Abortion refers to the premature end or termination of a pregnancy after implantation of the fertilized ovum in the uterus and before fetal viability or the point in fetal development at which a fetus can survive outside a woman’s womb without life support. The term refers to the expulsion of the fetus, fetal membranes, and the placenta from the uterus and includes spontaneous miscarriages and medical procedures performed by a licensed physician intended to end pregnancy at any gestational age.
I. Abortion Procedures
A. Early First-Trimester Abortions
B. Second-Trimester Abortions
II. Abortion as a Social Issue
III. Early Abortion Laws
IV. The Legal Right to Abortion
V. The Early Years Post Roe
VI. The Later Years Post Roe
VII. The Shift in Recent Debates
VIII. The Impact of Restrictive Abortion Legislation
An early abortion procedure, performed during the first trimester, or the first 12 weeks of pregnancy, is one of the safest types of medical procedures when performed by a trained health care professional in a hygienic environment. The risk of abortion complications is minimal, with less than 1 percent of all patients experiencing a serious complication. In the United States, the risk of death resulting from abortion is less than 0.6 per 100,000 procedures. The risks associated with abortion are less than those associated with childbirth.
There are two major types of procedures used to terminate a pregnancy. These procedures include both medical abortions and surgical abortions. The type of procedure that will be used is selected by the physician and the patient after determining the stage of pregnancy. Early-term abortions, or those occurring in the first trimester of pregnancy, may be either medical or surgical. Surgical abortions are used in later-stage abortions, or those occurring in the second or third trimester.
Early First-Trimester Abortions
Early first-trimester abortions are defined as those performed within the first eight weeks of pregnancy. Two procedures may be used: medical (nonsurgical) or surgical abortions. Medical abortions involve the administration of oral medications that cause expulsion of the fetus from the uterus (miscarriage). Medical abortions include the use of RU-486, commonly referred to as the abortion pill, as well as other combinations of drugs, depending on the stage of pregnancy. Typically, a combination of methotrexate and misoprostol are used to end pregnancies of up to seven weeks in duration. RU-486, a combination of mifepristone and misoprostol, is used to terminate pregnancies between seven and nine weeks in duration. Women opting for a medical abortion are typically administered methotrexate orally or by injection in a physician’s office. Misoprostal tablets are administered orally or vaginally during a second office visit that occurs five to seven days later. The procedure is then followed up with a visit to the physician to confirm complete expulsion of the fetus and the absence of any complications. Many women find that medical abortions are more private and more natural than surgical abortions.
A surgical abortion involves the use of suction aspiration to remove the fetus from the uterus. Surgical abortion is generally used to end pregnancies between 6 and 14 weeks duration. Vacuum aspiration uses suction to expel the contents of the uterus through the cervix. Vacuum aspiration is performed in a doctor’s office or clinic setting and typically takes less than 15 minutes. Patients receive an injection into the cervix to numb the cervical area. The physician inserts dilators to open the cervix, where a sterile cannula is inserted. The cannula, attached to tubing that is attached to a vacuum or manual pump, gently empties the contents of the uterus. The procedure is highly effective and is used most often in first-trimester abortions.
Second-trimester abortions refer to abortions performed between the 13th and 20th weeks of pregnancy. In some cases, second-trimester abortions may be performed as late as the 24th week of pregnancy. Second-trimester abortions carry a greater risk of complications due to the later stage of fetal development and are performed under local or general anesthesia. The cervix is dilated and a curette or forceps are inserted through the vagina, and the fetus is separated into pieces and extracted. Second-trimester abortions are typically performed in cases where a woman has not had access to early medical care and has only recently had a pregnancy confirmed, or in cases where a recent diagnosis of genetic or fetal developmental problems has been made.
The available abortion procedures provide many options to women. Pregnancy terminations performed between the 6th and 12th weeks of pregnancy are safe and include both medical and surgical procedures. Medical abortions, accomplished with a combination of drugs that induce a miscarriage, provide women with the option of ending a pregnancy in the privacy of her home in a relatively natural way. Surgical abortion, by using vacuum aspiration, gently removes the fetus from the uterus and includes minimal risks. These risks are usually limited to cramping and bleeding that last from a few hours to several days after the procedure. Most women who abort during the first trimester are able to return to their normal routines the following day. Antibiotics are generally prescribed following a first-trimester abortion to decrease any risk of infection, and a follow up visit several weeks later makes first-trimester abortions safer than childbirth.
Abortion as a Social Issue
As a contemporary social issue, elective abortion raises important questions about the rights of pregnant women, the meaning of motherhood, and the rights of fetuses. Since the late 1960s, abortion has been a key issue in the contemporary U.S. culture wars. The term culture wars refers to ongoing political debates over contemporary social issues, including not only abortion but also homosexuality, the death penalty, and euthanasia. Culture wars arise from conflicting sets of values between conservatives and progressives. The culture war debates, particularly those surrounding the issue of abortion, remain contentious among the American public. The debates have resulted in disparate and strongly held opinions and have resulted in the emergence of activist groups taking a variety of positions on abortion. Activists include those who support a woman’s right to abortion (epitomized in groups such as the National Abortion Rights Action League—NARAL Pro-Choice America) and those who oppose abortion on religious or moral grounds (such as right-to-life organizations).
Researchers suggest that the continuing debates over abortion have called into question traditional beliefs about the relations between men and women, raised vexing issues about the control of women’s bodies and women’s roles, and brought about changes in the division of labor in the family and in the broader occupational arena. Elective abortion has called into question long-standing beliefs about the moral nature of sexuality. Further, elective abortion has challenged the notion of sexual relations as privileged activities that are symbolic of commitments, responsibilities, and obligations between men and women. Elective abortion also brings to the fore the more personal issue of the meaning of pregnancy.
Historically, the debate over abortion has been one of competing definitions of motherhood. Pro-life activists argue that family, and particularly motherhood, is the cornerstone of society. Pro-choice activists argue that reproductive choice is central to women controlling their own lives. More contemporary debates focus on the ethical and moral nature of personhood and the rights of the fetus. In the last 30 years, these debates have become politicized, resulting in the passage of increasingly restrictive laws governing abortion, abortion doctors, and abortion clinics.
Early Abortion Laws
Laws governing abortion up until the early 19th century were modeled after English Common Law, which criminalized abortion after “quickening,” or the point in fetal gestational development where a woman could feel fetal movement. Prior to quickening, the fetus was believed to be little more than a mass of undifferentiated cells. Concurrent with the formal organization of the American Medical Association in the mid-1800s, increasingly restrictive abortion laws were enacted. In general, these laws were designed to decrease competition between physicians and midwives, as well as other lay practitioners of medicine, including pharmacists. A few short years later, the New York Society for the Suppression of Vice successfully lobbied for passage of the Comstock Laws, a series of laws prohibiting pornography and banning contraceptives and information about abortion. With the formal organization of physicians and the enactment of the Comstock Laws, pregnancy and childbirth shifted from the realm of privacy and control by women to one that was increasingly public and under the supervision of the male medical establishment. Specifically, all abortions were prohibited except therapeutic abortions that were necessary in order to save the life of the pregnant woman. These laws remained unchallenged until the early 1920s, when Margaret Sanger and her husband were charged with illegally distributing information about birth control. An appeal of Sanger’s conviction followed, and contraception was legalized, but only for the prevention or cure of disease. It was not until the early 1930s that federal laws were enacted that prohibited government inference in the physician-patient relationship as it related to doctors prescribing contraception for their women patients. Unplanned pregnancies continued to occur, and women who had access to medical care and a sympathetic physician were often able to obtain a therapeutic abortion. These therapeutic abortions were often performed under less-than-sanitary conditions because of the stigma attached to both the physicians performing them and to the women who sought to abort.
By the 1950s, a growing abortion reform movement had gained ground. The movement sought to expand the circumstances under which therapeutic abortions were available; it sought to include circumstances in which childbirth endangered a woman’s mental or physical health, where there was a high likelihood of fetal abnormality, or when pregnancy was the result of rape or incest. The abortion reform movement also sought to end the threat of “back-alley” abortions performed by questionable practitioners or performed under unsanitary conditions that posed significant health risks to women and often resulted in death.
By the 1960s, although the abortion reform movement was gaining strength, nontherapeutic abortion remained illegal, and therapeutic abortion was largely a privilege of the white middle to upper classes. A growing covert underground abortion rights collective emerged in the Midwest. Known as the Jane Project, the movement included members of the National Organization for Women, student activists, housewives, and mothers who believed access to safe, affordable abortion was every woman’s right. The Jane Project was an anonymous abortion service operated by volunteers who provided counseling services and acted in an intermediary capacity to link women seeking abortions with physicians who were willing to perform the procedure. Members of the collective, outraged over the exorbitant prices charged by many physicians, learned to perform the abortion procedure themselves. Former members of the Jane Project report providing more than 12,000 safe and affordable abortions for women in the years before abortion was legalized.
Activists involved in the early movement to reform abortion laws experienced their first victory in 1967, when the Colorado legislature enacted less restrictive regulations governing abortion. By 1970, four additional states had revised their criminal penalties for abortions performed in the early stages of pregnancy by licensed physicians, as long as the procedures followed legal procedures and conformed to health regulations. These early challenges to restrictive abortion laws set into motion changes that would pave the way to the legal right to abortion.
The Legal Right to Abortion
Two important legal cases reviewed by the U.S. Supreme Court in the 1970s established the legal right to abortion. In the first and more important case, Roe v. Wade (1973), the court overturned a Texas law that prohibited abortions in all circumstances except when the pregnant woman’s life was endangered. In a second companion case, Doe v. Bolton (1973), the high court ruled that denying a woman the right to decide whether to carry a pregnancy to term violated privacy rights guaranteed under the U.S. Constitution’s Bill of Rights. These decisions, rendered by a 7–2 vote by the Supreme Court justices in 1973, struck down state statutes outlawing abortion and laid the groundwork for one of the most controversial public issues in modern history.
The Supreme Court decisions sparked a dramatic reaction by the American public. Supporters viewed the Court’s decision as a victory for women’s rights, equality, and empowerment, while opponents viewed the decision as a frontal attack on religious and moral values. Both supporters and opponents mobilized, forming local and national coalitions that politicized the issue and propelled abortion to the forefront of the political arena. Opponents of abortion identified themselves as “antiabortion” activists, while those who supported a woman’s right to choose whether to carry a pregnancy to term adopted the term “pro-choice” activists. These two groups rallied to sway the opinions of a public that was initially disinterested in the issue.
The Early Years Post Roe
Following the Roe decision, antiabortion activists worked to limit the effects of the Supreme Court decision. Specifically, they sought to prevent federal and state monies from being used for abortion. In 1977, the Hyde Amendment was passed by Congress, and limits were enacted that restricted the use of federal funds for abortion. In the ensuing years, the amendment underwent several revisions that limited Medicaid coverage for abortion to cases of rape, incest, and life endangerment. The Hyde Amendment significantly impacted low-income women and women of color. It stigmatized abortion care by limiting federal and state health care program provisions for basic reproductive health care.
As antiabortion and pro-choice advocates mobilized, their battles increasingly played out in front of abortion clinics throughout the country, with both groups eager to promote their platforms about the legal right to abortion. Abortion clinics around the country became the sites of impassioned protests and angry confrontations between activists on both sides of the issue. Confrontations included both antiabortionists who pled with women to reconsider their decision to abort, and pro-choice activists working as escorts for those who sought abortions, shielding the women from the other activists who were attempting to intervene in their decision. Many clinics became a battleground for media coverage and 30-second sound bites that further polarized activists on both sides of the issue. Moreover, media coverage victimized women who had privately made a decision to abort by publicly thrusting them into the middle of an increasingly public battle.
By the mid-1980s, following courtroom and congressional defeats to overturn the Roe v. Wade decision and a growing public that was supportive of the legal right to abortion, antiabortion activists broadened their strategies and tactics to focus on shutting down abortion clinics. Moreover, antiabortionist groups began identifying themselves as “pro-life” activists to publicly demonstrate their emphasis on the sanctity of all human life and to reflect their concern for both the pregnant woman and the fetus. The change in labels was also an attempt to neutralize the negative media attention resulting from a number of radical and militant antiabortion groups that emerged in the 1980s, many of which advocated the use of intimidation and violence to end the availability of abortion and to close down clinics. For these more radical groups, the use of violence against a fetus was seen as justification for violence that included the bombing and destruction of abortion clinics and included, in some cases, the injury or murder of physicians and staff working at the clinics.
The polarization of activists on both sides of the issue and the increased incidence of violence at abortion clinics resulted in the passage of the Freedom of Access to Clinic Entrance Act (FACEA). FACEA prohibited any person from threatening, assaulting, or vandalizing abortion clinic property, clinic staff , or clinic patients, as well as prohibited blockading abortion clinic entrances to prevent entry by any person providing or receiving reproductive health services. The law also provided both criminal and civil penalties for those breaking the law. Increasingly, activists on both sides of the issue shifted their focus from women seeking to abort and abortion clinics to the interior of courtrooms, where challenges to the legal right to abortion continue to be heard. Meanwhile, increasingly restrictive laws governing abortion and abortion clinics were passed.
The Later Years Post Roe
With the legal right to abortion established and the battle lines between pro-life and pro-choice activists firmly drawn, key legislative actions impacting the legal right to abortion characterized the changing landscape of the abortion debate. In the 1989 Webster v. Reproductive Health Services case, the Supreme Court affirmed a Missouri law that imposed restrictions on the use of state funds, facilities, and employees in performing, assisting with, or counseling about abortion. The decision for the first time granted specific powers to states to regulate abortion and has been interpreted by many as the beginning of a series of decisions that might potentially undermine the rights granted in the Roe decision.
Following the Webster case, the U.S. Supreme Court reviewed and ruled in Planned Parenthood of Southeastern Pennsylvania v. Casey (1992), a case that challenged five separate regulations of the Pennsylvania Abortion Control Act as being unconstitutional under Roe v. Wade. Specifically, the Pennsylvania act required doctors to provide women seeking abortion with a list of possible health complications and risks of abortion prior to the procedure, required married women to inform their husbands of an abortion beforehand, required parental or guardian consent for minors having an abortion, imposed a 24-hour waiting period before a woman could have an elective abortion, and mandated specific reporting requirements for clinics where abortions were performed. The court upheld four of the five provisions, striking down the spousal consent rule, which was found to give excessive power to husbands over their wives and possibly exacerbate spousal abuse. Moreover, the Court allowed for waivers for extenuating circumstances in the parental notification requirement. Casey was the first direct challenge to Roe, and the court modified the trimester framework that Roe had created. It also restructured the legal standard by which restrictive abortion laws were evaluated. Casey gave states the right to regulate abortion during the entire period before fetal viability, and they could do so for reasons other than to protect the health of the mother. The increased legal rights provided to states to impose restrictions on laws governing abortion resulted in a tightening of the requirements for clinics providing abortions and adversely affected many women who sought abortions, particularly low-income women and women who lived in rural areas. As a result of the increased power granted to states to regulate abortion, women were required to attend a pre-abortion counseling session before the procedure, in which they received information on the possible risks and complications from abortion, and they were required to wait at least 24 hours after the counseling session to undergo the procedure. For poor women or for women who lived in states where there were no abortion clinics available, the costs associated with the procedure rose dramatically because of the associated travel and time off from work.
Since Casey, the Supreme Court has heard only one case related to abortion. In Stenberg v. Carhart (2000), the constitutionality of a Nebraska law prohibiting so-called partial birth abortions was heard by the high court. The Nebraska law prohibited this form of abortion—known as intact dilation and extraction (IDX) within the medical community—under any circumstances. Physicians who violated the law were charged with a felony, fined, sentenced to jail time, and automatically had their license to practice medicine revoked. The IDX procedure is generally performed in cases where significant fetal abnormalities have been diagnosed and represents less than one-half of one percent of all abortions performed. The pregnancy is terminated by partially extracting the fetus from the uterus, collapsing its skull, and removing its brain. In the Stenberg case, the court ruled that the law was unconstitutional because it did not include a provision for an exception in cases where the pregnant woman’s health was at risk. However, in 2007, the decision was reversed in Gonzales v. Carhart, the ban reinstated. The court held that the IDX prohibition did not unduly affect a woman’s ability to obtain an abortion.
The Shift in Recent Debates
The differences between activist groups involved in the abortion debates have traditionally crystallized publicly as differences in the meaning of abortion. Pro-life activists define abortion as murder and a violation against the sanctity of human life. Pro-choice activists argue that control of reproduction is paramount to women’s empowerment and autonomy. More recently the issues have focused on questions about the beginning of life and the rights associated with personhood. Technological advancements in the field of gynecology and obstetrics are occurring rapidly and influencing how we understand reproduction and pregnancy. Advances in the use of ultrasound technology, the rise in fetal diagnostic testing to identify genetic abnormalities, and the development of intrauterine fetal surgical techniques to correct abnormalities in the fetus prior to birth all contribute to defining the fetus as a wholly separate being or person from the woman who is pregnant.
These new constructions of the fetus as a separate person, coupled with visual technologies that allow for very early detection of pregnancy and images of the developing fetus, give rise to debates about what constitutes personhood and the rights, if any, the state of personhood confers upon the entity defined as a person. The issue of viability, defined as the developmental stage at which a fetus can survive without medical intervention, is complicated in many respects by these technological advances. Those who identify themselves as pro-life argue that all life begins at the moment of conception and point to technology to affirm their position. Many pro-life activists argue that the fetus is a preborn person with full rights of personhood—full rights that justify all actions to preserve, protect, and defend the person and his or her rights before and after the birth process. Those who identify themselves as pro-choice argue that personhood can only be conferred on born persons and that a developing fetus is neither a born person nor a fully developed being. These contemporary debates concerning personhood and rights continue to divide the public and are particularly germane to the issue of fetal surgery. Fetal surgery is cost-prohibitive, success rates are very low, and some argue that the scarcity of medical resources should be directed toward a greater number of patients or toward the provision of services that have greater success rates.
At the state level, the battle has recently been fought in terms of pre-abortion counseling, including the issue of whether to require ultrasounds and whether pregnant women should be shown the ultrasound images. Twenty states now require that an ultrasound be done prior to an abortion and that the pregnant woman be given an opportunity to view the image. One state, Oklahoma, requires both that an ultrasound be done and that the woman view the image, although the law is currently in litigation (National Right to Life Committee 2010).
The Impact of Restrictive Abortion Legislation
Abortion is one of the most common and safest medical procedures that women age 15 to 44 can undergo in the United States. According to the U.S. Census Bureau’s 2010 Statistical Abstract, which combines figures reported by the Centers for Disease Control and the individual states, approximately 1.2 million abortions were performed in the United States in 2005. Among women aged 15 to 44, the abortion rate declined from 27 out of 1,000 in 1990 to 19.4 out of 1,000 in 2005. The number of abortions and the rate of abortions have declined over the years, partly as a result of improved methods of birth control and partly as a result of decreased access to abortion services.
The number of physicians who provide abortion services has declined by approximately 39 percent, from 2,900 in 1982 to less than 1,800 in 2000. Although some of the decline is the result of a shift from hospital-based providers to specialized clinics offering abortion procedures, this shift is further exacerbated by the number of clinics that have closed in recent years due to increased regulatory requirements that make remaining open more difficult. Moreover, the decline in providers of abortion services means that some women will experience a more difficult time in locating and affording services. Today, only 13 percent of the counties in the United States provide abortion services to women; that is, abortion services are unavailable in 87 percent of U.S. counties. Moreover, the Hyde Amendment preventing federal funds from being used to pay for abortion services was reaffirmed in March 2010 by President Barack Obama as part of an overall health care reform legislative package.
The Food and Drug Administration’s (FDA) approval of Plan B, an emergency contraceptive best known as “the morning after pill” and mifepristone (RU-486) for early medication-induced abortions may be shifting the location of abortion procedures away from abortion clinics to other locations such as family planning clinics and physicians’ offices. However, neither of these recent FDA approvals eliminates the need for reproductive health care that includes abortion care. While the issue of abortion may spawn disparate opinions about the meaning of motherhood, family values, the changing dynamics of male-female relations, and sexual morality, as well as raise issues about personhood and rights, unintended pregnancies disproportionately impact women and their children. This is especially true of poor women and women of color whose access to reproductive health care may be limited or nonexistent. Historically, women from the middle and upper classes have had access to abortion—be that access legal, illegal, therapeutic or nontherapeutic—while women from less privileged backgrounds have often been forced to rely on back-alley abortionists whose lack of training and provision of services cost women their health and, often, their lives.
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