Diminished Choice

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.

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.

Lest all this sound too encouraging to pro-choicers, the bad news comes in one final JAMWA article: If access to abortion is becoming a problem in the United States, Deborah Maine, Katrina Karkazis, and Nancy Bolan report, the issue is one of life and death for women in much of the rest of the world. They note that about one in 21 women in Africa will die as a result of complications from pregnancy or childbirth, compared to one in 6,366 in North America. Complications of induced abortions–fully or partially outlawed in countries containing more than half the world’s population, but widely performed nevertheless–account for an estimated 14 percent of maternal deaths, totaling between 70,000 and 200,000 worldwide annually; in other words, every day 200 to 550 women die trying to terminate a pregnancy. In Latin America, botched abortions are the leading cause of death for women aged 15 to 39. For most of the world’s women, the authors conclude, “the bad old days are still here.”

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