As residents of one of the most pro-choice states in the nation, Vermont women seeking abortions may be less worried about president-elect Donald Trump's pledge to choose anti-abortion judges, support a ban on abortions after 20 weeks of pregnancy and cut federal funds for Planned Parenthood.
But even in Vermont, abortion — one of the most common surgical procedures for women — has never been included in mainstream medical care. Women seeking early-term surgical abortions rely on three Vermont Planned Parenthood clinics. To get a legal, late-term abortion, they often have to leave the state.
Only now, 43 years after Roe v. Wade, is the University of Vermont Medical Center, the state's largest hospital, quietly starting to change its long-standing policy of performing abortions only when they are "medically necessary" — meaning the mother's health is at risk or something is wrong with the fetus. Currently, only two other hospitals serving Vermont women acknowledge providing abortions.
"Abortion isn't treated like any other medical procedure, so it faces unique challenges — which is bullshit, in my mind," says UVM med student Emily Ryan. She's a member of Vermont Access to Reproductive Freedom, a nonprofit that helps local women arrange and pay for abortions.
Even if the 1973 decision were overturned, Vermont would almost certainly uphold a woman's right to abortion. Unlike a number of other states, it has no laws requiring waiting periods or parental consent. Private insurers and the state Medicaid program cover the procedure, although using federal Medicaid money is prohibited.
But knowing that choice in Vermont is almost entirely dependent on Planned Parenthood, which is under renewed attack, reproductive health advocates argue that it's time to expand access to abortion services in the state.
Around the time of Roe v. Wade, the UVM Medical Center's board decided that the hospital wouldn't provide elective abortions unless the need wasn't being met elsewhere, according to Dr. Ira Bernstein, chair of UVMMC's Department of Obstetrics, Gynecology and Reproductive Sciences. Physicians at UVMMC are willing to prescribe the abortion pill, but, with only occasional exceptions, the hospital refers women seeking elective surgical abortions to Planned Parenthood of Northern New England.
"We didn't feel as though we wanted to be in a position to compete around the basic service of elective termination," said Bernstein.
That position is out of character for an institution that competes with independent medical practices in almost every other specialty.
And why does the hospital compete with Planned Parenthood when it comes to contraceptive services, but not on abortion? Fear of the controversy appears to play a role: "From a historical perspective, I don't think anybody could believe that, in terms of social implications and the balance of what's going on in any community, that those are equal, relative to whether or not you're going to get picketers outside or other issues," Bernstein said.
Although Bernstein did not mention it until specifically asked, the hospital may start providing surgical abortions in a clinic setting as early as next summer.
Other hospitals remain more reluctant.
"Quite a few years ago as a board, a decision was made not to do abortions here unless it were an emergency," says Gifford Medical Center's medical director, Dr. Louis DiNicola. Like Bernstein, DiNicola, a pro-choice pediatrician who's worked at the Randolph hospital for 40 years, makes the case that offering abortions at Gifford is not necessary. "We are not afraid to do things that we feel will benefit our community if there is a strong community need. I'm not hearing from anyone that we have that kind of community need or desire."
DiNicola also acknowledged, "I think there is always a philosophical component. I don't think you can ever say it's only a medical decision."
Dr. Kym Boyman, who owns the independent Vermont Gynecology practice in South Burlington, disagrees: "In general, there really is no appropriate patient care reason to restrict access to a safe and legal procedure," she said, when asked whether hospitals should provide the service.
Four Vermont hospitals — Copley, Northwestern Medical Center, Central Vermont Medical Center and Mt. Ascutney — do not perform elective abortions. On the other end of the spectrum and across the Connecticut River in New Hampshire, Dartmouth-Hitchcock confirmed that it will terminate unwanted pregnancies for Vermonters in the Upper Valley. At Northeastern Vermont Regional Hospital in St. Johnsbury, spokeswoman Laura Ruggles responded, "It's legal, so why wouldn't we offer it?"
Most of the other Vermont hospital spokespeople equivocated when asked about abortion access.
A Rutland Regional Medical Center spokesperson said Planned Parenthood usually provides those services; spokespeople for Southwestern Vermont Medical Center and Porter Medical Center said they don't have policies addressing abortion.
Even more mysterious: Jared Jewett, a spokesperson for North Country Hospital in Newport, declined to answer the question, citing concerns about the "security and safety of our patients and staff."
Seven Days found only one independent provider that acknowledged performing abortions — and the entity didn't want to be identified.
This inclination to keep abortion services on the down-low suggests Vermont women may not know there are any options outside of Planned Parenthood. Not a single hospital shows up in a Google search for abortions in Vermont.
Vermont Department of Health stats support that theory. In 2012, Vermont clinics performed 1,215 abortions compared to 29 in hospitals and 29 in private doctor's offices.
Vermont is not unique in this regard. After Roe v. Wade, 100 ob-gyn professors nationwide signed an open letter urging independent obstetricians and hospitals to start providing abortions. The plea went unheeded: Today, 90 percent of U.S. abortions take place in freestanding clinics.
In Vermont, Planned Parenthood operates those facilities. The nonprofit provides the "abortion pill," a medication that can be used to induce abortion for women who are up to 10 weeks pregnant, at five of its health centers, but it provides surgical abortions at only three — in Burlington, Rutland and White River Junction.
"We have been working really hard to expand access around abortion care in this state in a couple different ways," said Jill Krowinski, vice president of education and Vermont community affairs at PPNNE. The organization is training more nurse practitioners to perform abortions, and it recently worked with state officials to ensure Medicaid reimbursement for nurse-midwives who provide the service.
Geography can be a barrier in Vermont. Krowinski noted that in rural areas such as the Northeast Kingdom, where public transportation is lacking, "there's not easy access to abortion providers."
Planned Parenthood provides abortions to women who are up to 19 weeks pregnant. That covers most cases — 92 percent of abortions take place during the first 13 weeks.
Getting an abortion after 19 weeks becomes significantly more difficult; the number of willing providers shrinks, and costs increase. Although state law doesn't restrict when an abortion can occur, most Vermont women must travel to another state to get the procedure.* Planned Parenthood refers these patients to hospitals in and around Boston, New York, Atlanta and Albuquerque.
Some women can't afford it, and travel adds to the cost. Vermont Access to Reproductive Freedom tries to help women who don't have insurance or don't want to use it because they're concerned family members will find out. First-term abortions generally cost about $500; late-term abortions can exceed $10,000. "We have more calls than we can fund, usually," said Ryan.
Planned Parenthood is widely praised for its reproductive health services, which go far beyond abortion. But the high-profile nature of the organization makes patients coming in for appointments easy targets for anti-abortion protesters and proselytizers. "Creating a very physical, very separate place for people to go when they have 'that thing done to them' — to me, it's an obvious problem," Ryan said.
Libby Day, a third-year medical student, got pregnant while on birth control in 2012 and sought out the abortion pill at Planned Parenthood. She said she was happy with the care she received and encountered "only two protesters" on her way in. Still, she said, "I hope in the future that it's more normalized and that it can happen with a physician or nurse practitioner that you know and are comfortable with."
She and Ryan both suggested that bringing abortion into hospitals and doctors' offices would reduce stigma in a couple of ways. On a practical level, it would provide a more discreet setting for women seeking abortions. It would also send a message — that abortion is no different than other medical procedures.
PPNNE would happily relinquish its de-facto monopoly, according to its medical director Donna Burkett, who said such a change would give "patients broader access and more choices for that procedure."
Mary Beerworth, executive director of the Vermont Right to Life Committeee, doesn't buy it. She doubted that Planned Parenthood, which she calls the "Abortions-R-Us" of Vermont, would actually embrace competition. But knowing that abortion will likely remain legal here, she said she'd prefer if primary care physicians handled the procedure. At least they'd be familiar with a patient's medical history, she noted. The goal of her group, she added, is to give women "balanced and real choices."
Limited options affect not just women seeking abortion but the medical students who want to learn the procedure. The only formal education UVM offers its students is an hourlong lecture in the second year of med school. "If you're interested in cardiothoracic surgery at UVM, you can just email the cardiothoracic surgeon and probably get invited to the OR and get to see a procedure," said Ryan, who's considering becoming an ob-gyn. In her experience, that kind of access doesn't exist for people interested in becoming abortion providers.
UVMMC does have an arrangement with Planned Parenthood in which the school pays the nonprofit to host residents. But Planned Parenthood has trouble accommodating everyone. "In New England we are fortunate to have a lot of students and residents who are very interested in learning this procedure," said Burkett. "On the flip side of that, there is, across the region, a shortage of clinical training opportunities."
Day, who intends to specialize in gynecology, said she'd have to travel to an out-of state hospital to learn how to terminate a pregnancy in the second trimester.
UVMMC is taking steps to improve its abortion training. In September, the medical school hired Dr. Lauren MacAfee, a physician who did her residency at UVMMC and completed a family planning fellowship at the University of Michigan.
The medical center is applying for a grant from the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning, which gives money to support abortion training for ob-gyn residents. If it gets the money, MacAfee aims to establish a training program by next summer. That means UVMMC would provide a wider range of services to patients, including elective abortions, at an outpatient clinic.
MacAfee noted that "while I love and support Planned Parenthood and have worked for them ... I do recognize the stigma that is placed on them and want women to understand that they have another option."
She told Seven Days that within the Women's Services division, which includes UVMMC's ob-gyn clinics, some physicians are already occasionally doing elective abortions for current patients, but she acknowledged that this is "not a very well-known fact." In the future, she said, "We will be more open about that."
She added, "I want women to feel supported, even more so in this political climate."
*Correction, November 23, 2016: An earlier version of this story misstated the time within which it's legal to get an abortion in Vermont. The story was also updated to clarify the distinction between the UVM Medical Center and UVM's medical school, known as the Robert Larner School of Medicine.
Tags: Healthcare, abortion, Planned Parenthood, Roe v. Wade, abortion access, reproductive rights, University of Vermont Medical Center, Planned Parenthood of Northern New England, St. Albans Health Center/Planned Parenthood