Where Are We Now?

In 1846, a few blocks south of Greenwich Village in Manhattan, a British immigrant hung out her shingle: “Madame Restell’s experience and knowledge in the treatment of cases of female irregularity is such as to require but a few days to effect a perfect cure. . . . Ladies will be accommodated with private and acceptable board.”

A century later, the “female irregularity” would more commonly be called pregnancy, and Madame Restell’s specialty would be known as abortion.

Although abortion was illegal, Madame Restell and other practitioners flourished because women’s desire to end unwanted pregnancies overcame legal prohibitions and social censure, as well as horrifically unsafe conditions.

On Jan. 22, 1973, 127 years after Madame Restell went into business, the U.S. Supreme Court legalized her occupation in its 5-4 decision in Roe vs. Wade. Far from settling the issue, however, the Roe ruling propelled the abortion debate beyond the fine points of legal briefs and into the murky and painful arena of individual morality.

Within a few years, the country plunged into an increasingly violent and divisive public battle over women’s rights versus those of the unborn. On the 25th anniversary of the Roe decision, abortion--while one of the nation’s most common surgical procedures--is still on the margins of medical practice.

It occupies a similar no man’s land in the American psyche. Although more than one pregnancy in four is terminated by abortion, the decision rarely comes easily--and often creates profound anxiety.

Paradoxes abound. Polls show that while a strong majority of Americans believe the decision should be left to the woman and her doctor, nearly half regard abortion as murder. A substantial slice of the American public--even including many of those who have had an abortion--believe a bit of both.

“I just feel guilty,” said Ginny, a 19-year-old from Houston who recently went to a Planned Parenthood clinic for an abortion. “I see so many children walking around; all I see now are babies, and it’s really hard.

“I felt like I wanted to keep it, but I know I can’t because of the facts of life. My boyfriend didn’t have a stable job, and I’m working and going to school. It’s really hard to go through [an abortion] because of God. He’s watching me and I feel like I’m doing something wrong, but I also feel that God can forgive me for this decision, because I’m only doing it for the good and not the bad.”

Ginny is one of an estimated 300,000 American teenagers who will have an abortion this year, and she chose to have hers in the sixth week of pregnancy. These numbers have been largely unchanged for nearly a decade: About 20% of abortions are obtained by women 19 and younger and 89% occur in the first three months of pregnancy.

But much else has changed since Roe vs. Wade legalized abortion. The number of abortions rose sharply in the years after the ruling. With unplanned pregnancies now 16% below their 1987 peak, abortions are also falling, from 1.6 million in 1990 to about 1.4 million.

As the practice of abortion rose, so did violent opposition--bombings, arson, clinic blockades and even murder. Not entirely coincidentally, the number of doctors providing abortions dropped.

Despite that, abortion technology has become more sophisticated over the last 25 years, making the procedure available earlier in pregnancy. Although the public debate focuses on late-term abortions, when the procedure is the most morally troubling and gruesome, only about 1% are performed after 20 weeks or more of gestation.

Seventeen states have banned “partial-birth” abortions--those that involve partial vaginal delivery of a living fetus before the fetus is killed--except in cases when the woman would otherwise die. Courts have partially or fully blocked enforcement of the bans in all 11 states where they have ruled.

But the courts, after striking down virtually all restrictions on abortion for the first 15 years after Roe, have begun upholding some limits. Eleven states require women to wait 24 hours between entering a clinic and having an abortion; 31 states require teenagers seeking abortions to involve their parents in the decision. California imposes no restrictions.

Nonetheless, the fundamental right to an abortion at any stage of pregnancy remains intact, and legal experts foresee no change. Most recently, the Supreme Court, in its 1992 ruling in Casey vs. Planned Parenthood of Southeastern Pennsylvania, reaffirmed that right in the first and second trimesters of pregnancy, although it permitted limitations that did not impose “an undue burden.”

Under both Roe and Casey, the states may ban third-trimester abortions, but must include exceptions when the mother’s life or health is threatened.

“There’s no chance Roe vs. Wade will be overturned,” said Lawrence Tribe, a constitutional scholar at Harvard. “It has now been through the fires of reconsideration by the court and, when the court very elaborately explained that it was not going to change, that’s as close to the last word as we’re going to get.”

With abortion’s legality largely settled, advocates on both sides have shifted their focus to its morality.

“Right after Roe, abortion was about whether you were for women or you were not,” said Helen Alvare, head of the Pro-Life Directorate of the Conference of Catholic Bishops. “Twenty-five years later, abortion is more about a terrible moral dilemma. . . . People start from a different place than they did in the late ‘60s and early ‘70s: They are saying, ‘This is a really vexing social problem. Abortions are problematic. I wish there weren’t so many of them.’ ”

Clinic counselors and directors note a similar change among women who are seeking abortions.

‘When I started working in an abortion clinic in 1977, women were incredibly frightened because they had heard stories of bleeding to death and butchers and incredible pain,” said Kitty Kahn, director of a Planned Parenthood clinic that performs abortions in Houston. “We don’t see that as much any more. Now the anxiety comes with making the decision; they have the luxury of being able to take the time and energy to look into the moral issue.”

Abortion Rate Declines

Since the national debate about “partial-birth” abortion began in 1995, a Gallup Poll in 1997 found that 64% of Americans believe abortions should be generally legal in the first three months of pregnancy. But that support drops sharply to 26% in the second trimester and 13% in the third.

“Partial-birth led people to evaluate the reality of abortion: not to just say, ‘It’s a woman’s right to choose,’ but to think about what it is that she is choosing,” said Vicki Thorn, director of the National Office of Post-Abortion Reconciliation and Healing.

Thorn’s group refers women to programs that help them come to terms with grief, depression and other emotions that sometimes follow abortion. It now receives 300 to 400 inquiries a month, double the number before the national debate on partial-birth abortion.

At least 34 million abortions have been performed in the United States during the 25 years since Roe, and far fewer women die or are injured by abortion than before it became legal.

The United States has the highest abortion rate--24 per 1,000 women of child-bearing age as of 1994--in the industrialized world, according to the Alan Guttmacher Institute, a nonprofit organization that compiles the most comprehensive abortion statistics.

The abortion rate rose consistently for 17 years after Roe, then it began declining. In 1994, the last year for which there are reliable statistics, there were at least 160,000 fewer abortions than in the peak year of 1988.

One reason is that unplanned pregnancies are also falling--by 16% since 1987, according to a report released Sunday by Guttmacher.

Teenage abortions are declining especially fast, and Stanley Henshaw, the institute’s director of research, pointed to wider use of contraceptives--stimulated by the AIDS crisis--as a chief cause. Also rising is the use by teenage women of highly effective injectable contraceptives.

The aging of the baby boom generation also is playing a role, said Lisa Koonin, an epidemiologist at the Centers For Disease Control and Prevention in Atlanta. “Although the number of reproductive-aged women has increased from 1980 to the present,” she said, “the proportion who are older and therefore in their less-fertile years has increased.”

As abortions have declined, so has the number of facilities where they are performed, from nearly 3,000 in 1982 to 2,380 a decade later.

Many large cities have several clinics and a number of individual doctors performing the procedure, while many rural areas have neither. North Dakota and South Dakota have one provider each, forcing some women to drive for up to 12 hours to reach an abortion doctor.

The decline in providers has made it easier for anti-abortion activists to concentrate their fire and more difficult for clinics to attract qualified doctors.

With violence against abortion providers on the upswing earlier this decade--four abortion practitioners were murdered in 1994--many physicians who perform abortions go to work wearing bulletproof vests.

Dr. Pablo Rodriguez, who works at Planned Parenthood’s office in Rhode Island, described surfing the Internet and coming across an anti-abortion Web site where “I found my name and the route I take to work and the names of my family and details about my life.”

The so-called “Nuremberg File” of abortion doctors is maintained on a Web site called the Christian Gallery. It includes photographs of some doctors, a list of “charges” and detailed physical descriptions, addresses and lists of their family members, cars and other property.

“I check my driveway for nails before I leave in the morning, and I am afraid of letting my children play unattended,” Rodriguez said.

Anti-abortion protests such as clinic blockades now appear to be on the decline after peaking in the early 1990s, thanks to a 1994 federal law that gives prosecutors the power to arrest abortion opponents who block clinic entrances.

Few hospital residency programs now teach abortion. A 1992 Guttmacher survey found that just 12% of obstetrics and gynecology programs required training in first-trimester abortion and just 7% offered second-trimester abortion training. Of the family practice programs surveyed, 15% trained physicians in first-trimester abortion procedures.

The Options Grow

Practitioners have become so scarce that a few abortion clinics have hired poorly qualified or even incompetent ones. In recent malpractice cases in California, New York and Alabama, doctors gave up their licenses or faced extensive civil damages after patients were injured or, in several cases, died.

In Moreno Valley, Bruce Saul Steir, a doctor who performed abortions, perforated the uterus of a 27-year-old woman who subsequently bled to death because of inadequate care. He surrendered his medical license.

In Birmingham, Ala., a 27-year-old mother of five died when Dr. Thomas Tucker failed to properly drain the amniotic fluid from her uterus and to complete the abortion. That resulted in sepsis, an infection of the blood, and massive bleeding, which led to cardiac arrest. A $10-million court judgment was entered against Tucker.

While the majority of clinics are extremely safe, according to the CDC, the malpractice cases are a disquieting throwback to the days of back-alley abortions.

Ted Amshoff, a Louisville attorney who specializes in abortion malpractice cases, said he has seen some “horrifying cases” that result from “abortion on the assembly line, where you have clinics competing with one another on price.”

Abortion providers complain that lawyers such as Amshoff bring lawsuits simply to drive doctors out of business, although they acknowledge that there are some bad practitioners.

“You have doctors in every field of medicine who don’t meet the standards you would like them to meet,” said Vicky Saporta, director of the National Abortion Federation. “Unfortunately, they often prey on low-income women and immigrant women.”

Although abortions are becoming less frequent, technological advances have increased women’s choices and blurred the lines between contraception and abortion in the very early stages of pregnancy, much as the distinction between abortion and infanticide seems narrow when abortions are performed late in pregnancy.

Emergency contraception is now available for up to 72 hours after intercourse. And abortions can be performed as early as 10 days after conception, when the embryo is “the size of a pea,” according to Planned Parenthood’s Jerry Edwards, who performs early abortions in Houston.

Until recently, such early abortions were not done because doctors feared they would not get the complete embryo and would have to repeat the procedure. More sensitive ultrasound images have changed that. Women can now choose between drugs that cause bleeding similar to a miscarriage and a new surgical procedure that relies on ultrasound to guide the surgeon’s syringe as it sucks out the contents of the uterus.

But zealous abortion opponents do not distinguish between early and late abortions.

“It’s not the size of the human being that makes him human,” said Geline Williams, board chair of the National Right to Life Committee. “If a human being has been conceived, it’s a human being. Anything that occurs to destroy a conceived human being . . . is considered an abortion.”

But for society, the tough issue is likely to remain those abortions that are performed late in pregnancy.

Consider the case of Kim Koster, a 29-year-old Iowa woman who became pregnant in 1995 after years of trying. “When I first saw my baby on the ultrasound was probably the most purely happy 15 minutes of my life,” she said.

At 18 weeks, however, ultrasound showed that her baby had anencephaly--poorly developed brain tissue that would prevent it from living more than an hour or two after delivery.

“Knowing I was pregnant but I wasn’t pregnant--that there wasn’t really any baby, or anything that would be a baby--that was devastating,” Koster said. “We’d had a girl’s name picked out for four years and had just picked out a boy’s name. And we had bought a house with a nursery, and I was playing Mozart and Bach on my piano every day for this baby that hadn’t really existed.”

She and her husband decided on abortion.

“I know there are women who decide to carry the baby to term and then have an hour to say goodbye to it,” Koster said. “But to go through that and know it was going to die anyway, and that nothing I could do could comfort it . . . that was more than I could bear.”

ABORTIONS IN U.S. SINCE ROE VS. WADE

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Number of abortions Abortion rate* Contraceptive use** 1973 744,610 19.3% n/a 1975 1,034,170 24.9 n/a 1980 1,553,890 30.0 n/a 1982 n/a n/a 55.7% 1985 1,588,550 29.7 n/a 1988 1,590,800 28.6 60.3 1990 1,608,600 28.0 n/a 1992 1,528,930 27.5 n/a 1994 1,430,000 26.7 n/a 1995 n/a n/a 64.2

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* percentage of pregnancies ending in abortion

** percentage of women between 15 and 45 using contraceptives

Source: Alan Guttmacher Institute