Abortion the Future Is Already Here

By Richard Lacayo

JUST BECAUSE ABORTION IS LEGAL in Illinois doesn't mean that Sheela Paine can easily get one. At the age of 30, she already has five children. Last week she was in the 19th week of a pregnancy she couldn't afford; her husband is unemployed and the family lives on welfare. She also couldn't afford the reduced $425 price of a second-trimester abortion at the clinic near her home in East St. Louis. During her last pregnancy Paine tried to induce miscarriage by taking quinine pills. She ruled out a cheap illegal abortion because a girlfriend bled to death after getting one. "I know other girls who've done different things," she says. "Jumped off the top of dressers or provoked their boyfriends to jump on them." But the prospect of trying to support yet another child made her sick with worry. "My hair started coming out," she says. After many anxious days, she finally got an abortion last week after she was able to borrow the money.

Abortions are still legal in Texas too. But that doesn't mean doctors can easily perform them. Four years ago, Dr. Curtis Boyd's Dallas clinic came under siege for weeks by antiabortion demonstrators. One day one of the protesters began asking after Boyd's children by name. "How's Kyle?" the man would inquire. "Has he had any accidents?" Then came the handwritten death threat in his mailbox. Boyd moved his family out of town for a while, and on Christmas Eve his clinic was torched. Boyd is back in business today, but with a sharper sense of the odds against him. "You have a President of the United States who says abortion should be illegal," he says. "You have religious leaders saying that doctors who perform this service should go to hell. You have antiabortion groups that harass medical staff. What professionals would continue to do a service that subjected them to this kind of abuse?"

This is how matters stand now, in what may be the last days for a woman's constitutionally protected right to abortion in America. The Supreme Court is widely expected to uphold the Pennsylvania law that would require a woman seeking an abortion to notify her husband and wait 24 hours after hearing a state-prepared presentation about adoption and child-support alternatives, among other things. By okaying the law, or most parts of it, the court would invite other states to introduce new restrictions of their own. Next year the nine Justices may entirely reverse Roe v. Wade, the 1973 Supreme Court decision that guaranteed abortion rights; states would then have the option of banning abortion outright.

But for all the attention paid last week to the arguments before the Justices in Washington and the outcry of the demonstrators in Buffalo, that is not where the issue is really being decided. At this moment, abortion is not available in 83% of America's counties, home to nearly a third of American women of childbearing age. For reasons of professional pride, or fear, or economic pressure, doctors have backed away from the procedure even where it remains available.

The reality in most American communities is that two decades of moral and religious reflection, legal maneuvering and political assaults have combined to do precisely what conservatives promised when Roe was handed down: roll back the Supreme Court ruling until it is no longer the law of the land. Now, in the noisy streets and legislatures and the bare chambers of the individual conscience, that most fundamental question -- Who decides whether a woman can have an abortion? -- must itself be redecided. With that, America is entering new moral and political territory, rough and uncharted, but lit by the phosphor of righteous certainties. And as the combatants square off with their irreconcilable notions of life and liberty, the middle ground, what there is of it, promises to become scorched earth.

THE WAR OF IMAGES

The National Abortion Rights Action League is distributing a map of America these days that offers its vision of the future. If Roe is overturned, naral predicts that just seven states, mostly along both coasts, can be counted on to keep abortion easily available. Across the broad middle of America, an area stretching from Idaho and Nevada east to Kentucky and Tennessee, the group foresees a nearly unbroken regime of tough new obstacles and outright prohibitions. Though opponents of abortion say the other side is overstating the threat as a way to mobilize supporters, they are quietly confident of roughly the same outcome. "At the end of this decade we will probably have a patchwork of state laws," says Gary Bauer, president of the conservative Family Research Council and formerly the domestic policy adviser in the Reagan White House. "But legal or illegal, it will be much more likely that abortion will be seen as a matter of shame and something to be avoided."

To reinforce the shame and remind women of the options, antiabortion groups are undertaking a war of images. Last month the Arthur S. DeMoss Foundation, a Pennsylvania-based group that contributes to conservative causes, began an ad campaign on cable stations to promote the idea that adoption is the solution to unwanted pregnancies. Michael Bailey, an Indiana advertising-promotions executive, declared himself a congressional candidate in his district's Republican primary, largely in order to run a series of antiabortion ads on television. The 30-second spots graphically depict what he says are aborted fetuses; under federal regulations, local television stations have no power to censor political ads. "I always have believed that if television stations ever aired pictures of aborted babies, it would begin to change many people's minds about the issue," Bailey explains. "People would focus on the evidence of abortion -- which is the aborted baby -- rather than this ill-conceived idea of women's choice. Choice is no choice to babies."

THE PREDICAMENT OF WOMEN trying to get abortions is harder to distill into a single wrenching image. There are 1.6 million abortions carried out in the U.S. each year, representing almost a fourth of all pregnancies. It is estimated that more than 46% of American women will have had one by the time they are 45. But while there are about 2,500 places around the country that provide abortions -- down from a high of 2,908 ten years ago -- they are mostly clustered around cities, leaving broad areas of the country unserved. A single clinic serves 24 counties in northern Minnesota. Just one doctor provides abortions in South Dakota.

For a glimpse of the future, look at Mississippi. Three of the state's four clinics are clustered around the capital and largest city, Jackson. But their survival is threatened by a new law that would require clinics to have advance transfer agreements with hospitals to care for patients who may suffer complications -- a provision designed to capitalize on the resistance among many hospitals to associate themselves with anything as controversial as abortion.

A law requiring a 24-hour waiting period will go into effect if the Supreme Court upholds that provision in the Pennsylvania law. Though it sounds benign enough, it can confound poor women who already have to travel long distances to find a clinic, only to discover they must also scrape together the price of overnight accommodations. Often by the time they get the money together, they have advanced into the second trimester, when the cost is higher. (Only 12 states -- Mississippi is not one of them -- routinely provide Medicaid financing for abortion.) Nancy Rogers owns one of the clinics near Jackson. Two years ago, when she went to the capital to argue against the bill before a state legislator, she got a sense of what she was up against. "His exact words were, 'I have no sympathy for anyone who cannot afford a motel room.' "

There's one other clinic in Mississippi, but lately it has not been open for business. When Dr. Joseph Booker first moved to the coastal town of Gulfport to set up a gynecology practice in 1988, local officials granted him every permit he needed to start business. But when he purchased a small commercial building last year and made plans to relocate his Gulf Coast Women's Clinic, he got a different reception. In January, when he applied for a permit for interior reconstruction, Harrison County code administrator Ben Clark told Booker he had learned that abortion was part of Booker's practice. The permit was denied.

Soon after, the Harrison County board of supervisors passed an ordinance prohibiting the operation of an abortion clinic within 500 ft. of a church, school, kindergarten or funeral home. There are two churches close by Booker's building. Four of the five hospitals in the Gulfport-Biloxi region have denied Booker admitting rights that would guarantee his patients a bed in the event of complications. For good measure, the local power company has refused to provide electricity to his unfinished clinic until he secures the building permit he cannot get.

Since the electronic security alarm has been rendered useless, the site has been vandalized four times in recent months. For now Booker is referring women seeking abortions to Jackson, 160 miles north. But he remains determined to revive his practice in Gulfport. "Nobody's going to tell me how to practice medicine or scare me out of practicing it," he says. His lawyer, John Jones, is challenging the 500-ft. ordinance in court but knows it won't be easy. "Every time we jump through a hoop," he says, "they create another hoop."

TARGETING DOCTORS

Discouraging the doctors who provide abortion has become one of the characteristic tactics of the most militant antiabortion groups. In Buffalo, the same Rev. Robert Schenck who pushed a fetus in front of abortion-rights demonstrators last week has promised to stand outside restaurants frequented * by doctors from abortion clinics, holding banners announcing that abortionists eat here. Other leaders are threatening to picket the schools attended by the doctors' children.

Death threats, obstruction and broken windows have taken their toll, but the medical profession has tiptoed away from abortion for less dramatic reasons as well. Though physician surveys show that a large majority of gynecologists and obstetricians are pro-choice, many doctors are inclined to see abortion as routine work that's poorly paid by their standards. Partly from a desire to keep abortion within reach of poor women, Planned Parenthood, which operates 900 clinics around the country, has succeeded in keeping prices low at their facilities. That in turn has put competitive pressure on everyone else, keeping the average price for a first-trimester abortion at just $251, not much of an increase over the $196 price of twenty years ago. At a Planned Parenthood clinic in New York City, a physician earns up to $125,000 annually for a four-day week, perhaps half what he or she might make in private practice.

Hospitals have also been withdrawing from the abortion business. In the years after Roe was handed down, more than half of all abortions were performed in hospitals. By 1988, 86% were done in neighborhood clinics and an additional 4% in the offices of individual doctors. Some hospitals shy away from the procedure because of opposition from potential donors or members of their governing boards. At the same time, because abortion is a relatively simple procedure that doesn't require general anesthesia or the costly equipment of a hospital operating room, groups like Planned Parenthood encouraged the move to clinics as a way to keep abortion cheap and accessible.

But clinics tend to be small outposts that offer easy targets for the sit- ins, arson and bombings that a large, well-guarded hospital is better suited to resist. And as the work has fallen largely to clinic doctors who specialize in abortion, it has dropped off the list of skills that a woman's regular physician can be expected to have. A new study by Dr. H. Trent Mackay of the University of California at Davis shows that last year just 12% of the nation's obstetrics-gynecology residency programs made training in first- trimester abortions a routine part of their program. Only 7% did so in the case of second-trimester abortion training. Compare that with 1985, when nearly a fourth of all such programs routinely taught abortion procedure for ( both trimesters.

So it's no surprise that many clinics must go far afield to find a doctor who is willing and able to perform abortions. The Allentown Women's Center in Pennsylvania can offer them in large part because one day each week Dr. Amy Cousins makes the 120-mile drive from New York City. On two other days she treks 200 miles north to provide the same service in Binghamton, N.Y., where the antiabortion group Operation Rescue has its headquarters. "I can't get anybody to cover for me," she says. "So I don't go on vacation."

As older physicians retire, the medical profession is also losing its institutional memory of the days before Roe. A generation raised in the era of safe and legal abortion is less likely to produce doctors ready to go to the barricades at the first sign of women being forced to undergo illegal -- and dangerous -- abortions. "I have personally taken care of women with red rubber catheters hanging out of their uterus and a temperature of 107 degrees," says Dr. David Grimes, 45, of the University of Southern California School of Medicine. "Once a physician has watched that happening, he or she will never be willing to watch the laws go back."

THE RISING BARRIERS

But what if the laws do "go back"? If Roe is eventually overturned, the first result is likely to be a wide-scale confused impression that the loss of the constitutional right means abortion will instantly become illegal in every state. "Women will see the big headlines, and some are going to lose the message," says Dr. Michael Burnhill, professor of clinical obstetrics and gynecology at the University of Medicine and Dentistry of New Jersey. "They are going to be confused as to whether they can get an abortion at all."

In some places they won't be able to. naral predicts that 13 states will ban abortion outright, though typically with exceptions for the so-called hard cases: when the life of the mother is at risk, the fetus is seriously deformed or the pregnancy resulted from rape or incest. Other states are likely to be satisfied with a raft of new restrictions, such as 24-hour waiting periods and laws requiring clinics to be equipped as hospitals, which would drive up prices. Parental notification laws, already in place in 18 states, will be even more widely adopted, posing problems for many girls under 18, who at present account for 11% of all abortions.

Such obstacles are hardly insurmountable. But they are likely to make it take longer for women to afford and arrange an abortion, which makes the procedure more dangerous. They also have the effect of sending a message. To abortion opponents, the message is that abortion on demand is immoral, and so should be illegal. But abortion-rights advocates see a different subtext. Instituting a waiting period suggests that women seeking abortions do so blithely and without reflection -- a notion belied by the experience of women who have endured the private, wrenching process of deciding to terminate a pregnancy. Experts calculate that 93% of married women who have abortions talk to their husbands about it. The others may have good reason not to. "If husband notification is upheld," says Jean Hunt, head of the Elizabeth Blackwell Health Center for Women in Philadelphia, "it will be almost impossible to provide services for women who live in fear of their husbands."

The idea of parental notification has a logic to it in communities where high school girls cannot receive aspirin from a school nurse without a parent's approval. But again, abortion rights advocates argue that a girl who does not want to tell her parents she is pregnant may have profound reasons for her silence, and no new law is likely to overcome that immediate fear.

Some extreme opponents of abortion would go well beyond waiting periods and notification laws. Though they refrain from pressing for such an outcome, they would impose criminal penalties, including prison time, for women who seek abortion -- not just for the doctors who perform them. But many pro-lifers, while they equate abortion with murder, are reluctant to treat women as killers, in part because throwing young women in jail would alienate too many Americans. Press them on the inconsistency, and they often reply that women who seek abortions are themselves victims of exploitation, economic desperation or misinformation.

No matter what penalties are imposed, past experience suggests that when women are sufficiently desperate, they will terminate their pregnancies by any means available. That is what worries abortion-rights advocates, as they recall the years just before Roe, when there may have been as many as 1.2 million illegal abortions annually in the U.S. States that keep abortion available in the future are likely to become magnets for women from nonabortion states. In the 2 1/2 years preceding Roe, nearly 350,000 women traveled for that reason to New York, which was at the time one of the few / states in which abortion was legal. Referral agencies popped up overnight to charge the out-of-staters as much as $100 for the names of abortion doctors. As prices climbed as high as $1,000, abortion became a hustler's game. "There were doctors who were literally becoming millionaires," says Dr. Irving Rust, the medical director of a Planned Parenthood clinic in the South Bronx. "Anytime you have a situation where supply and demand is the main dynamic, it brings out the worst."

PRO-CHOICE GROUPS ARE PREparing for the day when they will have to provide an abortion underground, with networks to help women get to states where abortion is available. Some are urging more radical solutions. Carol Downer, director of the Federation of Feminist Women's Health Centers, based in Los Angeles, travels widely to talk to women's groups about "menstrual extraction," a home-abortion procedure she co-developed in the early 1970s. A suction technique similar to the vacuum-aspiration process that is now the most common form of first-trimester abortion, it requires a 50-mL syringe attached to a flexible plastic tube, which withdraws the contents of the uterus and deposits them into a closed container.

The premise behind menstrual extraction is that a home abortion provided by concerned friends is better than one carried out in some surgical speakeasy. Downer insists that women without medical training can learn to perform menstrual extraction on other women safely. A cooperative doctor may still be needed to obtain the equipment, some of which can be purchased legally only by physicians or clinics. "It will take some thinking and determination and motivation to put ((the kit)) together," she says.

Many doctors and abortion-rights groups consider her message irresponsible and menstrual extraction far too risky to contemplate. They stress the danger of infection, sterility or even deadly sepsis in the event of a puncture in the uterus. If menstrual extraction is attempted more than six weeks after a woman's last period, it can also lead to severe complications, including cramps, bleeding and blood clots.

Downer's critics also fear that poor women and teenagers -- the ones most likely to have trouble getting to states where abortion is legal -- are the ones least likely to master the procedures for performing an abortion safely. It is small comfort that hospital emergency rooms would be obliged to treat any woman who developed complications. "Abortion is minor surgery," says , Barbara Radford, the head of the National Abortion Federation, an association of abortion providers. "But you need backup, you need proper equipment, you need proper medication."

So long as women can get to any state where abortion is legal, menstrual extraction is unlikely to become a real alternative to physician-provided abortions. But the very fact that it's under discussion once more is a sign of the ways in which America is bracing itself for a partial return to the past. In the two decades since Roe was handed down, a generation has grown up that knows nothing of the days of illicit abortions conducted on kitchen tables, or in doctor's offices at night with the blinds drawn.

For the same two decades, while pro-lifers have waved pictures of the developing fetus, there were no more new images of women victimized by illegal abortions. In the years to come, those pictures, and the desolate realities they represent, are sure to reappear. It was harsh experience that led to the climate of opinion that welcomed Roe. Will it take harsh experience again to sort out the national will on abortion once and for all?

With reporting by Julie Johnson/Washington, Priscilla Painton/New York and Elizabeth Taylor/Sioux Falls