Abortion is Vulnerable Because it was Never Assimilated into Mainstream Medicine

Even before the expected June announcement by the Supreme Court of its decision in Dobbs v. Jackson — a decision many believe will overturn Roe v. Wade — abortion care in America is in trouble, marginalized from the rest of medicine.

Nearly 50 years after legalization nationwide, the majority of obstetrician gynecologists and primary-care doctors do not provide abortions — even though 1 out of 4 American women will have an abortion in her lifetime. Women in the “abortion deserts” of the South and Midwest are forced to travel many hours to reach a clinic. Only 4 percent of abortions take place in a hospital and only 1 percent of abortions take place in private doctors’ offices. The remaining 95 percent occur in free-standing clinics, which offer excellent care, but are largely isolated from other medical institutions. Over 1,000 restrictions, such as mandatory waiting periods, have been passed by state legislatures that make abortion care considerably more difficult for patients and providers alike.

The embattled status of abortion care, and its failure to become accepted as a routine part of reproductive health services, is in part an outcome of the unprecedented amount of violence this field has experienced. Eleven individuals associated with abortion care have been murdered and countless others have been subject to vandalism, stalking and threats. Abortion has also become deeply politicized and a key battle in America’s culture wars. But another, less discussed factor explaining abortion’s marginality was the behavior of the medical establishment itself at the pivotal time of the Roe decision in 1973.

Before 1973, people needed and accessed abortion despite it being illegal in most of the country. Some estimate that as many as 1.2 million abortions were performed in the United States annually in the years leading up to Roe.

Some abortion providers in that era were those that I have termed “doctors of conscience,” individuals who were well-trained and embarked on successful mainstream medical careers. Compassion for women in desperate situations and concern about the harms that less capable practitioners would do motivated them to provide illegal abortions. Some provided this service free, while others charged substantially lower fees than other illegal practitioners of that era, including those who lacked formal medical training. Some doctors worked with the Clergy Consultation Service (CCS), a group of ministers and rabbis, organized in 1967, which made referrals to vetted safe providers. Those working with the CCS provided a large volume of abortions, taking all who came, while others performed fewer cases. All of these doctors of conscience, like other providers offering care illegally, risked losing their medical licenses and possible imprisonment.

Another subset of pre-Roe providers were also trained physicians or other health-care professionals who performed a much smaller number of abortions. They were not especially political, but they provided competent care for a fee.

Then there were the infamous “back-alley butchers” — some trained as physicians, some not — who were noted both for their inept medical skills and their egregious ethics, including sexual assault. The doctors within this group were often those who had failed at establishing an aboveboard career. Along with the many women who died inducing their own abortions through dangerous means, these “butchers” accounted for most deaths of abortion patients before Roe.

Though this last group made up only one segment of providers, they left an indelible mark on medical colleagues at the time of nationwide legalization. One third-generation OB/GYN told me, “In my family, the worst thing that could be said about anybody was that he was an abortionist.” His relatives did not object morally to abortion, but rather they held the assumption that illegal abortion doctors were “losers.” Even after Roe, a physician who supported freedom of choice, commenting on the small number of doctors doing abortions in New York City, remarked: “The rest of the staff regards these doctors with esteem not markedly higher than that previously reserved for the back street abortionist.”