Legal Abortion: Who, Why and Where

THE last thing that Valada Penny wanted was a baby. At 22, the beautiful black woman already had one child by a teen-age marriage. While separated from her husband and living with her parents in Brooklyn, working and trying to plan her future, she again became pregnant. She considered having the child. Then, when she was more than four months along, she decided instead to have an abortion.

The late procedure, which involved induced labor, was painful. "I was like to the point of screaming, and I muffled my screams and I was holding on to the table," she recalled. "It was worse than having a baby." It was also emotionally unsettling. One nurse in Kings County Hospital made a point of telling her "what a pretty little boy" had just been aborted, though Valada had asked not to be told the fetus' sex. Mothers in the maternity ward, where she was sent to recover, treated her like a pariah. 'They would just look at me." said Valada. "and the looks could tell me what they were thinking."

Despite her distress, Valada Penny was far more fortunate than many an American woman faced with an unwanted pregnancy. While she was pondering her decision a year ago last summer, the New York State law that allows abortion on demand at any time through the 24th week of pregnancy took effect. Her operation was thus performed legally, safely and--because she was eligible for Medicaid--free.

Valada Penny's experience underscores both the changes and the unsolved dilemmas in the practice of abortion. Though the precise figure is impossible to establish, it is estimated that up to 1,000,000 American women per year were undergoing illegal abortions before 1970. Some died from them, and others suffered serious injury. Now abortion is becoming increasingly acceptable in the U.S., though many doctors and a majority of the public disapprove of the trend. An actual count has not been completed, but the figures will probably show that in the past 15 months, 400,000 American women obtained legal abortions at hospitals and clinics. Even more are expected to take advantage of newly liberalized laws in the next year. This development is one of the most dramatic in American medicine and mores; yet inequities and problems remain for all concerned.

WHO AND WHY. The majority of those who have undergone legal operations across the country are between 20 and 30, white and single. Still, about half of the New York cases have involved married women. Hawaii authorities are now reporting requests from a growing number of older married mothers. The figures indicate that educated, middle-class women are better able, or more inclined to take advantage of the liberalized laws. But blacks, whose birth rate is 50% higher than that of whites, have recently begun to follow suit in large numbers, particularly where abortion is made easy for the poor. In New York City, blacks now undergo one abortion for every three live births, whites one for every five, Puerto Ricans one for seven.

Comparatively few who seek abortions have strictly medical reasons, such as their own health or suspected congenital abnormality in the fetus. Rape and incest account for a negligible percentage of unwanted pregnancies. Women seek legal abortions for the familiar reasons: reluctance to interrupt career plans, lack of money, fear of losing personal freedom, uncertainty about their relationship with the man involved.

One of the startling facts is that despite the widespread availability of the Pill and other means of birth control, so many unwanted pregnancies happen, even among the most educated and sophisticated. Subconsciously, many may want to become pregnant, according to Dr. Lawrence Downs, a Manhattan psychiatrist, who, in collaboration with Psychologist David Clayson, has been studying women selected at random at New York Hospital's therapeutic-abortion ward. Downs found that at least one-quarter of the first 108 women studied had suffered psychiatric problems in the previous two years; more than half had lost a parent or close relative during the past year. A slim majority said that members of their families had recently undergone hysterectomies, or that they themselves had experienced gynecological disorders that led them to question their fertility. "It really makes sense for these women to become pregnant," says Downs. "It is a response to the threat of loss, a proof of fertility, and therefore of femininity."

Of course, accidents do happen, though it is usually the user rather than the contraceptive that fails. Pills are forgotten, and diaphragms, condoms or spermicidal foam are either imprudently omitted or improperly used. I.U.D.s sometimes prove ineffective. Women occasionally become pregnant while in the process of changing from one means of contraception to another.

WHERE. So far, 17 states have liberalized their laws. Colorado became the first in 1967 when it adopted the American Law Institute's recommended code. The measure allows abortion up to the 16th week if a board of doctors agrees that the pregnancy endangers the physical or emotional health of the woman, if there is suspicion of fetal abnormality, or if pregnancy is the result of rape or incest. Since then, eleven other states, including California, have adopted variations of the recommended code.

Some states have gone far beyond the A.L.I.'s model. An 18-month-old Hawaii law allows unrestricted abortion of a "nonviable" fetus for any woman who has been a resident of the state for 90 days; a 14-month-old Alaska law permits abortion up to the 19th week for women who have lived in the state for a month. A Washington State law, adopted last December by voter referendum (56% to 44%), removed all restrictions on abortions through the fourth month of pregnancy.

RESIDENCY REQUIREMENT. For most women, however, obstacles are still abundant. Thirty-three states retain century-old laws making abortion a crime unless performed to save the life or, in a few instances, protect the health of the pregnant woman. In Utah, some lawyers interpret the law to hold that it may even be a crime to help a woman obtain an abortion elsewhere. Abortions are all but impossible to obtain in such states as New Jersey, Iowa and the Dakotas, difficult at best in Massachusetts, much of the South and Middle West. Women in Idaho, which has one of the toughest anti-abortion laws in the country, must cross the state line into Oregon. Women throughout the Southwest travel to California. Some go even farther. Though few women seem interested in going to Alaska, at least 500 mainlanders are known to have taken advantage of Hawaii's liberal attitude and resort atmosphere.

New York's approach is the most permissive of all because it has no residency requirement (though elsewhere, the provision can often be evaded). The nation's abortion capital is now New York City, where 200,000 women have had abortions performed in the past 15 months, more than 120,000 of them from out of state. This influx has posed surprisingly few problems for the city's medical services. "Freestanding" abortion clinics, prompted by a mixture of medical free enterprise and altruism, have taken a large part of the burden from the city's established hospitals. Women rarely have to wait more than a few days for an outpatient procedure. Doctors now report that 81% of the aborted pregnancies in New York are of less than twelve weeks' duration.

Out-of-state abortion seekers are not limited to New York City. Detroit Manufacturer Martin Mitchell, for instance, has established a clinic near Niagara Falls, N.Y., and has arranged a thrice-weekly charter flight to bring women there from cities in the Middle West. Others arrive by car. His venture has been booming, to the extent of 175 cases a week. Mitchell, who advertises his clinic on billboards, has even hired a plane to tow a huge airborne sign over Miami Beach. Once he planned airborne abortions, to be performed in a circling jetliner, but he could not find doctors willing to cooperate. Most women find his charge of $400 a bargain. It includes the round-trip flight from Detroit, ground transportation to the clinic, and lunch.

Yet even in the liberal states, women are frequently forced to travel. Hospitals in some upstate New York communities still refuse to allow abortions. When the California law first took effect, hospitals in the northern part of the state were willing to go along more quickly than in relatively conservative Southern California. Kansas and Colorado have virtually identical statutes; yet an abortion is far more easily obtained in Kansas than in Colorado. Reason: Kansas courts have given doctors great leeway in evaluating the physical and psychological impact of an unwanted pregnancy; Colorado courts have given doctors there very little.

Few appreciate the problem in Colorado better than Alice Johnson, 28, a Denver schoolteacher. When she became pregnant last fall, she believed that she could easily qualify for an abortion on psychological grounds. But a psychiatrist seeking to establish justification for the abortion asked her if she would kill herself rather than have the baby, and Alice was unwilling to lie ("I was not mentally ill, just pregnant"). Without a statement that Alice's pregnancy was likely to lead to suicide, the psychiatrist felt that he might not be able to convince the hospital board, which must approve the operations, that it was necessary. Alice went to New York.

GETTING INFORMATION. Lack of information makes abortion difficult for many women, and for a time provided an almost irresistible opportunity for profiteering. In New York, several dozen commercial abortion-referral services sprang up, some of them with little more equipment than a telephone. They advertised abortions as inexpensively as $175, their own fee included. But a call to one agency revealed that its advertised minimum was a "special," obtainable only on Wednesday evenings. The majority of agencies seemed honest, but many refused to disclose their commissions. The New York State Supreme Court barred one outfit. Abortion Information Agency, from doing business; and the state legislature this summer outlawed all commercial referral agencies.

Facts and referrals are available elsewhere without charge. Planned Parenthood-World Population, one of the pioneers in the field of birth control, works through 189 affiliated organizations in 41 states and the District of Columbia. The Clergy Consultation Service, founded by 26 ministers and rabbis in New York in 1967, has expanded to include 1,200 clergymen in 31 states. Zero Population Growth Inc. has a computerized abortion-data service that includes 500 hospital and clinic listings and 300 doctors. Any woman who applies receives by mail a list of eight or ten doctors and clinics nearest her home, plus information on fees and eligibility requirements.

THE COST. Many women, particularly in the ghettos, cannot afford abortion. Though Medicaid and other assistance programs pay all or most of the costs of abortion for those who are eligible for aid, women who are just above the poverty level or who come from another state often must pay for the operations. The prices can be prohibitive. An early, hence simple, abortion in a freestanding New York City clinic such as the privately run, nonprofit Women's Services or the newly established, profit-making Parkmed, is a relative bargain. Done under local anesthetic on an outpatient basis, it costs most women $150. The same procedure in a voluntary hospital is about $200, and when performed in a profit-making hospital, it can cost three times as much. But women in Hawaii covered by the Kaiser plan, a major prepaid group health arrangement, will soon be able to obtain abortions for only $40.

Some other medical insurance plans pay all or part of the costs. A number of organizations also help out. While regular hospitals usually want to be paid in advance, especially if the woman is a transient, some nonprofit clinics attempt to set terms according to need. In Seattle, the Y.W.C.A. university chapter provides living quarters and counseling for women undergoing abortions, and students at the University of Maine have set up an abortion-loan fund that subsidizes coeds' trips to New York.

Once the arrangements have been made, abortion can be relatively easy. Three methods widely used are both practical and safe:

· Saline induction, which is used between the 16th and 24th weeks of pregnancy, is one of the more drastic means. A doctor inserts a needle through the patient's abdomen into the uterus, draws off most of the amniotic fluid in which the fetus floats and replaces it with a salt solution. The saline substance kills the fetus, and then a miniature labor begins--with real pain--and continues until the fetus is expelled some 24 to 72 hours later.

· Dilatation and curettage, usually done under general anesthesia, has long been used within the first twelve weeks. The cervix, or opening of the uterus, is dilated with a series of progressively larger sounds--thin, blunt-ended metal rods. Then the uterus itself is scraped with a dull-edged curette, a small spoon-shaped instrument, until all embryonic matter has been removed. The entire procedure can take as little as 15 minutes. When it is done under local anesthesia, it sometimes produces painful cramping, but many women can return to their homes or jobs only hours after it has been performed.

· Vacuum aspiration, used on most outpatients, is a new variation on the D. and C. method that makes abortion even easier. Performed only through the twelfth week of pregnancy, the operation consists of dilating the cervix, inserting a metal tube attached to a small vacuum pump and drawing off the fetal matter into a bottle. Discomfort during the five-minute operation, which often includes a quick curettage, is minimal. Pain is all but eliminated in a refinement of vacuum aspiration developed by Harvey Karman, a Los Angeles psychologist: for pregnancies of less than ten weeks' duration, doctors use a thin plastic tube that is smaller in diameter than the more commonly used cannula. This avoids the dilatation process entirely.

One great fear about abortion, among doctors and nurses as well as patients, is that a fetus will be born alive. Claims by anti-abortion groups that doctors routinely throw "screaming, wriggling bundles of humanity" into garbage cans are unfounded. But despite laws banning abortions after the 24th week, well before a fetus can survive outside the womb, "live births" do occur. The reason, often, is that the date of conception has been miscalculated or misstated by the woman. At least 40 fetuses have reportedly been born "alive" in New York. All died within hours, despite doctors' efforts to maintain life.

In general, abortion has become safer since legalization. New York State recorded 21 fatalities in 1968, 24 in 1969; since the new law took effect, the state has recorded only eight, or 4.8 per 100,000 legal abortions. (The U.S. maternal-mortality rate is 27.4 per 100,000 births.) Abortion complications, which can include perforation of the uterus, hemorrhage and infection, are far less frequent in legal than in illegal procedures.

HOW IT FEELS. Many women find early abortions less traumatic than they had expected. Alice Johnson, who was seven weeks pregnant, reported to Manhattan's nonprofit Women's Services early in the morning to find the waiting room already crowded. "All these girls were sitting there with their boy friends or mothers or fathers or all alone," she said. After an examination and blood tests, Alice was given an explanation of the procedure, birth control information and a tranquilizer. Then she was escorted to an operating room, where a doctor gave her a shot of Novocain; the vacuum-aspiration abortion itself, though painful, took only five minutes. Alice rested in a recovery room, chatted with other young women who had undergone the same experience. "Most of us had been very tense," she said, "but now we were relaxed, and we were laughing and saying we never wanted to see a man again." An hour later, she paid $125 and left.

Most well-educated and relatively "liberated" women say that they have no regrets. But many older women, and some girls who feel conflict with their religious or ethical upbringing, find the experience psychologically scarring. Cindy, 17 and single, felt exhilarated immediately after her abortion. But when her hospital roommate, going into labor from a saline induction, began to moan with pain, Cindy's cheer gave way to guilt at the ease with which she herself had ended her pregnancy. She broke down and wept.

A woman's reaction often depends upon her relationship with the man. Some single women say that abortion ends any affection they might have felt for the man responsible. Another factor, according to Psychoanalyst Theodor Reik, is that women may unconsciously see abortion as a man does castration.

CHANGING ATTITUDES. The setting can have a profound effect on a woman's reaction. Most of those who have illegal abortions find the experience horrifying and degrading. Women who have abortions in public hospitals, where nurses and doctors are sometimes overworked and brusque, are often unhappy too. But women who undergo early abortions in specialized outpatient clinics are far less subject to depression. Many of the clinics are staffed by young women who have had abortions themselves and understand the patients' feelings.

Two New York women demonstrate the changing--but not completely changed--attitudes. Sarah, the 47-year-old wife of a policeman and mother of four, underwent four illegal abortions years ago in order to space out the arrival of her children. She remembers the operations as sordid and painful, still has difficulty discussing them and regrets that she had to "play God with my children." Her eldest daughter, Jane, 25, an attractive college graduate married to a systems engineer, has had two abortions. Jane had an illegal out-of-state operation 16 months ago because she wanted to finish her studies, and had a legal abortion at a New York clinic last spring because she wanted to continue working. Her outlook toward abortion is more positive than her mother's ("There was no question in my mind how important it is to plan children"), but even her attitude is not unclouded. After her second abortion, Jane felt weakened and developed a fever; she began to fear that some complication might render her sterile. "I suddenly realized that I did want children," she said. "Then I began to value the ability to conceive."

Doctors themselves often exhibit conflicting attitudes. Practicing Roman Catholics generally refuse to perform the procedure. Official church teaching holds unequivocally that abortion is taking human life and thus a crime against both God and man. The church threatens with excommunication anyone who obtains or performs the operation. Fundamentalist Protestants and some Orthodox Jews also oppose abortion. Though some rabbis and Protestant ministers have been leaders in the abortion reform movement, other liberal clergymen believe that abortion is justified only in those rare instances when it is necessary to save the mother's life.

Many doctors have nonreligious reasons for their reluctance to perform abortions. Dr. Robert Hall, associate professor of gynecology and obstetrics at Columbia University's College of Physicians and Surgeons, believes that some doctors resent laws allowing the woman to decide on abortion because they limit the physician's "godlike role." Many doctors also find the procedure alien to their experience. Hall estimates that before the New York law took effect, the typical specialist performed only one or two therapeutic abortions a year; much of his practice was devoted to assisting a normal delivery.

Still, a slowly growing number of doctors approve of abortion, especially the younger ones, some of whom euphemistically describe themselves as "specialists in delayed menstruation." A poll of 1,146 New York State obstetrician-gynecologists taken a year ago showed that only 59% favored the liberalized law. A follow-up survey last January showed 69% in favor.

Some nurses who work closely with abortion patients have difficulty adjusting to their assignment. Even those who volunteer for the duty have mixed feelings about it. They are sympathetic and try to help their patients through the abortion, but many find their work upsetting. Those with maternity-ward training have been drilled to do everything possible for the survival of infants. They look down on colleagues who work in the therapeutic-abortion ward.

THE OPPOSITION. Anti-abortion forces are active on several fronts (TIME, March 29) and have organized mail and telephone campaigns to pressure legislators into voting against abortion liberalization. The Roman Catholic Archdiocese of New York has founded a group called Birthright that seeks to offer women with unwanted pregnancies an alternative to abortion. The organization, which provides counseling, prenatal and postnatal care and adoption services, has received 1,800 calls since its formation last spring.

For the time being, at least, political efforts to alter abortion laws appear to be stalemated. Bills to repeal New York's new law failed to make their way out of committee during the past legislative session. Proposals to liberalize abortion laws in 29 other states fared no better. Many experts believe that the permissive policies in several states have relieved pressure on standpat states to act on abortion. Federal action is also unlikely, though Oregon Senator Robert Packwood has introduced a bill that would allow any physician to perform an abortion on demand during the first 31 months of pregnancy. The bill is given little chance of passage.

Still, some changes in the laws may be forthcoming. Some pro-abortion physicians want to limit to 20 weeks the period during which an abortion may be performed. The restriction would, however, impose a serious handicap on doctors trying to determine whether to perform an abortion on genetic grounds. Many tests for fetal abnormalities cannot be made before the 16th or 18th week of pregnancy, and some take as long as 30 days to perform and evaluate. There is also sentiment for limiting abortions to regular hospitals. Dr. Hall, a leader in New York's abortion-reform movement, feels that clinics are unsuited to handle the hemorrhaging that can result from even the most carefully performed abortion. Others, including spokesmen for Planned Parenthood, argue that clinic abortions are as safe as those performed in hospitals, and that eliminating clinics would deny many the opportunity to obtain abortions.

COURT TESTS. Meanwhile, restrictive laws are under challenge in the courts on the grounds of vagueness, violation of the right to privacy, and the denial of individual rights. Wisconsin's law is under a cloud; no final ruling has yet been issued on the constitutional question, but a U.S. district court has forbidden the prosecution of a Madison gynecologist for operating an abortion clinic. California law is also the subject of a court test as pro-and anti-abortion forces battle over an appellate court decision overturning part of the state's liberalized 1967 law.

The U.S. Supreme Court could render all these cases moot during its upcoming term. The court has agreed to hear challenges to Texas and Georgia abortion laws, and if it should decide for the plaintiffs, its action could nullify most anti-abortion laws.

Doctors, meanwhile, are seeking to make abortion easier, safer--and, ideally, unnecessary. Because the New York experience has shown that early abortions are only one-sixth as likely as later operations to result in complications, physicians and counselors are trying to educate women to come in as soon as they have missed a period. Research is also progressing on substances that can safely induce menstruation when it is late. This would be not merely a morning-after pill, but perhaps, eventually, a fortnight-after pill.

Experience with conventional contraceptives has shown, however, many couples do not seem willing or able to use them consistently or properly. Easily available abortion may even carry with it the risk of promoting still more sexual irresponsibility, the attitude that a lost gamble in bed will be easily remedied on a clinic table. Yet if freedom to get an abortion virtually on demand is to become as common in this country as it is in Japan and parts of Europe, then a correlative sense of responsibility is necessary. Research and public education concerning contraception must be promoted even more vigorously than they have been. Ideally, abortion should be relegated to its proper role: an available but rarely used last resort.

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