounded in evidence-based practices, especially considering that no hospital can deny a patient emergency care, regardless of the admitting status of the patient’s original physician at that hospital. Rather, these types of requirements serve only to limit abortion providers’ ability to offer the highest-quality reproductive health care for women, including safe abortion services.

No states have laws governing how hospitals and/or their regulatory boards (as individual entities independent of government bodies) implement a fair and objective process of admitting privileges or transfer agreements. Consequently, while hospitals cannot refuse any patient emergency care, they are free to deny admitting privileges to any health care provider via a process that is vulnerable to political interference and may not be based on patient safety or evidence-based standards of care. For example, a physician practicing medicine and providing abortion services in Texas had his hospital admitting privileges revoked in 2014 specifically because he was providing abortions outside of the hospital, which the hospital claimed would be “disruptive to the business and reputation of [University General Hospital Dallas].”[8]

Admitting privilege restrictions have demonstrated serious, tangible consequences for patients seeking care as a result of clinic closures cutting off their access and entry points to reproductive health care. Nearly 90% of counties in the United States—areas where close to 40% of women 15 to 44 years of age live—are without abortion providers,[4] and many women must already travel significant distances to access abortion services. In 2008, abortion patients traveled a mean distance of 30 miles one way (or 60 miles round-trip) to obtain an abortion, and almost one third of rural women obtaining abortions traveled more than 100 miles one way (or 200 miles round-trip).[9] The rate of unintended pregnancy among poor women is approximately five times that of women with an income of at least 200% of the federal poverty level,[10] and in 2008 43% of abortion patients were poor[11]; thus, the implications of additional travel burdens as a consequence of clinic closures due to issues surrounding admitting privileges are significant. Moreover, women of color, immigrant women, and women living in rural regions of the country who already face obstacles to accessing health care are burdened with traveling longer distances to obtain an abortion, often resulting in delays that can affect their health.[11] As such, already marginalized women may find it even more difficult to access safe, legal abortion services when clinics—or even one clinic—in their area are forced to close.

For example, after an admitting privileges law went into effect in Texas in 2013 (as part of enforcement of a bill that also restricted medication abortion and banned most procedures after 20 weeks’ gestation), more than a dozen abortion clinics were forced to close across the state. Subsequently, access to abortion services was significantly limited; the state’s abortion rate fell by 13% relative to the rate during the year before the law went into effect, and this decrease was likely associated with the state’s clinic closures.[12] The number of women of reproductive age in Texas living 100 miles or more from an abortion provider increased substantially between May 2013 and April 2014, from 417,000 to more than 1 million .[13] In areas such as the Lower Rio Grande Valley of Texas, where approximately 275,000 women of reproductive age reside (many of whom live below the federal poverty level[14]), clinic closures due to hospital admitting privilege laws have resulted in many women needing to travel 150 to 250 miles if they are seeking abortion services.[15]

Similar travel burdens threaten women in Louisiana; if all Louisiana abortion facilities were to close (as would be the likely outcome if the currently enjoined admitting privilege law were to be upheld), women would need to travel an average of more than 200 miles to access abortion services, and the percentage of women of reproductive age who would live more than 150 miles away from an abortion facility would increase from 1% to 72%.[16] It is reasonable to assume that women elsewhere would experience similar consequences from clinic closures as these laws spread to other states beyond Texas and Louisiana. Indeed, in Alabama, a federal judge struck down the state’s admitting privilege requirement, ruling that the law would have closed three of the state’s five abortion clinics, forcing women to travel out of state for abortion services and resulting in an impermissible undue burden.[17] Such a burden becomes even more severe in consideration of the concentrated increase of these laws in southern states, the cumulative effect of which would leave large swaths of the country without meaningful abortion access. However, southern states are not the only states enacting such legislation.

In Ohio, the seventh most populous state in the country, seven of the state’s 18 abortion clinics have closed since the state passed its stringent transfer agreement TRAP law.[18] Although the full impact of this law has yet to be documented scientifically, the state’s total number of induced abortions before and after the law’s passage may provide a clue regarding its effect on abortion access for patients. In 2012, the year before the law was passed, 25,473 induced abortions were reported to the Ohio Department of Health. By 2014, that number had dropped to 21,186.[19] While it is possible that this drop was not significantly associated with the transfer agreement law, anecdotal reports of many Ohio women traveling to Michigan to obtain abortion services increased during this same period.[20] Studies evaluating the inability of some Ohio women to obtain abortions in Ohio and the impact of their travel are forthcoming.

Clinic closures and subsequent travel burdens are not merely matters of inconvenience for women in states with admitting privilege or transfer agreement laws; lack of accessible providers can have tangible effects on the health of those seeking abortion services, as women may be relegated to receiving substandard or unsafe abortions from illegal providers or may need to delay abortion care to later gestational ages, when the procedure carries greater risks. While abortion remains an extremely safe procedure, the risk of infection and hemorrhage begins to increase after 13 weeks of gestation.[21] Because the costs and logistics of traveling to a provider are key contributors to delays in accessing abortion services,[17] clinic closures can obstruct women’s ability to access timely abortion services. By obstructing access to earlier abortion care, admitting privilege or transfer agreement laws not only are failing to increase safety for women but, in fact, are placing women at greater risk for medical complications by causing delays in timely service acquisition.[17,22]

Overall, as noted, abortion is a very safe and common procedure, and complications are rare. In the United States, 92% of women seeking abortions are less than 13 weeks pregnant.[23] Among women obtaining abortions within their first trimester, 98% report no complications, 1.5% experience minor complications that do not require hospital care, and approximately 0.05% have complications that require additional surgery or hospital care.[24] Moreover, abortion-related deaths are extremely rare. Between 1998 and 2010, there was less than one death per 100,000 abortions.[22] With respect to the documented abortion-related mortality during this period, the majority of women at less than 13 weeks of gestation had complications related to anesthesia rather than to the specific procedure,[22] suggesting that the associated risks are not exclusive to abortion procedures but, instead, are inherent among all surgical procedures. Abortion is much safer than many other common outpatient procedures, which involve significantly higher mortality and complication rates. For example, the mortality rate associated with a colonoscopy is more than 40 times greater[25] than that of an abortion,[26] yet gastroenterologists, who perform such procedures in office-based settings, do not face admitting privilege requirements.

The safety of abortion services in the United States is especially relevant in the context of hospital admitting privilege laws, as many hospitals require a number of specific and unrealistic qualifying conditions for physicians—particularly those who practice primarily in outpatient settings—to even be eligible for admitting privileges. Many hospitals require physicians to maintain an annual minimum number of patient admissions, a requirement that the vast majority of abortion providers cannot meet owing to the very low risk of complications. As such, their patients do not require hospital care.[27] For example, laws concerning hospital admitting privileges in Wisconsin were suspended in July 2013, and eventually struck down in March 2015, because hospitals’ credentialing committees required doctors to provide information on patients they had previously treated in the hospital (of whom there were none).[24] In April 2015, state attorneys submitted a notice to appeal the ruling. During the suspension period, Wisconsin doctors were required to continue pursuing admitting privileges, even though they had yet to send patients to the hospital after or during an abortion procedure.[28] This predicament demonstrates a bureaucratic loophole wherein a provider’s existing record for offering safe, quality care actually limits his or her ability to obtain admitting privileges. Counterintuitively, the law stipulates that providers who can supply records of their ability to meet an admitting minimum have a clearer path to obtaining privileges, strongly suggesting that admitting privileges are less about ensuring safe care for abortion patients and more about restricting women’s ability to access legal abortion care.

Finally, in addition to the potential financial and logistical burdens of traveling to receive quality reproductive health care at a limited number of service sites, requiring physicians to maintain admitting privileges within a given distance from their practices or homes ignores the existing realities of standard medical care practice. By the time abortion patients experience any potential postprocedure complications, they can be hundreds of miles away from the facility at which they obtained services and its affiliated hospital. Seeking care from an unaffiliated hospital does not pose a real harm to patients, as they can visit the closest hospital and, under the federal Emergency Medical Treatment and Labor Act of 1986, cannot be turned away or denied care.[29] Accordingly, it is unnecessary to require that clinicians have admitting privileges in order to provide care in facilities licensed independently of hospitals, as these requirements do not affect patients’ ability to receive emergency care from those hospitals. Similarly, it is also unnecessary to codify transfer agreements between clinics and hospitals in the case of complications during surgeries given that hospitals cannot deny patients entry or care.

Opposing Arguments

Supporters of hospital admitting privilege and transfer agreement requirements claim that laws that mandate relationships between abortion providers and hospitals make patients safer by ensuring that the abortion-providing physician assumes full responsibility for the well-being of patients through the conclusion of their care.[30] However, because the vast majority of abortion patients do not experience complications (and, among those who do, most are resolved in the clinic setting), physicians are already assuming and maintaining full responsibility for the care of their patients. In cases in which patients need additional care beyond that offered by the abortion provider, there is no evidence to suggest that they are not being referred appropriately. Moreover, because abortions must be provided by trained, licensed clinicians in all states, abortion patients are already treated under the same standards of care applicable to all patients receiving any type of medical care.

Furthermore, supporters of transfer agreement requirements for abortion-providing facilities argue that such policies establish an extra level of protection for abortion patients by codifying the agreement between outpatient facilities and hospitals in the case of complications during a procedure.[30] However, similar to admitting privilege requirements, transfer agreements are medically unnecessary, as hospitals are federally mandated to assist all individuals who present for emergency care.[29] Moreover, transfer agreements are, in many cases, extremely difficult for abortion facilities to obtain because legal and political barriers can inhibit completion of such agreements. For instance, Ohio requires all ambulatory care centers, including abortion clinics, surgical eye centers, and gastrointestinal facilities, to have written transfer agreements with a local hospital.[31] However, nothing requires hospitals to enter into such an agreement, and there is no exception made in rural areas. Furthermore, public hospitals are legally barred from arranging a transfer agreement with an abortion-providing facility, even if they are the closest hospital to that facility or the patient has expressed a desire to be transported to a public hospital.[32] Limiting abortion providers to transfer agreements with privately owned hospitals—many of which are religiously affiliated—makes it more difficult for providers to obtain such agreements, potentially leading to clinic closures.[32] Other non-abortion-providing ambulatory surgical clinics are not restricted in this way and can make arrangements with both public and private hospitals. Given the bureaucracy and difficulty abortion clinics can encounter in their attempts to obtain a hospital transfer agreement, these policies act only to further restrict abortion access at a policy level and do not improve the quality and safety of care. A judge in Ohio agreed and, in June 2015, issued a ruling allowing the only remaining clinic in the Toledo area to stay open, stating that the health department’s order overreached the limits of its regulatory authority and that state laws permitting hospitals or other third-party institutions to veto women’s abortion access are unconstitutional. In response, the state legislature drafted a proposed law seeking to reintroduce transfer agreements with new language, demonstrating that these types of restrictions will continue to pose an issue for women’s health. Indeed, in the same month, the United States Supreme Court allowed 10 clinics in Texas to remain open while it considered whether to hear an appeal on the state’s hospital admitting privilege and ambulatory surgery center requirements for abortion providers.

In 2003 the American College of Surgeons, along with the American Medical Association and an additional 30 professional medical organizations, convened a meeting to create and pass “10 Core Principles” for office-based surgery safety standards in recognition of the proliferation of invasive surgeries occurring outside of hospital settings. One of these core principles is as follows: “Physicians performing office-based surgery must have admitting privileges at a nearby hospital, a transfer agreement with another physician who has admitting privileges at a nearby hospital, or maintain an emergency transfer agreement with a nearby hospital.”[33] Although broadly written, this principle is still limited as it pertains to abortion providers. For example, the principle does not apply to physicians exclusively performing medication abortions (even though many admitting privilege laws do explicitly cover all abortion providers, regardless of type). The recommendation also leaves room for alternative admitting privilege strategies, ostensibly to ensure the best possible care for the patient rather than to limit clinicians’ ability to provide that care. Yet, this recommendation as written may be outdated, as these principles were never revisited. The American Medical Association, in conjunction with the American College of Obstetricians and Gynecologists, has since argued against hospital admitting privilege requirements for abortion providers in an amicus brief filed with the United States Court of Appeals for the Fifth Circuit in December 2013.[34] Moreover, ACOG’s Committee on Health Care for Underserved Women has recommended the cessation and repeal of legislative restrictions on abortion, including TRAP laws, and it “[encourages] hospitals and women’s health care providers to support abortion care as essential medical care for women [and] eliminate barriers to the provision of abortion care in these settings.”[1]

Evidence-Based Strategies

There is no evidence to support the claim that hospital admitting privilege requirements or transfer agreements protect or improve women’s health or safety. However, ensuring that women are able to receive the highest-quality care from licensed facilities and providers does protect women’s health, especially when those facilities follow the medical practice guidelines set forth by nationally and internationally recognized leaders in public health and women’s reproductive health, including the World Health Organization (WHO), the National Abortion Federation (NAF), and ACOG (in its practice bulletins).

The World Health Organization, an international public health leader, has set forth evidence-based abortion care guidelines for health care providers, program managers, and policymakers. In a publication titled “Safe Abortions: Technical and Policy Guidance for Health Systems,” WHO stresses that legislators should not “seek to create situations that lead women and adolescents to seek unsafe abortions.” Furthermore, WHO underscores that regulation of facilities and providers should be based on scientifically sound evidence and should ensure the quality, efficiency, and accessibility of abortions.[35] Because hospital admitting privilege laws seek to restrict the availability of abortion in outpatient settings and are not grounded in evidence-based practices, WHO recognizes these laws as structural barriers to equitable and safe abortion care.

The National Abortion Federation—the professional association of abortion providers in North America—sets standards for quality abortion care to serve as evidence-based guidelines for best practices in abortion procedures and clinical policy guidance.[36] An NAF publication titled “A Clinician’s Guide to Medical and Surgical Abortion” addresses both medical and surgical abortion procedures from an evidence-based standpoint. NAF’s evidence-based clinical policy guidelines provide a basis for ongoing quality assurance in abortion care. It is recommended that all abortion providers use these guidelines and those published by ACOG as the best evidence-based strategy for ensuring abortion patients’ health and safety. None of the NAF guidelines call for abortion providers to obtain hospital admitting privileges in order to offer high-quality care to their patients.

In addition, Ipas, a global nonprofit organization that strives to eliminate deaths and injuries from unsafe abortions, publishes “Clinical Updates in Reproductive Health. This resource outlines clinical guidance, research, and recommendations concerning the safety and quality of abortion care. The document highlights the high success rates and low complication rates of various abortion procedures among women of varying ages, stages of pregnancy, and levels of parity, reinforcing the fact that abortion is a safe procedure.[37]

Action Steps

Recognizing the need for full access to safe reproductive health care, including abortion services, without government interference or delays in care, APHA:

  1. Urges federal and state legislatures to reject targeted regulation of abortion providers, including legislation that mandates local hospital admitting privileges and/or hospital transfer agreements for abortion providers, including individual clinicians and facilities.
  2. Urges hospitals to create broad and inclusive admitting privilege standards and hospital transfer agreement contracts for abortion providers in a way that prioritizes maximum access to health care services for patients without creating unrealistic barriers to gaining privileges for providers, such as regular patient admissions, regardless of the existence of state-level hospital admitting privilege requirements in their governing state. Furthermore, this policy urges hospitals to act upon applications for admitting privileges in a timely fashion that will not delay access to care for potential patients.
  3. Urges hospitals to adopt objective, transparent admitting privilege and transfer agreement policies based solely on best practices and the highest standards of care for patients, without consideration of the diversity of political opinions regarding abortion services or provisions in their policies or decisions to grant such privileges. Also, they should provide clearly stated, written reasons for denial in instances in which providers are denied privileges, regardless of the existence of state-level hospital admitting privilege requirements in their governing state.
  4. Encourages all abortion providers to maintain current best clinical practices and the highest standards for patient care using evidence-based guidelines published by the National Abortion Federation and the American College of Obstetricians and Gynecologists.

References

1. American College of Obstetricians and Gynecologists. Increasing access to abortion: committee opinion No. 613. Obstet Gynecol. 2014;124:1060–1065.
2. Finer LB, Zolna MR. Shifts in intended and unintended pregnancies in the United States, 2001–2008. Am J Public Health. 2014;104(suppl 1):S43–S48.
3. Jones RK, Kavanaugh ML. Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstet Gynecol. 2011;117:1358–1366.
4. Jones RK, Jerman JJ. Abortion incidence and service availability in the United States, 2011. Perspect Sex Reprod Health. 2014;46:3–14.
5. Guttmacher Institute. State policies in brief: targeted regulation of abortion providers. Available at: http://www.guttmacher.org/statecenter/spibs/spib_TRAP.pdf. Accessed December 10, 2015.
6. NARAL Pro-Choice America. Choice-related laws in the states: targeted regulation of abortion providers. Available at:
http://www.prochoiceamerica.org/what-is-choice/fast-facts/issues-trap.html. Accessed December 10, 2015.
7. Gold RB, Nash E. TRAP laws gain political traction while abortion clinics—and the women they serve—pay the price. Guttmacher Policy Rev. 2013;16:7–12.
8. Schuetz C. Personal communication to Dr. Lamar Robinson, March 31, 2014. Available at:
http://rhrealitycheck.wpengine.netdna-cdn.com/wp-content/uploads/2014/04/UGHD-Letter.pdf. Accessed December 10, 2015.
9. Jones RK, Jerman JJ. How far did US women travel for abortion services in 2008? J Womens Health. 2013;22:706–713.
10. Jones RK, Finer LB, Singh S. Characteristics of U.S. Abortion Patients, 2008. New York, NY: Guttmacher Institute; 2010.
11. Boonstra HD, Nash E. A surge of state abortion restrictions puts providers—and the women they serve—in the crosshairs. Guttmacher Policy Rev. 2014;17:1–17.
12. Grossman D, Baum S, Fuentes L, et al. Changes in abortion services after implementation of restrictive law in Texas. Contraception. 2014;90:496–501.
13. Texas Policy Evaluation Project. Assessing the impact of state reproductive health legislation: access to abortion care in the wake of HB2. Available at:
http://www.utexas.edu/cola/orgs/txpep/_files/pdf/AbortionAccessafterHB2.pdf. Accessed December 10, 2015.
14. Center for Reproductive Rights, National Latina Institute for Reproductive Health. The fight for women’s reproductive health in the Rio Grande Valley. Available at:
http://www.nuestrotexas.org/pdf/NT-spread.pdf. Accessed December 10, 2015.
15. Grossman D, White K, Hopkins K, Potter J. The public health threat of anti-abortion legislation. Contraception. 2014;89:73–74.
16. Roberts SCM, Fuentes L, Kriz R, Williams V, Upadhyay UD. Implications for women of Louisiana’s law requiring abortion providers to have hospital admitting privileges. Contraception. 2015;91:368–372.
17. Planned Parenthood SE Inc v. Strange case text. Available at:
https://ecf.almd.uscourts.gov/cgi-bin/show_public_doc?2013cv0405-238. Accessed December 10, 2015.
18. Associated Press. (2015). Abortion clinics close in Ohio amid flurry of new restrictions. Available at:
http://www.cleveland.com/open/index.ssf/2015/05/abortion_clinics_close_in_ohio.html. Accessed December 10, 2015.
19. Ohio Department of Health. Induced abortions in Ohio. Available at:
http://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/health%20statistics%20-%20vital%20stats/Induced%20Abortions%20in%20Ohio%202014.pdf. Accessed December 10, 2015.
20. Culp-Ressler T. Ohio’s harsh laws are forcing more women to cross state lines to get an abortion. Available at: http://thinkprogress.org/health/2014/03/24/3417966/ohio-abortion-clinic-state-lines/. Accessed December 10, 2015.
21. Bartlett LA, Berg CJ, Shulman HB, et al. Risk factors for legal induced abortion–related mortality in the United States. Obstetrics Gynecol. 2004;103:729–737.
22. Zane S, Creanga AA, Berg CJ, et al. Abortion-related mortality in the United States: 1998–2010. Obstet Gynecol. 2015;126:258–265.
23. Pazol K, Creanga A, Burley K, et al. Abortion surveillance—United States, 2010. MMWR Morb Mortal Wkly Rep. 2013;62:1-44.
24. Weitz TA, Taylor D, Desai S, et al. Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver. Am J Public Health. 2013;103:454–461.
25. Ko CW, Dominitz JA. Complications of colonoscopy: magnitude and management. Gastrointest Endosc Clin N Am. 2010;20:659–671.
26. Pazol K, Creanga A, Zane S, et al. Abortion surveillance—United States, 2009. MMWR Morb Mortal Wkly Rep. 2012;61:1–44.
27. Guttmacher Institute. Induced abortion in the United States. Available at:
http://www.guttmacher.org/pubs/fb_induced_abortion.html. Accessed December 10, 2015.
28. Pieklo JM. Trial concludes in challenge to Wisconsin admitting privileges law. Available at:
http://rhrealitycheck.org/article/2014/06/02/trial- concludes-challenge-wisconsin-admitting-privileges-law/. Accessed December 10, 2015.
29. Zibulewsky J. The Emergency Medical Treatment and Active Labor Act (EMTALA): what it is and what it means for physicians. Proc Bayl Univ Med Cent. 2001;14:339–346.
30. Americans United for Life. Abortion Providers’ Admitting Privileges Act. Available at http://www.aul.org/downloads/2015-Legislative-Guides/Abortion/Abortion_Providers_Admitting_Privileges_Act_-_2015_LG.pdf. Accessed December 10, 2015.
31.  Ohio Laws and Rules. Chapter 3702: Hospital Care Assurance Program. Available at: http://codes.ohio.gov/orc/3702. 2014. Accessed December 10, 2015.
32. Center for Reproductive Rights. State of the states. Available at:
http://reproductiverights.org/sites/crr.civicactions.net/files/documents/CRRStateofStates2013_all.pdf.2013. Accessed December 10, 2015.
33. American College of Surgeons. Statement on patient safety principles for office-based surgery utilizing moderate sedation/analgesia, deep sedation/analgesia, or general anesthesia. Available at: https://www.facs.org/about-acs/statements/46-office-based-surgery. Accessed December 10, 2015.
34. American College of Obstetricians and Gynecologists. ACOG and AMA file amicus brief in Planned Parenthood v. Abbot. Available at: http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/ACOG-and-AMA-File-Amicus-Brief Accessed December 10, 2015.
35. World Health Organization. Safe abortion: technical and policy guidance for health systems. Available at: http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf. 2012. Accessed December 10, 2015.
36. National Abortion Federation. Health care professionals: continuing education. Available at: http://prochoice.org/health-care-professionals/educational-resources/. Accessed December 10, 2015.
37. Ipas. Clinical updates in reproductive health. Available at: http://www.ipas.org/en/Resources/Ipas%20Publications/Clinical-updates-in-reproductive-health.aspx. Accessed December 10, 2015.