The legalization of abortion following Roe v. Wade had a crucial, positive impact on the life choices available to all women. However, its contribution to women’s basic health and well-being was most dramatic for poor women, who disproportionately are women of color. For it occurred in a context involving major changes in the composition of the poor, specifically the growing number and economic burdens of poor women who support families. This development has been succinctly described as the "feminization of poverty" in the United States.44 While it denotes a contrast with the situation discussed above, in that it describes a group of women whose economic and social conditions worsened rather than improved over the decade, the point is that access to safe, legal, funded abortion helped greatly to relieve those conditions.
By 1980, 15 percent of all white families, over 20 percent of all Hispanic families, and 42 percent of all black families were headed by women, and these families constituted over half of all families living in poverty. About one-third of all female-headed families are officially classified as poor (the percentages are much higher among black and Hispanic female-headed families). They depend on food stamps, Medicaid, welfare—the very social programs that the state in the late 1970s began systematically cutting back. If the women heading these families work outside the home, they undoubtedly find themselves in marginal, low — paying service and clerical jobs. Their median income is roughly one — half that of married-couple families.45 Medicaid is virtually their only source of health care.
The importance of legal, funded abortion services in the lives of poor women dependent on Medicaid is a matter for them, as it is for all women, of gaining control over their sexual circumstances and the conditions of motherhood. But it is also a matter critically involving their physical health and their mortality. Legalization has radically changed the conditions under which poor women resolve the problem of an unwanted pregnancy. The illegal status of abortions prior to 1973 did not prevent poor women from having them, but they did so in circumstances that were frightening, unhygienic, and sometimes life threatening.
Before Roe v. Wade, the practical consequence of physicians’ control over hospital abortions was the virtual exclusion of poor and minority women from "therapeutic" services.46 The main feature of the days of illegality was not the absence of abortions but their invisibility. Abortions—hundreds of thousands of them a year—were performed in a class — divided system that relegated poor women to the sordid conditions of back-alley abortionists, while rich and middle-class women usually had access to safe, sanitary abortions in hospitals and physicians’ offices. The medical profession enforced this division under the aegis of the "therapeutic" rationale and the incentive of the profit motive. Through rigid requirements and hierarchical committee procedures, physicians maintained a strict monitoring process over hospital abortions that limited the number and types of abortions performed, legally and illegally. Restrictive abortion laws were widely disregarded to accommodate middle-class private patients, who could more easily find a doctor to attest that they had "psychiatric problems" or rubella.47 Moreover, there is evidence that state prosecutors were highly selective in their enforcement of abortion laws, seeking out clinics and back-alley abortionists as targets for prosecution but never prestigious hospitals where illegal abortions were performed routinely. Cost alone ($600 to $800) prohibited most women from securing hospital abortions, even if restrictive rules and the elitist structure of proprietary medicine did not. As a result, surveys done in the 1960s in New York City found that "four times" as many hospital abortions were done "on the private services as on the ward services" and that only a tiny number were done in the municipal hospitals that serviced primarily poor black and Puerto Rican women.48 This is in sharp contrast to the much greater number of ward patients hospitalized during the 1960s for complications from illegal, out-of-hospital abortions.51
A major effect of legalization and Medicaid funding of abortion was to make abortion a "safe and legal" medical service that for the first time was available to poor women. And poor and minority women seem by their numbers to have been eager to take advantage of this fact. Black and Hispanic women typically are somewhat older than white women when they get their abortions, but they are reportedly three times more likely than white women to get abortions. Similarly, Medicaid-eligible women, a disproportionate number of whom are women of color, have an abortion rate that is three times higher than that of the white, unmarried, middle — or working-class majority.49 The percentage of abortion recipients before the Medicaid cutbacks who were either "black and other" (33 percent) or Medicaid patients (22 percent nationally, 25 percent in New York State) substantially exceeded their proportion in the population at large.50 Even if these differences are inflated (e. g., by the likelihood of underreported abortions among middle-class women in private, nonclinic settings), they still indicate an important shift from prelegal days.
Moreover, legalization and the increased availability of abortion services have meant definite public health benefits for poor and minority women. Maternal mortality in the United States has dropped sharply in the last two decades; specifically, since 1973, "abortion-related deaths have decreased by 73 percent." Similarly, hospital data from New York City show that morbidity such as infections and uterine perforations caused by illegal abortions dropped substantially after legalization in 1970 52 Since poor and minority women are the main ones to suffer such deaths and morbidity, these declines are an important indication that legalized abortion has meant better reproductive health for them.
Neither the undeniable benefits to their health nor the high rate of use of abortion has guaranteed adequate access to abortion services for poor women. The reverse is true. Poor women are both three times more likely than other women to get abortions and much more likely to be denied access to abortion. The years following Roe v. Wade painfully brought home the lesson that abstract legal guarantees of "a woman’s right to choose" are not equivalent to the actual delivery of adequate abortion services to all women who need and want them. Most poor and minority people in the United States rely for their routine health care on the outpatient services of government (federal, county, municipal) hospitals and clinics. But even after abortion became legal throughout the United States and supposedly a "woman’s right," it did not become widely available. Surveys done by the Alan Guttmacher Institute and the Centers for Disease Control showed that "only a minority of all American doctors, about half of the ob-gyns who specialize in women’s health care, and only a few non-Catholic hospitals provide abortion services."53 Moreover, they indicated that "eight out of 10 public hospitals and six in 10 non-Catholic private hospitals," particularly in rural areas, provided no abortion services.54 Even hospitals that provide abortion services tend not to provide them on an outpatient basis (although the vacuum aspiration technique is decidedly cheaper and safer in the early stages of pregnancy) nor to accompany them with counseling or birth control services. And their costs range from one and a half to two times as high as those charged by private clinics. In fact, the total participation of U. S. hospitals in providing abortion services has declined in relative terms from 1973 to 1977, and absolutely since 1977. All of the growth in abortion service providers must be attributed to freestanding abortion clinics, which provide three-fifths of all U. S. abortions.55 Despite the clinics’ excellent record of service,
the estrangement of mainstream health providers from the
provision of abortion. . . hinders better integration of health
services and makes the development of adequate referral and informational resources for abortion more difficult. . . .
By limiting the accessibility of abortion services in the many less densely populated areas not feasibly served by clinics, it is likely to affect adversely those least capable of easily obtaining abortion services—rural women, the very young and the poor.56
The major reason for this "estrangement" has been found by researchers to be physicians’ negative attitudes about abortion and the decisive influence of attending physicians on hospitals’ abortion practices. Constance Nathanson and Marshall Becker have analyzed these attitudes and their impact on abortion availability in an important survey of practicing obstetrician-gynecologists in Maryland.57 (Maryland was one of the first states to legalize abortion in the late 1960s.) They point out that "since no state has enacted legislation authorizing nonphysicians to perform abortions, medical practitioners effectively control access to legal abortion services. "58 This is true regarding ob-gyn practice in both private offices and hospitals. With respect to the latter, the personal values and attitudes of staff obstetricians in the private non-Catholic hospitals surveyed were the main factor determining numbers of abortions performed in those hospitals; and where attending physicians were opposed to abortion psychologically or philosophically, their affiliated hospitals "were much less likely to perform abortions"—even when hospital policy favored providing abortion and contraceptive services.59
Equally interesting are Nathanson and Becker’s findings regarding abortion performance, both in terms of scope and conditions, in physicians’ private practice. As would be expected, the study found religion to be "the most powerful predictor of abortion performance," with 85 percent of Catholic doctors performing no abortions, as opposed to 28 percent of Protestant and 9 percent of Jewish doctors. Moreover, doctors refusing to perform abortions tended to have "conservative" views on the ethics of bodily self-determination, on the expansion of reproductive health and family planning services, and on the role of women in contemporary society.60 The most interesting aspect of this study is what it tells us about Maryland physicians who do perform abortions as part of their ob-gyn practice. Among providing physicians (who are the majority), "close to 40 percent. . . request women to obtain consent for the abortion from their husbands or parents," and "over half. . . report that they do not accept Medicaid as payment for the abortion." Fees average $250 for a first-trimester abortion and $300 for a later abortion.61 In other words, the abortion practices of providing physicians reflect a pronounced class bias. Physicians who have "liberal" values regarding the role of women in society and who are less likely to request parental or spousal consent are also those who refuse to treat Medicaid patients:
These are physicians with largely middle-class and predominantly white practices. Their comments in connection with fee policies reflect a generally suspicious and defensive attitude toward any patient who is personally unknown or is referred by an unknown physician. The patient management procedures of these physicians are the outcome of an abortion practice limited to women of their own social status with whom a prior personal or professional relationship exists. This relationship precludes the need for consent or for payment in advance; the abortion is done mainly as an accommodation. Medicaid patients are not accepted because they do not meet the physician’s interpersonal criteria for abortion performance.62
Thus, an intimate, personal doctor-patient relationship around abortion decisions is alive and well—for white middle-class women! Conversely, private, proprietary medical care in this country continues to function as an exclusionary device to deny poor women access to abortion services.
There is a striking contrast between the failure of the U. S. hospital system (particularly public hospitals) to provide abortion services to poor women and its central role in their sterilization. Hospitals are the major providers of contraceptive sterilizations, which increased threefold in the United States during the 1970s. (It was in 1970 that the AMA loosened its traditional abortion policy and decided to lift all parity and age restrictions on sterilization procedures.) It has been well documented that low — income women are disproportionately represented among those who have been surgically sterilized, and this would seem to be particularly true for Puerto Rican and Native American women.63 Beginning in 1973, court suits began to mount involving both private practicing and health-service physicians engaged in the involuntary sterilization of poor, minority, and retarded young women. At the same time, evidence accumulated concerning doctors’ attitudes favoring sterilization of AFDC mothers with illegitimate children; the routine performance of "elective hysterectomies" on poor minority women patients in teaching hospitals; and the requirements in these hospitals that abortion services be made contingent on consent to sterilization (the famous "package deal").64 Moreover, physicians, particularly the American College of Obstetricians and Gynecologists, have consistently opposed federal and local sterilization regulations that attempt to impose strict conditions assuring voluntary consent, claiming that such regulations are a violation of their First Amendment rights.
Apparently, physicians’ attitudes and practices regarding sterilization are very different from their attitudes and practices regarding abortion, and these differences are directly related to class and race. It would appear that, for the ob-gyn profession as a whole, abortion is taboo on moral grounds or is treated as a privilege reserved for white middle-class women, a "private" matter between the physician and "his" patients. Sterilization, today as fifty years ago, is deemed more appropriate for poor and minority women.
Passage by Congress of the Hyde Amendment in the late 1970s, which cut off Medicaid funds for abortion, made de facto denial to poor women of access to abortions a national policy. The virtual curtailment of publicly financed abortions in most states following Hyde aroused the apprehension of many feminists that poor women would be forced to bear unwanted children, to get unwanted sterilizations, or to risk death or injury from illegal abortions. Although it is too soon to gauge the impact of the loss of federal funding, these effects have not occurred. Rather, the immediate result of the Hyde Amendment was that an estimated 94 percent of the Medicaid-dependent women needing abortions continued to get them.65
That the Hyde Amendment "did not deter the majority of low-income women from obtaining legal abortions" should not be surprising, for it reflects two social realities that historically underlie abortion use and its restriction. First, the provision of legal abortion services to Medicaid recipients was always concentrated in a relative handful of states. These states have continued Medicaid funding for abortion on the state level. The high level of abortion use among Medicaid-dependent women since Hyde reflects the restricted geographic availability of abortion to poor women and the maintenance of funding in this limited group of states. More important, even in states where Medicaid funding was cut off, "between 65 percent and 80 percent of Medicaid-eligible women" wanting abortions managed to get them legally—and an undetermined number got them illegally. Legal abortions were at times available because local practitioners continued to provide them, despite loss of funding, under the pressure of popular demand. Elsewhere, however, poor women undoubtedly borrowed from friends or relatives, depleted clothing or food money, relied on charity or clinic goodwill, or traveled out of state and thus risked delay and medical complications. "Plenty of rent checks have gone unpaid, and plenty of food bills have been snipped in half, in order to pay for abortions—with disastrous results to poor women’s health and that of their families."66 These facts remind us of a lesson of history: Women will persist in getting abortions out of their own sense of need and right, even under substantial economic, legal, and medical obstacles.
Denying poor women access to abortion, thus forcing them to have children they do not want, and restricting their reproductive capacity through coercive measures such as sterilization abuse, would seem to be contradictory policies. Yet, as I suggested earlier, these ambiguities are inherent in a society geared historically to the need to control both its "relative surplus population" and the sexual and reproductive maneuverability of women. These goals hang in an uneasy tension and may
be tentatively worked out differently at different times or in different regions.
At present, when neoconservatism and antifeminism are the ascendant political tendencies, the denial of access to abortion is a pressing threat to poor women (and others).67 But this is only one dimension of the loss of reproductive control that poor women face. Especially in locales with large concentrations of poor blacks, Puerto Ricans, Haitians, Chica — nos, and Native Americans, a more serious problem regarding abortion may stem, not from its denial, but from its forced imposition. The limited evidence regarding this practice comes from firsthand accounts of Third World women patients and women who have worked in proprietary abortion clinics.68 They report that poor women of color may find that a positive pregnancy test automatically results in an aggressive attempt to persuade them to undergo abortion. Instead of being offered a choice, they are presumed to be too poor or too young or to have too many children already to bear a child. This is in part a function of the population control mentality, but it also reflects economic interests. In profit-making abortion establishments, Medicaid reimbursement and unregulated fee schedules operate as an incentive to some doctors to process as many abortion cases as possible.
All these situations make up a complicated reality. Poor women often cannot get abortions when they want them and are sometimes pressured to get abortions when they do not want them. But most frequently, they seek and get abortions because they need to—necessity, not freedom, dictates choice. All dimensions of this totality exist at present, and all are different in important ways from the reality of abortion for most middle-class women. It is not surprising that abortion has different meanings for different women, depending on their social conditions. But this does not contradict the fact that the rise in legal abortions coincides with major gains for women as a whole, gains that affect most women, but differentially, in a society structured on class and race divisions. While access to abortion services and contraception hardly guarantees "upward mobility" in such a context, those services provide one important material circumstance that can broaden a woman’s range of possibilities and give her a little more control over her life, especially if she is poor.