This is the final episode of our series examining recent legislation restricting abortion in Iowa and its potential impact on public health.

Lauren’s guest is Dr. Abbey Hardy-Fairbanks, OBGYN at University of Iowa Health Care and medical director of Iowa City’s Emma Goldman Clinic, who shares her perspectives on the bill and discusses the future of abortion restrictions and how they can impact the availability of OBGYN care, and create access and equity issues.

Lauren Lavin:

Hello everybody, and welcome back to From the Front Row. This is Lauren Lavin and I am super excited to announce that this is the third and final episode in our Heartbeat bill series. This week I’m joined by Dr. Hardy-Fairbanks, who is another OBGYN Board certified at the University of Iowa. She’s also the medical director for the Emma Goldman Clinic in Iowa City.

Dr. Hardy-Fairbanks brought a lot of firsthand experiential knowledge to this conversation, and I hope you find it just as informative as I did, though we’d like to provide a content warning for abortion related topics. Front Row is produced and edited by the students of the University of Iowa College of Public Health. The views and opinions expressed in this podcast are solely those of the guests and contributors. They do not necessarily reflect the views or opinions of the University of Iowa or the College of Public Health. Information shared in this podcast is intended for educational, general information and entertainment purposes only.

My name is Lauren Lavin, and if you’re new here, welcome. We’re a student run podcast that talks about major issues in public health and how they’re relevant to anyone, both in and outside the field of public health.

Thank you for being on the show. Would you like to introduce yourself?

Abbey Hardy-Fairbanks:

Sure. I’m Abby Hardy-Fairbanks. I’m an OBGYN. I am the medical director of the Emma Goldman Clinic, as well as a fellow of Physicians for Reproductive Health and a board certified general OBGYN, as well as board certified in complex family planning.

Lauren Lavin:

Wow. Okay. So you are a perfect person to talk to about this Heartbeat bill.

Abbey Hardy-Fairbanks:

I wouldn’t say that, but I’m glad to be here to be able to discuss it.

Lauren Lavin:

So let’s start off, can you explain what the Iowa Heartbeat bill is from your medical perspective?

Abbey Hardy-Fairbanks:

Sure. And I think I’m going to start by addressing our language. So we try really hard not to use the word Heartbeat bill. The word heartbeat is a very triggering, stigmatizing word. So going forward, I’m going to use the word six-week ban, which is really what this law amounts to.

So six-week bans got their start in Iowa in 2017. Iowa actually passed the first one before they hit the national stage. That law was then caught up in court and permanently enjoined, I believe in 2018. The Emma Goldman Clinic, the ACLU and Planned Parenthood sued and won at the Supreme Court level in the State Supreme Court to have it permanently enjoined.

Then after what is referred to as Planned Parenthood four, which the results of last summer, which allowed Iowa to then have a 24-hour wait. So that means that a patient or a client who presents for abortion care is not able to receive that care at the time that they present to the clinic. They must wait at least 24 hours, which I can explain later why that’s really problematic and never actually results in a wait of 24 hours. It’s usually much, much longer.

But after that decision and then the overturning of Roe v. Wade, the governor of the state of Iowa requested that the state revisit the permanent enjoinment in light of those recent decisions, and that occurred first at the district level where the permanent enjoinment was upheld and that basically the court didn’t feel that there was authority to undo a Supreme Court permanent enjoinment. And then that was appealed to the State Supreme Court where they were tied, so they did not make a decision, and so it went down to the district court, and so the permanent injunction stayed in place.

The Supreme Court decision essentially said, this case has been decided. If you want to have a six-week ban, you need to go pass it again. So shortly after that tie happened, the governor called a special session with the expressed purpose of passing abortion restriction legislation. That special session lasted 15 hours, less than the waiting period required to get abortion care. During that 15 hours, both houses at the same time, I’m going to say debated, although that really wasn’t the case, but basically passed a six-week ban again. The language is very similar and it was signed into law, I can’t remember, three days later I think, something like that.

And again, the same process happened. The ACLU, Planned Parenthood and Emma Goldman sued and won a temporary injunction on the law pending its review in the courts. So that’s where we stand right now. So it’s important to know that this Heartbeat, the so-called Heartbeat bill, or six-week ban, is currently not in effect. There is access to legal and safe abortion in the state of Iowa, and the Emma Goldman Clinic is open for business and we are happy to take care of people as we always have.

From a medical perspective, what this law states is that, first off, it’s very difficult to interpret laws such as this from a medical perspective. They are not written by those with medical experience or in the context of how medicine happens in the real world. So there is real ambiguity in how to interpret them in the way that medicine actually happens, because they’re not designed to really align with the purpose of medicine, which is to take care of people. They’re designed to disrupt, stigmatize and restrict access to healthcare, which is what they do.

So in the law it says that once a “heartbeat”, which I would say from a medical perspective is not what you’re seeing at six-weeks, but that’s what the law says. I know it’s an audio podcast, but I’m putting bunny ears around heartbeat. Once that is detected, a patient must certify or receive a piece of paper that they sign saying that they now are aware that abortion for them is illegal. And so essentially anyone after cardiac activity is detectable on ultrasound would not be able to access abortion care in the state of Iowa.

We call these six-week bans because essentially that’s when we can see cardiac activity with most modern ultrasound techniques. So essentially it would ban the vast majority of abortion. It’s essentially a complete abortion ban for the state of Iowa.

Lauren Lavin:

So not a very high percentage happens prior to that six week point?

Abbey Hardy-Fairbanks:

[inaudible] how we measure pregnancy. So pregnancy is measured from the first day of someone’s last menstrual period. So essentially conception happens when you’re already two weeks pregnant because that’s how we measure pregnancy. We don’t know when conception really happens, and so we measure dates based on someone’s last menstrual period because that’s a sign that someone can measure and mark down and keep track of. The only people who really can measure pregnancy from conception are people who have IVF or have inseminations.

Occasionally, a patient will know truly when they conceived because they know when that happened, but the vast majority of the time, that is not the case. And we measure pregnancy clinically, medically from the first day of the last menstrual period. So when you think about that, that means conception happens when someone is already 2 weeks pregnant based on the timing.

So they miss their period at four weeks pregnant. So that means a person would need to identify that their period is missed, recognize that maybe their period’s not just more than a few days late, which periods are allowed to do that every once in a while, take a pregnancy test, find that it’s positive, talk to their support systems, their partner, whoever they feel like they need to discuss that with. Make a decision about what they need to do, call, well, find a clinic, get the money together, get time off work, get an appointment all within the span of two weeks to be able to access care.

Now, I don’t know anybody who has ever called a doctor’s office for any reason and said, “I need an appointment within two weeks,” and been able to do that very rapidly. And it’s not just within two weeks, it’s less than that to be able to get in prior to. So it essentially results in a very absolute, almost complete and total abortion ban.

Now, you add to a six-week ban to the 24-hour wait, and you’re really running into problems because when a person presents for abortion care, they can’t get anything done that day anymore. They now must be seen, ultrasounded and then dismissed from the clinic and come back more than 24 hours later. And usually that amounts to waiting somewhere between five days to a week more because they have to come back when the clinic has abortion care again. Abortion clinics don’t do abortion care every single day. That’s not how abortion care works, and that’s important to understand. So a 24-hour wait sounds like not a big deal in practice, but it is a very big deal for patients when they’re seeking care.

Lauren Lavin:

How often do they do it? Could you explain that?

Abbey Hardy-Fairbanks:

It varies between clinics. So every clinic functions differently in terms of how they’re staffed and how often they offer abortion care. Most clinics that provide abortion care are not just abortion clinics. They also offer gender-affirming care, gynecologic care, well women care, contraception care, vaccines, primary care, a whole host of other healthcare services and abortion care is something they will offer some days of the week. And so a 24-hour wait is typically not just 24 hours.

Lauren Lavin:

Got it. Okay. You kind of touched on some of this, but what impact, if any, does this bill have on clinical practice?

Abbey Hardy-Fairbanks:

So it would eliminate the vast majority of our ability to provide abortion care to the patients that we see, and that is hugely problematic. So a patient who comes to us seeking abortion care would be turned away and they would then either have to travel out of state or remain pregnant. Only a small number of people have the resources to travel out of state. I’m not just talking about monetary resources, that’s childcare, time off work, the ability to travel, gas money, transportation that’s reliable enough, staying in a hotel there because some of our surrounding states also have waiting periods. Multiple logistical issues that are insurmountable for a lot of our clients.

In my clinical practice, it means that I would have to turn people away a lot, and that’s heartbreaking when you know that you are able to provide them with safe, often life-saving care, and you can’t. I think that it otherwise complicates clinical medicine in the sense that the law only has very narrow exceptions that basically for the life of the pregnant person, which is very rare, but some people have medical conditions where being pregnant is life-threatening, but not immediately life-threatening.

So is it legal? It just creates a whole bunch of ambiguity that makes it really difficult for us to feel comfortable providing what we would consider the standard of care in a lot of cases.

Lauren Lavin:

Yeah, this six-week ban seems to have a lot of gray area, or ambiguity, that can make it difficult to practice medicine, as I’ve talked to other people about it, as well.

Abbey Hardy-Fairbanks:

They all do. They’re designed that way on purpose.

Lauren Lavin:

I appreciate also the clarification of language and we’ll use six-week ban going forward. When you look at this bill, do you see any equity issues with it, just as it stands?

Abbey Hardy-Fairbanks:

Abortion restrictions in general have huge equity issues. First off, when you look at the population of patients seeking abortion, there is an overrepresentation of people of lower socioeconomic status. So around 60% of people seeking abortion care in the United States are at 200% of the poverty level or less, so a huge overrepresentation of people of lower socioeconomic status.

We also see a higher percentage of people who identify as Black and Latina in the abortion population. And so there was a really incredible article from the Guttmacher Institute that really summarized the inequity issues with abortion restrictions in general, but specifically these very, very draconian restriction essential bans in how they target communities that are already marginalized.

So one of the things to know is that in our country already, there is some real specific systemic exclusion of people who are non-white and living at lower income status, and those inequities result in less high quality healthcare, less social opportunities, and a lot of that plays into one of the reasons that these marginalized populations make up a bigger proportion of the abortion population. So if you think about when a community doesn’t have the opportunities for people to parent in safe and sustainable environments, or access contraception in an equitable and non-stigmatizing way, they may be more likely to access abortion care and have unplanned pregnancies.

When you look at the areas that have complete and total abortion plans currently because of the Roe v. Wade issue, a lot of them coincide with states that also did not expand Medicaid, that have very poor access to pregnancy healthcare, and have large areas of rural communities where there is not access to reproductive healthcare in general. So there’s a real coinciding, and I would say heartbreaking, alignment in the inequities of abortion care and other social and healthcare issues in our country.

We know that abortion restrictions definitely impact people that are marginalized already more than those who have the means to travel, get a hotel, figure out ways around typical processes, and that’s always been the case, but once restrictions become the law of the land, then those inequities and differences between those who have means and don’t really become exacerbated.

One of the other things that you brought up in your questions was issues of pregnancy healthcare in general, both in Iowa and abroad. If you look at areas where bans exist now, it’s predominantly in the Midwest and the South, which are areas that have the largest proportions of people who identify as Black, and also one of the regions that have the higher rates of maternal mortality and morbidity. So I think it’s really important to recognize the connection between those two. When you’re forcing people to stay pregnant in states where your maternal mortality rate is on par with developing countries, abortion really becomes a lifesaving option for a lot of people, both from a social standpoint and from a physical health standpoint.

The other things that we know from an inequity perspective, there was a really incredible study done in the past, so before all of this, called the Turn Away study. I encourage anyone who’s interested to read it, there’s a great book that summarizes its finding. It followed I think almost a thousand people for several years, and they compared three groups of people. People who received abortion care when they sought that care, a group of people who were turned away for abortion care because they were too far along for the state limit or the clinic’s limit, and then people who sought abortion care real close to the limit. So they were really able to get that care, but their care had been delayed for some reason.

And what they found was that the people who were denied abortion care when they sought it were more likely to have economic insecurity, difficulty paying bills. They had poorer bonding with future deliveries than people who had been able to access the care when they needed it.

Lauren Lavin:

Interesting. I had not heard of that before.

I think that we actually did a pretty great job of, or you did, of addressing what the impact is on public health. Is there anything else you want to say on that, on mother and child health, or prenatal care or anything like that?

Abbey Hardy-Fairbanks:

Iowa, we are usually either 48th or 49th in the country in terms of OBGYN per capita. So we are a state that really needs to improve its maternal healthcare access. So our healthcare access for pregnant persons is lacking significantly. You’ve seen, there’s several articles in our local newspapers, you’d be able to find them pretty easily, about how many labor and delivery units have closed in our state, making pregnancy healthcare inaccessible in large areas of our communities and making community hospitals not able to offer that care. That then causes the OBGYN practices in that area to not have a place to deliver, and then of course, they move.

It also means that someone who becomes pregnant can’t access that care in their community, and that is super problematic for multiple reasons, especially if you don’t have the resources to travel to a healthcare center easily from where you live. We’re also a rural state, so people are traveling long distances for healthcare on a regular basis. So then if you make that harder, you can see how that would create not only inequity, but less quality healthcare.

Also, when you think about pregnancy emergencies, not being able to access that care nearby can be problematic from an outcome standpoint. The other issue in our state is we only have one OBGYN residency, and without that residency, there’s a lot of concern about being able to continue to have OBGYNs who want to come to Iowa, stay in Iowa, and provide obstetrical care.

So when we look at states where total bans have occurred, the most recent articles I’ve read were on Georgia and Idaho, they are having a really hard time keeping the OBGYNs that are there in the state currently, recruiting new attending physicians to their state because of the restrictions, but also recruiting students and residents to their medical education systems.

So most students and residents seek training in the full spectrum of reproductive healthcare, and if you are a top tier student or top tier student going into residency, you may purposefully choose to get that education in a place where your training will not be restricted by those laws.

Lauren Lavin:

And that kind of creates a self-fulfilling problem if we already have a shortage and then can’t get more in.

Abbey Hardy-Fairbanks:

And the people who are there choose to go work where there aren’t laws. There is a really great article in a newspaper from Idaho about the efflux of OBGYN care because of their restrictions.

Lauren Lavin:

As we look to the future, what role does family planning services play in the provision of healthcare in Iowa?

Abbey Hardy-Fairbanks:

Important to recognize and lift up that contraception is not a solution to abortion care. Abortion care doesn’t need to be solved or prevented or reduced. Abortion care is an extremely safe option for people at multiple times in pregnancy and should be available without restriction, and in my opinion, should be covered by insurance.

Contraception we know can in large public health studies reduce the need for abortion, but it is not the solution. Contraception fails. Not all patients want contraception. And we also know that contraception is offered in inequitable ways. Patients who are Black or Latina, there’s really good studies showing that they experience stigmatizing contraception counseling and are often feel pushed towards contraception they may not desire more than white patients.

So I think I would push back that the solution to a six-week ban is more contraception. It doesn’t align with my thoughts on it. I think access to contraception has always been something that as a totally separate issue, needs to be something that patients can access in a non-stigmatizing, equitable way. We want patients to seek contraception care for what fits both their physical selves, but also their spiritual and reproductive goals. And sometimes that doesn’t necessarily line up with what you look on paper and think would be the best thing for a person.

So I feel like people are complex and it’s not an appropriate expectation to say, “Oh, well, there’s an abortion ban, now we need to just increase contraception care.” I think that oversimplifies the issue significantly, and it creates, again, it creates more inequities in what we offer. I think contraception access is something that always we can improve. Thankfully, the Affordable Care Act has made contraception availability much better than it used to be when I first started in medicine.

But that being said, even the most effective, long-acting reversible contraception fails. And if we don’t have abortion access, then those pregnancies that are not the result of a lack of access to contraception, but the natural and spontaneous risk of being a sexually active person who can get pregnant won’t be able to be taken care of in our state.

I think reproductive healthcare in general is something that we need to improve access to overall. My bigger concern is that if a Heartbeat bill becomes the law of our land, will reproductive clinics that previously provided abortion care be able to remain open and to offer the access to contraception that they currently do? A lot of people access contraception not at a doctor’s office or a big hospital, they access it at Planned Parenthood or the Emma Goldman Clinic or a Title 10 clinic. And many of those facilities also offer abortion care. So if abortion becomes unavailable, will they be able to continue to offer the other services?

Lauren Lavin:

Good. I think that was important clarification. Thank you for that. And then the last question, as policy continues to be modified at the state level, who or what should guide policies and service delivery, or who needs a seat at the table?

Abbey Hardy-Fairbanks:

Yeah. I think the question is do we need to regulate abortion? I think that’s the big question. I think that when you look at laws like this, they are not designed or intended to keep people safe. So I think when you think about making healthcare safer, doctors need a seat at the table, patients need a seat at the table, public health officials need a seat at the table. But when you’re looking specifically at abortion care restrictions, there’s no indication that any such restriction of the 1300 laws that have been passed since Roe v. Wade was first codified in 1973, has made anything safer for the people of our land. And so I would push back that it doesn’t belong in the State House at all.

Lauren Lavin:

Well, thank you for all of that information and for providing your expertise here today. We appreciate your time and effort.

That’s it for our episode this week. Thank you to Dr. Hardy-Fairbanks for joining us today. This episode was hosted and written by Lauren Lavin and edited and produced by Lauren Lavin. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcast and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends, or anyone interested in public health. Have a suggestion for our team? You can reach us at cph-gradambassador@uiowa.edu. This episode is brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.