WHEN THE US SUPREME COURT issued its 1973 Roe v. Wade decision, sanctioning abortion as a legal option, many feminists and health-care activists thought the matter was settled. They were wrong.
Forty-seven years later, a largely religious anti-choice movement has made tremendous strides in reducing access to the procedure. By pushing state lawmakers to restrict how and when those seeking to end unwanted, ill-timed, or unfeasible pregnancies can do so, they have helped create a climate in which abortion is treated differently from other types of medical care.
David S. Cohen and Carole Joffe, authors of Obstacle Course: The Everyday Struggle to Get an Abortion in America, call this “abortion exceptionalism.” Their clearly written text includes the voices of more than 90 patients, doctors, nurses, clinic escorts, policy experts, and activists, all of whom powerfully — and maddeningly, if you support reproductive choice — describe what it means to have to jump through hoops to obtain, or deliver, abortion care.
Each of the book’s chapters lays out a barrier, from financial to logistical, and details the emotional toll that that barrier presents. But the book is more than a laundry list of impediments and snags. Obstacle Course also posits suggestions for how to normalize abortion as routine health care and delineates ways to protect reproductive choice and promote reproductive justice.
Cohen and Joffe spoke to LARB’s Eleanor J. Bader about the book, the challenges facing reproductive justice, and the political landscape more generally.
ELEANOR J. BADER: Since 1973, many state legislatures have restricted abortion, imposing waiting periods, Medicaid bans, and burdensome architectural rules that only apply to abortion clinics. Is support for this agenda largely coming from people of faith?
CAROLE JOFFE: Yes, but my sense is that it’s Republicans who want to be elected or reelected who are doing the most damage. Some of them are no doubt affiliated with religious denominations that oppose abortion, but I think most conservative legislators figure that the best way to get or stay in office is to be anti-abortion. They worry that if they do not vote “correctly” on abortion legislation, they might be primaried.
DAVID S. COHEN: Donald Trump is a perfect example. He is probably personally pro-choice. We know he isn’t religious, but he took an anti-choice position to get elected. I see him and a lot of other anti-choice politicians as opportunists.
The book emphasizes the ways that so-called Crisis Pregnancy Centers, religious anti-abortion organizations that lure pregnant people in, misrepresent abortion. It shocked me to read that courts have decided that their right to lie is protected by the First Amendment.
DSC: Yes, it’s insane. The Supreme Court has ruled that fake clinics cannot be required to tell patients that they are not licensed. Other courts have also allowed states to force abortion clinics to give patients false information intended to shame them. In other words, fake clinics have real First Amendment rights while real clinics have fake First Amendment rights. And this is not the only way that anti-choicers are protected while those who support reproductive justice are not. The Church Amendment, which was enacted in 1973, allows hospitals that receive federal money, and their staffs, to opt out of providing abortion if it violates their religious beliefs or moral convictions. But this is a one-way street because the law does not respect the moral convictions of those who provide abortion care.
Patients who go to Catholic hospitals typically can’t access a full range of reproductive health-care options. How is this being addressed?
CJ: Patients need to be educated about whether a particular hospital is Catholic affiliated and, if possible, go somewhere else for reproductive health services. In some places, where Catholic hospitals are attempting mergers or affiliations with secular hospitals, activists are pushing back. For example, the University of California health-care system is currently considering an affiliation with a Catholic health-care chain, and many clinicians at UC facilities are struggling to prevent this, fearing that patients will no longer have access to contraception, abortion, sterilization, LGBTQ care, and so on.
DSC: I live in Philadelphia, where Abington Hospital has been an important abortion provider for decades. In 2012, Abington planned to merge with a Catholic hospital. Hospital staff and the community mobilized to stop the merger.
So many people have to travel such long distance — sometimes hundreds of miles — to get an abortion, that they often have to stay somewhere overnight. For those who have to wait between counseling and having the procedure, it’s even worse. How have clinics and supporters responded to this need?
CJ: In many places, volunteers offer a couch or a spare bed if they have one. As we describe in the book, in one place in the South — I don’t want to reveal the location for security reasons — clinic volunteers and supporters actually got together and bought a house for this purpose. They now coordinate child care, meal preparation, and other services for patients who need a no-cost place to stay for the night.
DSC: People in a few other places have been able to purchase property for this purpose in places where real estate prices are low. But it’s not feasible in big cities like New York, Los Angeles, San Francisco, or Chicago.
How about other practical supports, things like helping someone pay for the abortion?
DSC: There are a lot of fantastic practical support groups. Abortion funds have existed for a long time and were established when pro-choice people recognized the damage that was being done by the Hyde Amendment, which is a 1976 federal law that ended federal Medicaid coverage for abortion. Seventeen states now provide this funding out of their own tax revenue, but 33 don’t, so Medicaid-reliant people who want an abortion in these places has to come up with the money themselves. Abortion funds are mostly volunteer-run and solicit donations to help pay for care. These organizations and other practical support groups also sometimes offer other concrete help — things like paying for bus, train, or plane tickets to get to a provider, or funds to pay a babysitter.
Has the reproductive justice movement aligned with other constituencies whose rights have also been threatened?
CJ: Over the last several years, especially since Trump’s presidency, immigrant rights, anti-poverty, and reproductive justice groups have recognized that they have an overlapping constituency. Planned Parenthood in Flint, Michigan, for example, has given patients clean water, understanding that lack of access to safe bathing and drinking water is a reproductive justice issue, that reproductive justice means supporting individuals and families in concrete ways.
DSC: The National Network of Abortion Funds is doing incredible work in this area, linking reproductive health care to employment, education, food security, and affordable housing — all the things that support raising children in the healthiest, safest way possible. Reproductive justice supports abortion access, but it also supports people’s right to have children and raise them in good environments.
Another issue is raised in some particularly restrictive states, where patients need to show the clinic a government ID to prove that they are not too young to have an abortion without notifying a parent or getting parental permission. This is another impediment to abortion for the undocumented.
Let’s talk about clinics where there is a vocal anti-abortion presence. Have police protected patients and clinicians?
DSC: Some clinics have excellent relations with police, but many police departments fail to prioritize protecting the clinic. Maybe they don’t care or maybe they side with the antis, but the upshot is that in many places around the country, police do very little to help people entering the clinic.
CJ: Rewire.News made a video a few years back contrasting the response to protests in two cities: Charlotte, North Carolina, and Fargo, North Dakota. The protests in Charlotte were vicious, huge, with as many as 1,000 or more protesters on occasion, and police did nothing to protect staff or patients. The opposite was true in Fargo. There, the clinic director and the police work well together. Police response is variable. Places that have a bubble zone where protesters can legally stand, or noise ordinances to keep the shrieking to a minimum, can make a huge difference if they are enforced.
DSC: The Freedom of Access to Clinic Entrances Act, FACE, passed in 1994. It has not been vigorously enforced by Trump, but this was also true under Obama. As a statute, FACE has been effective in eliminating blockades, but it has been less effective in stopping other forms of harassment.
Medical staff in some states are required to tell patients that there is a link between abortion and breast cancer; that they may be unable to conceive after an abortion; or that they may suffer from post-abortion mental deterioration. All of these assertions are false. Why are clinics mandated to make these bogus claims?
DSC: These statements undermine the health-care profession and confuse patients, especially because providers feel ethically obligated to then explain to patients that the statements they just read to them are not supported by medical evidence.
CJ: Clinics do their best to counsel patients, but if a patient shows up and is confused, upset, or ambivalent, and then has to listen to a recitation of falsehoods, it means that time is taken away from the conversation that needs to take place. Right after Roe, counselors had more time to zero in on the patient’s needs. Clinics always want decisional certainty about abortion, and while most patients know what they want when they walk in the door, some are unsure or may be facing other problems, like being in an abusive relationship, poverty, homelessness. Forcing counselors to adhere to a mandated script of lies makes it harder for them to do any real counseling and focus on the patient.
What about medication abortion as an alternative to surgery?
CJ: Many people hope that medication abortion — a highly successful alternative when the pills are taken within the first 10 weeks of pregnancy — will eventually be available over the counter. Realistically, this is not going to happen under a Republican administration.
Medication abortion is a highly successful method of abortion when used in the first 10 weeks of pregnancy. The regimen consists of taking two medications, mifepristone and misoprostol. This method now represents about 40 percent of all abortions taking place in the United States, and would likely be even more utilized were it not so tightly regulated by the FDA. Rather than being available at pharmacies with a prescription, the pills can only be dispensed at a clinic or doctor’s office, and ordering them can be cumbersome for clinicians. This level of excessive regulation is an example of what we call in our book “abortion exceptionalism.” Hopefully, a federal case from Hawaii will eventually permit pharmacy dispensation.
You report a few progressive developments in an otherwise bleak landscape. Can you say a little more about some of the work that is being done in different states to expand reproductive justice?
DSC: In the past several years, several progressive state legislatures have realized that they can do some good. They’ve pushed bills that expand access to reproductive care and have gotten rid of provisions that harmed patients.
Maine is an example. Last summer, Maine extended Medicaid coverage to abortion and allowed nurse practitioners and physician’s assistants to perform abortions. These two advances, along with already-allowed telemedicine, will greatly enhance access in such a large, sparsely populated state.
CJ: California recently required all four-year colleges and state universities to have medication abortion pills available to students. This is huge.
Are you worried about the abortion case that will be argued before the Supreme Court this spring?
DSC: In early March, the Court heard a challenge to a Louisiana law that requires abortion doctors to have hospital admitting privileges. In 2016, the Supreme Court found an almost identical Texas law unconstitutional, but there are two new conservatives on SCOTUS now, so yes, I’m worried.
If the Louisiana law is upheld, it will drastically limit access to abortion in Louisiana because most abortion doctors do not have a relationship with the local hospital. And they aren’t needed because the procedure is incredibly safe. This is just one of the laws that contributes to a crazy obstacle course that patients have to go through to get an abortion, even in a world in which Roe is still good law.