politics

The History of and Current (In)accessibility of Abortions in the United States

Meta Williams (2018) is a Biological Chemistry and Spanish double major at Grinnell College. Outside of academics, she runs, hikes, bakes and cooks; she prides herself on her ability to make vegetables appealing to non-vegetable eaters. Meta will be joining the AmeriCorps after graduation, and hopes to eventually attend medical school.

Abortion. Think about it: abortion. As an issue always on the forefront of the American collective conscious, abortion is about as loaded of a word as one can find. So what do you think when you think “abortion”? You may use words like “prolife” or “prochoice”. You may think “good” or “bad”, “immoral” or “necessary”.

You probably, however, did not think about “accessible”. Yet, the accessibility of abortion services and abortion clinics in perhaps one of the most important aspects of the abortion debate. Who can get one? How is it paid for? Where do you go to get one? These are all questions pertaining to the accessibility of abortive services and centers that perform abortions.

In 1973, the landmark US Supreme Court case of Roe v. Wade recognized womyn’s constitutional right to abortion [1].  In subsequent years, the Supreme Court has upheld that decision, ruling that a state cannot ban abortion before the point at which a fetus can survive outside of the uterus. They also ruled that the restriction on abortion after this period may be overridden if the life of the womon is at risk, and that it is unconstitutional to place “undue burden” on a womon seeking an abortion [2].

Despite these laws, which have been repeatedly tested through our judicial system, Americans still are grappling with what to do about abortion. As of January 1st of this year, all but 10 states sported one or more of five major obstructions to abortion. In this post, I will break down each of the five so-called “Major Obstructions” and provide evidence that demonstrates that we, as a society, are not only failing the Roe v. Wade ruling, but also the thousands of womyn searching for an alternative to a pregnancy they cannot support, be it biologically, socially, financially or emotionally [3].

Before delving into these specific obstructions, however, I think it would be beneficial to review the pre-legal history of abortion in the United States. As Rachel Benson Gold and Megan K. Donovan report in their article “Lessons from before Abortion Was Legal”, the “history of abortion underscores the reality that the procedure has always been with us, whether or not it was against the law” [4].

In the 1700s and through the mid-1800s, abortion was permitted by states. In fact, before the criminalization of the procedure, aborting an early pregnancy was, actually, legal until an event called “quickening”, which was when the pregnant womon was able to feel the movements of the developing fetus. This event normally fell around four months into the pregnancy, and interestingly, at this point in history, not even the Catholic Church believed that a human life existed before quickening [5].

Early abortion legislature began to pop up in the 1820s and 1830s, but rather than to control womyn’s access to abortions, the laws were more poison control measures, set in place to control the spread of dangerous abortifacient drugs, which were dangerous to the womyn that imbibed them [6].

Despite these regulations, however, abortion was a booming practice during the first half of the nineteenth century. Estimates show that “between 1800 and 1830, one abortion occurred for every twenty-five to thirty births”, but that by the 1850s, “the proportion had increased to as many as one abortion per every five to six live births” [7].

It was only in the mid-1800s that the procedure fell out of legal favor, due, in part, to the American Medical Association’s (AMA) desire to consolidate medical power in the United States [8]. By 1900, abortion’s fall from grace was complete, as most every state viewed abortion to be a crime.

This increase in abortion-related legislation, however, was met by a lack of contraceptive options, leaving womyn with few ways to prevent unwanted pregnancies. As John D’Emilio and Estelle B. Freeman report in their book Intimate Matters: A History of Sexuality in America, “women [attempted to] induce miscarriage themselves or seek abortions. In the early nineteenth century, and in rural areas for many later generations, herbal and home remedies for terminating unwanted pregnancies continued to be passed on through oral tradition… surgical procedures, such as the use of a probe by a doctor or by a pregnant woman herself, were available but dangerous” [9].

By the 1960s, many abortion-seeking womyn were left to utilize underground abortion services, such as Chicago’s Jane Collective, which from 1967 to 1972, had helped facilitate up to 15,000 illegal abortions [10]. Still, many of these services, not to mention self-performed “coat-hanger abortions”, were not safe. In the 1950s and 60s, “between 200,000 and 1.2 million women underwent illegal abortions each year in the US.” In 1965, “illegal abortion accounted for an estimated 17 percent of all officially reported pregnancy-related deaths”. Remember: that that number is for “officially reported pregnancy-related deaths” [11]. What about deaths that were put under another cause to preserve the reputation or legal status of a woman?

As recently as 2016’s Whole Woman’s Health v. Hellerstedt, the staggering number of abortion-related Supreme Court cases demonstrate the American public’s resistance to womyn’s right to abortion and have begun to chip away at the foundations of the Roe v. Wade ruling. In 2017, the Guttmacher Institute released a report that determined 15 obstructions to abortion, which were grouped into five barrier groups [12].

Travel-related logistical issues:

Due to the decreasing number of abortion facilities across the United States, womyn frequently must travel farther distances to get to clinics or facilities that can provide the services they need. S.C.M. Roberts et al.’s 2014 article “Out-of-Pocket Costs and Insurance Coverage for Abortion in the United States” reports that “women also reported paying up to $2200 for out-of-pocket travel costs, with a median (mean) of $15 ($54). Women with first trimester abortions paid a median (mean) of $10 ($23) out-of-pocket travel costs, women 14 to less than 20 weeks paid $20 ($47; p < 0.01 compared with first trimester), and at or after 20 weeks $30 ($100; p < 0.001 compared with first trimester) [13].

System navigation issues:

Navigating the system, as well as the stigma associated with the United States’ abortion system, can be a major barrier for some womyn seeking abortion services. Kimport et al.’s 2012 article on abortion clinic structures and processes noted that although most womyn are satisfied with the abortion care they receive in clinics, factors such as the presence of protesters or the emotional constitution of the staff played a role in abortion access [14]. Kimport reports that “even with [the anticipation of protesters], these interactions with protesters increased women’s feelings of stigma, secrecy and shame”, and that the security measures in place to protect abortion-seeking womyn from protesters reportedly made some survey respondents uncomfortable [15].

Limited clinic options:

In the clinical research of abortion-providing facilities, there seem to be four types of locations: abortion clinics, non-specialized clinics, hospitals, and physicians’ offices. According to “Abortion Incidence and Service Availability in the United States, 2014”:  Abortion clinics are defined as non-hospital facilities in which half or more of patient visits are for abortion services, regardless of annual abortion caseload. Non-specialized clinics are non-hospital sites in which fewer than half of patient visits are for abortion services. Physicians’ offices are defined as facilities that provide fewer than 400 abortions per year…Physicians’ offices that provide 400 or more abortions per year were categorized as non-specialized clinics” [16].

Between 2011 and 2014, the abortion rate declined by 3-6% per year, while the total number of abortion facilities declined 3% over the same three years; however, the closings were most likely to be of heavy caseload abortion clinics, which provide 1,000-4,999 per year (26% of abortions) [17].

Financial issues:

Clients at Title X-supported facilities, which are involved in “ensuring access to a broad range of family planning and related preventive health services for millions of low-income or uninsured individuals” are frequently young and low-income, a statistic that draws attention to the dire financial situations of many of these womyn and couples. [18, 19] In addition, 42% of abortions in the United States occur among women living below 100% of the federal poverty level (FPL) and 69% occur among women below 200% FPL [20].

A 2014 study determined that two-thirds of womyn seeking an abortion received some financial assistance assisting in the cost of their procedure, whether it was private insurance (7%), Medicaid (34%), and/or other organizations (29%) [21].

Still, twenty-nine percent of womyn seeking an abortion did not receive any financial assistance, which would be a tremendous financial blow, considering the median price of a first trimester abortion in 2014 was $490, with a range of $225 to $750 (mean of $497). However, the price increases to a mean of $860 for an abortion between 14 and 20 weeks; after 20 weeks the mean is $1874. These costs are for the procedure, only: womyn also must factor in transportation costs and the time and potential income lost from their daily lives, be it work, school or family care [22].

State or clinic restrictions:

Even though Roe v. Wade set a nation-wide ruling for abortion legislature, state-level abortion restrictions are making abortions more difficult to obtain. In 2013, Texas implemented targeted regulation of abortion providers, colloquially known as TRAP, laws that mandated that doctors who provide abortions have admitting privileges at local hospitals, and that clinics meet strict standards set for ambulatory surgical centers. These TRAP laws led to the closing of more than half of Texas’ abortion clinics, and although the Supreme Court overturned these regulations in 2016 and the decision was used several times in the next months to block similar laws in Alabama, Florida and Indiana, as of August, 2016, at least 24 states had enacted TRAP laws [23].

There are also state-level abortion restrictions that mandate longer waiting periods and limit facility availability, this issue is further complicated by the fact that most providers have limits on when in a pregnancy they will perform an abortion; womyn very early on or in their second trimester frequently have a difficult time finding facilities to help them [24].

Clearly, there are many efforts in place to attempt to prevent womyn from receiving the Constitutionally-sound care they need, and, arguably, deserve. Throughout the history of the United States, the relationship between the public, the state, the womon and abortion has experienced its fair share of trials and triumphs. Looking to the future, however, it would be impossible to say anything certain about the future of abortion in this country, except for the fact that the question of accessibility to this life-changing, and potentially life-saving, procedure will continue to be one of the major players in this debate.

 

Further readings

Levine, Phillip B., Amy B. Trainor and David J. Zimmerman. “The effect of Medicaid abortion funding restrictions on abortions, pregnancies and births.” Journal of Health Economics 15 (1996): 555-578.

Pollitt, Katha. Pro: Reclaiming Abortion Rights. Picador, 2014.

Roe v. Wade: Its History and Impact.” Planned Parenthood Federation of America, January 2014.

 

Endnotes

[1] In this paper, I will be spelling woman as “womon” and women as “womyn”; this is an intentional decision, based on my belief that abortion is a womyn’s health issue, and therefore should be a topic that womyn have power in. Utilizing these alternative spellings of the words cements that womyn are not dependent, nor should they be, on men or their opinions on what they can or cannot do with their bodies.

[2] “United States Abortion.” Guttmacher Institute. Last modified 2018. https://www.guttmacher.org/ united-states/abortion.

[3] Jerman, Jenna, Lori Frohwirth, Megan L. Kavanaugh, and Nakeisha Blades. “Barriers to Abortion Care and Their Consequences For Patients Traveling for Services: Qualitative Findings from Two States.” Perspectives on Sexual and Reproductive Health 49, no.2 (2017): 95-102.

[4] Gold, Rachel Benson and Megan K. Donovan. “Lessons from before Abortion Was Legal.” Scientific American September 2017.

[5] Reagan, Leslie J. When Abortion Was a Crime: Women, Medicine, and Law in the United States, 1867-1973. University of California Press, 1997, 8-9, 25.

[6] Ibid., 42-43.

[7] D’Emilio, John and Estelle B. Freedman. Intimate Matters: A History of Sexuality in America. University of Chicago Press, 1988.

[8] Reagan, 14-18.

[9] D’Emilio and Freedman, 65.

[10] King, C.R., “Calling Jane: the life and death of a women’s illegal abortion service.” Women’s Health 20 no. 3. (1993): 75-93.

[11] Gold and Donovan, Online.

[12] Jerman, Frohwirth, Kavanaugh and Blades, 98.

[13] Roberts, S.C.M., Heather Gould, Katrina Kimport, Tracy A. Weitz, Diana Greene Foster. “Out-of-Pocket Costs and Insurance Coverage for Abortion in the United States.” Women’s Health Issues 24, no. 2 (2014): e211-e218.

[14] Kimport, Katrina, Kate Cockrill and Tracy A. Weitz. “Analyzing the impacts of abortion clinic structures and processes: a qualitative analysis of women’s negative experiences with abortion clinics.” Contraception 85 (2012): 204-210.

[15] Ibid., 207.

[16] Jones, Rachel K. and Jenna Jerman. “Abortion Incidence and Service Availability In the United States, 2014.” Perspectives on Sexual and Reproductive Health 49, no. 1 (2017): 17-27.

[17] Ibid., 20.

[18] “About Title X Grants.” Office of Population Affairs, United States Department of Health and Human Services, March 6, 2018. https://www.hhs.gov/opa/title-x-family-planning/ about-title-x-grants/index.html.

[19] Frost J.J., L.F. Frohwirth and M.R. Zolna. “Contraceptive Needs and Services, 2013 Update.” New York: Guttmacher Institute, 2015.

[20] Jones, R. K., & Kavanaugh, M. L. ”Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion.” Obstetrics and Gynecology 117 no. 6 (2011) 1358–1366.

[21] Roberts, S.C.M., L. Fuentes, R. Kriz, V. Williams, U.D. Upadhyay. “Implications for women of Louisiana’s law requiring abortion providers to have hospital admitting privileges.” Contraception 91 (2015): 368-372.

[22] Ibid.

[23] Jones and Jerman, 19.

[24] Jones, Rachel K. and Kathryn Kooistra. “Abortion Incidence and Access to Services in the United States, 2008.” Perspectives on Sexual and Reproductive Health 43, no. 1 (2011): 41-50.

 

Beside The Golden Door

Leah Barr is a fourth year Gender, Women’s, and Sexuality Studies major at Grinnell College from Evanston, IL. Her maternal great grandparents met on the boat to Ellis Island. Leah plans to spend the next few years in pursuit of her lifelong goal of becoming a library curmudgeon. At the base of the Statue of… Read more Beside The Golden Door

A Crisis We Would Rather Avoid: Water Quality and Public Health in the United States

Thomas Aldrich is a third year history and religious studies double major at Grinnell College. In his free time he enjoys singing, riding his bike around campus and out of town, and advocating for stronger government oversight. For those of us who have lived our entire lives with a safe, secure water supply, the idea… Read more A Crisis We Would Rather Avoid: Water Quality and Public Health in the United States

History of Welfare in United States: Equality for Some

Summer White is a senior political science major with a concentration in policy studies at Grinnell College. Interested in pursuing public health and social justice oriented policy, Summer will begin her career this July in Washington, DC as a federal strategy and operations business analyst. Health is a universal human experience. Physical, social, emotional, mental,… Read more History of Welfare in United States: Equality for Some

Widening the Healthcare Gap: The AIDS Epidemic and “The Other”

Kyra Neylan is a fourth year student at Grinnell College studying biology and neuroscience. She is interested in pursuing a career in medicine. From the onset in 1980 of what would come to be a national epidemic, the disease now known as HIV/AIDS was framed as a disease of male homosexuality. Initially termed Gay Related… Read more Widening the Healthcare Gap: The AIDS Epidemic and “The Other”

Choice? Alternative Birthing Options for Black Women in the Southern U.S. From the 1970s-now

Haley O’Neill (’18) is a Biology and Gender, Women’s, and Sexuality Studies major from SE MN. After Grinnell, she is working with maternal healthcare and reproductive rights advocacy. She hopes to pursue midwifery or women’s healthcare policy. The U.S. maternal mortality rate, in 2018,  is comparable to the rate in the 1970s. Approximately 700-900 women die… Read more Choice? Alternative Birthing Options for Black Women in the Southern U.S. From the 1970s-now

“One of Our Greatest Investments”: Breastfeeding in the Early 20th Century United States

Sam Curry is a fourth year Anthropology major from South Kingstown, Rhode Island. His main academic interests involve humans’ relationships with the nature and environmental health, and he hopes to work in environmental policy after graduation. His other main  interest is racquetball. In 1912, pediatrician Henry L. Coit, mourning his son’s death from typhoid fever,… Read more “One of Our Greatest Investments”: Breastfeeding in the Early 20th Century United States