Introduction:
● What’s the purpose of this learning tool?
o Self-education
o Awareness leading to (we hope) advocacy
o Sharing information with others and answering their questions will prompt you
to dig deeper
● How do I use this curriculum?
o Start in the section which interests you most
o Within each section, references and articles are arranged from general to
specific
o Read at your leisure and consider the questions at the end of the section (there will NOT be a quiz)
● Why should I read something just because Dr. Betsy Wickstrom puts it out there?
o Thirty one years as a high risk obstetrician has positioned me directly in
line with attacks on healthcare access of all kinds- these references are based on real life experiences of myself, my staff, my colleagues, my patients and my family.
o Following the Kansas Legislature 2023 session has been an eye-opening
experience and has connected me with many activists and their organizations,
though I’m ALWAYS open to meeting more people!
o It was my own naivete, ignorance and inattention to what is happening in our
own state capital which created enough shock and confusion as the last year
has unfolded to finally light a fire under me to “be the change I want to see in
the world”. If that is your experience, you came to the right place.
● Table of Contents
o Medicaid expansion
▪ Rural healthcare access
▪ Pregnancy and postpartum care access
o Mental healthcare in Kansas
o Access disparity for minority families and individuals
o Reproductive healthcare access
▪ Birth control
▪ Abortion healthcare access
o Gender affirming care access
o Resources embedded where applicable
o Appendix A- the science behind emergency contraception
1. Medicaid Expansion- what is it and what are the pros and cons?
Medicaid is a federal health insurance program and is offered only to specific categories of individuals for very specific purposes. The rules and regulations vary by state, and any expansion of the program must come through the state legislature and be signed by the Governor. In Kansas, the Medicaid program is administered by KanCare, and benefits are restricted to seniors over 65, low income families with children (or pregnant people), and those with disabilities. Medicaid expansion would remove the restrictions except for meeting an income standard, with benefits provided to all residents with a household income at or below 138% of the federally established poverty level, regardless of disability, age or having children.
To put that figure into perspective, the annual income at 138% of the federal poverty level depends on the number of people in the household:
In locations with expanded state health insurance, federal funding is increased alongside the state funds, resulting in a net gain to the state in direct funding, jobs created, and personal income for the residents (which can then be taxed). States that have not expanded the program have opted out of (all 10 states together) over $43 Billion dollars in federal funding.
From Governor Kelly’s office in 2021: https://governor.kansas.gov/icymi-new-report-today-says-medicaid-expansion-would-create-23000-new-jobs-in-kansas/
Historically, there have been bills introduced in Kansas for several years (at least since 2012) to expand Medicaid and take advantage of federal designated funds, some of which Kansas is already missing out on because it has refused to expand the program. In every case, the legislature voted along party lines or a Republican Governor (Sam Brownback) refused to sign a bill which passed both the house and senate, and the proposals were voted down, usually stating that the expansion would be “too expensive”. More recently, the Republican legislators tried to tie a “poison pill” (an amendment which is so unpopular it will keep an otherwise attractive bill from being passed) to the Medicaid expansion legislation, by stating they would only vote for the bill if it also contained a state constitutional amendment banning abortion from the moment of conception.
All but 10 states in the US have voted to expand Medicaid to the fullest extent allowed by the Affordable Care Act. Some of the states had to create ballot measures to force their legislators to expand Medicaid (not an option in Kansas, because there is no process in our state constitution which allows citizens to create ballot measures- this can only be done by legislators). In the states that have expanded Medicaid, health outcomes have almost universally improved in multiple areas of medicine (none worsened).
From KCUR (public radio) in December, 2022:
News story about why Medicaid expansion is critical to keep Kansans from falling through the “gap” and failing to obtain care:
News story about why Medicaid expansion is critical to keep Kansans from falling through the “gap” and failing to obtain care:
KFF article by Guth and Ammula:
A. What is the impact on rural healthcare access of expanding Medicaid (or not)?
In the several years that lawmakers have not managed to pass Medicaid expansion, one of the sticking points is that legislators believe that hospitals would be overwhelmed by the influx of patients who would seek care once they were insured. In truth, it is the rural hospitals that have strongly recommended expanding the program, as the effect of increasing the number of insured patients (rather than the number of uninsured patients, who will still come into the hospital in crisis situations but NOT for preventive care, which would be less expensive and improve health outcomes) would improve the proportion of uninsured/ insured patients resulting in fewer uninsured cases that go unreimbursed, increase income and provide more jobs at these small hospitals.
Figure from Appendix A of the KFF article by Guth and Ammula:
Information regarding the impact on rural hospitals from the KCUR article:
“Tom Bell, former chief executive of the Kansas Hospital Association, testified in 2020 that 85% of rural Kansas hospitals were operating at a loss. Since then, operating under the strain of the pandemic, about one-third of rural hospitals nationwide are now at risk of closing in the next year, including 55 in Kansas.
Nearly 75% of rural hospital closures nationwide since 2010 were in states that have not yet enacted Medicaid expansion, or waited too long for it to make a difference, according to a report from the American Hospital Association.
By keeping hospitals open, Medicaid expansion could create jobs at those hospitals, said Don King, chief executive of Ascension via Christi, in testimony to lawmakers in 2020. Governor Kelly’s office forecast as many as 23,000 jobs could be created.”
(These statistics are from embedded hotlinks in the KCUR article, referenced above).
Rural Kansas hospitals which closed between 2010 and 2023
Kansas
Central Kansas Medical Center (Great Bend)
Horton Community Hospital
Mercy Hospital Fort Scott
Mercy Hospital Independence
Oswego Community Hospital
Herington Hospital
January 2023 article from the same site shows that 53% of rural Kansas hospitals are at high risk of closure:
Please note, to read these articles from Beckers Hospital Review, you may need to enter your email address. If you would rather not, one of the articles is quoted here, and you only need to put up with ads:
Therefore, the expansion of Medicaid would help the state with funding, keep rural hospitals open, and give more Kansans access to health insurance. This would encourage more preventive instead of crisis care, which has been demonstrated to improve health outcomes.
Here is the most recent article regarding Governor Kelly’s take on the issue:
More than 50% of rural hospitals at-risk of closing, Kansas governor says there’s simple solution (kwch.com)
B. Expanding Medicaid in Kansas: how would this affect prenatal and postpartum care?
i. Prenatal care:
For background, before the Affordable Care Act, we were seeing far too many pregnant patients in Kansas and Missouri who would come late to care- more than halfway through the pregnancy, after many preventable complications have already begun and the outcome of the pregnancy is already mostly determined. When interviewing these patients about what made them come in so late to care, almost all of them knew it would be better to come sooner (not a public education issue), almost none of them were prevented from coming to care by family members, employers or other outside influences, and almost ALL of them gave “difficulty getting insurance” as the reason for the delay. Pregnancy is expensive without health insurance. Pregnancy without adequate care can be deadly. Since the Affordable Care Act has allowed most (not all) citizens to have prenatal and delivery insurance coverage, uninsured patients are a rarity, rather than the rule, or they can apply for the insurance in the hospital and the funding will be retroactive for the entire pregnancy.
“If you enroll in health insurance while you’re already pregnant, Medicaid retroactively covers qualifying medical bills. Medicaid pays for pregnancy-related medical expenses incurred within three months prior to enrolling in a plan.
One issue which makes it difficult to determine whether further expanding Medicaid as described above in section one would improve the wellbeing of pregnant people and their families, is that most states already have more lenient rules for Medicaid coverage during pregnancy and for young children since the enactment of the Affordable Care Act. Therefore, the legislative consideration regarding how or whether to expand Medicaid coverage does not impact pregnant people as much as those who are not seeking prenatal care. However, the rules governing who may or may not be eligible for Medicaid are confusing and vary widely from state to state:
Nonetheless, it is clear that the Medicaid expansion which occurred with the Affordable Care Act has already improved access to prenatal care and maternal/ infant outcomes:
ii. Postpartum care:
During the global COVID 19 pandemic, the federal government mandated that any persons currently receiving Medicaid benefits could not be removed from the program for any reason. The logic behind this decision was that people were avoiding physician offices and hospitals out of fear of becoming infected, allowing chronic conditions to worsen and acute conditions to go untreated. The result of this rule was that many people who had delivered babies suddenly had more than their 60 day Medicaid coverage, and despite overall harmful effects of COVID 19 on pregnant people and their infants, even during the height of the pandemic pregnancy and newborn outcomes were actually improving slightly overall. This indicated that, as most obstetric care providers could tell you, the months AFTER delivery can be as important to give care and monitor health as the months BEFORE delivery, and not having insurance coverage was a huge barrier to receiving that care.
Last year, Governor Kelly and the Kansas legislature proposed an extension of postpartum Medicaid coverage from 2 months to 12 months after delivery. The federal government organization in charge of Medicaid, (the Centers for Medicaid and Medicare Services or CMS), approved that change in July of 2022. The two areas most expected to be improved are access to mental health services for patients suffering from postpartum depression, anxiety or psychosis, as well as heart and blood pressure complications, all of which can be deadly and cause increased maternal and newborn deaths. In addition, this expansion leveled the proverbial playing field for minority families who disproportionately counted on their KanCare coverage, only to have it abruptly end after a few months, while mothers and babies are still at their most vulnerable. The result was newborn mortality rates in certain zip codes in Kansas being the worst in the nation. Though it is too soon to tell what the effect of extending postpartum Medicaid will be, many organizations whose purpose is to evaluate and address maternal and infant mortality are cautiously optimistic.
This article is from Missouri, but the principles are still relevant:
Questions to ponder:
● The Affordable Care Act increased the number of insured Kansans (T/F)
● During the COVID 19 pandemic, the federal government mandated that no one
could be removed from federal and state insurance plans. Is this still true in July,
2023?
● Initially, state legislators in Kansas resisted expanding Medicaid, as recommended
by the Governor, because they felt it would be too expensive. Why would that not
be the case?
● Legislators have also stalled the proposed legislation for Medicaid expansion in
Kansas because they felt that rural hospitals would be overwhelmed with too many
patients and undergo financial stress, risking closure of these critical access
hospitals. What do the hospitals have to say about expanding Medicaid?
● This legislative session (2023), what “poison pill” did legislators try to attach to a
Medicaid expansion bill?
● How are rural Kansans’ access to their local hospitals being hampered by the
legislature’s apparent refusal to expand Medicaid?
● If Medicaid is expanded, will this have much impact on prenatal care in 2023- 2024?
● How has the state of Kansas changed the coverage for postpartum Medicaid this
year?
● Why was that move necessary?
● Do we know yet what the result of this change might be?
2. Mental Healthcare access in Kansas
If you are a history buff, this next article is for you. It traces the timeline of mental health services in Kansas from the opening of the Osawatomie State Hospital in 1866 to the State Hospital Commission created by Secretary for Aging and Disability Services in 2019. The document was created by the research department of the Kansas legislature and is relatively reasonable to read.
Moving on to more current events and widening our lens a moment, let’s look at the baseline of healthcare access in the US before the COVID 19 pandemic (to take that variable out of the question), and discover the barriers to receiving adequate mental health care. According to a study of over 50,000 participants published in 2021, even after the Affordable Care Act improved insurance coverage and healthcare access overall, 1 in 5 people facing mental health challenges did not have a “usual source of care” for their psychological needs. Barriers included finances (avoiding appointments for therapy or advice regarding medication changes, or picking up prescriptions on time due to cost), the pervasive stigma against mental illness in our country, and the illness itself interfering with the executive functioning (decision making processes) needed to navigate a complex health provider system. But the most critical element that prevented people from seeking or continuing care was the scarcity of mental health providers in the US. Another facet that needs to be considered is the interplay between mental illness and physical illness. With mental health challenges, diagnosis and treatment of physical illnesses can be delayed and/or inadequate. Therefore, this mental health access issue represents a public health crisis.
Barriers to healthcare access among U.S. adults with mental health challenges: A population-based study - PMC (nih.gov)
This issue of lack of access is particularly troublesome in rural America, with 65% of nonmetropolitan US counties having no mental healthcare providers at all. “While there may be no uniform definition of rurality, there are several commonly accepted factors that shape the culture of rurality and its impact on mental health, such as low population density and remoteness, isolation, poverty, religion, social support, and stigma. There is variability across these factors, but their combined influence on mental health care remains significant.”- Morales, et al, October 2020. Compounding the rural location studied by these authors are specific groups of people like veterans, older adults and minorities, all of whom share disparity in access to care and prevalence of mental illness compared to the average.
“When considering rural disparities in mental health treatment, the impact of race and ethnicity is considerable. For example, research suggests that racial and ethnic minorities living in rural areas are more likely to live in persistent poverty and be unemployed or underemployed. In addition, while stigma related to mental disorders and seeking treatment for it has been a well-documented factor associated with rural disparities, it is especially pronounced among racial and ethnic minorities, for whom issues of cultural mistrust are high and the acceptability of psychological and psychiatric forms of treatment is low.“
Important points brought up by this USC study published in 2018 to describe the landscape of mental healthcare and its financial impact in Kansas include that psychiatric admissions to the hospital are less profitable, because they tend toward longer stays and fewer reimbursable procedures, as well as highlighting the overlap between mental illness and incarceration. If you are a finances, charts and numbers person, you will LOVE this presentation:
As a baseline, where did Kansas stand in 2022 in comparison to other states regarding the mental health of our citizens as measured by rates of mental illness, addictions, suicidal thoughts and access to mental healthcare? According to one NPR article published last Fall by KCUR and KMUW (Wichita), dead last (pun intended). By every parameter measurable, including percentage and number of individuals with mental health insurance coverage, physician/ patient ratio, employers that provide mental health benefits, and duration of therapy for depression, our state was scraping the bottom of the barrel.
More visually oriented? Here’s a site with maps comparing state-by-state mental illness prevalence and access:
So, what can be done about the desperate state of mental healthcare access in Kansas, with folks using their local Emergency Department when they reach a point of crisis, or worse, not seeking care at all until they are incarcerated or suicidal? Enter KDADS (Kansas Department of Aging and Disability Services) – hold your applause, please. This state government division is responsible for distributing mental health funding from multiple sources: the state general fund, primarily, and federal Title XIX funding (Medicaid and Medicare). KDADS does not direct client funding from private insurance, but this is an additional source of income for many organizations providing mental health services. They do, however, work on a county-by-county basis to grant funds for local solutions to local problems.
What was fascinating to me about this website is their link to various Kansas county maps (linked here: https://kansaspreventioncollaborative.org/behavioral-health-indicator-maps/ ) that show the prevalence of various issues county by county. It really brought home the issues of rural access being a more severe problem than urban/ metropolitan access, and each county shown is interactive, with individual statistics if you click on the county.
Besides the cool maps, the work of KDADS is important because they continue to help press for- you guessed it- MEDICAID EXPANSION! (Are you sensing a theme, here?).
Their main website can be accessed here:
There have been some strides made by our legislators (well, most of them) to provide better healthcare access in our state, exemplified by the 2021 House Bill 2208, which allowed rural Kansas hospitals to participate in the federal “Rural Hospital Emergency Act”:
“The bill passed the House on a vote of 120-2 and the Senate on a vote of 34-4. In late April [2021], Gov. Laura Kelly signed it into law. It [also] established certification for community behavioral health clinics, or CCBHCs, authorized licensed out-of-state physicians with telemedicine waivers to practice [in Kansas] and provides grants for economically distressed rural hospitals.”
Read the remainder of the Kansas Reflector article here:
The focus of improving healthcare in rural areas is now swinging toward mental health:
The work of grassroots organizations and nonprofit organizations has also been paramount in the improvement of mental healthcare services to our state. Here are some supportive resources:
Association of Community Mental Health Centers of Kansas, Inc. | Association of Community Mental Health Centers of Kansas, Inc. (acmhck.org)
Questions to reflect upon:
● Is residential psychiatric care still a thing? (Trick question, the answer is yes and no)
● How does Kansas stack up against other states regarding prevalence of mental
health challenges as well as access to resources/ providers?
● Why is inpatient mental healthcare more expensive?
● What sort of barriers do Kansans (particularly in rural areas) face when trying to
access mental health services?
● What is the state organization for managing mental healthcare funding?
● What was the intent of the “Rural Hospital Emergency Act”?
● If you have a friend or family member suffering from mental illness, where can you
point them for assistance?
● Would expanding Medicaid in Kansas benefit citizens with mental health
challenges? (Hint: the answer will always be YES in this curriculum)
3. How is healthcare access disproportionately more difficult for minority families and individuals?
We’ve already alluded to the idea that race and ethnicity can raise additional barriers to receiving quality mental health. Does this inequity also involve general healthcare? The short answer is “yes”.
A 2021 New York Times article quotes a study of nearly 600,000 Americans published in the Journal of the American Medical Association (JAMA). The point of the study was to discover whether the Affordable Care Act magically improved health across the board, or whether inequality in health parameters still existed.
From the New York Times article:
“Despite innovations like Medicare Advantage, [ buyer beware- we are NOT endorsing Medicare Advantage] which increased access to health care overall, Medicare beneficiaries who are minorities — defined as Black, Hispanic, Native American or Asian-Pacific Islander — still have less access than white or multiracial individuals to a physician who is a regular source of care.
They are also less likely to have influenza and pneumonia vaccinations, and they have more limited access to specialists, the study found.”
It goes on to say that white Americans are more likely to visit a primary care clinic for treatment of chronic conditions, and to have access to specialists when needed. In contrast, Black people answering the survey were more likely to use hospital or Emergency medicine services, overall. This difference persisted even among patients having the same exact insurance (Medicare for older adults).
The problem is not simply a choice on the part of certain people to use one form of care over another. Very often the presence of primary care and specialty offices is sparse in certain neighborhoods, but more plentiful in others. As in Kansas City, where red-lining (a real estate practice that kept minorities out of certain neighborhoods as they developed, and prevented home loans from being granted to non-white buyers) has caused health care “deserts” in majority Black neighborhoods, many cities around the nation face this issue of segregation by real estate.
The article goes on to discuss behavioral differences (lack of trust in the healthcare system as a whole), the presence or absence of easily accessible healthy food, being able to walk outside for exercise, and increased pollution. All of these are social determinants of health, and they are not evenly distributed across our cities and counties.
There is more to this article, about Black maternal and infant mortality and the more devastating effects of the COVID 19 pandemic on minority Americans, but I’ll let you read it for yourself.
This article is gifted, so you should not meet with a firewall if you don’t subscribe to the New York Times:
When studies indicate that folks from minority populations are less trustful of healthcare providers and institutions, this is not an intrinsic bias without foundation on their part. Black and Hispanic patients ARE treated differently in clinics and hospitals, and the worse outcomes tell the story.
From a Pew Research study (the people who do polls and then analyze them scientifically):
“Black women, especially younger Black women, stand out for the frequency with which they report having had negative health care experiences. Taken together, 63% of Black women say they’ve experienced at least one of the seven negative health care experiences measured in the survey. Among Black men, 46% say they’ve had at least one of six negative experiences with doctors or other health care providers. Black women were asked one more item than men, but the gap between men and women on the six experiences in common is almost identical (62% vs. 46%).”
My new favorite resource, KFF, has a lot to say about healthcare disparities. This is the group that puts out all the cool charts and figures.
Guess what is the largest determinant of quality of care country wide: (You know the answer is going to be Medicaid expansion). But what does that have to do with being Black? This map from KFF gives you the picture, literally:
The overlap between states that have more nonwhite citizens and those states that have not expanded Medicaid is obvious. THIS is one of the driving forces of poor healthcare outcomes for people of color in our nation and our state.
So, what can be done about this systemic racism and poor treatment of people of color within the medical system? Before you object and say “my (doctor/ nurse practitioner/ clinic/ hospital) is NOT racist”, let’s take a second to realize that a system can be skewed to disadvantage a group of people, even if individual people are not intentionally treating one patient different from another. I’m not going to get into the idea that, in order to correct systemic racism, all of us need to actively practice being anti-racist, not just passively think we are doing ok if we don’t intentionally insult or harm anyone. But it’s a thing and I have a great analogy about those moving walkways at the airport that describes this effect- ask me sometime.
Also, before you think those young, impressionable med students who haven’t been jaded by their experiences in the world could not POSSIBLY be racist, studies of medical student attitudes and beliefs demonstrate that there is a significant percentage of doctors graduating from our medical schools who actually believe that Black people are somehow intrinsically different than white people, though physically this is not true. The most horrifying statistic to me is the number of med students who answered that Black people are more resistant to pain than white people. This plays out in the real world as people of color receiving less pain medication and not being taken seriously when they say they are in pain. In the case of Black women who have recently delivered a baby, the results of this heinous bias can be deadly. I just picked the first article that came up in my search to describe this issue, but I could give you ten more in a heartbeat:
Doctors Still Believe Black People Don't Feel Pain; And It's Being Taught In Medical School - BlackDoctor.org - Where Wellness & Culture Connect
OK, I got sidetracked. Here are some ideas about how to improve our healthcare system’s intrinsic bias, starting with bringing up our med students better. I love that the sensitivity training recommended also includes gender and sexuality differences, disabilities, socioeconomic status, etc. They even list medical schools that are intentionally doing better in their specific training on these issues.
So that’s all well and good for the country as a whole, but what about Kansas, specifically? This website from the Kansas Health Foundation highlights differences in household income, insured vs. uninsured, and something that became critical during the pandemic but is here to stay, broadband internet access to allow for telehealth visits. The American Rescue Plan Act, a federal program to aid economic recovery after the COVID 19 pandemic, earmarked $20 billion specifically to expand broadband throughout the nation. (I know, I’m back to talking about the whole country again- sorry! But this issue significantly impacts rural and urban/ minority families and their access to education and healthcare).
This article from the Brookings Institute details the costs of expanding broadband, and highlights the disparities in internet availability in both rural and urban areas:
To sum up, people of color, particularly Black and Hispanics, have worse health outcomes than white people, even when accounting for income and geography. There are many reasons this is true, and it will take a concerted, multifaceted approach to bring healthcare equity to our state.
Resources:
Discussion questions:
● True or False- the Affordable Care Act virtually eliminated healthcare access
disparity for minority patients by improving the number of insured individuals.
● Choose all applicable answers-
o Healthcare inequity in America and specifically in Kansas is related to
▪ Fewer clinics and primary care physicians in primarily minority
neighborhoods
▪ Food deserts where healthy foods are not readily available
▪ Systemic racism within the medical community
▪ Hesitancy to interact with the healthcare system due to prior poor
treatment
▪ Lack of appropriate places to walk outside for exercise
▪ Red-lining/ segregation
▪ Pollution
● True or False- a significant number of medical students in a large study believed
that Black people are less capable of feeling pain.
● What are some ways to combat health inequities in Kansas?
4. Reproductive Healthcare Access
A. Contraception (Birth Control)
Enjoy this history of contraception from Genesis (not kidding) to 1990, which tracks the discovery of the human ovum (indicating that people with a uterus are not just a receptacle for life-creating sperm, but actually contribute to conception), discovering and defining hormones that influence ovulation and menstruation, and the actual timeline of creation of the various barrier and hormonal methods to prevent unplanned pregnancy. Oh, and there’s also stuff about the role of the Roman Catholic and Anglican churches, as well as the US government, both the executive branch and the FDA having their say about the pros and cons of contraceptive use.
With that history as background, you can see where many of the barriers to obtaining contraception have come from, some of which are still interfering with access today. County health departments do provide contraceptive advice and prescriptions, usually with federal and state funding- for now. The official position of the Roman Catholic church is still that only natural family planning (abstinence and rhythm method- also known as fertility awareness method) are sanctioned, though this is not making a difference to the majority of US couples, regardless of their church attendance or denomination. As recently as July, 2022, Pope Francis, when asked about contraception, cited the following:
“On the subject of birth control, the Catechism of the Catholic Church
states that ‘legitimate intentions on the part of the spouses do not justify recourse to morally unacceptable means (for example, direct sterilization or contraception).’
St. Paul VI issued Humanae Vitae, the landmark encyclical reaffirming Church teaching against contraception, on July 25, 1968.
In the encyclical, Paul VI warned of serious social consequences if the widespread use of contraceptives became accepted. He predicted that it would lead to infidelity, the lowering of morality, a loss of respect for women, and the belief that humans have ‘unlimited dominion’ over the body.”
The following study, released in January, 2023 is based on a poll conducted from 2015- 2017 and confirms that the majority of people who identify as Roman Catholic are using a method of family planning outside the official teachings of the church:
Regardless of this information, contraception access is still curtailed for “religious reasons” in Catholic hospitals and clinics, and with some employers continuing to decline to cover contraception as part of their insurance benefits. The latter issue defies the Affordable Care Act of 2010 which requires insurance companies and plans to cover contraception.
So, overall, the federal government has promoted access to birth control- but that’s not the end of the story. On an individual basis, obtaining affordable family planning can be extremely difficult:
So what are the remaining barriers? Cost, obviously, though contraception is supposed to be free. In addition, until 2021, use of oral contraceptives (“The Pill”) have required a physician/ advanced practice nurse visit to obtain a prescription, which means taking time from work and/or finding childcare, figuring out transportation, and often paying a co-pay at the office visit. However, one of the few good things that came about due to the COVID 19 pandemic is that many states (including Kansas) began authorizing pharmacies to distribute birth control pills without an office visit. (To be clear, the law was passed in 2021 but did not go into effect universally right away).
OK, so contraceptives should be free to insured people (well, there’s a major problem- see Medicaid expansion in Kansas, above), and readily available, so why are there still unplanned pregnancies in our state? The major contributing factor is not using contraception or using it sporadically. Duh, right? But why do people not use birth control correctly, or at all? Misinformation and lack of education are common around the topic of birth control, especially hormonal methods. Interestingly, the same concerns are expressed all over the world: delay in return of fertility, weight gain, irregular bleeding, causing promiscuity, causing cancer and other health risks are all themes in counseling around why someone with an unplanned pregnancy was not using contraception.
I loved this study which described using educational methods which are nonjudgmental to have a productive conversation around these concerns:
The special case of “Morning After” emergency birth control:
This medication uses the progestin hormone Levonorgestrel to prevent ovulation when taken within 72 hours after intercourse. The hormone acts to interrupt the menstrual cycle and block conception. Its safety and effectiveness are proven, and in recent years it has become more and more available, including over the counter in pharmacies. These facts are not always common knowledge, and because it must be used before ovulation has occurred, it is not effective during the second half of the menstrual cycle. That’s an important distinction, because right now (Summer of 2023) there is a cultural battle over use of this pill. There are politically motivated groups who are insisting that the “Morning After” pill actually causes abortion and should not be available in states where abortion is prohibitive. There is no Science at all behind this claim, (remember that it is designed to block ovulation- it has literally no effect on a pregnancy that is already conceived), but that doesn’t stop these groups from going after the distribution of the medication. In fact, on June 24, 2022 when the Dobbs decision was handed down from the Supreme Court, abolishing the federal protection of the right to privacy in healthcare decisions, multiple healthcare systems sent out memos to their clinics stating that they were forbidden to distribute emergency contraceptives. By the time the smoke cleared the next week, cooler heads prevailed and patients once again were able to access the pills. If you have an interest in the science behind why emergency contraception is NOT abortion, see Appendix A at the end of the course.
B. Abortion Care
Is there a soul reading this curriculum who hasn’t heard all about abortion access? I acknowledge that you all don’t live and breathe this information like I do (by the way, if you want the most up to date information regarding abortion legislation and politics delivered to your email inbox on a daily basis, and you are not averse to a few well-placed f-bombs, subscribe to the “Abortion Every Day” substack newsletter by Jessica Valenti). Anyway, let’s take it from the top:
i. Definition and history of abortion
Abortion is defined, medically, as the interruption of any pregnancy. It is divided into spontaneous abortion (commonly known as miscarriage) and therapeutic abortion, which may include treatment of ectopic pregnancy as well as surgical or medical intentional pregnancy termination. Let’s make one thing clear- ALL of these are abortions, and having the skills to manage each of these processes is an integral element in the training of Ob/Gyns. Keep that in mind as you read on.
As far back as all recorded history, there are accounts of people intentionally terminating undesired or unhealthy pregnancies, either for themselves or for others, with varying success. According to everyone’s favorite internet source, Wikipedia:
“The first recorded evidence of induced abortion is from the Egyptian Ebers Papyrus in 1550 BCE.
Many of the methods employed in early cultures were non-surgical. Physical activities such as strenuous labor, climbing, paddling, weightlifting, or diving were a common technique."
If you don’t want all the historical background about how we got where we are today regarding abortion access, I suggest you skip down to section “vi”. If you are into it, hang on to your hats!
ii. History of abortion as a political litmus test
Did you love the timeline in the last section giving the history of contraceptive access? Here you go:
More of a photos and text person? This article in National Geographic required my email address and I’m sure I’ll be swatting spam out of my email inbox for a while, but it’s very well done:
Rather listen to an audio interview or read the transcript? Here’s NPR:
What all of these histories have in common is their chronicling of how abortion went from a normal part of life to an immoral, banned procedure, to protected private healthcare, to fodder for a social culture war, to what is now a political hot potato in our country, yanking pregnant people and providers around with confusing and unclear laws, draconian healthcare bans, 1800s rules, and growing maternal care deserts.
How did “Right to Life” become the battle cry of the right-wing Republican party? NPR put this story out in their program “All Things Considered” in May, 2022, just after the leak of the Supreme Court decision overturning Roe v Wade:
It all boils down to the 1972 presidential election campaign of one Richard Nixon. They recognized that, to win the election, they would need to court the Catholic vote, and that’s when the historically pro-choice Republican Party suddenly began promising to restrict abortion rights in the US. At the time, Protestants perceived the abortion issue as unique to Roman Catholics, and even the Southern Baptists and other Evangelicals had no hard-line objection to medical care for unintended pregnancies. The views of this segment of the population shifted sharply to the right in the late 1970s, becoming rabidly anti-choice, and the platform of the Reagan Republicans swung with them. This change was helped along by the “Moral Majority” crew and anti-feminist Phyllis Schlafly, drawing parallels between the Equal Rights Amendment and the loss of the traditional family structure. Abortion was seen as just another way that women could assert control over their own lives, and that simply didn’t fly with these extremists for whom anything but sex and childbearing within the marital union of a man and a woman was an abomination. Over the course of the 1980s, what was previously a somewhat divisive issue, and never along party lines, became increasingly entrenched as an “us vs them” litmus test between anti-abortion Republicans and pro-choice Democrats.
iii. The “conservatization” of the Supreme Court (yes, I just made that word up)
During the Obama administration, right-wing Republicans (I’m looking at you, Mitch McConnell) made it their mission to shift the political views of the judicial branch of the US government to the right. Specifically, this meant blocking the judicial nominations of the President, including thwarting the March, 2016 nomination of Merrick Garland as Supreme Court Justice (replacing Antonin Scalia) using some nonsense logic about not holding Senate nomination hearings too close to an election (referring to the 2016 Trump vs Clinton race). The lower courts were packed to the gills during the Trump administration of 2016- 2020, with appointees who espoused “conservative” views or outright lied during their Senate hearings about their views on controversial issues like Roe v Wade. Though the judicial branch is supposed to interpret laws according to the Constitution and not follow partisan lines, several Supreme Court Justices with a clearly rightward bent were rushed through their hearings, including Justice Amy Coney Barrett, who was confirmed in late October, 2020. What’s that, you say? She was confirmed AFTER voting had already begun in the 2020 Presidential election? So much for Mitch McConnell’s claims that this just isn’t done in the same year as a federal election. <insert eye roll emoji here>.
iv. The result of these Supreme Court changes
Within the 2021- 2022 judicial term, the tone of the Supreme Court changed dramatically. Whereas previously there were many decisions handed down with a 9-0 vote alignment (43% according to this article from SCOTUSblog),
the majority of cases were now decided by a 6-3 vote.
“Most of those 6-3 decisions — 14 out of 19 — were polarized along ideological lines, with the six conservative justices in the majority and the three liberal justices in dissent. Most notably, the six conservatives voted as a bloc to broaden Second Amendment rights, expand the role of religion in public life, and limit the Environmental Protection Agency’s authority regulate carbon emissions. (The six conservatives also were in the majority in Dobbs v. Jackson Women’s Health Organization, though one of them — Chief Justice John Roberts — wrote that he preferred a narrower result and would not have overturned Roe v. Wade.) And in other lower-profile but highly consequential decisions, the conservatives voted together to strike down a campaign-finance law, restrict relief for prisoners challenging their convictions, and limit the ability of citizens to sue police officers and federal agents for alleged constitutional violations.”
2022- 2023 continued this trend, as described in this gifted Washington Post article, the link for which should get you past the paywall:
How the Supreme Court ruled in the major decisions of 2022 By Ann E. Marimow, Aadit Tambe and Adrian Blanco. June 30, 2022
The point of all that history is to understand what led to the decision of June 24, 2022, when Roe v Wade was overturned, removing the federal protection of abortion prior to viability (as decided by each state) and past viability in certain specific cases. Without Roe v Wade, many states already had “trigger laws” in place, some dating back to the 1800s, which were now enforceable, criminalizing abortion and banning this aspect of reproductive healthcare.
v. The VOTE NO movement and August 2nd, 2022
Thanks to groups like “Vote NO Northeast Kansas”, from which this 802 United nonprofit was born, and the clever and dedicated members of “Vote Neigh” regarding the proposed state constitutional amendment to turn all decisions regarding abortion over to the legislature and remove the constitutional protection of the right to abortion before viability, Kansans overwhelmingly rejected the extremist, falsely worded “Value Them Both” amendment.
This left Kansas right where we were before that attempt to take away our human/ civil rights, with a state constitution that allows abortion with certain restrictions. Abortion has never been a free-for-all in our state. See below for current laws regarding access to abortion in Kansas. But meanwhile, we can celebrate that ordinary Kansans throughout the state recognized that a few extremist legislators should NOT determine our healthcare decisions for us and refused to criminalize abortion.
So it ended there, right? The anti-abortion crusaders left the subject alone and went back to actually governing the state and writing important legislation! Didn’t they….?
vi. What about access in the US in 2023?
a. State by state abortion access at this moment:
Because the subject is a moving target, I prefer using a “live” interactive map like this one to describe abortion access:
The map is color coded by different categories of restriction/ support for reproductive choice.
The seven policy categories are:
● Extremely restrictive: State bans abortion completely
● Very restrictive: State has multiple restrictions and early gestational age ban
● Restrictive: State has multiple restrictions and later gestational age ban
● Some restrictions/protections: State either has a few restrictions or protections, or
has a combination of restrictive and protective policies
● Protective: State has some protective policies
● Very protective: State has most of the protective policies
● Most protective: State has all or almost all of the protective policies
“The map will be updated to reflect policy changes that affect a state’s category. We recognize that any type of restriction may be the one that prevents an individual from accessing an abortion; our map aims to take into account a state’s entire policy environment.”
b. Current state of abortion access in Kansas:
In order to obtain an abortion in our state, pregnant people must find a provider, figure out how to pay cash (in our state, insurance companies- even private ones- may not pay for abortion care), obtain parental permission if under a certain age (which can be a HUGE barrier if the pregnant person was raped by a family member), see a provider to determine their gestational age, which determines whether they can terminate the pregnancy at all and whether they qualify for a self-administered medication abortion, have an ultrasound (trans-vaginal if the pregnancy is not visible from the abdomen), read lengthy consent forms, wait 24 hours, and then receive their care. The absolute last moment a pregnancy can legally be terminated (unless the pregnant person is actively dying, and even then usually they would just be delivered and the newborn would be handed off to the NICU team) is 22 weeks and 0 days. This date was originally chosen by the legislature without any scientific basis, because some “expert” somewhere said 22 week fetuses can feel pain. The laws refer to not terminating the pregnancy of a “pain-capable” fetus. But I’ll let it go because there have been a few surviving infants at 22+ weeks.
During the 2022-2023 legislative session, extremist regressive legislators tried to push through 1) An abortion ban from the moment of conception (including using frozen embryos for IVF fertility care) 2) A law stating that individual communities can enact laws more strict than the state restrictions (that one, by the way, was put forward by a freshman lawmaker who was appointed to his position, not even elected) 3) Something called the “born alive” bill that states any newborn delivered as part of an intended abortion must receive medical care…. Blink. Blink. What on earth do they think we do? 4) A law preventing abortion providers from participating in the Kansas Healthcare Stabilization Fund (malpractice insurance), even though they are required by medical licensing regulations to contribute to the fund. Good news, though this bill passed, it was vetoed by Governor Kelly and the legislators didn’t have the supermajority votes to override the veto. 5) Requiring clinics providing information on self-administered medication abortions to have a posted sign (even designating the font size) telling patients that medical abortion is reversible. This last one really gets to me. It’s a cookie-cutter bill being passed around all over the nation in regressive states, saying that if a person takes enough progesterone, they can reverse the effects of Mifepristone. One small problem: There are ZERO studies proving this has any effect and there is ZERO proof that this technique is safe. National medical authorities have condemned the practice as potentially dangerous and definitely unproven. Lawmakers passed the bill, anyway and it was due to take effect July 1, 2023.
The Kansas Reflector has a run down from earlier in the summer about anti-choice laws proposed and passed this year:
The abortion care providers are not sitting back and waiting for these laws to interfere with their patients’ rights. They are suing the State’s Attorney General (Kobach), the District Attorneys in Johnson and Sedgwick Counties, and top officials at the State Board of Healing Arts who can suspend physicians’ licenses for breaking Kansas law to object to the “abortion reversal signage” requirement which was added to the 24 hour waiting period already in place. This lawsuit has made national news:
The bottom line is that abortion care is available in Kansas, for now. But the new legislative session begins in January, 2024.
Questions for reflection:
● True / False- Preventing unwanted pregnancy is a relatively new concept, beginning
with the development of the contraceptive pill in the 1960s
● Insurance companies are required to absorb the cost of contraceptive benefits to
their clients as of the Affordable Care Act of _______ (fill in the year), leaving
contraception “free” to the insured
● What barriers to obtaining contraception are still a problem (indicate all that apply)
● Cost- for the uninsured, and/ or for modern contraceptive methods rather than a
few, select (less expensive) types of birth control
● Hormonal contraceptives require an office visit to be prescribed (on a state by state
basis, where they are not available over the counter in a pharmacy)
● Accurate information about side effects of hormonal contraception may be limited,
keeping some people from embracing birth control
● The stigma attached to a young, single person taking oral contraceptives (even
though it may be indicated for other reasons than preventing pregnancy) may limit
filling prescriptions or seeking care in the first place
● Emergency Contraception (“the morning after pill”) is: (select the one best answer)
● A medicine which causes abortion
● Available over the counter in some locations
● Not well proven to be effective and safe
● Supported by the Roman Catholic and Evangelical churches
● True/ False- Abortion is defined as the interruption of any pregnancy, including
miscarriages, ectopics, and intentional termination
● Anti- abortion beliefs became a defining aspect of the Republican party during
which decade?
● 1960s
● 1980s
● 2000s
● 2020s
● After the Supreme Court decision in the Dobbs case (June 24, 2022), overturning
the 1973 Roe v Wade decision, the effect on abortion rights was to:
● Send the decision about private medical issues back to the states to
individualize
● Remove the national Constitutional protection of privacy and bodily autonomy
● Put “trigger laws” from the 1800s into effect in some states
● Embolden the Kansas legislature to promote a state constitutional amendment
which would reverse the current right to abortion care in our state
● All of the above
● On August 2, 2022, Kansans voted down the “Value Them Both” amendment. True/
False- this 60% majority vote caused extremist lawmakers to heed the voice of their
constituents and stop trying to legislate away civil and human rights
● Current state laws surrounding abortion are confusing, causing some physicians,
advanced practice nurses and pharmacists to be hesitant to provide even
counseling regarding abortion options, much less services themselves. What issues
contribute to this murky situation? (Choose all that apply):
● The definition of what constitutes a life-threatening emergency for the pregnant
person is not clear in states where this is an exception to an abortion ban
● States differ in their application of gestational age after which abortion is banned
(from “conception”, 6 weeks menstrual age, “pain capable”, “viability”)
● Many state laws have gone into effect, only to be suspended pending lawsuits
about the constitutionality/ legality of the statute. As a higher court may uphold or
overturn a lower court ruling, and appeals are made, laws may have an “on again,off again” status
● The wording regarding consequences of breaking these laws is intentionally vague,
creating a “chilling effect” upon care providers, who don’t know what they might be
risking if they give evidence – based, proven advice to their patients.
5. Access to care for transgender people
A. Definitions
i. What is gender dysphoria and why does it require medical care?
According to the Human Rights Campaign, gender dysphoria is a psychological condition in which “clinically significant distress [is] caused when a person's assigned birth gender is not the same as the one with which they identify.” Mayo Clinic warns that, if left untreated, “gender dysphoria impairs the ability to function at school or at work… the result may be school dropout or unemployment. Relationship difficulties are common. Anxiety, depression, self-harm, eating disorders, substance misuse and other problems can occur.
ii. What is gender affirming care?
a. For children (from the Human Rights Campaign cited above)
“Transgender and non-binary people who begin transitioning
during childhood or adolescence work closely with parents and
health care providers — including mental health providers — to
determine which changes to make at a given time that are age
appropriate and in the best interest of the child. At all stages,
parents, young people and medical professionals make decisions
together, and no permanent medical interventions happen until a
transgender person is old enough to give truly informed
consent.
Prior to puberty, transition is entirely social, and may involve
changing names, pronouns, clothing, and hairstyles. During and
after puberty, some medical treatments may be available, but only
after significant consideration and consultation between the youth,
their families and their health care providers.”
The latter statement likely refers to “puberty blockers”, which
temporarily suspend puberty while the patient is deciding whether
they want/ need to go through with physical transition. The
medicines have been used for decades, to treat precocious
puberty, a medical condition where puberty can begin in 6 and 7
year old children and, if not blocked, can prevent their normal
growth surge and lead to impaired growth. Same medicine,
different indication.
b. For adults
Gender affirming care may include hormone therapy and/or
surgery, once a trans person reaches the age of informed consent.
Being able to understand the consequences of hormone therapy
(not necessarily permanent) and surgery (permanent) isn’t just a
matter of age, however. Prolonged counseling/ therapy and
discussion is involved in the consent process. For that reason, the
“regret” rate for adults who have undergone transition is
vanishingly small (less than getting a tattoo or having a
hysterectomy, for instance).
B. Where does a person with gender dysphoria seek gender affirming care?
Pediatricians, gynecologists, family and internal medicine providers and specialists in transgender medicine practice gender affirming care all over the state. Every major hospital has this type of care available, though some provide only maintenance hormone therapy rather than initiation of care or surgery. The key with early care is to find a counselor or therapist who is knowledgeable about gender dysphoria treatment and transgender care. A quick online search offered these options (please evaluate any care provider thoroughly before engaging with them, and do not take this document as an endorsement or referral):
C. When did care for trans persons become such a divisive topic?
Writing bills that target transgender individuals is not new, particularly in the area of youth sports and “bathroom bills”. Basically, as soon as same sex marriage was approved in all 50 states (2015), extremists needed to pick a fresh group of vulnerable people to threaten and oppress, to keep their base fired up. Similarly, since the overturning of Roe v Wade in 2022, the number of anti- trans bills around the nation is exploding even further. Extremists have to keep their voters coming to the polls, dontcha know? But I digress…
Anti-trans laws are on the rise. Here’s a look at where — and what kind.
From bans on gender affirming care to restrictions on names changes, state lawmakers across the country have introduced a slew of anti-trans legislation. By Anne Branigin and N. Kirkpatrick, October 14, 2022
(gift article)
D. What’s happening in state legislatures in 2023, and what is likely to happen in 2024?
In regressive, extremist-led states, anti-trans care legislation is even more frantically promoted. Many, if not most of these bills are produced by institutions like The Heritage Foundation (right-wing “think tank”), as well as evangelical groups “The Alliance Defending Freedom” and the “Family Research Council” and then reproduced all over the nation. Now the tone of these bills has shifted from access to sports and bathrooms to actually criminalizing trans healthcare and defining it in inflammatory terms like “child abuse”, “chemical castration” and “genital mutilation” (By the way, this is not hyperbole. All of these phrases appeared in comments on a recent post on The 802 United Facebook page in response to a factual article about gender affirming care).
If you are a “visual learner” like me, you will appreciate this graphic-laden article from Reuters describing the busy 2023 state legislative session:
Reuters also addresses states where 2023 laws are sparking 2024 controversy.
How does trans medical care access vary from state to state?
E. What’s the effect of all this anti-trans legislation?
a. On transgender people (especially the youth)-
Unsurprisingly, “research overwhelmingly shows these bills and laws, which target
access to health care, sports participation, and school policies, have resulted in
heightened levels of anxiety, depression, and suicide risk among the transgender
community.”
b. On providers of gender affirming care-
Also not a surprise, the bills have had a “chilling effect” on the number of programs
and providers willing to practice trans medicine in the involved states. Also, the
inflammatory rhetoric, designed to keep a certain element of the US population
engaged and voting, instead is leading to violence against those clinics and
practitioners.
F. What’s it going to take to support and protect our trans family?
Just like reinstating federal protection for abortion rights, and equal rights for
LGBTQIA+ individuals (such as with the Equality Act), gender affirming care deserves a
law at the federal level preventing discrimination over this type of medical care. Just
such a bill was introduced in the House in March of this year by Rep Pramila Jayapal
from Washington (state). Titled “A Transgender Bill of Rights”, the short description of
the bill reads:
“H.Res.269 - Recognizing that it is the duty of the Federal Government to develop and
implement a Transgender Bill of Rights to protect and codify the rights of transgender
and nonbinary people under the law and ensure their access to medical care, shelter,
safety, and economic security. 118th Congress (2023-2024)”
Until such a national law can happen, there are many ways to support our trans friends
and family, from emotional support to rallying and lobbying, from education (of
yourself and others) to holding our elected officials accountable. You can financially
support organizations that provide help to trans youth and their families, and stay
current in your own community about anti-trans rhetoric and legislation.
Here are some resources to start your journey:
Questions to ponder:
● True/ False: Trans medicine providers are operating on children as part of gender
affirming care
● Gender affirming care may include (select all that apply)-
● Using pronouns consistent with chosen gender
● Changes in clothing or hairstyle
● Calling someone by their name of choice
● Changing “sex” designation on a drivers’ license
● Puberty blocking hormones
● Psychiatric counseling for the patient and family
● Surgery
● What percentage of trans or nonbinary persons eventually elect to have gender
affirming surgery? (according to the Scientific American article cited above)- select
the best answer
● 100%
● 75%
● 25%
● 10%
● When did anti-trans laws begin to pop up more frequently in state legislatures?
● 2010
● 2015
● 2020
● 2023 (trick question, this is when they REALLY exploded, but the question asks
when the bills BEGAN to pop up)
● Bonus points if you can indicate my hypothesis about what happened that year
to prompt this effect _____________________________
● What group of people are affected by anti-trans legislation?
● Trans persons
● Families of trans persons
● Providers of gender affirming care
● All of the above
● Select one:
● It’s hopeless. There’s nothing I can do to help my trans friends and family
through this stressful and worrying time
● There are resources at the national, state and local level that can help me be
more aware of how I can help
So that’s the end of the curriculum, friends. You can suggest additional topics, give feedback, find out more about how to be an advocate, and generally connect with The 802 United at www.802united.org
Additional reading beyond the scope of this curriculum but nonetheless helpful for deeper background:
Appendix A- the Science behind emergency contraception
"Plain Language" article with references:
An excerpt from an article by one of the two committee members who repeatedly presented Plan B to the FDA for OTC approval, regarding how the politicization of the drug delayed its approval:
What Does the Timing of Plan B's Effectiveness Reveal About Possible Interference With Postfertilization Events? If Plan B interferes with implantation, it should be capable of preventing pregnancy when it is used after fertilization. In a recent clinical study23 in which timing of ovulation was determined quite precisely using hormonal criteria, no pregnancies occurred in the 34 women who had unprotected intercourse on days –5 to –2 (day 0 being the day of ovulation) and took Plan B (1.5 mg as a single dose) before or around the time of ovulation; 4 or 5 pregnancies would have been expected in this group if they had not used the drug. In contrast, 3 pregnancies occurred among the 17 women who had intercourse around days –1 to 0 and took Plan B on day +2; 3 or 4 pregnancies would have been expected had they not used the drug. Although the results of this study need to be confirmed and extended, they are consistent with epidemiological evidence on the efficacy of emergency contraception in relation to the timing of ovulation24 and are directly contrary to what would be expected if Plan B interferes with implantation.
Even the Roman Catholic church, when looking at ACTUAL SCIENCE, agrees that Levonorgestrel has no post ovulatory (abortifacient) effect:
Review article in the journal Contraception in 2010:
International Society for Gynecological Endocrinology Statement 2014:
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Follow up review article in Contraception in 2022:
Direct evidence at the genomic level that Levonorgestrel does not inhibit the endometrium (to affect implantation of a fertilized ovum):
[BW2]I took it to mean how rural a particular community is (as opposed to urban). I could put a definition in brackets- how would you phrase it?
[JW3]I might be confused. Is this available to anyone or only people who are over 65? From my research, this program is private and sucks. If I am right, do we want to even put that out there?
[BW4]It is only for disabled folks or those over 65. I have also heard bad things about it, but it's in the quote so I left it there. I could put in brackets [buyer beware- we are not endorsing Medicare Advantage]
[JW5]I believe the Kansas counties that will be receiving assistance here have been identified. Is there any value in sharing which counties in KS will have expanded broadband?
[BW6]Likely yes, I just have to figure out which ones that would be LOL
[JW7]Love all of the different ways you listed to get the information!
[JW8]I don’t understand this comment. Surviving infants that were born naturally? Surviving infants after abortion attempt?
[JW9]Does this EVER happen?
[JW10]Change to took effect?
[JW11]Is there a specific age in Kansas? Is that age/maturity determined on individual basis? Does the medical facility decide the age for all of their patients?
[JW12]Do you think it would be appropriate to have Hazel do a little video about her journey?
;