Obstacles to Abortion in the United States

Martin Donohoe, MD, FACP

Disclosures

July 05, 2005

In This Article

Barriers to Abortion

Barriers to abortion are manifold and include legal point of viability; cost and coverage; the availability of mifepristone, an oral abortifacient; provider availability; harassment of patients and providers; laws designed to limit the provision of abortion services; and a culture of pseudoscience which promotes the dissemination of misinformation regarding human reproduction through a wasteful diversion of the public's tax revenues.

Roe vs Wade[13] protects the privacy and availability of abortion procedures at < 24 weeks, the point of legal viability.[14] After viability, states can ban abortion, except when necessary to protect the woman's life or health.

An average self-paying patient was charged $372 for a surgical abortion at 10 weeks and between $438 and $490 for a medical abortion in 2001.[15] Second-trimester surgical abortions are 2 to 3 times more expensive than first-trimester surgical abortions. Most patients pay out of pocket.[15,16] Only 26% of abortions are billed directly to public or private insurance.[15] Most insured patients are reluctant to file claims because of concerns about confidentiality. Some health plans cover sterilization but not abortion, leaving poor women in the unenviable position of having to choose sterilization if they lack the resources for adequate contraception.[17,18,19]

The 1978 Hyde Amendment prohibits federal Medicaid dollars from being spent on abortion, except to preserve a woman's life or in cases of rape or incest.[20] Twenty-two states allocate a portion of their share of Medicaid funding to cover abortion. The Hyde Amendment was applied to Medicare, which covers disabled women, in 1998. Women of color are more likely than white women to be poor, to lack health insurance, and to rely on government healthcare programs. Thus, they are disproportionately harmed by prohibitions on public funding for abortions.[21,22] In addition, black women and Hispanic women are more likely than white women to have an abortion.[23] Higher rates of abortion are explained, in part, by higher rates of unintended pregnancy, a greater proportion of conceptions that end in abortion, and greater poverty.

The Defense Department, through TRICARE, provides health coverage to military personnel and their families. TRICARE has instituted a permanent ban on abortion coverage, except when the life of the woman is endangered.[20,24] American Indians and Alaskan natives covered by the Indian Health Service are subject to the Hyde Amendment.[20]The Federal Employees Health Benefits Program pays for abortions only in cases of life endangerment, rape, or incest. Women in federal prisons are allowed to obtain an abortion only when their lives are endangered or when the pregnancy is the result of rape,[20] which may be difficult to prove.

Between 1995 and 2003, approximately 350 anti-choice measures were enacted, including statutes that protect pharmacists who refuse to fill birth control prescriptions on moral or religious grounds.[25,26] In 2003, 10 states introduced 15 measures that would ban all or most abortions.[27,28] In 2004, Michigan enacted a ban on abortion.[29] The ban prevents physicians from performing most abortions, even in cases when a woman's life or health is in danger (eg, a woman with diabetes or a heart condition). However, on June 14, 2005, the American Civil Liberties Union, the Center for Reproductive Rights, and the Planned Parenthood Federation of America sought to block the ban in federal court. The law has been enjoined pending the court's decision.

In the month of January 2005 alone, 15 states introduced 19 bills that would require counseling and waiting periods for abortion; and 12 states introduced 17 bills that would mandate parental involvement in minors' abortions. Twenty-three states already have mandated waiting periods for women wishing to obtain an abortion,[30] augmenting patients' exposure to anti-choice harassment and increasing the gestational age at which pregnancy termination occurs, thereby also enhancing the risk associated with the procedure.[31,32]

On April 27, 2005 the House of Representatives passed the "Teen Endangerment Act".[33] The first section of the law (which is also known as the "Child Custody Protection Act ") would make it a federal crime for anyone other than a parent from accompanying a young woman across state lines for an abortion without complying with the home state's parental involvement statutes.[32,34,35] Although 33 states enforce parental consent or notification laws for minors seeking an abortion,[2] 24 of these have parental involvement requirements that meet the Teen Endangerment Act's restrictive definition of a "parental involvement law."[32] This barrier would delay an abortion for a teenager determined to have one but unable to draw on her parents' assistance, increasing its economic cost and placing additional physical and emotional burdens on her.

The second section of the Teen Endangerment Act (Child Interstate Abortion Notification Act) would make it a federal crime to provide an abortion to a teenager outside of her home state unless the physician has notified a parent at least 24 hours in advance. There is no exception made for when an abortion may be necessary to protect a young woman's health. It further requires a 24-hour waiting period and written notification even if a parent accompanies his or her daughter to an out-of-state abortion provider.[32]The Senate is currently considering a bill similar to the Teen Endangerment Act but without interstate abortion notifications.

Parental notification laws can be dangerous if a pregnancy results from incest, or if the adolescent's home environment is abusive or otherwise unstable. A national survey of female adolescents found that mandated parental notification laws would likely increase risky or unsafe sexual behavior and, in turn, the incidence of sexually transmitted disease (STDs) and adolescent pregnancy.[36] Others have found that parental consent and notification laws could prevent up to half of teens from using Planned Parenthood services, including contraception, while only stopping 1% from having sex.[37] Based on the projected number of additional pregnancies, births, abortions, and untreated STDs and resulting pelvic inflammatory disease, the potential annual costs of parental consent and law enforcement reporting requirements in 1 state (Texas) have been estimated at $43.6 million for girls younger than 18 years currently using publicly funded services.[38] In May 2005, the U.S. Supreme Court agreed to hear a case involving New Hampshire's parental notification law, which had been ruled unconstitutional by the First U.S. Circuit Court of Appeals because it contained no health exception in the event of a medical emergency.[39]

Targeted Regulation of Abortion Provider (TRAP) Laws are designed to add excessive regulations and extra costs to abortion clinics.[40,41] TRAP regulations far exceed the usual recommendations and requirements of respected scientific organizations. Increased retrofitting, design, and training costs, combined with increased licensing fees and burdensome documentation requirements, have put some clinics out of business and forced others to close temporarily or reduce services. Zoning ordinances have also been passed to force clinics to move. Some facilities shut down and do not reopen. The overall effects of TRAP laws and unfair zoning ordinances are to decrease access and increase costs of abortion.[42] As of 2004, 19 states and Puerto Rico enforce TRAP laws that apply to abortions performed at any stage of pregnancy, and 14 states enforce TRAP laws that apply only to abortions performed after the first trimester.

Forty-six states have enacted "refusal clauses," which allow employers to refuse to provide contraceptive coverage in their health plans; pharmacists to refuse to dispense, or provide referrals for, oral contraceptive pills; and certain medical personnel, health facilities, and/or institutions to refuse to provide abortion services.[28] Healthcare professionals can deny patients' requests for information on, or referral for, family planning services, regardless of patients' healthcare needs.[17,27,28,43,44]] The Weldon Federal Refusal clause, signed by President George W. Bush in December 2004, allows federally funded healthcare entities to deny women information on abortion services, even if state laws mandate that such information be given upon request.[45] The National Family Planning and Reproductive Health Association filed suit soon afterward, on the basis that the Weldon clause is in conflict with the requirements of Title X, the nation's only federal program solely dedicated to providing family planning and reproductive healthcare to low-income and uninsured women.

The current administration has aggressively attempted to grant rights usually available only to living US citizens to the unborn, creating a movement for "fetal rights." It has extended coverage under the State Children's Health Insurance Program (SCHIP) to fetuses, while failing to extend full prenatal care to all women.[17,43,46] The mission of the federal Advisory Committee on Human Research Protection, which oversees the safety of human research volunteers, has been expanded to include embryos.[47,48,49] The "Unborn Victims of Violence Law" criminalizes harming fetuses was signed into law by President Bush on April 1, 2004.[50] the National Abortion Rights Action Network (NARAL) argues that this legislation is an attempt to undermine Roe vs Wade.[51] In February, 2005, a Cook County, Illinois judge ruled that parents of a frozen embryo accidentally destroyed by a Chicago fertility clinic could file a wrongful death lawsuit.[52] By contrast, the European Court of Human Rights declined to extend full human rights to fetuses.[53]

The so-called "Partial Birth Abortion Ban" criminalizes the seldom performed and often lifesaving (for the mother) procedure known as intact dilatation and extraction).[14,54] The ban makes no exceptions for the health of the woman. A federal appeals court judge in San Francisco blocked the administration from enforcing the ban against Planned Parenthood of America clinics and their doctors, who perform roughly half the nation's abortions.[55] Two other courts have also struck down the ban.[56] Courts have also blocked the United States Justice Department's attempts to access confidential medical records as part of their case against opponents of the law.[57] The present U. S. Supreme Court previously ruled that a similar 2000 Nebraska State Law was unconstitutional.[3]

In 2001, more than 20 states had biased counseling laws,[58] often (mis)labeled "Mandated Informed Consent" or "Women's Right to Know" laws, which employ scare tactics and unbalanced data to convince women that abortion is especially dangerous. Similar biased (dis)information is promulgated at up to 4000 "Crisis Pregnancy Centers" nationwide, some of which receive federal and state funding.[59,60] Staffs try to dissuade clients from having abortions through exaggeration of risks, myths, and fetal photographs.

Oral mifepristone allows medical termination of pregnancies up to 49 days from the last menstrual period.[61,62,63,64] Many women are unable to obtain this drug because of lack of awareness of its existence, providers' lack of knowledge and fears of prescribing it, and cost. Medicaid restricts funding for mifepristone to cases of rape, incest, or to preserve the pregnant woman's life. The current administration has asked the United States Food and Drug Administration (FDA) to reconsider its approval of mifepristone. Currently proposed state and federal legislation aims to curtail the availability of mifepristone and to limit the number of prescribing doctors.[65,66]

Over one third of US women live in the 87% of counties in the United States, including 30% of metropolitan areas, that have no abortion provider.[7] The situation is worst in rural areas.[15,67] Only 1800 physicians provided abortion services in 2000, down 11% from 2400 in 1996.[3,7] Only 12% of obstetrics and gynecology residency programs required abortion training in the mid-1990s, down from 25% in 1985.[68,69,70,71,72] More recently, Espey and colleagues[73] conducted a survey on abortion education throughout the 4 years of medical school. The results show that abortion education remains limited in US medical schools. Most states bar nonphysicians from performing abortions.[74]

Since 1977, there have been 80,000 reported acts of violence and/or disruption at abortion clinics in the United States and Canada, including 7 murders, 17 attempted murders, 41 bombings, 166 arsons, 125 assaults, and 654 anthrax threats (480 of them since September 11, 2001).[15,75,76] Patients are often harangued, belittled, defamed, and taunted with verbal and physical threats, despite the federal Freedom of Access to Clinic Entrances Act.[46,77] Between 55% and 86% of providers report that they have been harassed.[16]

The environment in which this harassment occurs has been perpetuated by the federal administration's philosophy and anti-choice rhetoric. For example, when President Bush declared January 20, 2002, 2 days before the 29th anniversary of Roe v. Wade, "National Sanctity of Life Day," he likened abortion to terrorism: "On September 11 [2001], we saw clearly that evil exists in this world, and that it does not value life.... Now we are engaged in a fight against evil and tyranny to preserve and protect life. In so doing, we are standing again for those core principles upon which our Nation was founded."[78] Such rhetoric is permissive of extremism, in that it likens the "battle" against prochoice advocates and abortion providers to that against malevolent suicide bombers.[14]

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