The Washington PostDemocracy Dies in Darkness

Failing to embed abortion care in mainstream medicine made it politically vulnerable

Actions by the medical profession in the 1970s still reverberate today

Abortion opponents kneel in prayer in 2019 outside Reproductive Health Services, an abortion clinic in Montgomery, Ala. (Blake Paterson/AP)
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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.”

By the time of Roe, a majority of the medical community supported legal abortion — but not necessarily those who provided it, who remained stigmatized and thought to be more closely associated with a back-alley quack than a respected medical professional. Beyond their discomfort with abortion providers, the largely White, male and conservative medical profession of that era was ambivalent about incorporating abortion care for other reasons.

The threat that abortion posed to conventional medical authority was one. As a doctor complained at an American Medical Association (AMA) meeting in 1970, where legalization was under discussion, “Legal abortion makes the patient truly the physician: she makes the diagnosis and establishes the therapy.” That this scenario would typically involve a female patient dictating a course of treatment to a male doctor only compounded the discomfort in an era when medical authority was almost entirely reserved for men and motherhood was considered normative for women.

Moreover, the evident association of abortion with social movements — both for and against legal abortion — was disturbing to many in a conflict-averse profession. On one hand, many in medicine were less than sympathetic to the feminist activists demanding “abortion on demand” in the years leading up to Roe. On the other hand, four days after the Roe decision was announced, the Church amendment, which offered “conscience protections” for health-care workers who refused to participate in abortion, was reintroduced in Congress (and passed several months later). This quick action sent a signal that this procedure would be more scrutinized than the rest of medicine.

What is striking about the years after Roe affirmed a constitutional right to abortion were the measures that were not taken.

Very few medical organizations took the steps that would normally be expected after a major policy change. Most medical groups issued no guidelines, standards or even statements of support. Leaders within OB/GYN did not make any effort at education, for legislators or the general public, about the health benefits of legal abortion. Most significantly, the organizations charged with establishing residency requirements in OB/GYN did not mandate routine training in abortion for another 20 years. Even then, Congress immediately weakened the mandate. In short, at a crucial time, medical leaders passed on the opportunity to fully integrate abortion care into mainstream medicine.

The significant violence and harassment that is now central to abortion politics in America did not begin in earnest until 1988, some 15 years after Roe, when a new organization, Operation Rescue, began blockades and clinic invasions. Days before the first abortion doctor was assassinated in 1993, Randall Terry, the organization’s founder, told a crowd, “We’ve found the weak link is the doctor. … We’re going to expose them, we’re going to humiliate them.”

To be sure, in recent years as abortion has become increasingly restricted and vulnerable, leading medical organizations have begun to speak out strongly in support of abortion. Training has finally increased, primarily due to the efforts of private philanthropic funding. A new generation of abortion providers — disproportionately female, many of them people of color — has entered the field, driven by social justice commitments.

Encouraging as these more recent developments are, they have occurred too late to secure abortion’s place as part of routine reproductive health care in all parts of the country. The likely future of abortion in America will include an intensification of a phenomenon already underway — the massive movement of abortion patients from red states to blue states, with some simply unable to arrange this travel. In the future, this failure to embed abortion care in mainstream medicine will mean even greater geographic and wealth disparities in terms of who may obtain care.

Some women will “self-manage” by obtaining, mainly over the Internet, the drugs necessary for a medication abortion, a solution that will work well for many, but not for all. Some will attempt their own abortions by resorting to risky methods. Some will be forced into a pregnancy that will result in a child they are unable to care for. It is painful to imagine how different these scenarios might be had the medical establishment acted more forcefully at the time of Roe.