The technical definition of induced abortion is the removal of products of conception from the uterus of a pregnant woman. Throughout recorded history, there is evidence that women have found the means to limit and space their childbearing through the use of induced abortion. Women of all identities and living in a wide variety of conditions all over the world continue to choose termination as one response to unintended pregnancy. In 2000, an estimated 16 to 21 of every
1,000 women in the United States ages 15 to 44 had induced abortions. The abortion rate has been stable or declining since the 1980s. Another way to express the frequency of abortion is the number of induced abortions compared with the number of live births. In 2000, this ratio was estimated to be 246 per 1,000 births, consistent with a declining trend over the past two decades. These statistics do not include abortions that happen spontaneously, usually called miscarriages.
Who Has Abortions?
Nearly half (48%) of all pregnancies that occur in the United States are not intended, and about the same proportion (47%) of unintended pregnancies is resolved by abortions. Most women (53%) who have abortions were using some form of birth control during the month they became pregnant, but misused or experienced failure of their contraceptive product or method. By the age of 45, about 43% of women in the United States have experienced at least one abortion. Among the women choosing to have abortions at a given time, most (61%) have already given birth to at least one child, and nearly half (48%) have had at least one previous abortion.
There is not one particular type of woman who is likely to have an abortion. About two thirds of the women having abortions have never been married. Most (56%) are in their 20s, and fewer than 20% are teenagers.
Women of all racial or ethnic, religious, and socioeconomic groups obtain abortions. The largest number (41%) of abortions are performed on non-Hispanic white women, but black women are three times as likely and Latinas or Hispanic women are twice as likely as white women to have an abortion in a given year. Women who identify themselves as Catholic are only slightly less likely to have abortions than other women in the United States. Poor and low-income women are more likely to have abortions than those who are more affluent.
Abortions occur for many reasons, and women tend to have multiple explanations for their decisions to terminate pregnancies. The most common reason, given by three fourths of women having abortions, is that having a baby at that time in their lives would conflict with major commitments such as work, school, or existing family responsibilities. Two thirds of women having abortions give economic reasons for delaying or foregoing parenthood. Half of women choosing abortion do not have the supportive relationship that they would like for becoming a parent— either they do not want to start out as a single mother, or they are having problems in their relationship with a husband or partner. About 13,000 women a year choose abortions to terminate pregnancies resulting from rape or incest.
When Abortion Was Illegal
Major complications from induced abortion are very rare in the United States, occurring in less than 1% of abortions. The risk for death from childbirth, an uncommon event in industrialized countries, is 10 times greater than the mortality risk of abortion. The safety of legal abortion is in stark contrast to the danger women faced before abortion was decriminalized in the United States in 1973. In the 1950s, for example, there were about 1 million illegal abortions every year, with at least 1,000 associated deaths.
Before legalization, some courageous and qualified providers took considerable personal risks to offer safe procedures to women in need. Women with adequate financial and social resources were sometimes able to seek safe abortions in legal settings outside the United States. Desperation often drove other women to unskilled abortionists working in unsanitary conditions. Women who survived so-called back-alley abortions of this sort or attempts to self-abort sometimes suffered painful chronic illnesses, lost the ability to have children, or experienced trauma that affected their psychological health and well-being.
Judicial And Legislative Rulings
On January 22, 1973, the U.S. Supreme Court handed down the Roe v. Wade decision, which created a legal, though limited, right to abortion. Roe v. Wade concluded that the “right of privacy… founded in the Fourteenth Amendment’s concept of personal liberty . . . is broad enough to encompass a woman’s decision whether or not to terminate her pregnancy.” Based on their individual right to privacy, women in consultation with their doctors gained the legal right to choose abortion in the first 3 months (or first trimester) of pregnancy. State laws were permitted to limit second-trimester abortions “only in the interest of the woman’s safety.” In the final 3 months (third trimester) of pregnancy, Roe v. Wade allowed states to protect the fetus by restricting abortion unless there is potential danger to the life or health of the pregnant woman.
Roe v. Wade granted women the right to early abortion with a physician’s consent, but it did not guarantee financial or medical access to abortion. In 1976, the U.S. Congress passed the Hyde amendment to a federal appropriations bill, eliminating federal reimbursement for induced abortions from Medicaid public insurance coverage for low-income women. As of 2004, Congress had annually reinstated this ban on federal funding of abortion, with narrow exceptions for rape, incest, and threats to the life of the woman if she continued the pregnancy. In 2001–2002, the cost of early surgical abortions was highly variable. On average, women were charged $364 for procedures in specialized clinics and $632 in physicians’ offices. The average amount paid by women without insurance coverage for abortion was $372.
Funding issues have been only one arena of debate in the controversy over women’s right to abortion. Religious and personal beliefs lead some people to reject abortion as an option for themselves. Among those with personal objections to abortion, some advocate for the right of other people to make their own decisions. Others attempt to use the judicial or legislative system to return to the situation that existed before legalization. Attitudes toward sexuality and women’s autonomy, as well as fundamental beliefs about social control over individual decision making, motivate activists on different sides of the abortion issue.
The U.S. Supreme Court heard another major abortion case in July 1992. In Planned Parenthood v. Casey, the court reviewed a Pennsylvania statute that required women seeking abortions to receive counseling from physicians in favor of continuing their pregnancies, and then to wait at least 24 hours before obtaining an abortion procedure. Notification of spouses and parents about requests for abortions was also required. Only the provision for spousal notification was considered to impose an undue burden on women by the Supreme Court, and this provision was thus judged unconstitutional. The Court acknowledged the situation of women in abusive relationships, with the potential for violence perceived as part of the burden for women wishing to act independently of their partners. Other provisions of the statute were left intact, although most were seen by the Court as medically unnecessary and burdensome to a lesser extent.
Although Roe v. Wade was not overturned by the Supreme Court in the Planned Parenthood v. Casey decision, the Court’s strict interpretation of undue burden set a precedent for states to impose numerous restrictions on women exercising their right to abortion. Systematic attacks have eroded women’s access to abortion despite its legal status. As of 2002, 32 states required parental consent or notification for adolescents seeking abortions. In many of these states, it is possible to seek a “judicial by-pass” of parental involvement, but this provision can only be used if a teen has the information and resources to bring a persuasive request to a court. Eighteen states in 2002 mandated delays in accessing abortion pursuant to state-directed counseling. Four states disallowed private insurance coverage of abortion services, and another state required companies to offer alternative policies excluding abortion coverage.
Under the second Bush administration, abortion opponents made significant inroads by labeling a rarely used procedure “partial-birth” abortion. Most (88%) abortions are performed in the first 12 weeks of pregnancy, and very few occur after 20 weeks. By evoking distorted images of abortion, antiabortion activists succeeded in getting the so-called PartialBirth Abortion Ban Act of 2003 passed by Congress and signed by President Bush in November 2003. Lawsuits ensued to challenge the constitutionality of the ban and prevent its enforcement, based on the lack of any exceptions to protect the health or life of the woman. As of June 2004, a federal district judge ruled favorably on a lawsuit brought by Planned Parenthood Federation of America (PPFA), and action on other suits was pending.
Access To Abortion
Restrictions on abortion and lack of broad access to abortion services are unique for a legal medical procedure. It is difficult to imagine similar infringements on medical decision making in clinical areas such as heart surgery or cancer treatment. Because of political opposition and associated harassment and violence toward patients and providers, the United States now has a limited number of active abortion providers. In 2000, 87% of U.S. counties (home to more than one third of all women of reproductive age) had no abortion provider. The number of providers declined from 2,042 in 1996 to 1,819 in 2000, with rural areas most seriously underserved.
Most medical residents specializing in obstetrics and gynecology (OB/GYN) are not required to perform first-trimester induced abortions as part of their training. As of 1995, only 12% of OB/GYN residency programs routinely offered abortion training. In 1995, the Accreditation Council for Graduate Medical Education (ACGME) issued a requirement for OB/ GYN residencies to provide training for management of spontaneous abortion. In contrast, programs are only required to provide “access to experience” with induced abortion, and residents can opt out of training for elective procedures. A 1998 survey indicated a positive response, with nearly half (46%) of respondents reporting provision of routine training subsequent to the new guidelines. Information on training is incomplete, however, because many programs did not respond to the survey.
The New York City (NYC) chapter of the National Abortion and Reproductive Rights Action League (NARAL/NY) started its own residency training initiative in response to the provider shortage. In 2002, NYC supported a requirement for all OB/GYN residents working in the city’s public hospitals to receive training in surgical and medical abortion through this program. After implementing the program in New York, NARAL/NY began working to disseminate their training initiative in other states. California has also legislated abortion training for OB/GYN residents in state-sponsored medical schools. The California initiative also has an “opt-out” provision, which allows schools to offer training indirectly through agreements with other institutions. Training in procedures for early abortion is recommended by the Council on Residency Education in Family Practice, yet 71% to 88% of family practice residency programs did not offer such training in 1995.
U.S. Food and Drug Administration (FDA) approval of pharmaceutical agents to induce abortion medically rather than surgically, granted in 2000, could increase the number of U.S. abortion providers. Past experience in several European countries showed mifepristone to be a safe option for inducing abortions without surgery, but acceptance by European women and providers was conditioned by cost and other issues. The early experience with medical abortion in the United States has been promising. Many women prefer the privacy and autonomy of the medical alternative, and acceptance by providers appears to be growing. However, this recently introduced technology requires medical supervision and does not eliminate the need for legal, safe, and accessible surgical procedures. Women’s preferences will continue to be influenced by many practical, physiological, and psychological factors.
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