Notes of a foot-soldier.

• Author: Vinciguerra, Timothy J.
• Position: Symposium on abortion

INTRODUCTION

She lay there shivering, black, but pale nonetheless. Her skin contrasted against white sheets with the wrong hospital name printed in blue. The intravenous bottles were glass back then. Three hung from cross-like poles, draining colorless solution into separate cutdown sites. She had been taking the most potent antibiotics the medical world had ever known for three days; still neither her fever nor her delirium broke.

I pulled the curtain closed and hustled to my four o'clock seminar.

When I returned at seven the next morning, I found the bed made, the window open to the breeze and the traffic on First Avenue, and a housekeeper emptying a wastebasket. She was humming something, and didn't speak to me, her baleful brown eyes looked away quickly.

I didn't say anything to her either.

She was somebody's daughter, undergoing a postmortem examination on that morning in 1972. She was one of an estimated two million women (including fetuses) that died in 1972 as a result of abortion procedures, typically performed in haste and often under conditions marked by squalor and filth.(1)

The Roe v. Wade decision has prompted many changes in the field of obstetrics and gynecology, ranging from differences in education and training to the resultant effects on women's health. Part I of this Article offers a snapshot from the viewpoint of the practitioner in the early 1970s.(2) Part II of this Article confronts the impact that Roe has had on the landscape of women's health.(3) In Part III, the Article examines the trends concerning abortion services education in the medical community.(4) Finally, Part IV of this Article discusses the effects of Roe on health care providers.(5)

1. HISTORICAL PERSPECTIVE

   For obstetrician-gynecologists and their patients, the 1973 U.S. Supreme Court decision in Roe v. Wade(6) had a wide range of downstream effects. Certainly women's health care would change, and some of these changes were easy enough to anticipate. Other changes were surprises that prompted the rethinking of some firmly held principles in medical, educational, and ethical arenas. Physicians who were previously adept at avoiding political briar patches inevitably found themselves dealing with the thorns.

   Most medical students in the early 1970s had no concept of the sociology and history of abortion. It was a seventies issue, larger than leisure suits, but smaller than the turmoil in Southeast Asia. We were ignorant of the fact that abortion is not unique to any point in time or level of societal organization, unaware of a history that dates back to hunting and gathering tribes.(7)

   Sociologists tell us that not only has abortion been openly practiced in primitive societies, but also similarities to current attitudes have persisted. Few societal groups have given the concept unqualified approval.(8) The same conditions that influenced primitive societies to approve or impose abortion continue to be influential factors today: unmarried status of the mother, ambiguous paternity, adultery, poor maternal health, rape, and incest.(9) Though these conditions were prevalent in the pre-Roe era, many women had to negotiate various health hazards typically associated with an illegal abortion.

2. IMPACT OF ROE ON WOMEN'S HEALTH

   1. Magnitude of the Issue

      During the 1960s, New York municipal hospitals found that complications from illegal abortions contributed to nearly twenty percent of all pregnancy-related admissions as well as twenty percent of the deaths.(10) Infection and hemorrhage, combined with delay in medical intervention, represented frequent causes of these cases, for there was great reluctance to seek medical care.(11) Today, a small number of abortions continue to be done clandestinely by untrained or unlicensed operators.(12) Occasionally, in situations of desperation arising from poverty, the mother will perform the abortion herself.(13) While there are no statistics recorded, most moderate to large hospitals ultimately treat these patients, and mortality is negligible.(14) A significant number of these women are adolescents attempting to self-abort by various techniques, some of which pose substantial risk.(15) In most cases, self-induced abortion is performed with a crude instrument or ingestion of various substances that the aborter has been led to believe would be effective.(16)

      During the 1970s, it became increasingly clear that there was in fact a steep price to pay for decreasing the number of hysterectomies and deaths due to complications of illegal abortion. As inexperienced physicians inherited the demand for the procedure in the early years of legalization, there were still substantial risks to the mother.(17) Though abortions had become legal, the mortality rate in 1972 remained relatively high, approximately ten times what it would be fifteen years later.(18) If the mother was forty years old or more, she had triple the risks of a woman under the age of twenty.(19) If she was black or a minority she was subject to two and one-half times the risk of dying, regardless of her age.(20) Before 1983, aborters died in the same ways as they had died before legalization--by bleeding to death or by overwhelming infection.(21) In the years after 1982, anesthesia-related complications became the most common cause of death.(22)

      The decreasing mortality rates and increasing safety of abortions over the years is apparent by looking at the frequency with which the procedure is performed.(23) In 1972, 600,000 abortions were reported.(24) In 1979, 1,300,000 were reported.(25) After a peak of almost 1.5 million in 1990, procedures reportedly declined to 1.2 million in 1996.(26)

      The number of reported abortions continues to decrease and several possible explanations are being studied.(27) First, more abortions are performed at very early gestational ages, in obstetrical/gynecological clinics that have no reporting requirement.(28) Thus, while the number of reported abortions is decreasing, the total number performed may be increasing. Also, the demographics include more women in older age groups that tend to have lower pregnancy rates.(29) Furthermore, there is a decreasing incidence of unintended pregnancies, particularly among teenagers, as a result of improved contraceptive availability and use.(30)

      The increasing ability to interrupt very early pregnancies by medical rather than surgical techniques represents another possible explanation for the decrease. Researchers know more about mifepristone (also known as RU-486) and the anticancer drug, methotrexate; consequently, they are used with increasing frequency. These drugs are either cytotoxic to the developing pregnancy or cause expulsion of the pregnancy from the uterus; as such, reporting is not required.(31) Some other factors, such as changing attitudes toward abortion on the part of both pregnant women and abortion providers, decreasing access to abortion services, and antiabortion violence may be also contributing to the decrease.

      There is increasing indication that negative attitudes of pregnant women toward abortion may be affecting abortion rates, especially among women lower on the socioeconomic scale, who are less supportive of abortion in general. There appears to be less stigma attached to single parenthood and the increased availability of split-shift employment allows the single mother to continue her unexpected pregnancy.(32) Approximately ten percent of women change their minds about an abortion that they originally had planned.(33) Much of the ambivalence experienced by these women stems from an abortion decision based primarily on pragmatics, a belief in their right to choose, and knowledge of the safety and simplicity of the procedure.(34) In addition to these reasons, some women electing to abort may also possess contradictory personal feelings about the process.(35) Offsetting these personal feelings is an increasing tendency for women victimized by abusive relationships to terminate their pregnancies, often without ever making the pregnancy known to the abusive father.(36)

   2. Availability of Abortion Services

      Abortion services were available before Roe from well-trained physicians as well as unlicensed nonmedical abortionists.(37) These were, by necessity, done surreptitiously, frequently disguised in documentation as diagnostic or therapeutic procedures for the treatment of menstrual disorders.(38) They were mostly provided in private offices, since hospital procedures required the cooperation and discretion of other staff such as nurses and anesthesiologists.(39) Since all tissues removed surgically are required to be histologically examined, committees that reviewed tissue specimens following surgery were always aware of the true nature of these procedures. Abortionists considered the resulting reviews by hospital tissue committees to be a delicate, though not an insurmountable, problem.(40)

      Obtaining a safe, competent abortion required a connection. Most medical communities included at least one willing physician who tended to the long standing patients of other physicians.(41) Even prominent physicians in leadership positions at Catholic hospitals participated in a clandestine fashion, usually in a nearby community's nonsectarian hospital. Although some physicians were motivated by financial concerns, others performed these services with altruistic reasons in mind.(42)

      For the patient who was otherwise unable to obtain an abortion, the public stance taken by gynecologists was that no illegal services were to be performed by physicians.(43) As a consequence, the nonphysician abortionists and untrained criminal profiteers supplied these services to the less fortunate.(44) The more desperate the mother, the higher the fee, which in turn generated further desperation, as poorer women looked for ways to finance their procedure.(45) The least costly procedures were done by the least trained operators in makeshift operating rooms and...