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.
So how did we get here?
Where might all of these various roadblocks to reproductive freedom
lead us? Marlene Gerber Fried directs the Civil
Liberties and Public Policy Program at Hampshire College. An
author and editor (Fried was most recently the co-author of Undivided
Rights: Women of Color Organize for Reproductive Justice,
South End Press, 2004), Fried also co-founded both the Abortion
Rights Fund of Western Massachusetts and the National Network of
Abortion Funds. As a longtime advocate for reproductive justice,
her perspective on dwindling services is: "After Clinton was
elected, there was this brief period when the legal rights seemed
safe: not true during the Reagan era. So, advocacy groups formed
to work on access, because it was clear during Reagan access had
been compromised."
"Most groups approached
access in terms of providers, and not necessarily in terms of low-income
women," she says, and the number of groups focused upon access
has increased. "Since 1993, a great deal of organizing has
taken place, including NNAF." Originally a coalition of 24
community-based funds helping low-income women pay for abortion
services, NNAF is now a consortium of 102 grassroots organizations
that advocates on abortion access issues nationally, as well as
providing direct assistance for those in need. Fried also cites
efforts like those of the Abortion Access Project (abortionaccess.org)
and the National Abortion Foundation (naf.org) to train mid-level
providers such as nurse midwives and Physician Assistants to perform
abortions. Fried says, "In the late 1990s, when medical abortion
was just being introduced into the United States, advocates saw
the possibility of normalizing abortion by integrating it into routine
health care. However, FDA regulations on Mifipristone as well as
state and federal restrictions on abortion which apply to both medical
and surgical procedures, created significant barriers. Despite the
obstacles, some primary care providers are offering medical abortion
in places where previously there were no abortion services."
The advent of medical
abortion (RU486) affected access because it was much easier to provide,
even in a family practice doctor's office. "While medical abortion
blurred the line between a procedure and more routine health care,
normalizing early abortion at the same time, the restrictions are
the same as for those providing surgical abortions. Thus, few doctors
outside the abortion clinic setting are willing to prescribe the
medication."
While obtaining services
-- medical or surgical abortion -- may be difficult for women with
financial resources, for women on welfare the task is nearly impossible.
Sharon Hays underscores this point: "The problems, the absolute
Catch-22 poor women face, are so evident to welfare caseworkers.
While the Federal Government pushes women to get connected to men
-- to marry them -- women on welfare have trouble gaining access
to birth control, and should they find themselves pregnant, no resources
are available. It's hard for middle-class people to conceptualize
the multiple difficulties poor women face. Say, for example a woman
with two children is working as hard as she possibly can to get
things together in terms of work, raising the kids, getting some
education or vocational training and then she becomes pregnant unexpectedly.
She has no options. I've seen caseworkers hand state monies under
the table to women to help them pay for abortions, because they
know how dire the situation really is for these women, women doing
all they can to survive."
Linda Wharton was lead
co-counsel in the Casey case. While overturning Roe is the scenario flooding the news each time a potential Supreme
Court nominee is named, Wharton warns other scenarios are more likely
and probably equally worrisome. She says, "A more likely scenario
[than overturning Roe] could occur, in which the Court
would eviscerate Roe by interpreting the Casey undue burden standard in ways that allow multiple, harmful restrictions
on access to abortion."
The role Judge Alito
played as a dissenter in the Casey decision is, according
to Wharton, real cause for concern. "Alito," Wharton continues,
"would have upheld the husband notification provision. He purported
to apply the undue burden standard; however, he was willing to overlook
the severe obstacles to abortion access posed by this provision
to victims of spousal assault and rape. Instead, in his dissent,
he highlighted all the women to whom the husband notification provision
did not pose a problem. He also assumed that victims of spousal
assault would evade the requirement by falsely reporting that they
had told their husbands. Lastly, he deferred to the judgment of
the state legislature that it had provided adequate exemptions in
the statute. This approach suggests that he will rarely, if ever,
be willing to find that restrictions on access, short of outright
bans, unduly burden women. What we may be left with is protection
for outright bans, but no protection whatsoever for restrictions
on access that, in practice, make abortion effectively unavailable
or extremely difficult for certain women. Although the trial record
showed that husband notification posed a lethal threat to some women,
Alito found no undue burden."
The radical right has
used Roe to galvanize its forces, as attention over Supreme
Court nominees and their potential views about abortion reveals.
In doing so, the right has attached increasing stigma to abortion
itself. Policies that make abortion inaccessible -- due to funding,
difficulty in finding a clinic or getting to one, fear of on-site
violence, or laws that enforce waiting periods or parental consent
or notification -- increase fear and shame for women. "Fear,"
says Barbara DiTutullio of the Women's Law Project (womenslawproject.org),
"is a big factor."
For a woman seeking an
abortion, slowing her ability to obtain the procedure -- due to
physical distance from clinic care, economic factors or the time
it takes to seek judicial bypass or travel out-of-state for care
-- the consequences are real. Delays increase the monetary cost
of the abortion and often add to the physical and emotional health
risk, since early abortions are less involved procedures. Up to
seven weeks, medical abortions are available; up to twelve, the
care can be completed in one office visit, rather than an additional
day for pre-operative care.
DiTutillio worries about
doctors and hospitals refusing care. "This 'conscience clause'
turns health care delivery into a choice. It's dangerous to have
health care delivery be optional. When you add in the bans on various
services-from emergency contraception in certain places to partial
birth abortions -- along with all the regulations that limit access
-- you have so many limitations upon care, it's no longer clear
whether a woman can actually secure services."
Marlene Fried is even
more emphatic about providers' citing "conscience clauses."
Fried says, "Being a pharmacist or a physician isn't a right.
A right in this country is access to health care."
Dayle Steinberg, CEO
of Planned Parenthood of Southeastern Pennsylvania believes that
access will be won or lost state-by-state. "We have to push
our state reps and state senators on issues of access," she
urges.
The New York Daily Record
(November 20, 2005) reported on just such an initiative. Because
Pennsylvania hospitals are not required to offer Emergency Contraception,
two Pennsylvania senators and one state representative have introduced
bills that would mandate hospitals to provide information about
the pills and give them to rape and sexual assault victims who want
them. The legislation as it is written has no opt-out for individual
doctors or religious-affiliated facilities Currently, some hospitals
offer the medication, while others have policies that allow health-care
providers to opt out of providing the medication because of personal
religious or moral reasons.
As Steinberg points out,
the country largely -- sixty-five percent, that is -- supports a
woman's right to have an abortion. "Roe might signify
to people that abortion remains legal. That's why we have to get
people more concerned about what's happening locally, because it's
in so many individual states that the rights are being taken away."
Sharon Hays believes
that advocates should be looking at another generation entirely.
"Children pay the largest price for welfare and Medicaid policies
that make raising children as a single mother incredibly arduous.
Children's suffering becomes invisible," says Hays. "A
child born poor is doubly disadvantaged in these times." Looking
back before so many of these cuts and regulations went into effect,
Hays believes the solution for poor women lies in returning welfare
services to the place they were thirty years ago. "We'd be
in good shape," Hays asserts, "if we provided more aid,
fewer untenable restrictions and caps, and again offered all health
care -- including reproductive health care services -- to women
on welfare." She believes that education about the situation
is critical as a first step. "People need to understand the
issues involved, how deeply problematic the situations are that
poor women and children face in this country. It's as if poverty
has gone underground. The only way to change the situation is to
make it visible again."
If the obstacles poor
women face have invisibility attached, what will make issues of
access visible? Dayle Steinberg muses, "When women who have
enjoyed access all along, even as it's been lost for many women,
lose access, they will be angry. The majority believes that women
have an absolute right to health care. And anger is what changes
things."
mmo : december
2005
Sarah
Werthan Buttenwieser is a freelance journalist
and regular contributor to the MMO. She lives in Western Massachusetts.
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