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Women's Health in Context
Obstacles to Abortion in the United States
Martin Donohoe, MD, FACP
Medscape Ob/Gyn & Women's Health. 2005;10(2) ©2005 Medscape
Posted
Introduction
Despite being a legal (and commonly used) medical procedure, numerous barriers have been
placed in the way of women attempting to exercise their right to abortion and in the way of
healthcare providers and educators attempting to assist women in exercising this right. This issue
of "Women's Health in Context" considers obstacles, particularly those erected by the current
United States administration, and calls for reform, education, and activism by those concerned
about women's reproductive healthcare. (See footnote.)
Footnote: An earlier version of this article was published in the Journal of the American Medical
Women's Association. Donohoe MT. Increase in obstacles to abortion: The American perspective
in 2004. J Am Med Women's Assn 2005;60(1):16-25. Available at
http://www.amwa-doc.org/index.cfm?objectid=1B138032-D567-0B2557EE86AC69902184
http://www.amwa-doc.org/index.cfm?objectid=1B138032-D567-0B25-57EE86AC69902184
. Accessed 6/21/05.
Epidemiology of Abortion
More than 42 million American women have had an abortion since its legalization by the United
States Supreme Court in 1973.[1,2] In 2002, 1.29 million abortions took place, down by 5% (about
1.36 million) in 1996 and by nearly 27% since 1980.[2,3] More than half of abortions occur in
women younger than 25, with a third of all abortions occurring in women aged 20-24.[2] Nearly half
(49%) of all pregnancies are unintended.[4] More than 30% of these occur in married women.
Fifty-four percent of women with unintended pregnancies become pregnant while using birth
control.[5] By age 45, the average female will have had 1.4 unintended pregnancies, and 43% will
have had an induced abortion.[4]
Abortion remains one of the safest medical procedures available.[6-10] It is more dangerous to carry
a fetus to term than to undergo an abortion before 21 weeks; the risk of death with childbirth is 11
times higher.[2] Importantly, a delay in having abortion until after 15 weeks of pregnancy, when
medical risks associated with abortion increase significantly, is more common among adolescents
than among older women.[2] Most data suggest that only a self-limited sense of loss and guilt
occurs after a woman has an abortion, and there seem to be minimal to no long-term emotional
and psychological sequelae.[11] Anxiety symptoms have been identified as the most common
adverse response in the short term.[11] Women denied abortions often experience resentment and
distrust, and their children may face social and occupational deficiencies. [12]
Barriers to Abortion
Barriers to abortion are manifold and include legal point of viability; cost and coverage; the
availability of mifepristone, an oral abortifacient; provider availability; harassment of patients and
providers; laws designed to limit the provision of abortion services; and a culture of
pseudoscience which promotes the dissemination of misinformation regarding human
reproduction through a wasteful diversion of the public's tax revenues.
Legal Point of Viability
Roe vs Wade[13] protects the privacy and availability of abortion procedures at < 24 weeks, the
point of legal viability.[14] After viability, states can ban abortion, except when necessary to protect
the woman's life or health.
Costs and Coverage
An average self-paying patient was charged $372 for a surgical abortion at 10 weeks and
between $438 and $490 for a medical abortion in 2001.[15] Second-trimester surgical abortions are
2 to 3 times more expensive than first-trimester surgical abortions. Most patients pay out of
pocket.[15,16] Only 26% of abortions are billed directly to public or private insurance.[15] Most insured
patients are reluctant to file claims because of concerns about confidentiality. Some health plans
cover sterilization but not abortion, leaving poor women in the unenviable position of having to
choose sterilization if they lack the resources for adequate contraception. [17-19]
The 1978 Hyde Amendment prohibits federal Medicaid dollars from being spent on abortion,
except to preserve a woman's life or in cases of rape or incest.[20] Twenty-two states allocate a
portion of their share of Medicaid funding to cover abortion. The Hyde Amendment was applied to
Medicare, which covers disabled women, in 1998. Women of color are more likely than white
women to be poor, to lack health insurance, and to rely on government healthcare programs.
Thus, they are disproportionately harmed by prohibitions on public funding for abortions. [21,22] In
addition, black women and Hispanic women are more likely than white women to have an
abortion.[23] Higher rates of abortion are explained, in part, by higher rates of unintended
pregnancy, a greater proportion of conceptions that end in abortion, and greater poverty.
The Defense Department, through TRICARE, provides health coverage to military personnel and
their families. TRICARE has instituted a permanent ban on abortion coverage, except when the
life of the woman is endangered.[20,24] American Indians and Alaskan natives covered by the
Indian Health Service are subject to the Hyde Amendment.[20]The Federal Employees Health
Benefits Program pays for abortions only in cases of life endangerment, rape, or incest. Women
in federal prisons are allowed to obtain an abortion only when their lives are endangered or when
the pregnancy is the result of rape,[20] which may be difficult to prove.
Legal Barriers
Between 1995 and 2003, approximately 350 anti-choice measures were enacted, including
statutes that protect pharmacists who refuse to fill birth control prescriptions on moral or religious
grounds.[25,26] In 2003, 10 states introduced 15 measures that would ban all or most abortions. [27,28]
In 2004, Michigan enacted a ban on abortion.[29] The ban prevents physicians from performing
most abortions, even in cases when a woman's life or health is in danger (eg, a woman with
diabetes or a heart condition). However, on June 14, 2005, the American Civil Liberties Union,
the Center for Reproductive Rights, and the Planned Parenthood Federation of America sought to
block the ban in federal court. The law has been enjoined pending the court's decision.
In the month of January 2005 alone, 15 states introduced 19 bills that would require counseling
and waiting periods for abortion; and 12 states introduced 17 bills that would mandate parental
involvement in minors' abortions. Twenty-three states already have mandated waiting periods for
women wishing to obtain an abortion,[30] augmenting patients' exposure to anti-choice harassment
and increasing the gestational age at which pregnancy termination occurs, thereby also
enhancing the risk associated with the procedure.[31,32]
On April 27, 2005 the House of Representatives passed the "Teen Endangerment Act". [33] The
first section of the law (which is also known as the "Child Custody Protection Act ") would make it
a federal crime for anyone other than a parent from accompanying a young woman across state
lines for an abortion without complying with the home state's parental involvement statutes.[32,34,35]
Although 33 states enforce parental consent or notification laws for minors seeking an abortion, [2]
24 of these have parental involvement requirements that meet the Teen Endangerment Act's
restrictive definition of a "parental involvement law."[32] This barrier would delay an abortion for a
teenager determined to have one but unable to draw on her parents' assistance, increasing its
economic cost and placing additional physical and emotional burdens on her.
The second section of the Teen Endangerment Act (Child Interstate Abortion Notification Act)
would make it a federal crime to provide an abortion to a teenager outside of her home state
unless the physician has notified a parent at least 24 hours in advance. There is no exception
made for when an abortion may be necessary to protect a young woman's health. It further
requires a 24-hour waiting period and written notification even if a parent accompanies his or her
daughter to an out-of-state abortion provider.[32]The Senate is currently considering a bill similar to
the Teen Endangerment Act but without interstate abortion notifications.
Parental notification laws can be dangerous if a pregnancy results from incest, or if the
adolescent's home environment is abusive or otherwise unstable. A national survey of female
adolescents found that mandated parental notification laws would likely increase risky or unsafe
sexual behavior and, in turn, the incidence of sexually transmitted disease (STDs) and adolescent
pregnancy.[36] Others have found that parental consent and notification laws could prevent up to
half of teens from using Planned Parenthood services, including contraception, while only
stopping 1% from having sex.[37] Based on the projected number of additional pregnancies, births,
abortions, and untreated STDs and resulting pelvic inflammatory disease, the potential annual
costs of parental consent and law enforcement reporting requirements in 1 state (Texas) have
been estimated at $43.6 million for girls younger than 18 years currently using publicly funded
services.[38] In May 2005, the U.S. Supreme Court agreed to hear a case involving New
Hampshire's parental notification law, which had been ruled unconstitutional by the First U.S.
Circuit Court of Appeals because it contained no health exception in the event of a medical
emergency.[39]
Targeted Regulation of Abortion Provider (TRAP) Laws are designed to add excessive
regulations and extra costs to abortion clinics.[40,41] TRAP regulations far exceed the usual
recommendations and requirements of respected scientific organizations. Increased retrofitting,
design, and training costs, combined with increased licensing fees and burdensome
documentation requirements, have put some clinics out of business and forced others to close
temporarily or reduce services. Zoning ordinances have also been passed to force clinics to
move. Some facilities shut down and do not reopen. The overall effects of TRAP laws and unfair
zoning ordinances are to decrease access and increase costs of abortion.[42] As of 2004, 19
states and Puerto Rico enforce TRAP laws that apply to abortions performed at any stage of
pregnancy, and 14 states enforce TRAP laws that apply only to abortions performed after the first
trimester.
Forty-six states have enacted "refusal clauses," which allow employers to refuse to provide
contraceptive coverage in their health plans; pharmacists to refuse to dispense, or provide
referrals for, oral contraceptive pills; and certain medical personnel, health facilities, and/or
institutions to refuse to provide abortion services.[28] Healthcare professionals can deny patients'
requests for information on, or referral for, family planning services, regardless of patients'
healthcare needs.[17,27,28, 43,44] The Weldon Federal Refusal clause, signed by President George W.
Bush in December 2004, allows federally funded healthcare entities to deny women information
on abortion services, even if state laws mandate that such information be given upon request. [45]
The National Family Planning and Reproductive Health Association filed suit soon afterward, on
the basis that the Weldon clause is in conflict with the requirements of Title X, the nation's only
federal program solely dedicated to providing family planning and reproductive healthcare to lowincome and uninsured women.
The current administration has aggressively attempted to grant rights usually available only to
living US citizens to the unborn, creating a movement for "fetal rights." It has extended coverage
under the State Children's Health Insurance Program (SCHIP) to fetuses, while failing to extend
full prenatal care to all women.[17,43, 46] The mission of the federal Advisory Committee on Human
Research Protection, which oversees the safety of human research volunteers, has been
expanded to include embryos.[47-49] The "Unborn Victims of Violence Law" criminalizes harming
fetuses was signed into law by President Bush on April 1, 2004.[50] the National Abortion Rights
Action Network (NARAL) argues that this legislation is an attempt to undermine Roe vs Wade.[51]
In February, 2005, a Cook County, Illinois judge ruled that parents of a frozen embryo
accidentally destroyed by a Chicago fertility clinic could file a wrongful death lawsuit. [52] By
contrast, the European Court of Human Rights declined to extend full human rights to fetuses.[53]
The so-called "Partial Birth Abortion Ban" criminalizes the seldom performed and often lifesaving
(for the mother) procedure known as intact dilatation and extraction). [14, 54] The ban makes no
exceptions for the health of the woman. A federal appeals court judge in San Francisco blocked
the administration from enforcing the ban against Planned Parenthood of America clinics and
their doctors, who perform roughly half the nation's abortions.[55] Two other courts have also
struck down the ban.[56] Courts have also blocked the United States Justice Department's
attempts to access confidential medical records as part of their case against opponents of the
law.[57] The present U. S. Supreme Court previously ruled that a similar 2000 Nebraska State Law
was unconstitutional.[3]
In 2001, more than 20 states had biased counseling laws,[58] often (mis)labeled "Mandated
Informed Consent" or "Women's Right to Know" laws, which employ scare tactics and
unbalanced data to convince women that abortion is especially dangerous. Similar biased
(dis)information is promulgated at up to 4000 "Crisis Pregnancy Centers" nationwide, some of
which receive federal and state funding.[59,60] Staffs try to dissuade clients from having abortions
through exaggeration of risks, myths, and fetal photographs.
Limited Availability of Mifepristone
Oral mifepristone allows medical termination of pregnancies up to 49 days from the last menstrual
period.[61-64] Many women are unable to obtain this drug because of lack of awareness of its
existence, providers' lack of knowledge and fears of prescribing it, and cost. Medicaid restricts
funding for mifepristone to cases of rape, incest, or to preserve the pregnant woman's life. The
current administration has asked the United States Food and Drug Administration (FDA) to
reconsider its approval of mifepristone. Currently proposed state and federal legislation aims to
curtail the availability of mifepristone and to limit the number of prescribing doctors.[65,66]
Provider Availability
Over one third of US women live in the 87% of counties in the United States, including 30% of
metropolitan areas, that have no abortion provider.[7] The situation is worst in rural areas.[15,67] Only
1800 physicians provided abortion services in 2000, down 11% from 2400 in 1996. [3,7] Only 12%
of obstetrics and gynecology residency programs required abortion training in the mid-1990s,
down from 25% in 1985.[68-72] More recently, Espey and colleagues[73] conducted a survey on
abortion education throughout the 4 years of medical school. The results show that abortion
education remains limited in US medical schools. Most states bar nonphysicians from performing
abortions.[74]
Harassment of Patients and Providers
Since 1977, there have been 80,000 reported acts of violence and/or disruption at abortion clinics
in the United States and Canada, including 7 murders, 17 attempted murders, 41 bombings, 166
arsons, 125 assaults, and 654 anthrax threats (480 of them since September 11, 2001).[15,75,76]
Patients are often harangued, belittled, defamed, and taunted with verbal and physical threats,
despite the federal Freedom of Access to Clinic Entrances Act.[46,77] Between 55% and 86% of
providers report that they have been harassed.[16]
The environment in which this harassment occurs has been perpetuated by the federal
administration's philosophy and anti-choice rhetoric. For example, when President Bush declared
January 20, 2002, 2 days before the 29th anniversary of Roe v. Wade, "National Sanctity of Life
Day," he likened abortion to terrorism: "On September 11 [2001], we saw clearly that evil exists in
this world, and that it does not value life.... Now we are engaged in a fight against evil and tyranny
to preserve and protect life. In so doing, we are standing again for those core principles upon
which our Nation was founded."[78] Such rhetoric is permissive of extremism, in that it likens the
"battle" against prochoice advocates and abortion providers to that against malevolent suicide
bombers.[14]
Effects of United States' Policy on Access to Abortion Worldwide
U.S. policy has affected access to abortion and other reproductive health services worldwide.
Lack of access to reproductive education, condoms, and contraceptives in the developing world
has led to a large need for abortion, which has not been matched by appropriate numbers of
providers and facilities.[79,80] One third of the developing world lives where abortion is prohibited or
allowed only in cases of rape or incest or to save the mother's life.[81] At least 80,000 women die
annually from unsafe abortion (8 per hour).[82] Unsafe abortion deaths account for 13% of all
maternal deaths.[82] For every 1 abortion death, 30 women suffer injuries, severe blood loss, or
infection.[82] In 2001, President Bush reinstated the global gag rule first adopted by President
Ronald Reagan in 1984 and later rescinded by President Bill Clinton in 1993. [83-85] This edict
prevents US government aid from being used by any organization operating outside the country
that discusses, advocates for, or performs abortions. Since the resumption of the global gag rule,
at least 430 organizations in 50 countries have stopped performing abortions or speaking about
abortion laws in order to qualify for US funds.[86] In 2005, the Bush administration has blocked the
release of $34 million for the United Nations Population Fund, which provides women's
healthcare, promotes women's rights, and prevents violence against women in 140 countries. [87]
Furthermore, despite the recommendation of a World Health Organization (WHO) expert
committee that mifepristone and misoprostol should be added to its Essential Medicines list, the
WHO, possibly in response to U.S. Department of Health and Human Services pressure, has still
failed to act.[88]
Pseudoscience and Ideology Trump Science
The Bush administration has displayed a consistent pattern of disregarding sound science and
making appointments to key scientific posts based on ideology rather than scientific expertise and
experience.[89]This has had wide-ranging, detrimental effects on women's reproductive health and
rights.
For instance, limiting unwanted pregnancies through comprehensive sex education programs and
increased availability of contraception would seem to be one approach to decreasing the number
of abortions that would please most Americans. As opposed to abstinence-only sex education,
comprehensive sex education programs delay initiation of sexual intercourse by teens, reduce the
frequency of intercourse, decrease numbers of sexual partners, increase condom and
contraception use, lower rates of STDs, and reduce the number of unwanted pregnancies. [90,91]
They are supported by the scientific community[92] and by many Americans.[91,93,94]
In 1988, only 2% of US schools relied solely on abstinence only sex education; by 1999, 23%
did.[90] The federal government will spend approximately $170 million on abstinence-only
education programs in fiscal year 2005, more than twice the amount spent in fiscal year 2001. [95]
Over 80% of the abstinence-only curricula, used by over 2/3 of grantees in 2003, contain false,
misleading, or distorted information about reproductive health, including: false information about
the effectiveness of contraceptives; false information about the risks of abortion; and scientific
errors, including mistaken information regarding HIV transmission.[96] The curricula blur science
and religion and treat stereotypes about boys and girls as scientific fact. [96] These stereotypes
undermine girls' achievement, claim that girls are weak and need protection, and reinforce male
sexual aggressiveness.[96] In late 2001, the administration redefined "success" for these programs
as "completion of a course" or "a commitment to abstain from sexual activity," rather than by
actual outcomes such as delayed onset of sexual activity or decreased teen pregnancy rates. [96,97]
The diversion of government funds to abstinence-only programs represents a shift of financial
resources away from effective measures to reduce the need and demand for abortions.[97]
Combined with Bush administration cuts to family planning programs and the diversion of funds
away from other social programs into the administration's so-called "Healthy Families Initiative,"
this will likely increase the number of unwanted pregnancies and thus the number of women
seeking pregnancy termination.[90,97,98]
Although the FDA approval of prescription emergency contraception (EC) has increased women's
options for the prevention of unwanted pregnancy, only one quarter of reproductive age women in
the United States have heard about EC, and some pharmacists refuse to fill prescriptions for
EC.[17,42,44,99] Arkansas, Mississippi, and South Dakota explicitly protect pharmacists who refuse to
dispense EC; other states are considering similar legislation.[100] The American College of
Obstetricians and Gynecologists, the American Academy of Family Physicians, and the American
Academy of Pediatrics support over-the-counter (OTC) availability of EC.[101] Even so, the FDA,
influenced by the opinions of political appointees, ignored its own advisory panel's 23-4 vote to
approve Barr Pharmaceuticals' petition to sell levonorgestrel EC (Plan B) OTC.[102] In June 2005,
however, New Hampshire became the seventh state to allow pharmacists to dispense EC without
a prescription, and New York is considering following suit.[103] The other 6 states are Alaska,
California, Hawaii, Maine, New Mexico, and Washington. And, on June 23, 2005, the New York
State Senate approved a bill that would allow pharmacists to dispense EC to women who do not
have a prescription. It is unclear whether Governor George Pataki will sign the bill. [104]
Conclusions
Although some barriers to abortion in the United States are long-standing, many new ones have
been erected since the current president took office. The Bush administration has limited public
access both to scientifically sound sex education and to effective methods of STD prevention and
contraception. It has attempted to prevent (or at least delay) availability of EC. The
administration's policies opposing women's right to choose have been backed by pseudoscience
and by inflammatory rhetoric. These policies have helped to create an environment in which
women inclined toward abortion may be delayed in undergoing, or even have to forgo, the
procedure. President Bush has nominated a number of anti-choice judges for the federal bench,
and may have the opportunity to select 1 or even 2 new Supreme Court justices. This would shift
the current balance in favor of abortion rights to one in which Roe v Wade could be overturned,
making abortion illegal in many states and/or circumstances.
Preserving women's access to abortion services will require vigilance, legislative efforts at the
federal and state levels, and court challenges to unjust laws. Advocates should continue to lobby
at the state and federal level for access for women to a full range of reproductive health options.
Acts of harassment and violence against abortion providers and clinics should be treated by law
enforcement officials as acts of domestic terrorism. Efforts to prevent the government from
inserting itself into the doctor-patient relationship through legislation should be countered
aggressively.[105] Finally, healthcare providers and educational institutions should enhance their
professional and public education programs to ensure the promulgation of scientifically sound
information regarding contraception and abortion and the availability of trained providers for
women who choose to exercise their legal right to terminate an unwanted pregnancy.
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Martin Donohoe, MD, FACP, is a practicing internist and teaches public health.
Disclosure: Martin Donohoe, MD, FACP, has disclosed no relevant financial relationships.
Public Health and Social Justice Website
http://www.phsj.org
martindonohoe@phsj.org