When Dr. Andrea Henkel was training at Stanford Health Care, a patient visited the emergency room twice in one week for vomiting associated with early pregnancy. The patient said she didn’t plan on continuing the pregnancy and had an appointment for an abortion the next week.

“She was clearly miserable from a pregnancy that she didn’t want,” Henkel, a complex family planning specialist, said. “I wondered why we couldn’t just initiate her abortion via pills while she was in the emergency department—we already knew her gestational age and medical history, and she was certain on her decision.”

Henkel’s experience that day inspired change. Along with Dr. Monica R. Saxena, an emergency medicine physician at Stanford Health Care, Henkel developed a new protocol to offer medication abortions to patients in the emergency department. The two doctors began developing the program in the summer of 2021 and had it up and running by February 2022.

Now, if a patient checks into the Stanford ER with a pregnancy they wish to terminate, they receive comprehensive options counseling and are offered the option to initiate a medication abortion in the emergency department if they are less than ten weeks along. This approach cuts down delays, integrates abortion care rather than siloing it away from the rest of medicine, and acknowledges that not all pregnant people want to remain so—something that is often missing in hospital settings, where pregnant patients are frequently referred to prenatal care based on an assumption that they want to continue their pregnancies.

Saxena said the response to the change has been overwhelmingly positive.

“As emergency physicians, we treat all comers no matter their medical problem or station in life,” Saxena said. “As abortion is health care, it belongs in the [emergency department].”

In the United States, clinics provide the overwhelming majority of abortions—95 percent, to be exact. A mere 5 percent take place in hospitals and physicians’ offices.

However, since the Supreme Court overturned Roe v. Wade in late June, 14 states have banned all or most abortions. As a result, at least 66 clinics across 15 states have stopped providing abortion care. With overwhelmed clinics reporting wait times as long as six weeks, many advocates are pushing for hospitals to take a page out of Stanford’s book and use their tremendous resources to expand access.

Major obstacle in key states

In New York, initiatives to make abortion more accessible in hospitals—particularly New York City’s public hospitals—predate this current crisis. After state lawmakers enacted the Reproductive Health Act in 2019, New York City Health + Hospitals created easy-to-navigate resources for people seeking an abortion, built capacity to provide them through 26 weeks’ gestation, and increased the number of its facilities that provide abortion care.

When, in 2022, Gov. Kathy Hochul announced a $25 million Abortion Provider Support Fund as a part of New York’s post-Roe plan, numerous hospitals received support to expand their services. She also signed bills to improve access and protect abortion patients and providers in the state.

The governors of California, Oregon, and Washington jointly pledged to take similar steps, but a major barrier exists in these states: Catholic hospitals, which prohibit almost all abortions.

According to a 2020 report from the nonprofit consumer advocacy group Community Catalyst, in Oregon, 30 percent of acute care hospital beds are in Catholic-affiliated facilities. In Washington, it’s a whopping 41 percent, second only to Alaska’s 46 percent. Colorado, another supposed abortion haven state, also has a disproportionately high number of Catholic hospital beds at 38 percent. Nationwide, the average is about 16.8 percent, or roughly 1 in 6 hospital beds.

Though its overall numbers aren’t as high as in Oregon, Colorado, and Washington, California is home to numerous large Catholic hospital systems, and the University of California contracts with Catholic hospital giant Dignity Health. This association has been controversial, and in 2021, the University of California Board of Regents approved new regulations intended to limit Dignity’s ability to impose religious restrictions on doctors or other UC staff. However, it remains to be seen how effective this policy change will actually be. Pressure is mounting for UC to end its partnership with Dignity entirely.

At the University of California-San Francisco, renowned for its progressive OB-GYN education and research, both procedural and medication abortion care are already offered to patients in the emergency department, said Dr. Ashley Jeanlus, a complex family planning fellow at UCSF and fellow with Physicians for Reproductive Health. Jeanlus confirmed that California hospitals are seeing a noticeable uptick in out-of-state patients, which began after Texas enacted a near-total abortion ban in September 2021. Now, Jeanlus said she sometimes cares for people from five different states in the course of a single day.

‘Providers have an important role to play’

In addition to expanding access to abortion counseling and care, Jeanlus said hospitals need to get familiar with other forms of patient support in which clinics are so well-versed.

“Hospitals need to recognize that abortion funds are really doing the hardest work of making sure that individuals actually have the funds to be able to travel to get that abortion care,” she said.

Finally, hospitals have a critical role to play in making sure that the next generation of doctors doesn’t miss out on abortion training. UCSF is hosting as many medical residents as possible from states where abortion is banned to provide training they can’t get at their home institutions, said Flor Hunt, executive director of the Training in Early Abortion for Comprehensive Health Care (TEACH) program, which trains family medicine doctors in abortion care. However, there are capacity challenges involved in hosting out-of-state groups, because not all clinical settings offer trainees enough exposure to abortion care to become truly proficient.

“You’re not going to gain competency in abortion care by doing three miscarriage follow-ups per week in a hospital,” Hunt said. “You’re going to get it by working with high-volume family planning clinics. Clinical training is only one component of supporting providers who want to incorporate abortion into their scope of work, so we have put a lot of effort into developing a leadership, reproductive justice, and advocacy training component—understanding that the barriers that these providers will face when leaving residency go beyond clinical experience.”

Such barriers can include resistance from hospital and practice administrators who are hesitant to offer abortion care, or difficulties in securing malpractice insurance based on the misperception that abortion care is “risky.” TEACH also worked with California lawmakers on AB 1918, a law that established a Reproductive Health Service Corps to expand and diversify the state’s reproductive health workforce and better reach underserved areas.

“Providers have an important role to play in the conversation around reproductive freedom, and we want to equip them with the tools to take part in that dialogue and use their knowledge and experience to inform public policy,” Hunt said.