Providing controversial health care: Abortion services since 1973

Abstract

Half of the 6.4 million pregnancies annually in the US are unintended and half of these result in 1.6 million abortions/year. When abortion was legalized in 1973, it was assumed that hospitals would provide the service. In fact, only 1040 of the nation's 5401 non-Catholic hospitals currently offer abortions (a decline from 1687 in 1976). By 1988, 64% of abortions occurred in specialized clinics, with another 22% taking place in clinics which offer other services. Among the 2600 providers, 20% perform over 1000 abortions/year (80% of the total). 40% of the clinics offer middle and late second-trimester abortions, with 60% of late abortions ( 20 weeks since the last menstrual period [LMP]) occurring in clinics or doctor's offices. The overall safety record for all abortion services has been excellent (0.6 deaths/100,000 procedures from 1980-87). However, many women face a problem of access to the service; 31% of women of reproductive age live in counties with no provider. In 1988, 6% of abortion-seekers traveled outside of their home state, 33% traveled to another county, 9% of women traveled more than 100 miles, and 18% traveled 50-100 miles. This shortage of providers has increased, and, in some clinics, physicians are flown in from out-of-state. A cause of continuing concern is that 11% of abortions occur in the second trimester, with 4% after 15 weeks since the LMP. A survey of these women revealed that almost 50% were delayed by the difficulty in making arrangements for the procedure (transportation, finding a provider, funding). The largest proportion, 71%, were late in recognizing their pregnancy. Since 42% of obstetrician-gynecologists in private practice surveyed in 1983 stated that they do not provide abortions (41% for moral or religious reasons), the scarcity of providers is not surprising. This situation is made worse by the harassment of anti-abortion activists. In 1988, 81% of clinics performing at least 400 abortions/year had been picketed; for 46% the picketing involved physical contact, for 38% the demonstrations resulted in arrests, 36% had bomb threats, 34% vandalism, and 17% picketing of the homes of staff members. In addition to these problems, the renumeration for abortions is very low. An abortion which cost $165 in 1976 should cost $474 today but, in fact, costs $251. Physicians still receive the same amount per abortion (about $50). These fees, which are too low to provide a financial incentive for physicians, nevertheless provide a barrier for poor women, especially since the fees for second trimester abortions are much higher (over $900 at 20 weeks since the LMP). This means that lack of Medicaid coverage for abortion is the most serious abortion access issue. The problem of funding will also have to be faced by any universal health insurance plan so that the need for referral, approval, or screening is minimized. A further access problem is the increasing number of restrictions placed on abortion-seekers which may be difficult and expensive for smaller clinics to comply with. This will likely continue the trend toward fewer, larger clinics.