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Abortion, emergency contraceptives, contraceptives

By Sarah Werthan Buttenwieser

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Before abortion became legal, the desired attributes advocates sought were these: safe and legal. In an article on the economics of abortion access for (Conscience, the journal of Catholics for Choice, Winter 2005-2006), Marlene Gerber Fried writes about Laura Kaplan, author and former member of the Jane Collective, a feminist underground abortion service which provided 11,000 abortions to women in Chicago between 1969 and 1973. "Kaplan notes, 'The cost of abortion was a constant problem, since few women, regardless of their economic status, could easily manage $500.' The women in Jane were constantly arguing and negotiating with their provider to get him to drop his price. After the women in the collective got rid of their 'doctor' and became providers the group dropped the price to $100, but a woman only paid what she could afford and Jane became essentially a service for poor women." Although some -- like the Jane Collective -- long ago understood it to be an issue, access was not the third attribute listed after safe and legal.

Fast forward to 2005: abortion remains legal, but with many caveats; depending where you live, abortion might be effectively illegal. Not only is access to abortion constricted in this country, other legal health care is also no longer universally accessible, including emergency contraception (the "morning after" pill) and oral contraceptives. With this smattering of examples, you will glimpse just how limited access to routine reproductive health services has become twenty-three years after Roe:

An ACLU fact sheet on abortion explains that "since 1995, bans on safe abortion procedures have been enacted in more than half the states and challenged in courts throughout the country." Thirty-one states have enacted bans on safe abortions. Although the bans have been challenged and struck down in twenty-one states, other states continue to introduce new bans.

Thirty states have mandatory delays and require that clinics share biased information with their clients. This is enforced, according the Center for Reproductive Rights, by twenty-four of those states.

In 1976, the Hyde amendment halted Medicaid's provision of funding for abortion. Only seventeen states still provide limited Medicaid funding for abortion. Again, according to the ACLU: "Federal funding restrictions have left some women on Medicaid little choice but to use money they need for food, rent, clothing, or other necessities to pay for an abortion. One study showed that nearly 60% of women on Medicaid were often forced to divert money that would otherwise be used to pay their daily and monthly expenses, such as rent, utility bills, food and clothing for themselves and their children. Many Medicaid-eligible women delay their abortions, increasing their medical risks, while they scrape funds together. Other women have been forced to carry their pregnancies to term or to seek illegal abortions.

Studies have shown that from 18 to 35 percent of Medicaid-eligible women who want abortions, but who live in states that do not provide funding for abortion, have been forced to carry their pregnancies to term." The National Network of Abortion Funds points out in its report, "A Matter of Justice," that women of color are disproportionately represented among low-income women. Because of this, they also represent a high proportion of welfare recipients, meaning that the lack of Medicaid funding has a higher impact upon women of color, especially black women, than any other group. Sharon Hays, professor and author of Flat Broke With Children researched mothers and welfare. "When abortion isn't covered by Medicaid, then women find themselves pregnant without options," she explains. "The caps on welfare are such that an unmarried woman who becomes pregnant after she's begun to receive aid cannot get assistance for that child, if she continues the pregnancy."

Beyond funding for abortions, locating abortion services is increasingly difficult. The Abortion Access Project (www.abortionaccess.org) reports that as of 2002, 87 percent of all U.S. counties and 97 percent of all rural U.S. counties have no abortion provider.

A 2002 article in the Expectant Mother Care newsletter reported that New York City was "the first city in the country to make abortion training mandatory for the 150 residents who pass annually through the eight city hospitals that offer OB-GYN programs." Exemptions were granted to those declaring religious or moral grounds. This development was especially newsworthy when the numbers of providers are considered. The number of abortion providers in the United States fell by one-third between 1982 and 1996, to roughly 2,000, according to the most recent study by the Alan Guttmacher Institute (guttmacher.org), especially because half of those doctors are slated to retire in the next 10 years. In 1996, the Accreditation Council for Graduate Medical Education began requiring OB-GYN programs to provide instruction on abortion and family planning. These initiatives have considerable impact: the National Abortion Federation reported that between 19995 and 2002, the percentage of residency programs that included routine abortion training rose from 12 percent to nearly half of all programs.

This doesn't mean that providing abortion services is a safe endeavor for doctors, though. According to the Abortion Access Project, there have been 15,087 reported instances of violence and/or harassment against abortion providers since 1977, including 7 murders and 17 attempted murders (actual instances are most likely much higher the report suggests). In 2000, more than half of all providers experienced harassment from anti-abortion forces.

Access has been severely limited by court rulings. Judge Alito's nomination to the Supreme Court has reproductive rights advocates worried because he dissented in the Planned Parenthood v. Casey case, which was about spousal consent to abortion. Although spousal consent was overturned, laws in effect that mandate the involvement of at least one parent in the abortion decision exist in thirty-four states.

In those states with parental notification or consent laws, teenagers unable to tell their parents must either travel out of state or obtain approval from a judge -- known as a "judicial bypass" procedure -- to obtain an abortion. A report from the Planned Parenthood Federation of America (plannedparenthood.org) cites research indicating that "sixty-one percent of the respondents reported that at least one of their parents knew about their abortion. Of those minors who did not inform their parents of their abortions, 30 percent had histories of violence in their families, feared the occurrence of violence, or were afraid of being forced to leave their homes. Minors who did not tell their parents were also disproportionately older (aged 16 or 17) and employed." As abortion advocates and health care providers working with teens have said for decades, most teens do tell a parent or other, significant and trustworthy adult. Younger teens especially entrust this information to their parents, unless they cannot.

One development thought to potentially decrease the abortion rate in this country was introduction of Emergency Contraceptives (EC, basically a very high dose of an oral contraceptive). Five states have passed laws requiring medical providers to offer Emergency Contraceptives to rape victims treated in emergency care facilities. Yet, according to a recent study by the ACLU, "fewer than 40 percent of emergency care facilities in eight of eleven states surveyed provide EC on-site to rape victims." If taken within 72 hours of unprotected intercourse or contraceptive failure, EC reduces the risk of pregnancy by as much as 89 percent. Pennsylvania lawmakers introducing a bill that requires hospitals to offer EC to women after a rape noted that of the 300,000 women raped each year in the United States, it is estimated that more than 25,000 women become pregnant as a result of rape.

Hospitals and Emergency Care Centers are not the only ones impeding access to EC. Since 1997, Wal-Mart has refused to sell EC. The company calls this a business decision, without regard to the fact that for many women, Wal-Mart is the only pharmacy within miles. A report by the Alan Guttmacher Institute explains this policy has an especially broad reach for women living in rural areas. "A 2003 projection estimated that Wal-Mart would control 25% of the drug store industry by 2007."

General access to contraceptives is also limited for many women. The Center for Reproductive Rights explains the disparity that purchasing contraception creates between women and men: "Women of reproductive age spend 68% more than men on out-of-pocket health care costs, largely on reproductive health care services. Two-thirds of U.S. women of childbearing age rely on private, employer-related plans for their health coverage, yet 49% of large group plans do not routinely cover any contraceptive method." When the United States government allowed comprehensive coverage for contraceptives, that out-of-pocket gap was narrowed. But Medicaid doesn't cover contraception costs, nor are caseworkers even permitted to discuss family planning. Sharon Hays remarks, "By law, caseworkers aren't allowed to utter the phrase 'birth control.' Further, they are pressured to push abstinence. The mixed messages for poor women are hopelessly confusing: the government is pro-abstinence, pro-marriage, against contraceptives. Welfare imposes family caps and yet provides no coverage for abortion."

The Center for Reproductive Rights quotes an article in the Economist from April of this year: "A rising number of pharmacists are refusing to dispense prescriptions for birth control and morning-after pills, saying it is against their beliefs." Currently, four states-Arkansas, Georgia, Mississippi and South Dakota-have laws or policies on the books that explicitly allow pharmacists to refuse to dispense contraceptives. Similar legislation was introduced in nine other states this year, although none became law.

Teens might face roadblocks other than pharmacists' refusals or cost when seeking contraceptives. Only twenty-one states and the District of Columbia grant all minors the authority to consent to contraceptive services. Approximately eleven other states grant most minors this authority.

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