Linda J Beckman. Feminism & Psychology. Volume 27, Issue 1. February 2017.
Feminists both in the United States and in other parts of the world need to understand the background, key issues and current components of the “abortion debate” in the United States. Examination of how in recent years anti-abortion advocates have been successful in restricting abortion access through legislation may help us to better protect and enhance women’s rights. Understanding major reasons for trends in abortion rates (e.g., use of effective contraception versus legal restrictions on access) may facilitate more accurate assessment of the status of women’s reproductive rights. Finally, consideration of disparities in abortion access can facilitate political and policy efforts to increase access for the groups most underserved. Below, first I will briefly summarize the current socio-political context and relevant trends for abortion in the United States; then I will explore important questions about this context that have been raised by national and international observers.
The constantly evolving social-political context of abortion in the United States is contentious, convoluted, and unpredictable. Had I written this commentary a year ago, I would have been more pessimistic about the mushrooming of state laws then winnowing away at access to abortion services. While state legislative restrictions are still a major concern in November of 2016, events during the past year have emphasized the role of state and regional courts and the US Supreme Court in limiting implementation of statutes that restrict women’s access to abortion services. Most importantly, however, Donald Trump’s recent election to be the next President of the United States poses serious threats to women’s reproductive rights. Trump and his political party, which controls both Houses of the US Congress, oppose legal abortion under most circumstances. It is impossible to predict what will happen to abortion rights in the US during the next decade. What we can confidently predict is that the political process, i.e., the outcomes of federal and state elections, and the composition of the Supreme Court and regional courts, will play a major role.
The current US situation is typified by high polarization and intense conflict rarely seen in other Global North (Western higher income) countries. An acrimonious battle between two competing ideologies remains at the crux of US abortion politics. Those who support abortion view it as a right required for social equality for all women; those who oppose it see it as a threat to motherhood, morality, and social cohesion (Harvey, Beckman, & Bird, 1998). Pro-abortion proponents believe women’s empowerment requires that they have control over their bodies, including the right to end an unwanted pregnancy. Therefore, reproductive health policy must enable women’s access to safe, legal abortion. Most anti-abortion advocates believe that personhood begins at conception; therefore legalized abortion is a threat to social, moral, and religious values. For them, abortion ignores the sanctity of human life, involves the murder of a living being and hence is morally reprehensible. The attempt of those who oppose abortion on moral and religious grounds to impose their behavioral standards on all American women and their sexual partners has resulted in this intense political conflict (Beckman, in press).
Current demographic trends
There has been a dramatic drop in abortion rates in the US over the last few decades. Since rates peaked in 1981, the incidence and rate of abortion have shown a significant long-term decline. In recent years, these declines have been relatively consistent across most geographic regions and have occurred for all racial and ethnic groups (Jones & Jerman, 2014; Pazol, Creanga, & Jamieson, 2015). At the same time, geographic, socioeconomic, and ethnic disparities in access to abortion services have continued and even intensified.
While abortion rates have fallen, the public’s attitudes about whether abortion should be lawful in various situations have remained relatively stable (Bowman & Marisco, 2014). The majority continues to believe that abortion should be legal, but that some restrictions should apply. At the same time that abortion rates have fallen, pregnancy and birth rates also have declined, especially among teens. Birth rates attained an all-time low in 2013 (Martin, Hamilton, Osterman, Curtin, & Mathews, 2015). The incidence of unintended pregnancy decreased from 2008 to 2011, with disparities in rates between groups narrowing (Finer & Zoina, 2016).
In addition, the mix of available abortion methods has changed. The US Food and Drug Administration (FDA) first approved the use of Mifeprex (mifepristone) as a medication abortion procedure in September 2000. Since that time the percentage of abortions that were medically induced has increased. By 2011, 23% of all non-hospital abortions were medication abortions (Jones & Jerman, 2014).
Relevant questions
Consideration of the possible precursors and effects of these trends has raised questions of importance to feminists who desire the best possible reproductive healthcare for women. Five relevant questions that will be considered below are:
- What is responsible for a new wave of restrictive laws (discussed in detail below) and what are their effects?
- What is most likely responsible for changes in abortion rates?
- What are the likely effects of the addition of medication abortion into the mix of abortion services?
- What continues to fuel the economic, geographic and racial/ethnic disparities in access to abortion services?
- Why have gay rights been embraced by a majority of the US public and supported in legislation and judicial decisions, while during this same time period political support for abortion rights has stagnated or declined, even though popular attitudes have not changed?
Legislation that restricts abortion access
Before passage in 1973 of the landmark Supreme Court decision of Roe v. Wade, each of the 50 US states had its own laws regarding abortion. In a few states first trimester abortion was legal under all circumstances, in some abortion was permitted only under certain conditions (i.e., in cases of rape, incest and/or danger to a woman’s health) and in the majority of states abortion was illegal (Gold, 2003). The Roe v. Wade decision recognized that women under the constitutional provision of privacy had a right to make their own personal medical decisions including the right to have an abortion. In effect, this court decision legalized elective abortions during the first trimester of pregnancy for US women residing in all 50 states and supported abortion in the second trimester except for restrictions to women’s health. (In a later Supreme Court decision, Planned Parenthood v. Casey, the trimester determination was replaced by the test of the viability of the fetus.) Although they could not ban abortion outright after the passage of Roe v. Wade, individual state legislatures still had significant latitude in passing laws that constrict women’s rights to abortion, such as parental notification for minors and required counseling prior to abortion. Using this power, particularly in recent years, many state legislatures have chipped away at women’s unconstrained right to abortion.
Today there are a much greater number of state laws limiting abortion in a wider variety of ways than was the case in the year 2000, and the trend towards restrictive legislation appears to be accelerating. During the first quarter of 2015 alone, 332 provisions were introduced in legislation (Guttmacher Institute, 2015b). The new legislation is not limited to a few specific types. Existing restrictive laws include: gestational limits; targeted regulation of abortion provider [TRAP] laws that impose unnecessary requirements on abortion sites and providers, such as meeting the standards of an ambulatory surgical center; prohibition of use of state funds for abortion; mandated counseling before abortion; required waiting periods; parental involvement for minors; and restriction of coverage of abortion in private insurance plans (Guttmacher Institute, 2016a). Of the 50 states in the US, the number hostile to abortion (defined as enacting four or more separate provisions against abortion) increased from 13 in 2000 to 27 in 2013 (Boonstra & Nash, 2014). In 2013, the majority of women in the US (56%) lived in states hostile to abortion, whereas in 2000 only 31% lived in such states (Boonstra & Nash, 2014). These states are concentrated in the Southern and Midwestern sections of the country.
How were anti-abortion activists able to restrict women’s legal access to abortion over the last several years while during the same period public attitudes remained relatively constant? The surge in anti-abortion legislation is the direct result of the election of politicians to state governments who oppose abortion under most or all circumstances. Several anti-abortion legislators were elected as governors and politicians opposed to abortion took control of several state legislatures as a consequence of the 2010 and 2014 elections. By 2015, individuals opposed to abortion held 31 of 50 governorships and controlled two-thirds of state legislatures (Cunningham, 2014).
Ironically, the Affordable Care Act (ACA) of 2010, a federal health care program intended to provide broad access to health insurance, may have intensified introduction of laws that limit various aspects of provision of abortion services. Politics associated with the ACA have fueled national debate about use of government funds to pay for abortion and led to additional limitations on insurance coverage for abortion in several states (Boonstra & Nash, 2014). The ACA, which has resulted in significant advances in women’s access to other reproductive health services such as breast cancer and STI screening, treats abortion differently from all other health services. It allows states to restrict coverage for abortion in insurance plans that are part of their exchange marketplaces; as of 1 September 2016, 25 (50 percent) of the states have done so (Guttmacher Institute, 2016b).
What can be concluded about the effects of restrictive laws? Certainly they make access more difficult and impose greater burdens on many women who seek an elective abortion. Although there are court decisions supporting both sides, in many recent instances, state and regional federal courts have blocked the execution of state laws restricting abortion rights. In June 2016, in the landmark case of Whole Woman’s Health v. Hellerstedt, the US Supreme Court declared as unconstitutional the part of a Texas state law that required abortion clinics to meet ambulatory surgical center standards and clinic physicians to have admitting privileges at a hospital within 30 miles of the clinic. The majority of the Supreme Court judges held that these requirements constituted an “undue burden” for women and had no significant health benefits. This decision is particularly significant because the principles of the case are likely to be applied to court cases involving facilities in other states across the country.
Whether or not restrictive state laws reduce the abortion rate remains to be seen. Many laws have not been in effect long enough for such impact to be determined. However, it logically follows that an increased burden on women seeking abortion will result in at least some forgoing the procedure entirely, instead having children, some of whom are unwanted. Furthermore, while a single statute may not critically restrict medical professionals’ ability to conduct abortions or patients’ access to them, unless reversed by the courts, the multitude of new laws passed by state legislatures is likely to contribute to further declines in abortion rates.
Why have abortion rates declined sharply?
An unintended pregnancy often is a stressor for women, as is the process of having to make a decision regarding its outcome. However, the evidence supports the conclusion that a single elective abortion does not cause mental health problems for women (Major et al., 2009). In fact, emotions, both negative and positive, decrease over time post-abortion (Rocca et al., 2015). Yet, most individuals, no matter what their opinions about abortion, agree that it is better to prevent a pregnancy than to have an abortion or an unwanted birth.
Pro-abortion and anti-abortion advocates have different reactions to the decline in abortion rates depending on the reasons they perceive behind this decline. The falling abortion rate has been attributed both to increasing legal restrictions and to the use of more effective contraceptive methods. While anti-abortion proponents contend that new laws that curtail access primarily are responsible for recent declines, current research provides little support for this. The largest number of restrictive laws was passed from 2011 on, and many did not go into effect before 2012 (Dreweke, 2014), whereas the latest national data on abortion rates are from 2011 (Rachel Jones, personal communication, 7 July 2015) and 2012 (Pazol et al., 2015). The dramatic decline in abortion rates started well before the deluge of restrictive state laws occurred. These laws could not have retrospectively influenced declines in abortion rates. Therefore, other factors must have had a significant influence.
At the same time that abortion rates have declined, birth rates have also declined. If the rhetoric of the anti-abortion forces were correct and restrictive legislation led to “saving the lives” of those embryos/fetuses to whom they attribute “personhood,” then birth rates should have risen. On the contrary, a better explanation for declines in abortions, at least up to 2011, is that women were using more effective contraceptives.
Although there are no definitive data linking lower abortion rates with effective contraceptive use, evidence supports wider use of effective long-lasting contraception as a major determinant. Jones and Jerman (2014) concluded that changes in contraceptive use rather than increasing restrictions on abortion was the reason for a 13 percent decline in abortion between 2008 and 2011. The percentage of women using long-acting reversible methods increased from 2.4 percent in 2002 to 11.6 percent in 2012 (Guttmacher Institute, 2015a) as the abortion rate continued to decline. Other evidence also supports the strong relationship between use of effective contraceptive methods and abortion rates. For instance, Biggs, Rocca, Brindis, Hirsch, and Grossman (2015) recently reported declines in abortion in Iowa following increases in use of highly effective contraceptive methods. In Colorado, when adolescents were offered free long-lasting contraceptives, there was a 42 percent decline in their abortion rate (Tarvernise, 2015).
Taken together, the available data reinforce the contention that the abortion rate has declined primarily because of increased use of more effective contraceptive methods rather than because of new laws that have curtailed access to abortion services (Dreweke, 2014). For feminists, this is the cause for celebration; women in the US have become more successful at reducing unwanted pregnancies and in delaying pregnancies until they want to have children. On the other hand, much of the information comes from a period before the glut of new abortion legislation went into effect. No doubt restrictive laws already have contributed to a somewhat reduced number of abortion providers and have intensified the unequal geographic distribution of services. In the future, both the difficulty of obtaining abortions and the greater access to and use of effective long-lasting contraceptives are likely to influence falling abortion rates.
Although abortion rates do not appear to vary internationally based on the restrictiveness of countries’ abortion laws (Sedgh et al., 2016), changes in laws within a country may have a very different effect. In the aftermath of the recent US presidential election, news reports have noted that women already are rushing to their providers to obtain long-lasting reversible contraceptives such as IUDs. Women fear that access to contraception and abortion will be severely curtailed under a Trump presidency. Trump has indicated that he will appoint anti-abortion Supreme Court justices and attempt to dismantle most of President Obama’s ACA, which provides highly effective prescription contraception to millions of American women (Karlamangla, 2016). If the election of Mr Trump motivates significant numbers of women to rush to obtain effective long-lasting contraceptives, it could indirectly contribute to a continuing decline in abortion rates in the US during the next few years.
Has the availability of medication abortion made a difference?
In September 2000, the US FDA approved mifepristone (marketed as Mifeprex) combined with misoprostol (administered 24–48 hours after mifepristone) as a medication alternative to surgical abortion. The protocol originally approved by the FDA used a high dose of mifepristone, limited maximum gestational age to 49 days, required that both drugs be administered in the prescriber’s (i.e., physician’s) office, and required three or more clinic visits. After the World Health Organization concluded in 2006 that research evidence showed that a lower dose of Mifeprex was effective and medication abortion was effective up to at least 63 days post-gestation, many providers have used an “off-label” alternative protocol (supported by the National Abortion Federation and Planned Parenthood Federation of America). In March 2016, the FDA revised its protocol, making it similar to protocols recommended by major US professional associations. The recent FDA protocol lowers the dosage of mifepristone, increases treatment to 70 days of gestational age, allows for home administration of both drugs, decreases the number of clinic visits to 1 or 2, allows non-physicians (e.g., nurse-practitioners) to prescribe the drugs and lowers the cost of the procedure (Reproductive Health Access Project, 2016).
A major advantage of medication abortion is that it allows for abortions to occur very early in pregnancy. Many American women clearly see early pregnancy termination as an advantage (Harvey, Beckman, & Branch, 2002) and most prefer to have an abortion as early as possible. The large majority of women who have had a medication abortion appear satisfied with it (Harvey et al., 2002). Like surgical abortion, it can be safely prescribed by mid-level professionals, such as nurse practitioners. Another advantage of medication abortion is that, as shown by successful pilot projects, it can to be used via telemedicine (Ibis Reproductive Health, 2016).
Several prominent American professional organizations have recommended increased training for mid-level professionals in the provision of medication abortion services. However, the potential advantages of medication abortion currently are limited in many states by requirements that only licensed physicians can provide medication abortions (37 states) and that the provider physically be present during administration of the oral medications (19 states) (Guttmacher Institute, 2016c).
Despite protocol limitations, the use of medication abortion has grown rapidly at the same time that the total abortion rate has continued its decline. By 2011, 59 percent of abortion providers in the US had offered medication abortion to women (Guttmacher Institute, 2016d). The number of medication abortions performed in 2011 was estimated at almost 240,000, or 23 percent of all non-hospital abortions (Jones & Jerman, 2014) as compared to 6 percent in 2001. Data from the Centers for Disease Control (the federal government agency responsible for public health monitoring) support that the average time of abortion is now earlier in pregnancy than it was previously, most likely as a result of the use of medication abortion (Boonstra & Nash, 2014).
The increasing numbers and percentages of medication abortions support its growing popularity and role in the variety of abortion options available to women. Its popularity is likely to continue to grow and, especially given the latest FDA-approved protocol, a greater proportion of total abortions will be conducted using this procedure. Although medication abortion is a good option for many women, there is no evidence to suggest that the availability of medication abortion will have a significant effect on overall abortion rates in the US. More likely, this option’s availability will lead to greater overall satisfaction with treatment among women who seek abortions.
Disparities in access to abortion
A disturbing aspect of the current context of abortion in the US is the disparities in access to this important reproductive health service. The ability to get an abortion and the amount of stress and burden involved should not depend upon where in the US a woman lives. Yet today more than ever before, the ease of access or even the ability to obtain an abortion is affected by the geographic area in which a woman lives. As previously mentioned, women living in the Southern and Midwestern states generally face more restrictive abortion laws than women in the Northeastern and Western states. In 2011 state abortion ratios (i.e., number of abortions per 100 unintended pregnancies) ranged from 14 percent in South Dakota to 61 percent in New York. The states with the lowest ratios were generally Southern and Midwestern states and 12 of the 13 states with low ratios were states in which the number of restrictive laws led researchers to characterize them as hostile to abortion (Boonstra & Nash, 2014). This may suggest that recent abortion legislation has had some effect.
The burden associated with obtaining an abortion should not fall more heavily on socially and economically disadvantaged women. Yet, as some clinics have closed and the number of abortion providers declined somewhat, disparities between socioeconomic groups have increased. Women from wealthier backgrounds, who have well-paying jobs, spouses or partners with more economic resources, and/or their own accumulated assets, can more easily access abortion care. They are likely to have more comprehensive health insurance, plus the social and financial resources to take time off from their jobs, find and pay for competent childcare, and travel to another state if necessary. They have the means to seek a safe abortion provider, no matter how restrictive the laws are, and to pay for an abortion that insurance will not cover. Poor women are not as fortunate. Restrictions to access, especially TRAP laws that may cause clinics or entire clinic systems to shut down, are particularly insidious in the burden they place on poor women.
Socioeconomic, ethnic, and racial groups differ in abortion rates (Cohen, 2008). African American, Latina, and poor women generally have higher abortion and unintended pregnancy rates than do non-Hispanic white women and women with higher family incomes. Ethnic group differences in rates remain even after income is taken into account (Cohen, 2008). If it is more difficult for poor and ethnic minority groups to find abortion providers that they can afford, why are their abortion rates so high? Variation in unintended pregnancy rates across racial/ethnic groups and poverty levels can largely explain variation in abortion frequency across groups. These disparities may indicate differences in access to effective long lasting contraceptives because of limited insurance, lack of economic resources and rigid schedules that make it difficult to see a service provider (Cohen, 2008).
The ACA recently has improved reproductive health care, especially for women of limited economic means. Access to long-lasting highly effective prescription contraception, contraceptive counseling and services, without cost sharing, has been extended to greater numbers of women. Extending health insurance coverage to 20 million additional Americans as of early 2016 (US Department of Health and Human Services, 2016), the ACA should reduce disparities in access to contraception, which in turn should make abortion less necessary. As previously stated, the ACA currently is in jeopardy because President-elect Trump has vowed to dismantle most of its provisions. If not overturned, the ACA can do much to improve women’s health, but as long as unimpeded access to abortion is limited by legislative and other governmental policies that fail to meet the needs of diverse economic and cultural groups, abortion services will continue to be plagued by the economic and social disparities.
Why have gay rights gained acceptance while abortion rights have been limited?
Though many Americans still oppose gay marriage, attitudes towards it have changed rapidly, whereas abortion attitudes have stagnated. Gay men and lesbians who want to marry have rapidly come to be perceived by a majority of Americans simply as couples in a relationship who desire to legalize their commitment to each other. The change in attitudes about gay marriage has fostered a change in laws enacted by state legislators and voters, and on 26 June 2015 the US Supreme Court legalized gay marriage nationally in a narrow 5-4 decision.
Why, at a time when the gay rights movement has made such significant strides in the US, have abortion rights languished behind? One explanation is that gay rights, particularly the right to marry, is now perceived as an issue that crosses class and socioeconomic lines whereas abortion is seen in terms of policy as a problem primarily affecting women with low incomes and women of color. Gay men and lesbians can be of any social class, though most whom we see in the media are (or are perceived as) successful and well-educated, middle- or upper-class individuals. In contrast, women seeking abortion often are characterized as primarily low-income women, women likely to be oppressed and without much influence, women far removed from the centers of power that control our media and politics. Moreover, women who seek abortion are often stigmatized as irresponsible (i.e., didn’t refrain from sex and/or didn’t use contraception effectively) individuals who expect others to pay for their own misdeeds.
Several other factors combine to explain why abortion rights in the US have languished during the last 15 years while gay rights have not (Politt, 2015). Whereas gay marriage equality and most other gay rights do not require the government to spend money, someone has to pay for the abortions of low-income women. The government funding necessary presumably means more taxes (Politt, 2015). In addition, abortion is perceived by many religious and social conservatives who oppose it to be a form of intentional murder, the deadliest of the seven deadly sins. Although homosexuality may be considered as morally unacceptable, it is by far the lesser moral transgression.
Moreover, marriage equality promotes family values and gives further support to marriage, a conservative institution. Thus, it supports the social and economic status quo rather than promoting change in the social and economic status of women (Politt, 2015). Even putting aside the strong moral objections, abortion is suspect because it and other reproductive rights (such as access to contraception and free or low cost childcare) can empower women. It is associated with feminism, possible changes in the gender hierarchy, and reform of unjust social and economic institutions that limit women’s power (Politt, 2015). This is why it is so important to retain and enhance these reproductive rights.
What about the future?
Legislation enacted from 2011 on will likely impede access to abortion services, thus leading to further reduction in the number of abortions conducted annually. Increased use of effective contraception should have a similar effect. But women are not always motivated to limit pregnancy or successful in their efforts to do so. Although women, the majority of whom are resourceful and resilient, will find ways to access abortion providers, it may be at significantly greater burden to them, psychologically and economically.
Whether abortion rights in the US during the next decade will continue in a backward slide or be strengthened partly depends on the results of national and state elections. Too often those who oppose provision of abortions to women also oppose the distribution of effective contraception, especially to poorer women. If, as appears to be the outcome of the 2016 elections, the result is a president, a national congress and a majority of conservative office holders at the state level who oppose abortion, not only abortion rights but also all reproductive rights will suffer, perhaps internationally as well as in the United States. A Trump administration is likely to institute greater restrictions on US funded family planning and other reproductive health programs in the Global South.
The volatility of recent changes in the landscape of abortion access and women’s reproductive rights in the US offers a cautionary lesson that can be applied to other countries that currently have legal abortion. We have to be vigilant to possible threats to abortion rights. Laws can be changed, executive powers used to limit abortion access, and the composition of judges in the courts be altered depending on who (in the US, which of the two major political parties) has political power in a country.
What can feminists do? Feminists nationally and globally must make all reproductive rights a priority and advocate and vote for candidates in their countries supportive of these and other rights for women. Most importantly, we must focus on the underlying social inequalities (e.g., Cohen, 2008). A social justice perspective requires that we work to promote broader social and structural reforms that reduce poverty and the oppression of women, further their education and provide a context in which women’s aspirations for themselves and their families can be fulfilled. Only through changing the social context of women’s lives, while recognizing the diversity of their lived experiences, can women’s reproductive health be maximized.