Roe v. Wade at 30: what are the prospects for abortion provision?

29 Volume 35, Number 1, January/February 2003 At the 30th anniversary of Roe v. Wade, it is time for the inevitable stocktaking by the prochoice movement. But rather than celebrating such a landmark anniversary, many in the movement appear grimly relieved that abortion is still legal at all in the United States. It was not supposed to be like this. Acknowledging such a milestone should involve looking back on the considerable advances in public health that resulted from legalization—the dramatic reductions in rates of abortion-related death and injury, and the enormous changes in American women’s lives that were enabled, in considerable part, by the availability of reliable and safe abortion services.1 Instead, the story is about how abortion emerged as one of the most divisive issues in American society, the target of a nonstop assault by its foes in Congress and in the streets—and seemingly everywhere in between. As of this writing, in the immediate aftermath of the November 2002 elections, which gave Republicans control of both the House and the Senate, the situation looks particularly bleak. Antiabortion forces have introduced yet another “partial-birth abortion” bill (although the Supreme Court has found nearly identical bans unconstitutional);2 President Bush has overruled his own State Department’s recommendations by refusing to allow funding for international family planning; contentious hearings have been held for Bush judicial nominees seemingly chosen for their antiabortion record; and the antiabortion movement has trumpeted its newest tactic of videotaping patients as they enter abortion clinics and then posting the tapes on the Internet. And of course, the prochoice movement trembles while it waits for the proverbial other shoe to drop: When will George W. Bush have the opportunity to nominate a Supreme Court justice who could provide the fifth vote to overturn Roe altogether? A similar feeling that things have not turned out the way they were supposed to pervades the medical wing of the prochoice movement. Certainly no physician could have predicted that providers would be harassed and violently attacked—including seven who were gunned down by antiabortion terrorists—in the years after Roe. Just before Roe, in 1972, 100 professors of obstetrics and gynecology wrote to their colleagues of the necessity to prepare for abortion’s imminent legalization. Their statement confidently predicted that “if only half of the 20,000 obstetricians in this country do abortions, they can do a million a year, at a rate of two per physician per week....Independent clinics will probably not be necessary if all hospitals cooperate in handling their proportionate share of these cases.”3 It is deeply frustrating to read these words today. Far from half of the some 48,000 practicing obstetrician-gynecologists4 provide abortions, although the precise proportion is unknown. Currently, only 1,819 known facilities provide abortions—46% of these sites are clinics, 33% are hospitals and 21% physicians’ offices.5 Hospitals provide fewer than 5% of all abortions. The absence of a provider in some 87% of U.S. counties6 has become the mantra of the beleaguered prochoice movement. These figures reflect one of the greatest obstacles to legal abortion provision in the past 30 years: American medical culture itself. From the period immediately preceding Roe to the present, mainstream medicine has supported legal abortion—but not the individuals who provide it. As I have argued at length elsewhere,7 physicians’ discomfort with colleagues who provide abortion stems from the pre-Roe era, when the dominant image of the illegal provider was the inept and unethical “back-alley butcher.” The reality, however, was that some of those offering illegal abortions were highly skilled and principled physicians, who risked their medical licenses and personal freedom to provide safe abortions. A peculiar medical version of “not in my backyard” with respect to abortion developed from a combination of the stigma attached to providers, the antiabortion movement’s record of harassment and violence after Roe, and the medical profession’s historic discomfort with controversy (especially when it involves sexuality). Although most members of the profession, especially obstetrician-gynecologists, continue to identify themselves as “prochoice,” in reality, this typically means that they are only willing to refer patients to freestanding clinics. The medical profession as a whole is reluctant to incorporate abortion training and services into hospitals or group practices, or to promote abortion-related activities in such forums as professional societies and journals.