Diminished choice

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The first to notice the effect of doctor shortages are women in rural areas. Already, according to the Alan Guttmacher Institute in New York, which studies the economics of reproductive health issues, nine out of ten abortion providers are located in metropolitan counties; 27 percent of women seeking an abortion have to travel more than 50 miles. And while that kind of trip may not faze a financially secure adult woman who has a car, it can be a daunting obstacle for poor women and teenagers.

The same groups, not surprisingly, have the most trouble with the other big practical obstacle to abortion: money. Thirty-seven million Americans, including nine million women of childbearing age, had no health coverage as of 1993, according to census figures, and one-fifth of those who do must show some kind of medical problem to get an abortion paid for. Medicaid, the federal/state health care program for the very poor, hasn't been required to cover abortions since Congress passed the Hyde amendment in 1976; only six states currently choose to cover the procedure, while 9 more do so by court order.

According to the Guttmacher Institute, first-trimester abortions currently cost $300 on average. And raising that money out of pocket is more than an inconvenience: Frequently, delays due to financial problems result in a more complicated second-trimester abortion or none at all. Kathryn Kolbert and Andrea Miller, writing in JAMWA, cite one stunning statistic: 'Between 18 and 23 percent of Medicaid-eligible women living in those states that do not provide coverage for abortion carried unwanted pregnancies to term because they could not afford to pay for the procedure.' Those figures may rise as more states enact the kind of restrictions the Supreme Court found constitutional in the 1992 Casey decision: 24-hour waiting periods, state-scripted lectures from physicians on the risks of abortion, parental consent for minors, and so on. Those restrictions can be financially tough on clinics -- when, for example, they require doctors rather than nurses or social workers to do the mandatory counseling. That burden, plus violent protests and the doctor shortage, could drive some clinics out of business.

There are some signs that the problems are starting to register in the medical profession. In an article for the Women's Feature Service, Leslie George notes that after the 1993 killing of Dr. John Britton outside a Pensacola, Florida, abortion clinic, young doctors-to-be formed Medical Students for Choice with the goal of pushing for increased abortion training; some of their older counterparts hold workshops to train family practitioners and other doctors in the procedure. JAMWA's Westhoff reports that a medical committee charged with setting standards for ob-gyn training is considering language under which 'experience with induced abortion and management of its complications must be part of residency training, except for residents with moral or religious objections to the former'; some hospitals are working out rotation arrangements with abortion clinics for their residents. And there are efforts to encourage other medical professionals, like physician assistants, to do abortions in areas where the doctor is many miles away.

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