It was time to take action. In a span of a month in 2010, three physicians were charged with performing abortions in Elkton that were inconsistent with safety standards.
The botched procedures spurred the Maryland Department of Health and Mental Hygiene to begin to craft and then propose a new set of health and safety regulations for surgical abortion facilities, department Secretary Joshua Sharfstein said.
Formally proposed in December 2011, DHMH's preliminary draft consisted of requiring all surgical abortion clinics that routinely perform the procedure to secure a license from DHMH, unless the facility is already regulated by the state. It required department officials be permitted to drop in for inspections. About seven months and nearly 1,200 public comments later, the new regulations went into effect around the state.
"The goal of the standards is to avoid problems," Sharfstein said.
The issue of abortion is a politically charged one. Some advocate a life is a life, and it shouldn't be taken away. Others say the woman has a right to choose what the best option is for her.
This year saw a renewed effort for state legislatures across the U.S. to pass abortion restrictions.
But DHMH's 2012 regulations differed from many changes enacted around the country, some of which pro-choice proponents said are aimed at shuttering abortion clinics. In a showing of uniformity, many Maryland pro-life and pro-choice advocates lauded the new standard of care protocol.
"It is certainly opening up a new era of policy," Jeffrey D. Meister, Maryland Right to Life director of administration and legislation, said. "As these begin to be enforced, and we get to see this new era unfolding where some of the unfortunately negligent facilities can finally be accountable for endangering lives of women."
The new regulations lessen the potential harm a woman may experience, he said, and that's a good thing.
Defend Life Director and Founder Jack Ames said it was a step in the right direction, but more should be done. Maryland should heed the example of Nebraska, Texas and several other states banning the procedure after the fetus reaches 20 weeks post-fertilization on the basis that it can feel pain at that point.
"Of course, all abortions are wrong, and we want to get rid of all of them," Ames said. "But maybe the way [Maryland is] going, to get rid of them is incrementally tightening up the regulations."
Per Maryland's code, the DHMH has the authority to regulate surgical abortion sites. However, it must adhere to two strict guidelines: Adopted regulations must not impede with the life or health of a woman, nor are they allowed to be inconsistent with established medical practices.
The proposals did not include "unnecessary requirements that could substantially limit access to surgical abortion services," according to a December 2011 DHMH news release, citing specific width requirements that other states have passed for a clinic's hallways as needless.
"Rather, the proposed regulations require that the environment be safe, functional and sanitary," the release states.
A dozen states specify the size of procedure rooms and a dozen also specify corridor width, according to Guttmacher Institute, which keeps tabs on abortion issues and seeks to advance sexual and reproductive health through research and analysis.
In preparation for instituting new regulations, DHMH officials reviewed other states' laws and met with various advocacy groups. They consulted gynecologists and anesthesiologists, obstetricians and outpatient surgeons, according to a June 2012 DHMH news release announcing the changes would become effective July 23, 2012.
"We did our best to put together a good set of regulations to prevent problems," Sharfstein said.
And this is what they came up with: For the first time, outpatient facilities performing surgical abortions regularly were required to obtain a license from the state. Clinics must pay a three-year $1,500 licensure fee. To receive a license, clinics must meet requirements for anesthesia, radiologic, emergency and laboratory services that are adopted from ambulatory surgical centers.
Beforehand, a national nonprofit accredited most Maryland clinics. The change gave the state health department oversight, allowing it to perform inspections. It can suspend clinics, revoke licenses and disseminate administrative penalties when violations occur, according to the new regulations.
And it was a big change, said Jenny Black, Planned Parenthood of Maryland's CEO and president.
"[Abortion is] one of the safest procedures in health care," she said, "but we still believe that the state should have appropriate parameters on providers so that they can ensure patients are receiving quality care no matter where they go in Maryland."
The department suspended licenses of three facilities with the same owner on March 5, but the suspension was lifted 20 days later, according to official letters on DHMH's website.
On May 9, four facilities received suspended licenses, which have not yet been re-issued, official letters on DHMH website show.
These high health standards are a model for what regulations other states should be implementing, National Abortion Federation President and CEO Vicki Saporta said, praising Maryland's new regulations as an "enlightened" methodology.
"Maryland took an evidence-based approach to developing regulations, so that they actually haven't had a negative impact on women's access to quality abortion care in the state," she said, "unlike other states that didn't take an evidence-based approach and developed regulations that were aimed at shutting down clinics."
About 26 states require facilities where abortions are performed to meet the same standards of care as ambulatory surgical centers. About nine states require an abortion facility to be within a set distance away from a hospital, according to Guttmacher Institute.
In 2011, Virginia passed a law requiring abortion clinics to meet the same standards as hospitals, according to the bill. The issue has been in flux, and the Virginia Board of Health officially voted 11-2 in April to permanently require abortion clinics to meet the criteria of hospitals, the board's meeting minutes show. This includes ensuring entryways and hallways are wide enough and could mean expanding parking lots.
Some, such as Saporta, say these measures are politically motivated, unnecessary and an attempt to shut down clinics.
"[Virginia] passed the most stringent regulations in the country," she said. "There's no evidence to support the kinds of restrictions that they passed - making every clinic regulated like a hospital - and it does nothing to improve the quality of care or the safety of care for women in Virginia."
But Meister, of Maryland Right to Life, said these laws make sense. It's about increasing safety.
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"Considering these are regulations that are held against other surgical facilities, why aren't abortion facilities - who portray themselves as pro-women and pro-health - why wouldn't they voluntarily submit to the highest level of safety for their patients?" he said.
During the public comment period for DHMH's proposed changes, Maryland Right to Life advocated for these requirements to be included, and Meister said he still hopes they will be adopted at a later date.
DHMH addressed the issue in its proposed draft released December 2011. It states that surgical abortion sites do not meet the formal definition of an ambulatory surgical center. However, the regulations were based on the framework of those centers and "provide appropriate safety standards, modified in specific areas where the nature and circumstances of surgical abortion procedures differ from other procedures."
Black, of Planned Parenthood of Maryland, said the measures adopted in the state a year ago were appropriate.
"I think what you're seeing here is a positive contrast to what's happening in many other parts of the country," she said. "When you allow politicians to make health policy, you're inherently going to have a much more politically charged dynamic."
That's been avoided in Maryland, she said, as health professionals and not elected officials created the most recent regulations.
DHMH is constantly looking at its regulations, continuously evaluating them, Sharfstein said. For now, the department will review the changes, a little more than a year since they went into effect.