American Association of Pro-Life Obstetricians and Gynecologists: An Interview with Dr. Christina Francis, CEO
Dr. Christina Francis is CEO of the American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG), a professional medical organization of women’s health care professionals committed to practicing medicine according to pro-life principles, and board member of Indiana Right to Life. She has testified before Congress on abortion’s impact on the health of her patients. She is a board-certified obstetrician and gynecologist currently working in Fort Wayne, Indiana. She has previously worked with orphans in Romania and Burma and spent three years as the only OB-GYN at a rural mission hospital in Kenya. She addressed the 2023 March for Life in Washington and spoke with the Human Life Review (HLR) about pro-life issues post-Dobbs from a medical professional’s perspective.
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HLR: Please provide a global overview of the challenges facing pro-life professionals in health care, especially OB-GYNs. Where are the likely flashpoints that would present challenges to the convictions of a pro-life health care professional wanting to work in the fields of obstetrics and gynecology?
Dr. Francis: One of the main challenges facing U.S. pro-life medical professionals is the significant pressure placed on them by medical professional organizations, such as the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG), to support, refer for, and perform induced abortions. These organizations ignore the fact that when we are caring for pregnant women we have two patients. They staunchly support unrestricted access to abortion—not because the science demonstrates any health benefits, but rather purely for ideological reasons. As a result of these ideological biases, aspiring pro-life medical professionals face challenges at pretty much every step of their career. In undergraduate studies and medical school, they face a general hostility towards pro-life views or even free discussion of the issue and are told that being openly pro-life will hurt their future career options. During medical training, as of 2018 they must actively opt out of participating in procedures that intentionally end the lives of preborn human beings, which results in being perceived as less willing to put in necessary work to complete their OB-GYN training. Many OB-GYN residents have faced a negative, coercive environment as a result of their decision to opt out of performing these procedures. Once they complete their residency, they must deal with continued threats to their ability to practice according to the oath they took to never intentionally harm their patients.
For example, following the Dobbs decision, the American Board of Obstetrics and Gynecology (ABOG, the OB-GYN board certification body) released a statement threatening the board certification of any physician who promotes “misinformation or disinformation” on abortion. Because ABOG has refused to specify their definition of “misinformation,” pro-life OB-GYNs have reasonably extrapolated from ABOG’s history of supporting unrestricted induced abortion that this was a veiled threat against them, designed to have a chilling effect on their willingness to practice or publicly discuss life-affirming medical care and offer their patients evidence-based information about abortion.
In short, being a pro-life medical professional means pushing back against the forces that are turning medicine away from its purpose of promoting and restoring health as well as advocating for the dignity of one’s patients, born and preborn.
HLR: In 1973, Congress enacted the Church Amendment, ostensibly providing conscience protections to medical personnel who did not want to participate in abortions or sterilizations. Why does it seem that what is supposed to be legally protected is under such stress, if not outright subversion?
Dr. Francis: It’s interesting that as soon as Roe legalized abortion nationwide, Congress recognized that there would be a danger of medical professionals facing pressure to perform them. That was not mere conjecture: The effort was already in process. Beginning in the early ’70s, a vocal pro-abortion minority within ACOG’s leadership began pushing a change to ACOG’s position, from only supporting medically necessary separations between a pregnant mother and her preborn child (or a “therapeutic abortion”) to endorsing induced abortion for any health reason. By redefining “health” to broadly include emotional, financial, and social health (following Doe v. Bolton), ACOG ensured that any abortion that a mother feels she needs is medically necessary and vital to protecting her health. This paved the way to framing abortion as essential health care, a necessary step towards trying to ensure that every physician provide them.
Then, in 2007, ACOG published its Ethics Statement #385, “The Limits of Conscientious Refusal in Reproductive Medicine.”1 This guidance statement ostensibly sought to answer the question, “what should physicians do when asked to participate in a practice that violates their conscience?” In it, ACOG argues that physicians ought to be required to perform certain procedures against their conscience if the patient requests it or if it is deemed to be essential health care. The paper redefines conscience, reducing it to a personal problem, something physicians only consider in the context of maintaining “personal wholeness or identity.” It ignores the true definition of conscience as one’s awareness of objective right from wrong,2 and thus justifies dismissing outright the moral concerns of physicians whose ethical views deviate from the patient’s or the state’s. Rhetoric like this paved the way for the trampling of conscience rights in the medical community.
Other members of the medical community paid attention. In a 2017 New England Journal of Medicine article,3 Drs. Ronit Stahl and Ezekiel Emanuel outline what they see as the “problem” of conscientious objection. You may recognize the name Ezekiel Emanuel—he worked for the Obama Administration and was the architect of the Affordable Care Act. In this article, the authors set up ACOG as the ideal for how other medical associations should combat conscience protections, stating they have “upheld the primacy of the patient” and referring to their 2007 ethics statement. They encourage other medical associations to follow suit, and indeed they have. What is Stahl and Emanuel’s solution for those of us who desire to provide life-affirming care for our patients? “[S]elect an area of medicine, such as radiology, that will not put them in situations that conflict with their personal morality or, if there is no such area, leave the profession.”
HLR: The Accreditation Council for Graduate Medical Education and ACOG claim abortion training should be a “readily available” component of specialist training, leaving the threat that medical education programs in states that restrict abortion under the Dobbs decision will be unaccredited, suggesting their graduates are not competently trained doctors. They also assert that such physicians will lack vital skills for uterine evacuation, even in non-abortion contexts. What do you say?
Dr. Francis: Surgical induced abortions are performed using the same procedures that are used to manage miscarriages. The only difference between, for example, a D&C performed to treat a miscarriage and a D&C abortion is that the former is used to evacuate a woman’s uterus when her embryonic or fetal child has already passed away, whereas the latter is used to intentionally end that child’s life, in a very painful way. Every OB-GYN physician receives training in uterine evacuation regardless of whether they obtain additional instruction in induced abortion. It is a vital component of OB-GYN care that every physician in our specialty uses regularly.
For these reasons, physicians can gain competence in these procedures by treating patients experiencing miscarriage, something that is tragically very common. The ACGME only requires that OB-GYNs perform twenty pregnancy-related uterine evacuations before completing residency. That is easily achievable over four years. Thousands of OB-GYNs around the country, including myself, completed their residency training at hospitals that have policies against performing induced abortions and are currently offering excellent health care to patients.
HLR: Many of these groups have been threatening to use accreditation standards as leverage to force young doctors into abortion, particularly since
pro-abortionists claim that the number of doctors willing to do abortions is declining. Can you give us some historical perspective on this issue? What percentage of OB-GYNs actually perform abortions? And how many of those performing abortions are not actually OB-GYNS?
Dr. Francis: Despite the assertion by abortion advocates that it is “essential health care,” the vast majority of OB-GYNs—76 percent in academic practice, 86 to 93 percent in private practice—don’t perform abortions. That number showed a steady decline into the 2010s and has remained relatively stable since, in spite of efforts by various medical bodies to push more OBGYNs into participating in the practice (one major example being the changing OB-GYN abortion training requirements I explained previously). If, in fact, induced abortion was essential health care for women, these percentages would be significantly higher.
Though I don’t know the exact numbers of abortionists who are not OBGYNs, I can tell you that this number has likely increased due to endeavors by organizations such as National Academy of Science (NAS)4 to encourage ancillary health care workers to start practicing induced abortions. Advanced Practice Registered Nurses (APRN) and Certified Nurse-Midwives (CNM) are now allowed to perform them in some states.
HLR: Doctors enjoy some measure of autonomy compared to, say, other medical personnel like nurses or ultrasound technicians who could get threatened, at the cost of professional credentials or employment, to participate in abortion. Is this legal? What can a nurse or someone in that situation do?
Dr. Francis: No medical professional should ever be coerced into participating in a procedure that violates their conscience or that they see as morally wrong. Thankfully, our federal and many state governments have long recognized this. Through several federal conscience protections, medical professionals who are censured for refusing to violate their conscience or harm their patient can file a case with the Office of Civil Rights (OCR) at the Department of Health and Human Services (HHS). It is their job to protect us. They have shown they are willing to do this, but that has been very administration-dependent. For instance, a Vermont nurse was fired for not assisting in an abortion. Despite the Department of Justice’s (DOJ) finding during the Trump Administration that the hospital had clearly violated federal law when they fired her, the Biden DOJ dismissed5 the suit, and the nurse was left with no recourse. Medical professionals need but currently lack a private right of federal action so they can sue on their own behalf. Some states have this in place, and I hope more will follow suit. Until that happens, all medical professionals are dependent for conscience protection on the whims of HHS and DOJ. I always encourage medical professionals who might be in situations where they could be pressured into participating in induced abortion to be familiar with their hospital’s policies on conscientious objection.
HLR: In a bid to “expand abortion access,” some states have legally authorized non-physicians to perform abortions, something you noted NAS has pushed. As an OB-GYN, what is your professional opinion of this? Does this endanger women?
Dr. Francis: This is clearly an example of the push to expand access to abortion at any cost—including patients’ health. To put this into perspective, note that OB-GYNs receive over a decade’s worth of education and training before qualifying to perform surgical procedures such as those used in induced abortions. They start with a bachelor’s degree, followed by medical school, followed by four years of residency. Only at the end of all this are they licensed to perform surgeries. This training prepares them to recognize and manage complications that may arise; at least 1 in 506 surgical abortions require further surgery to treat complications. Many of the common complications of surgical abortion would best be served by people with extensive medical and surgical knowledge.
In contrast to the extensive training OB-GYNs receive before being able to perform surgeries, CNM training programs only require a bachelor’s or associate’s degree and focus on the normal delivery of term infants. Many APRN training programs only require a three-year associate’s degree, and offer one to three years of additional training, none of which is focused on the performance of surgery or management of complications. While ancillary health care workers are essential to the health care system, it is incredibly risky to allow health care professionals to perform surgery beyond their training or administer drugs with the high complication rate (including an approximately 8 percent rate of needing surgery) of abortion pills. No medical body would accept this in any context other than abortion. Our patients deserve better.
HLR: Pro-abortionists also contend that laws requiring those performing abortions to have admitting privileges at a local hospital are really “TRAPs,” i.e., “Targeted Restrictions on Abortion Providers,” having no medical purpose but to provide legal excuses to keep abortionists out of some places. How do you answer this claim? Isn’t it sufficient that any woman can go to a local emergency room should she suffer post-abortion complications?
Dr. Francis: Hospital admitting privilege requirements are about ensuring high-quality health care for women undergoing a risky7 procedure at an outpatient clinic. As even ACOG admits, accurate communication of patient information from one health care team to the next during a patient handoff is essential: Breakdowns in such communication are a leading cause of medical error, which can seriously harm patients. Admitting privileges, which would allow physicians to directly admit women to the hospital in the event of complications after or during an abortion, allow for more expeditious care for potentially life-threatening conditions as well as clear handoffs from the abortion provider to the team that will care for the woman in the hospital. Currently, women are either directed to the emergency room or urgent care centers when complications arise or occasionally are transported from the abortion facility to the hospital via ambulance—but with very little, if any, communication between the abortion provider and the receiving medical team. The receiving team typically does not have contact with the abortion providers or access to patient histories, which represents a significant gap in crucial communication. It’s interesting that organizations like ACOG recognize the importance of proper patient handoffs but don’t apply those standards to women seeking abortion. They do not encourage any form of handoff between abortion providers and emergency personnel, and no standards for such handoff exist.
HLR: Prenatal diagnosis is increasingly being used to identify and eliminate handicapped children prior to birth. Even in those states that outlaw abortion for eugenic reasons, it seems one might evade such restrictions simply by claiming other reasons for an abortion. What is your take on this?
Dr. Francis: Since I am not a policy expert, I can’t say much on how policymakers can make restrictions on eugenic abortions more enforceable. As a physician, however, what I can say is that medical professionals can do their part to achieve the goal of such policies: to ensure that all human beings, no matter their level of ability or development, are treated with dignity in the health care system. This includes using life-affirming language when speaking with pregnant women about their preborn child after receiving a difficult prenatal diagnosis. We should avoid using terms like “non-viable,” “lethal,” or “incompatible with life” when describing the child or her diagnosis. Instead, medical professionals can keep in mind that she is still a human being even with her diagnosis, and that we are committed to promoting good outcomes for her as much as possible. Often, patients obtain abortions after receiving adverse diagnoses because their health care team makes termination sound like the easier or even more ethical option. We can combat this trend by rejecting the eugenic framework that often shapes these conversations.
Another thing medical professionals can do to empower their patients to choose life is to talk to them about perinatal palliative care. Often, when faced with a potentially life-limiting prenatal diagnosis, parents choose abortion because they assume it will make the grieving process easier—despite the lack of evidence for this. Perinatal palliative care gives families support as they walk with their child in her final stage of life when that stage comes much sooner than any parent would want. This service gives them the opportunity to hold and grieve their child if the diagnosis does, in fact, lead to her death, but also allows for the possibility that the diagnosis was wrong or that medical treatment can be provided. It is associated with better mental health outcomes than induced abortion and respects the child’s dignity and value in a way that abortion never can. There is no material difference between a child receiving a serious diagnosis prenatally and after birth; both deserve respect for their lives and to know that they are loved.
HLR: Several states have “wrongful life” laws, making OB-GYNs liable if a handicapped child that could have been aborted wasn’t. I imagine this contributes in no small measure to OB-GYN malpractice insurance premiums. What’s a pro-life doctor to do in these cases?
Dr. Francis: Every life has inherent value and worth, and this is not dependent on a person’s ability level. With increasing medical technology, we are now able to diagnose certain genetic conditions prenatally. However, as is common in many other arenas, the ethics have not quite caught up with the technology. As an OB-GYN, my job is to provide both my patients with excellent health care. This means never intentionally ending the life of my preborn patient and providing my maternal patient with the support and resources she needs, even in cases of complex prenatal diagnoses.
HLR: Pro-abortionists claim that women do not resort to third-trimester abortions except out of dire medical necessity and that terms like “partial birth abortion” are medically inaccurate mischaracterizations of rare but serious medical situations. Myth or truth?
Dr. Francis: Myth. The implication that women need third-trimester abortion to manage life-threatening pregnancy complications simply isn’t true. There is no pregnancy complication that could arise in the third trimester that cannot be treated by delivering the baby. Induced abortion aims to end a pregnancy specifically by ending the fetus’s life. There is no reason to do that—especially well past the point of viability. In fact, given that it takes several days to prep a woman for a third-trimester abortion versus the thirty minutes or some hours it would take to perform a C-section or deliver via induction of labor (respectively), choosing abortion in a true medical emergency is likely extremely risky for the mother as well. In fact, the medical literature is very clear that the further along in pregnancy an abortion is done, the higher the risk for the mother. The risk of dying from an abortion increases by 38 percent for every week beyond eight weeks an abortion is performed. If mom and baby need to be separated, the physician can do that via delivery and then treat them both separately.
A handful of studies have been conducted to explore the reasons that women choose second and third-trimester abortions. One 2022 study8 found that a California university aborted an average of 10 fetuses per month at 20 or more weeks that had no fetal anomalies. Recently, a Colorado-based late term abortionist told The Atlantic that at least half of his patients have no fetal or maternal health conditions.9 Often, women abort in later weeks for the same reasons that they would do so in earlier weeks: poverty, lack of support, not feeling ready to parent. The only difference is, they have reasons to delay accessing their abortions. Some don’t know they are pregnant until later. Some take longer to gather the money.
Recently, the pro-abortion activist organization Physicians for Reproductive Health acknowledged that many later abortions are done for purely social (elective) reasons in an Instagram post, stating “. . . this idea that abortion later in pregnancy is rare and only ever happens in emergency medical situations isn’t true . . . there are a myriad of reasons people get abortion at any stage of pregnancy, and they all matter.”
HLR: To what degree do you think this pro-abortion pressure transforms medical personnel from a conscience-bearing health care professional to a provider who supplies what the consumer wants? How does that change the ethos of the vocation?
Dr. Francis: This is a huge issue within our profession—we are increasingly being viewed as “providers,” which has a strong implication that our job is to offer patients what they want rather than making expert recommendations in service of maximizing the patient’s health, based on our judgment of the patient’s clinical scenario, in a way that aligns with medical ethics and our own conscience. This is one of the forces pushing pro-life professionals out of the profession of medicine and eroding the doctor-patient relationship. HLR: Given the pressures put on pro-life health care personnel, there’s clearly a concerted effort to push such people out of the profession. What would you say to a pro-life young person who is considering such a profession?
Dr. Francis: I would absolutely say there is an effort to push pro-life medical professionals out of health care, led by major medical associations. Especially in the past two years, we have seen deliberate efforts to exclude them from the field. Most recently, AAPLOG was barred from exhibiting at one of ACOG’s major medical education conferences, a decision which they openly admitted was due to our pro-life views. A few months prior to that, AAPLOG faced a nearly identical situation with the American College of Nurse-Midwives (ACNM).
To pro-life prospective medical professionals, I would say: Be aware of, but not deterred by, the challenges that you will face. Remain grounded in the truth that human lives at all stages—from fertilization to natural death— are valuable and worth all the sacrifices you will make. Know that you are not alone; the radical agendas of organizations like ACOG do not reflect the views of most medical professionals or even most of these organizations’ members. You are in the company of tens of thousands of health care workers who, like you, entered the field to save, not end, lives. They have no interest in their extremist ideology. Last, you would be working alongside pro-life medical professionals like our members at AAPLOG, who can offer you support, fellowship, and mentorship. AAPLOG exists to support your pro-life practice. If you’re interested in getting involved, you can visit our website at www.aaplog.org.
HLR: Thank you, Dr. Francis.
NOTES
2. https://aaplog.org/wp-content/uploads/2019/07/AAPLOG_1-1.pdf
3. Stahl RY, Emanuel EJ. Physicians, Not Conscripts—Conscientious Objection in Health Care. N Engl J Med. 2017 Apr 6; 376(14):1380-1385. https://www.nejm.org/doi/10.1056/NEJMsb1612472. PMID: 28379789.S
5. “US Dismisses Suit Against Vermont Hospital Over Abortion.” Associated Press, 2 August 2021. Accessible at https://apnews.com/article/business-religion-vermont-3ba43d690bad76f3f9680df4ad99 bcd3
6. Niinimäki M, Pouta A, Bloigu A, Gissler M, Hemminki E, Suhonen S, Heikinheimo O. Immediate complications after medical compared with surgical termination of pregnancy. Obstet Gynecol. 2009 Oct;114(4):795-804. https://journals.lww.com/greenjournal/Abstract/2009/10000/Immediate_ Complications_After_Medical_Compared.14.aspx
7. Risk of abortion-related death increases by 38 percent for every additional week of gestation at which it is performed starting at 8 weeks. Chemical abortion has four times the risk of complications that surgical abortion has. Common complications include hemorrhage, sepsis, and uterine perforation. See more at Bartlett L, Berg C, Shulman H. 2004. “Risk factors for legal induced abortion related mortality” in the U.S. Obstet Gynecol. 2004 Apr;103(4):729-37. https://www.ncbi. nlm.nih.gov/pubmed/?term=Obstet+Gynecol+103%3A729-737; Niinimäki M, Pouta A, Bloigu A, et al. “Immediate complications after medical compared with surgical termination of pregnancy.” Obstet Gynecol. 2009;114(4):795-804. For AAPLOG research on the risk issue, see https://aaplog. org/wp-content/uploads/2022/07/CO-9-Mifepristone-restrictions-update-Jul-22.pdf and https://aaplog.org/wp-content/uploads/2020/01/FINAL-CO-6-Induced-Abortion-Increased-Risks-ofMaternal-Mortality.pdf
8. Lundberg BR, Tabuyo-Martin A, Ponzini MD, Wilson MD, Creinin MD. “Contraceptive plans before preoperative assessment and at procedure in surgical abortion patients.” Contraception. 2022 Mar; 107:48-51. doi: 10.1016/j.contraception.2021.10.008. Epub 2021 Nov 5. PMID: 34748751; PMCID: PMC10091507.
9. Godfrey, Elaine. “Warren Hern: The Abortion Absolutist.” The Atlantic, 12 May 2023. Accessible at https://www.theatlantic.com/politics/archive/2023/05/dr-warren-hern-abortion-post-roe/674000/
