Diminished Choice

Why it's harder than ever to get an abortion


| September-October 1995


At age 79, Dr. Jane Hodgson still regularly makes the 150-mile trip from St. Paul to the Duluth Women’s Center, a reproductive health clinic in northern Minnesota that she helped found. The veteran abortion-rights crusader does it in part because she “can’t let go” and in part because—more than two decades after the Supreme Court legalized the procedure—the clinic can’t find a local doctor to terminate pregnancies.

Abortion rights have gone through a lot of ups and downs since Hodgson first got active after seeing too many women bleeding from back-alley attempts. The issue has faded from the headlines a bit since the Supreme Court narrowly reaffirmed the right in 1992; even conservative groups have been holding their fire, focusing on things like budgets and taxes instead. But away from the limelight, the abortion landscape has been shifting in ways that could affect women’s options more dramatically than any amount of political debate. Some observers warn that between a growing doctor shortage, financial obstacles, and a variety of other quiet de facto restrictions, women may keep the right to choose but find it harder and harder to actually exercise that right.

The issue hasn’t attracted a lot of headlines; one of the few media to take note has been the Journal of the American Medical Women's Association (JAMWA), which considered the topic hot enough to devote its entire September-October 1994 edition to it. The journal's first warning is directed at the fact that, as Hodgson’s generation of frontline abortion doctors retires, fewer and fewer young physicians are learning the procedure. In 1976, reports Dr. Carolyn Westhoff, almost one out of four OB-GYN programs required students to learn how to terminate a first-trimester pregnancy. Another two-thirds offered the training as an option. But in 1994, fully one-third of programs didn’t offer abortion training at all, and most of the rest made it voluntary—an option, Westhoff warns, that busy med students won’t necessarily choose when they know that “harassment, poor pay, low prestige, and tedium” are among the rewards awaiting abortion doctors.

Ironically, Westhoff and others note, the problem is exacerbated by the fact that in the years since Roe, independent clinics have picked up an ever greater share of women’s reproductive health care. Doctors get their basic training as residents in hospitals, where only 7 percent of abortions were performed in 1992; as a result, many OB-GYN residents end up doing tubal ligations more often than abortions. Clinics are also much more likely to be targets of protests, further discouraging doctors from practicing there. And though clinics are usually more accessible than hospitals, they often can’t or won’t perform some of the more complicated abortion services: 43 percent don’t terminate pregnancies past the first trimester, and one-third won’t serve HIV-positive women.

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.