Abortion was a polarizing issue a century ago during the progressive era, and it remains so. In fact, you may have a firm perspective on whether abortion should be legal always, in certain c

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Journal of Human Behavior in the Social Environment, 20:658–671, 2010

Copyright © Taylor & Francis Group, LLC

ISSN: 1091-1359 print/1540-3556 online

DOI: 10.1080/10911351003749177

Abortion Policy and Vulnerable Women in the United States:

A Call for Social Work Policy Practice

GRETCHEN E. ELY College of Social Work, University of Kentucky, Lexington, Kentucky

CATHERINE N. DULMUS School of Social Work, Buffalo Center for Social Research, University at Buffalo,

Buffalo, New York

Repressive abortion policy in the United States creates undue

burdens for groups of vulnerable women, including adolescents,

women of color, women living in rural areas, and women with

economic disadvantages. Repressive abortion policy creates a two-

tiered system of access to reproductive health care that is a par-

ticular disadvantage to vulnerable women. In this study, current

policy is discussed with examples of such policies outlined in three

areas: insurance coverage and Medicaid restrictions, mandatory

waiting periods, and mandated state counseling. Social workers’

role in policy practice is emphasized in regard to advocacy and

abortion policy.

KEYWORDS Abortion policy, abortion access, vulnerable women,

undue burdens, forced pregnancy, policy practice

Lack of access to abortion is arguably the most important barrier to economic and social equality for women in the United States (U.S.). Legal access to abortion ensures that women will not be forced to continue pregnancies against their will, which is necessary if women are to enjoy a level of human rights equal to those afforded to men. Elective abortion in the U.S. was decriminalized in 1973 in the landmark Supreme Court case Roe v.

Wade and, in 1992, the Planned Parenthood v. Casey court case upheld the

Address correspondence to Gretchen E. Ely, College of Social Work, University of Kentucky, 639 Patterson Office Tower, Lexington, KY 40506, USA. E-mail: [email protected]

uky.edu

658

Abortion Policy 659

right to abortion while also allowing individual states to enact restrictions as long as they did not create an ‘‘undue burden’’ to the women seek- ing the service (Harper, Henderson, & Darney, 2005). Despite the court’s ruling that states could not create ‘‘undue burdens’’ for women seeking abortions, current public policy efforts consistently seek to restrict access to abortion in ways that do create undue burdens to women, especially vulnerable groups of women. Thus, much of the current abortion policy in the U.S. essentially violates the law yet is overlooked owing to a moral agenda present in many lawmakers. Examples of such policies include the imposition of parental notification laws, mandatory waiting periods, and mandatory state-scripted counseling (Kaplan, 1998). These abortion policies reflect a punitive ideology and a moral perspective rather than evidence- based science (Fried, 2006). Though laws that impede access to safe, legal abortion reflect a moral preference that is shared by a few, they infringe on the reproductive rights of all women and acutely affect groups of vulnerable women.

Social policy has not historically been a helpful or positive force in the quest for women’s reproductive rights, especially in the U.S. (Ruhl, 2002). This becomes evident when one examines the list of historical and present social policies that curtail reproductive freedom and define the con- text in which women may exercise their reproductive choices (Ruhl). In the U.S., laws governing abortion in particular are frequently irrational, as they are based on the notion that the fetus, from the moment of conception, has individual rights and obligations that are equal to or surpass those of the pregnant woman (Ruhl). Laws limiting access to abortion violate the basic principles of the separation of church and state (Fried, 2006), yet are passed and implemented without regard to their unconstitutional- ity. Such public policy flourishes under the assumptions that the fetus and the pregnant woman have conflicting interests, that the pregnant woman cannot be relied upon to act responsibly when confronted with the condi- tion of pregnancy, and further allows no consideration for the innumer- able problems associated with birth, pregnancy, and childrearing in less than ideal social and economic conditions (Ruhl). Furthermore, regarding the notion of self-sacrifice for the benefits of one’s offspring, parents have the right to refuse to donate organs, blood, or other body parts to a sick child, whereas pregnant women are expected to undergo heroic measures to carry a child to term, even if such measures are against their will (Cook, Dickens, & Bliss, 1999; Ruhl). Thus, under current abortion laws in the U.S., the pregnant woman, considered an autonomous subject under the law the day before becoming pregnant, no longer enjoys a status that can be associated with autonomous personhood once a pregnancy occurs. In fact, in the cases of pregnant women in the U.S., neither the pregnant woman nor the fetus can be defined as having the status of personhood (Ruhl), yet laws restricting reproductive autonomy elevate the fetus to the

660 G. E. Ely and C. N. Dulmus

status of personhood above the status of the pregnant woman. Laws that decrease access to abortion do not in fact increase the autonomy of the fetus, even though this is how such laws are often framed to garner public support. Rather, they are punitive and explicitly coercive attempts to control women in situations wherein they cannot be trusted to control themselves (Ruhl).

Attempts to make abortion illegal across the U.S. in a post-Roe v. Wade

culture have failed. Thus, repressive policy efforts have focused, recently in particular, on chipping away at abortion rights and limiting access to the procedure by any means possible. Such efforts have mostly resulted in unfairly limiting the reproductive rights of vulnerable groups of women rather than reducing abortion rates in the population as a whole. Historically, white women of middle- to upper-class means have enjoyed the highest levels of reproductive autonomy, even before modern abortion procedures were deemed legally accessible, which is still the case today. Prior to abor- tion’s being decriminalized in the U.S., well-to-do women could seek safe abortions through private physicians or by traveling abroad to developed nations where abortion was safe and legal (National Abortion Federation, 2009a). Conversely, more economically disenfranchised women seeking ac- cess to abortion were subjected to illegal and unsafe procedures or forced into childbearing against their will (National Abortion Federation, 2009b). Unfortunately, modern disparities in reproductive rights related to abortion access are similar to the disparities that existed before the modern legalization of abortion.

In principle, all women in the U.S. gained equal access to abortion ser- vices with the 1973 Supreme Court decision (Harper et al., 2005). However, despite residing in the land of the free, where the constitution provides equality for all citizens, different groups of women enjoy vastly different levels of reproductive rights based on factors beyond their control, such as economic class, race, and age. Such differentials are created through the passage and enforcement of public policy aimed at regulating abor- tion while violating separation of church and state. This creates a two- tiered system of abortion access for women in the U.S. Women who fall into the ‘‘upper tier’’ enjoy higher levels of reproductive autonomy in the area of abortion rights, as policy efforts such as mandatory counseling and mandatory waiting periods create more of an inconvenience for this group than an undue burden. Women falling into the ‘‘lower tier’’ are subjected to limited and sometimes nonexistent reproductive autonomy in the area of abortion rights, as repressive abortion policy creates serious undue burdens for women in these groups by limiting physical access to the services, by making the costs of services prohibitive, and by creating a social stigma surrounding abortion that challenges the self-trust and overall trust (McLeod, 2002) that women must have to confidently exercise sound reproductive choices.

Abortion Policy 661

ABORTION AND VULNERABLE GROUPS OF WOMEN

Adolescents younger than age 18 experience difficulty in accessing abor- tion owing to prohibitive costs and legal restrictions resulting from parental involvement laws (American Civil Liberties Union, 2001). As approximately 80% of counties in the U.S. have no abortion provider (Finer & Henshaw, 2003), women living in rural communities are significantly less likely than women in urban areas to have direct access to family planning services that include abortion. Women with incomes below 200% of the poverty level find themselves at a great disadvantage when it comes to accessing and affording both family planning and abortion services (Jones, Darroch, & Henshaw, 2002). Women of color are also among the groups of adult women who are most harmed by the politicization of abortion policy (Fried, 2006), as they reportedly access abortion services at higher rates than other groups of women, yet often face multiple problems related to access to reproductive freedom, such as poverty and other economic disadvantages. Owing to the limited access these women particularly have to abortion, the reproductive freedom and human rights of women who fall into one, or more, of these categories are severely threatened.

Adolescent Women

Fifty percent of adolescent women in the U.S. have intercourse by age 17 (Center for Reproductive Rights, 2004), yet do not have the autonomy under the law to access abortion services in response to unwanted pregnancy often associated with adolescent involvement in sexual activity. Adolescent women are engaging in the same sexual intercourse as adult women, frequently with adult men older than the age of 18. Furthermore, the legal age for consenting to sexual activity in most states is actually lower than the age of adulthood. For example, in Kentucky, the state law dictates that the age of consent to sexual activity is set at 16, whereas a person in this same state is not a legal adult until age 18 (Governor’s Office of Child Abuse and Domestic Violence, 2009). This creates a legal conundrum in which a young woman at age 16 can legally consent to sexual intercourse but cannot give her informed consent for abortion without parental permission should an unwanted pregnancy occur. Despite the fact that the same type of activity creates identical needs for abortion access in women both below and above age 18, one group of women has legal autonomy to access abortion services while the other group does not. Such disparity of access to abortion could detrimentally alter an adolescent’s life course. This disparity is allowed to occur even though our society is doing little to provide effective, evidence-based sex education designed to prevent the need for abortion in the first place. Young women are among the vulnerable groups most harmed by current conservative policy efforts to limit access to abortion (Fried, 2006).

662 G. E. Ely and C. N. Dulmus

It can be argued that lack of life experience, lack of sex education, and lack of knowledge about one’s body contribute to adolescent women’s being especially vulnerable to the negative effects of early sexual activity. The most obvious of these effects is unwanted pregnancy. The unintended pregnancy rate in 2001 was 104 per 1,000 women ages 15 to 44, which represents about 5% of women having experienced an unplanned pregnancy in 2001; almost half (48%) of these pregnancies ended in abortion, and the highest rates of unplanned pregnancies occurred among women aged 19 and younger (Finer & Henshaw, 2006). Adult women have three legal options to choose in regard to resolving unwanted pregnancy: giving birth and raising the child, giving birth and placing the child for adoption, and abortion. They do not have to involve another person when making any of these three choices. However, adolescent women are not granted the autonomy necessary to choose from all three of these options in most states. Though adolescents do not need parental permission to engage in sexual intercourse, become pregnant unintentionally, give birth to a child, parent a child or place a child for adoption, they often need parental permission to terminate an unwanted pregnancy.

In the U.S., 32 states currently restrict adolescent access to abortion through parental involvement laws that either require permission for an abortion from one or both parents or require that one or both parents be informed prior to an adolescent’s having an abortion (Adler, Ozer, & Tschann, 2003). All except four of the states with parental involvement laws allow for a judicial bypass of parental involvement (Adler et al.). Judicial bypasses can be requested if adolescents can prove that they are capable of giving their own informed consent and that requesting parental involvement would put them at risk for problems such as physical violence or being forced from their homes (Adler et al.; Boonstra & Nash, 2000). In theory, this option is available to offset the limitations of parental involvement laws, yet there is no guarantee that a judge will grant judicial bypasses, as hearings may not be scheduled in a timely manner, and family court judges hearing these cases may not be supportive of abortion. The delay created for an adolescent seeking a judicial bypass for her abortion naturally leads to a delay in being able to get the abortion, thus resulting in later-term abortions. This is problematic because earlier-term abortions are less costly and less risky and involve less fetal development (Harper et al., 2005; National Abortion Federation, 2009).

Laws requiring the involvement of a third party in an abortion decision have been denounced for their potential to negatively affect health and infringe on the human rights of women (Cook et al., 1999). Many national professional organizations that provide social and medical services to ado- lescents take a stand against parental involvement laws related to adolescent abortion. For example, The National Association of Social Workers (NASW) and the American Psychological Association (APA) do not support parental

Abortion Policy 663

involvement policies related to adolescent access to abortion (Adler et al., 2003; National Association of Social Workers [NASW], 2006). Furthermore, in a survey of 668 physician members of the Society of Adolescent Medicine, 96% reported that abortion should be available for pregnant adolescents in at least some circumstances, and 69% supported that abortion should be an option for adolescents in all circumstances (Miller, Miller, & Koenigs, 1998).

Vulnerable Groups of Adult Women

Early and unwanted childbearing accounts for a significant amount of illness experienced by women, especially lower-income women (Global Health Council, 2009; United Nations, 1995). Despite evidence that most Americans favor access to safe and legal abortion services, low-income women, rural women, and women of color often have virtually no access to abortion services in the U.S. (Montanez, 1998). Lower-income women experience more unplanned pregnancies, likely owing to limited access to and knowl- edge of contraceptive options; thus, they tend to have more abortions when compared to women of higher incomes (Harper et al., 2005). In 2000, the rate of abortion for lower-income women was 44 per 1,000, an increase in rates from 1990, compared to 10 per 1,000 in high-income women, a decrease in rates from 1990 (Harper et al.). Because of the need for abortion services experienced by lower-income women and the economic and social burdens that result from childbearing in less than idea economic situations, it is essential that access to abortion be increased and maintained. Women who want to choose abortion but who experience burdens regarding access may end up carrying pregnancies to term against their will.

African American women experience the highest rate of unplanned pregnancy compared with other racial groups, with the rates of abortion at 49 per 1,000 for African American women, 33 per 1,000 for Latinas, 31 per 1,000 for Asian women, and 13 per 1,000 for white women (Harper et al., 2005). An in-depth analysis of reproductive rights and health in South Carolina and Florida indicates that access to abortion is limited most severely for African American and Hispanic women in those states, although poor access to abortion for all women in those states was also reported (McGovern, 2007).

Abortion is least likely to be available in rural areas. Because of a decline in the availability of abortion physicians and an increase in illegal policies that create undue operating barriers for clinics, 87% of U.S. counties had no abortion provider in 2000, despite that more than one-third of the population of women ages 15 to 44 lived in these counties (Finer & Henshaw, 2003; Harper et al., 2005). Approximately one-fourth of women seeking abortion services travel a distance of 50 miles or more to access the service (Harper et al.; Henshaw & Finer, 2003). Results from one study indicate that women living in rural areas in Washington State almost universally had to travel

664 G. E. Ely and C. N. Dulmus

outside their home counties to access abortion services, resulting in later- term abortions with greater risks to the health of the women (Dobie et. al., 1999). Results from this study also reveal a decrease in abortion rates in rural areas, suggesting that lack of access to providers contributes to women’s carrying pregnancies to term that they might otherwise choose to terminate.

Many vulnerable women fall into more than one of the vulnerable groups mentioned earlier, thus further decreasing their access to abortion services. For example, women of color and women living in rural areas are also often women with economic disadvantages. The more burdens experienced by these vulnerable groups of women related to their ability to access abortion services, the more likely that they will end up hav- ing no reproductive autonomy at all, leaving them with childbearing as their only reproductive choice. Forced childbearing has documented neg- ative effects on both mothers and children (David, 2006; Russo, Horn & Schwartz, 1992) and is certainly not consistent with human rights afforded other groups of people both in the U.S. and other parts of the industrialized world.

REPRESSIVE POLICIES IN THREE AREAS

Illegal policies that attack access to abortion result in undue burdens to accessing services and adversely affect the aforementioned groups of women who are already vulnerable to other types of social and economic oppression (Fried, 2006; Harper et al., 2005; McGovern, 2007). Policies in the following three areas particularly impede access to abortion for all women but acutely affect women in the vulnerable groups mentioned earlier.

Insurance Coverage and Medicaid Restrictions

One who chooses an abortion almost always has to pay for it out of pocket, as most states do not allow for public funding, Medicaid support, or even private insurance coverage for elective abortions, so the high cost of abortion services alone severely limits access for vulnerable groups of women (Harper et al., 2005; Montanez, 1998). States such as Kentucky do not allow Medi- caid coverage of elective abortion and also will not allow private insurance to cover the procedure (National Abortion Federation, 2009b). The Hyde Amendment of 1977 mandates that state Medicaid programs cannot cover elective abortion services, although it requires coverage in cases of threat to the life of the mother, rape, and incest. Currently, all states are in compliance with Hyde Amendment regulations, sometimes owing to court order, except South Dakota, which has illegally skirted these requirements altogether and now allows Medicaid coverage for abortions only in cases wherein the

Abortion Policy 665

life of the mother in endangered (Center for Reproductive Rights, 2004; Harper et al., 2005; National Abortion Federation, 2009b). What is rarely discussed is that one usually must file a police report to be eligible for coverage for rape or incest, a process that many victims do not have the stamina to proceed through, as paperwork is burdensome and rehashing the crimes can be humiliating and debilitating. Even after taking time to file these labor-intensive reports, coverage for abortion under Medicaid is almost always denied (Poggi, 2005). It is also difficult for physicians to diagnose with certainty that a condition endangers the life of the mother in absolute terms, as medical science is not exact, and many women are told such things as they ‘‘might’’ be at risk. Thus, requirements for Medicaid funding are not met, and vulnerable women are left having to pay out of pocket for a prohibitively expensive procedure that they need for physical or emotional health reasons. Evidence suggests that poor women often pay for abortions with money that was supposed to be used for food or rent; they have trouble getting money together, resulting in later-term and more costly abortions; or they cannot afford the abortion and are left only with the option of forced pregnancy (Henshaw et al., 2009; Henshaw & Finer, 2003). Estimates indicate that as many as one of three women on Medicaid would choose abortion if coverage were provided but instead continue a pregnancy to term against their will, as they feel it is their only choice (Henshaw et. al., 2009; Henshaw & Finer). Such restrictions illegally create undue burdens for women seeking abortion for health-related reasons and for victims seeking abortions, and they produce unwanted children.

Mandatory Waiting Periods

Mandatory waiting periods create economic burdens for poor and rural women and implicitly question whether women can be trusted or trust themselves to decide how to resolve an unwanted pregnancy. Thirty-three states require that a woman must receive counseling before an abortion can be performed (Guttmacher Institute, 2009) despite the lack of empirical evidence that such counseling is necessary or beneficial to potential patients. Twenty-four states require up to a 24-hour waiting period between pre- abortion counseling and being able to access the procedure, and seven states require that the counseling be in person and take place before the official waiting period begins, thus creating a need for at least two trips to the clinic before the procedure can be accessed (Guttmacher Institute). These requirements undermine the decision-making capacities of pregnant women and create undue burdens for rural women who must travel long distances to seek services and then must either spend money to stay overnight during the waiting period or spend money to travel to and from the clinic twice for the same purpose (Guttmacher Institute).

666 G. E. Ely and C. N. Dulmus

Mandatory State-Scripted Counseling

Closely related to mandatory waiting periods are policies requiring manda- tory state-scripted counseling. Mandated counseling can be understood as part of a larger societal and political climate that seeks to punish women who get abortions and take away their confidence in their moral ability to know the best means by which to control the size of their families (Ely, 2007). Thirty-two states require that counseling take place before an abortion can be performed (Guttmacher Institute, 2009). Such legislation has created undue burdens for both patients and service providers (Henshaw, 1995). Almost all states direct that women be given specific scripted information, with 23 states requiring that the state health agency, not the clinic where services are actually obtained, develop the materials (Guttmacher Institute). Such materials are often designed to discourage abortion and sometimes include pictures of fetuses at various stages of development, information about the unsubstantiated link between abortion and breast cancer, infor- mation that the fetus feels pain (unsubstantiated) along with the option of administering anesthesia to the fetus, and information on the unsubstantiated psychological effects of abortion (Guttmacher Institute). In an analysis of state abortion counseling laws, Richardson and Nash (2006) found that state counseling laws disregard the basic principles of informed consent in favor of a politicized antiabortion goal, and counselors are often required to distribute misleading information and materials. Moreover, though it is required that this information be communicated before the procedure can be performed, the antiabortion agenda of the state law does not have to be disclosed, the laws disregard the well-being of the patient in favor of antiabortion political goals, the laws are punitive and demeaning to women, and such laws undermine self-trust as they create and sustain the negative stigma associated with abortion (Richardson & Nash).

IMPLICATIONS

Forced pregnancy can be described as a state of denial of abortion services when pregnancy termination is desired (Cook et al., 1999). Reproductive freedom cannot exist in a society wherein forced pregnancy is not only allowed to occur but is promoted by biased, unjust, or illegal social policy. Universal access to safe, legal elective abortion services regardless of age or socioeconomic status all but eliminates the possibility of forced pregnancy. Practices of forced pregnancy are discriminatory based on gender, as there is no other case wherein a parent is forced to provide their bodily resources, such as bone marrow or organ donation, to serve a born child (Cook et al.). Parental involvement laws that limit adolescent access to abortion can result in cases of forced pregnancy. Even judicial bypass laws do not ensure

Abortion Policy 667

that forced pregnancies do not occur. Lack of access to public funding for abortion makes abortion unaffordable for many women who would other- wise resolve their unwanted pregnancies via termination, thus resulting in forced pregnancy. Mandatory waiting periods create burdens for women by requiring multiple trips to the clinic that often make the abortion financially unobtainable, also resulting in forced pregnancies. Both mandatory waiting periods and mandatory counseling laws push a pro-birth agenda and are designed so that women will question their trust in their own decision- making capacity, thus resulting in some women’s carrying pregnancies to term that they would have chosen to terminate if given access to abortion services. Forced pregnancy is a condition associated with theocratic and dictatorial governments in countries where women lack access to social equality. However, such practices are not in line with American values of freedom and self-determination, and the end results of forced pregnancy are not beneficial to vulnerable women, to children, or to our society as a whole.

The policies mentioned earlier take away the autonomy of vulnerable groups of women, thereby creating a two-tiered system of access to repro- ductive health in which women who are not members of these vulnerable groups have more freedom to resolve unwanted pregnancies than do women who are members of the vulnerable groups. These policies are allowed to flourish because they are not being met with the resistance required to impede their implementation. It is critical that the social work profession take the lead in policy practice that targets the repeal and elimination of the repressive policies mentioned heretofore.

RECOMMENDATIONS FOR SOCIAL WORK

POLICY PRACTICE

Social work is a profession with a historical commitment to advocacy that is not paralleled by any other profession (Reamer, 1991; Lundy & van Wormer, 2007; Van Voorhis & Hostetter, 2006). Repeal of regressive reproductive health policies can be accomplished through social workers engaged in competent policy practice, yet professional interest in advocacy related to this topic is not prevalent in the social work field. Because social justice is the foundation of the social work profession (Weiss, Gal, & Katan, 2006), social workers in all areas of practice should be concerned with these issues, regardless

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.