Abortion Decline

O nce upon a time, physicians- in-training learned to do abortions as a routine part of their schooling. As a result, the roster of experienced practitioners grew. What’s more, a network of freestanding clinics developed and the number of abortions began to increase. By 1980—seven years after the Supreme Court issued the Roe v. Wade decision—29.3 of every 1,000 pregnancies were surgically terminated. 

Flash forward to 2003. According to a recent study by the Alan Guttmacher Institute (AGI), the surgical abortion rate is now 21.3 per 1,000, a 3 percent decline since 1996 and a 27 percent decline since l980. Not surprisingly, the anti- abortion movement is ecstatic and its leaders are patting themselves on the back for a job well done. Some of their jubilation is well-founded. The anti-abortion movement has clearly succeeded in getting states to promulgate onerous restrictions on access; the percentage of teenagers having sexual intercourse has fallen; and encounters with vitriolic picketers in front of clinics have made many women think twice about ending a pregnancy. 

Nonetheless, it is a mistake to give the antis full credit for the reduced number of procedures. Indeed, AGI estimates that increased access to birth control, including “morning after” emergency contraception, has contributed to the abortion drop-off. According to AGI calculations, 51,000 abortions were prevented by emergency contraception in 2000 alone.Lawrence B. Finer, Assistant Director of Research at AGI, also believes that mifepristone (formerly called RU-486) has played a small but significant role in abortion provision: 6 percent of all abortions—130,000 procedures—were done with mifepristone during the first 6 months of 2001 and Finer believes that this percentage will escalate as both providers and patients become more familiar with the drug. 

Unfortunately, that’s where the good news ends. The AGI study, released on the 30th anniversary of the Roe decision, reveals a huge decrease in the number of clinics, hospitals, and private physicians who perform abortions, from 2,908 in 1982 to 1,819 today. This decrease has had a significant pragmatic impact: 1 in 4 women now have to travel at least 50 miles to obtain reproductive healthcare. Worse, 8 percent have to travel 100 miles or more. Overall, the picture is stark: 86 of the country’s 276 metropolitan areas—cities like Canton, Ohio; Myrtle Beach, South Carolina; Provo, Utah; and Scranton, Pennsylvania—are without a single abortion facility and only 3 percent of rural counties have providers. 

Part of the blame for this limited access rests on the fact that 57 percent of the doctors who perform abortions are aged 50 and older. Couple this with a bewildering and costly array of state-imposed restrictions on how, when, and where a provider can operate, and you can practically see the number of clinicians dwindle before your eyes. 

The restrictions, called Targeted Regulation of Abortion Provider (TRAP) laws, allow states to place specific licensing or management obligations on abortion facilities, restrictions that are not imposed on other types of ambulatory health centers. Says the National Abortion Federation (NAF), “TRAP laws are designed to discourage doctors from providing abortion services.” Such laws are presently in effect in 17 states and Puerto Rico. 

 A relatively new way to restrict access, they are already having a disastrous impact. 

Take South Carolina as a case in point. In 1995 providers there received a 30-page document from the Department of Health and Environmental Control dictating a bevy of licensing requirements for anyone performing 5 or more abortions a month in either a private office or clinic. Among the requirements: 6 air changes per hour in the recovery and operating rooms; temperature maintenance between 72 to 76 degrees at all times; removal of grass and weeds from land surrounding the office; and the installation of particular alarms in all restrooms. The regulations also gave state health inspectors the right to peruse patient records whenever they choose, confidentiality be damned. Although a lower court found the law to be unconstitutional, in September 2002 the U.S. Court of Appeals for the 4th Circuit overturned the decision. “The rationality of distinguishing between abortion and other medical services when regulating physicians or women’s health care providers has long been acknowledged,” the judges wrote. “Abortion is inherently different from other medical procedures.” 

This judicial go-ahead emboldened the antis and 10 states are presently considering a variety of TRAP laws. “The bills come in two flavors,” says Janet Crepps, an attorney with the Center for Reproductive Law and Policy. “Some put all the details—air current restrictions; staffing requirements; regulations about temperature and door width—into the legislation. Other bills are very broad and give state licensing departments the right to draft regulations for abortion clinics. These restrictions leave providers vulnerable to constant changes. A shift in the legislature can lead to a shift in licensing staff so every two years there can be new rules. When this happens abortion stops being medical care and becomes a political football.” 

In South Carolina there has been a 29 percent drop in the number of providers since the state’s TRAP law took effect in 2001; 10 remaining clinics are concentrated in three cities: Charleston, Columbia, and Greenville. Add to the mix the fact that the state does not fund Medicaid abortions and requires young women to get the consent of a parent or guardian before having the procedure, and the reasons South Carolina’s abortion rate has declined become exceedingly clear. 

Still, at this juncture, one-third of all women in the U.S. will have an abortion at some point between ages 15 and 45. This number may be smaller than it used to be, but it is nevertheless significant. 

The National Coalition of Abortion Providers (NCAP) is urging reproductive health activists to not only fight burdensome TRAP laws, but to reframe the debate by reclaiming the ethical ground that reproductive choice represents. “While more than one million women a year have abortions in the United states, abortion is a highly stigmatized procedure,” NCAP’s website admits. “Most people are uncomfortable talking about the issue and if they do it is often in judgmental or uninformed terms. The stigma associated with abortion can have unfortunate consequences. It can cause unnecessary guilt or remorse and it can lead to a feeling of alienation or isolation...supporters of legal abortion need to challenge the notion that abortion is immoral. It is time to lift the veil of secrecy and candidly address the core of the abortion experience: the relief, the conflict, the confusion, the sadness and the empowerment.”