U.S. abortion policy since Roe v. Wade

After noting in its introduction that in Roe vs. Wade the US Supreme Court federalized (rather than nationalized) abortion policy with the result that states were given parameters in which they could develop their own abortion policies, this article reviews subsequent Supreme Court decisions about abortion from Doe vs. Bolton in 1973 through Bray vs. Alexandria Women's Health Clinic in 1993. The narrative review is illustrated by a table which indicates year, ruling, case name, and major findings for each of the 23 cases. The review reveals that the parameters set for states by the Supreme Court have been subject to change and reversal as the composition of the Court has changed. The Court has also given states wide discretion in the area of paying for abortions for women who are eligible for Medicaid with the result that 30 states provide no abortion funding unless a Medicaid patient's life is endangered by the pregnancy. The Supreme Court rulings have also allowed states to develop widely differing policies about parental consent/notification before a minor can obtain an abortion. Of the 35 states with parental consent notification laws on their books, only 15 actually enforce them. Other state restrictions include the requirement for the performance of specified tests before an abortion can occur, a prohibition on the use of public facilities for abortions, and a prohibition on public employees participating in the performance of an abortion. State activity in the realm of abortion legislation is expected to continue as an outcome of the Webster and Casey decisions, but with the election of President Clinton, more abortion policy developments are expected to take place on the federal level. These include repeal of the "gag rule" which banned abortion counseling in federally-supported family planning clinics, passage of the Freedom of Choice Act (stuck in committee in 1992) to codify the rulings in Roe vs. Wade, passage of the Freedom of Access to Clinic Entrances Act, provision of additional Medicaid funding for abortions, and the introduction of RU-486 for medically induced abortions. Changes in the Court composition as a result of Clinton-appointed Supreme Court justices will also lead to changes in policy development.     

Provider "conscience" questions re-emerge in wake of managed care's explosion

This review of conscience-clause legislation opens by noting that in the first years after the US Supreme Court issued its decisions that protected abortion rights, more than half of the states and the federal government adopted provisions permitting individuals and some medical facilities to invoke religious, ethical, or moral objections as a reason to decline to perform certain procedures. After a period of dormancy, 4 states considered conscience clauses in 1997, with 2 of these adopting provisions. While the emergence of managed care conglomerates, some of which merged religious and secular institutions, raises new questions about this issue, the fact that informed consent requires that a patient understand all treatment options has not changed. Abortion-related laws are on the books in 42 states that have conscience clauses covering individuals and facilities, and 4 states with clauses covering only individuals. A table illustrates whether specific state laws covering individuals apply to participation and/or information dissemination, are limited to religious/moral objections, and/or require notification; and whether other state laws apply to all or only private facilities, to participation and/or information provision, and/or require notification. Legislation applying to contraceptive service and/or information provision is on the books in 13 states and applies to individuals in 5 states, public employees in 7, and medical facilities in 6. Sterilization-specific laws exist in 11 states, 10 of which have statutes applying to individuals and 10 to facilities. A table illustrates the range of legislation covering contraceptive services and sterilization. The review ends by analyzing which state laws cover managed care explicitly or implicitly and by noting the reemergence of conscience-clause issues on the federal level.     

Coverage of abortion controversial in both public and private plans

During 1995-96, 17 of 50 US states used their own resources, either voluntarily or under state court order, to pay for all or most abortions for low-income women. Alaska, Maryland, New York, and Washington are the only states to voluntarily pay for these abortions. Anti-choice legislators in California, Illinois, New York, and West Virginia tried unsuccessfully to cut funding for these abortions. Arkansas is the only state to circumvent direct payment for abortions for low-income women. Alabama, Mississippi, and South Dakota still are not complying with the court order but remain in the Medicaid program. Massachusetts has passed legislation to allow health insurance to cover abortions for state and city employees, thereby undoing a 17-year ban on the use of public funds for abortions for employees or their spouses. On the other hand, Virginia's governor has unilaterally, via an executive order, eliminated health insurance coverage for most abortions for state employees and their dependents. Anti-choice legislators have shepherded legislation that prohibit private insurance coverage for abortion unless women pay an extra premium in Idaho, Kentucky, Missouri, and North Dakota. Legislators in Illinois and Minnesota have passed state subsidized health care reform programs that exclude abortion from coverage except when the mother's life is endangered. There appears to be a loophole in the MinnesotaCare program that allows women to obtain state-financed abortions for other reasons, so antifunding lawmakers will introduce a bill in 1997 to close the loophole. The loophole is a result of a conflict between state and federal laws as a result of a 1995 federal waiver granted to Minnesota. The waiver allows pregnant women who earn up to 275% of the federal poverty level to be eligible for either MinnesotaCare or Medicaid. Abortion-rights legislators find MinnesotaCare's exclusion of abortion coverage to be a violation of the court order. They plan to submit a bill in 1997 to repeal this prohibition.     

Efforts underway to impose harsh regulations on abortion providers

Legislators or regulators in Mississippi, South Carolina, and Missouri have imposed burdensome and unnecessary clinic requirements on abortion providers. In each case, the legislators or regulators designed the requirements to make abortions more difficult to obtain. Mississippi, a state with only two licensed abortion clinics, already had restrictive abortion laws. In August 1996, it implemented stringent regulations on private physicians who provide abortion services in their offices. Some requirements include purchasing specific equipment, widening hallways, and hiring more staff. Several physicians have filed a lawsuit to stop enforcement of the regulations because they make the provision of abortion services so cumbersome and expensive as to discourage physicians from offering abortions. Antiabortion groups testified before the legislature that the Department of Health had been negligent in monitoring private practices for compliance with Mississippi's many abortion laws, particularly counseling requirements. The Republican governor signed the legislation in March 1996. In July 1996, a federal judge prohibited the South Carolina Department of Health from enforcing a new regulation making physicians who perform as few as five abortions a month to meet strict specifications for their office (e.g., disclosure of patient records and medical agreements). The regulation was a response to a 1995 law targeting private physicians who perform abortions in their offices. The judge held that the substantial changes in terms of privacy and expense could bring an undue burden on women seeking abortions. The state denied that the regulation would close clinics or would increase costs so much as to make abortions inaccessible. In September 1996, the House did not override the Democratic governor's veto of a bill that would have required all facilities where abortions are done to be licensed and undergo annual inspections and that would have required all physicians to have $500,000 in medical malpractice insurance and to have ob/gyn privileges at a Missouri hospital.     

Maternal mortality,abortion access,and optimizing care in an increasingly restrictive United States: A review of the current climate

The United States is facing a national crisis related to increasing rates of maternal morbidity and mortality. Over the past few years, significant focus has been turned to initiatives that aim to address maternal morbidity and mortality rates. In parallel, the United States has seen a significant increase in restrictive abortion access state laws. The link between abortion restrictions and worsening maternal outcomes has been proposed. This review article outlines the national crisis of maternal morbidity and mortality, the potential role of limiting abortion access in this crisis, and the significant racial, socioeconomic, and geographical disparities that exist.     

Avoiding legal pitfalls in surrogacy arrangements

The goal of this article is to discuss the legal pitfalls that reproductive endocrinologists face when participating in gestational surrogacy contracts. This paper was composed using Westlaw and LexisNexis commercial legal search engines to perform a review of statutes and cases pertaining to gestational surrogacy. The search results demonstrated that in the absence of suitable preparation, there is significant potential for litigation while participating in gestational agreements. Providers caring for gestational carriers have been named as parties in lawsuits for failure to provide psychological screening, failure to screen for infectious disease and participation in gestational contracts that are not compliant with state law. There is great disparity in state laws and court rulings pertaining to gestational agreements. When legal disputes arise, individual state laws and court rulings are controlling over the Uniform Parentage Act. Likewise, recommendations by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine do not supersede state laws. The failure to abide by individual state laws unnecessarily exposes reproductive endocrinologists and their IVF facilities to potential litigation. In order to lessen exposure to litigation, an understanding of individual state legislation or historical court rulings is advised.     

Health care reform: will quality remodeling affect obstetrician-gynecologists in addition to patients?

The Patient Protection and Affordable Care Act is a federal statute that attempts to address many fundamental problems with the current health care system including the uninsured, rising health care costs, and quality care. Quality metrics have been in development for years (by private and governmental sectors), and momentum is growing. The purpose of this commentary is to explore quality changes in the way practicing obstetricians and gynecologists will be held accountable for quality service. Two new options being explored for health care, both focusing on improving quality and physician metrics, include value-based purchasing and accountable-care organizations. Both will likely consist of universal clinical algorithms and cost monitoring as measures. For obstetrics this will probably include physician's rates of cesarean deliveries and elective inductions. For gynecology this may comprise of indications for hysterectomy with documented failed medical management, minor surgical management, or both medical and minor surgical management. It is anticipated patients will no longer be able to request obstetric testing, pregnancy induction, or hysterectomy. It is imperative we, as obstetrician-gynecologists, are involved in health care reform that inevitably involves the care of women. The expectation is that the American Congress of Obstetricians and Gynecologists (ACOG) will further develop evidenced-based opinions and guidelines, as medical communities embrace ACOG documents and reference these in hospital policies and peer review.     

Legal aspects of abortion practice

Focusing on the legal aspects of abortion, this chapter considers the development of constitutional law on the right to abortion, rights for adults and minors, conscience clauses, and abortion and malpractice issues. In 1973 the US Supreme Court in the cases of Roe v. Wade held that the right of privacy grounded in the concept of personal liberty guaranteed by the 9th and 14th amendment to the US Constitution included a woman's right to decide whether or not to have an abortion. The cases held unconstitutional any statute that prohibited abortion and statutes that imposed such stringent requirements on abortion as to make abortion unavailable. The Court recognized the state's interest in protecting maternal health and preserving the life of the fetus but said that a woman's right to privacy was a paramount fundamental right and could be interfered with only if the state could show a compelling interest. The Court analyzed the right to abortion based on different stages of pregnancy. During the 1st trimester, a woman has a virtually unfettered right to have an abortion free from interference by state or federal government; the decision is between the woman and her physician. Due to the fact that abortions during the 2nd trimester are more dangerous to the health of the mother, the state can regulate the abortion procedure so long as the regulations are limited to preservation and protection of maternal health. Thus, the state can establish licensing requirements for facilities in which the procedure is to be performed as well as requirements concerning reporting and record keeping. During the 3rd trimester, the viability of the fetus allows the state's compelling interest in the protection of fetal life to be dominant over the mother's right to privacy. During this trimester, the state may, but is not required to, proscribe abortion except where necessary to preserve the life or health of the mother. During the 1973-83 period, numerous attempts were made to chip away at the Court's ruling. Most frequent efforts were to pass state statutes making it unreasonably difficult to obtain an abortion. A basic legal rule for medical practice is that a procedure cannot occur without first obtaining consent from the patient, and to obtain informed consent, the patient must be told of the risks, benefits, and alternatives to any procedure. The Supreme Court has stated that not all consent requirements for minors would be unconstitutional. Although parents cannot have an absolute veto power over their child's abortion decision, state statutes requiring parental notification are valid. The Court has held that spousal consent is unconstitutional since the right of privacy is specific to the pregnant woman. The Court has made it clear that the right to an abortion does not imply the duty of the state or federal government to pay for abortion for indigent women. In the summer of 1983 the Supreme Court decided a trilogy of cases involving the regulation of abortion by state and local governmental units. The Supreme Court imposed some limitations on abortion but upheld the Roe case.     

ABORTION 1980: Battleground for Reproductive Rights

Our country is in turmoil over the question of abortion. The growing anti-abortion, Right To Life movement views the fetus as a person from the moment of conception, and regards abortion as murder. This movement has caused the cut-off of all federal and most state funding for abortions. Their goal is to make all abortion illegal in the United States. The abortion rights or Pro-Choice movement sees the decision of whether to have an abortion as a democratic right which must not be controlled by the state, church, or a political party. The Pro-Choice movement is organizing to keep abortion safe and legal. This article presents a history of abortion and an update on abortion legislation and the current situation. It analyzes the contended forces, and develops an overall context in which to view the struggle. Nurse-midwives are urged to take a strong stand in favor of abortion rights.     

Stigmatisation and commercialisation of abortion services in Poland: turning sin into gold

This paper is about the economic consequences of the stigmatisation and illegality of abortion and its almost complete removal from public health services in Poland since the late 1980s. Once abortion left the public sphere, it entered the grey zone of private arrangements, in which a woman's private worries became someone else's private gain, and her sin turned into gold. The most important consequence was social inequality, as the right to health, life, information and safety became commodities on the free market. Women with money, who are more likely to have political influence, find this bearable, while working class women lack the political capital to protest. In the private sector, there are no government controls on price, quality of care or accountability, and almost no prosecutions. With an estimated 150,000 abortions per year, a rough estimate of US$ 95 million is being generated annually for doctors, unregistered and tax-free. Thus, the combined forces of right-wing ideology and neoliberal economic reforms have created reproductive and social injustice. To address this, stigmatisation of abortion must be countered. But a change in the political climate, a less restrictive interpretation of the law, or even a new law would not resolve the problem. Given reductions in public health care spending, abortion would remain excluded from state coverage unless neoliberal health care reforms could be reversed.     

A review of therapeutic abortions and related areas of concern in Canada

ObjectiveTo review the legal status of abortion and its prevalence, safety, and accessibility in Canada and to highlight related areas of concern.MethodsWe conducted a review of research literature, published reports, websites, and articles in order to describe abortion services and associated issues such as access, availability, and safety in Canada.ResultsTherapeutic abortion is often the result of unintended pregnancy. Even so, emergency contraception may not be accessible for all Canadian women, and effective contraception is underutilized. In Canada, abortion has been decriminalized and is generally safe, but current reports of prevalence and complication rates are inconsistent. Abortion rates appear to be decreasing. Medical or surgical termination of pregnancy is available and often publicly funded. However, barriers related to time, cost, travel, and regional disparities hamper unrestricted access to therapeutic abortion in this country, and although the place of abortion in medical education remains controversial, current curriculum content appears to be inadequate.ConclusionsThe Society of Obstetricians and Gynaecologists of Canada states that comprehensive family planning services, including therapeutic abortion, should be freely available to all. The Canadian Medical Association affirms that induced abortion should be uniformly available to all women. In Canada, the issues related to therapeutic abortion access, availability, and safety must be addressed.     

Abortion-related morbidity and mortality in Benin City, Nigeria: 1973-1985

In a 13-year review of maternal deaths at the University of Benin Teaching Hospital, Benin City, abortion was one of the three major causes of death, accounting for 37 (22.4%) out of the 165 deaths. Induced abortion was responsible for 34 (91.9%) of these deaths. The usual victim is the teenage, inexperienced school girl who has no ready access to contraceptive practice. Death was mainly due to sepsis (including tetanus), hemorrhage and trauma to vital organs, complications directly attributable to faulty techniques by unskilled abortion providers, a by-product of the present restrictive abortion laws. Total overhaul of maternal child health services and the family health education system, as well as integration of planned parenthood at primary health care level into the health care delivery system, are suggested. Contraceptive practice should be made available to all categories of women at risk, and the cost subsidised by governmental and institutional bodies. Where unwanted pregnancies occur, the authors advocate termination in appropriate health institutions where lethal and sometimes fatal complications are unlikely to occur. In effect, from the results of this study and a review of studies on abortion deaths in Nigeria and other developing countries, it is obvious that a revision of abortion laws as they operate, notably in the African continent, is overdue.     

Financing family planning services: is categorical legislation still needed?

Federal and state funds have provided for family planning services in American since the 1960s. Since 1976, services have been funded principally through federal statutes Title X of the Public Health Service Act and Titles V, XIX, and XX of the Social Security Act as well as various state appropriations. While these statutes aim to ensure that women of lower socioeconomic status enjoy access to reproductive health care services, levels of public expenditure in this area vary widely among states. In 1987, public family planning expenditures/woman at risk ranged from $60.16 in Wisconsin to $9.41 in Florida. Within this range of expenditures, the relative importance of each funding source per state varies widely. States with the most robust Title XIX programs, Medicaid, however, have highest per woman family planning expenditures. Upon reviewing the complement of public funding sources and how they are spent at the state level, the authors argue that categorical legislation is still needed to protect access to contraceptive services in America. In particular, of funds from supporting statues, Medicaid is distributed most equitable across the country. These funds paid for 36% of all public outlays for family planning in 1987. Without categorical legislation, however, Medicaid is insufficient to maintain the national family planning effort; the 1987 contribution of $10.49/woman at risk of unwanted pregnancy was insufficient to provide minimum services. Title X requires grantees to follow regulations which ensure state uniformity of quality and service distribution; submission of annual 5-year plans to Congress on how family planning goals will be achieved; and also authorizes monies for training and research. Despite political attacks, family planning funding must remain separate from maternal and child health programs. Such independence will keep these services politically visible; allow use of the more extensive family planning delivery system; catalyze states to spend other monies on family planning; and fuel innovations in service delivery, client education, and new contraceptive technologies. Title X should even be reauthorized under more precise mandates and include a national data collection system, consideration of the shortage of clinicians, and codification of 1981 guidelines reversed by the gag rule.     

米非司酮配伍米索前列醇行药物流产的安全性评价

目的　评价米非司酮配伍米索前列醇行药物流产的安全性。方法　检索国内外 9个医学数据库及 9种中文期刊。采用循证医学的方法对收集有关药物流产安全性研究的文献 ,进行质量评价和数据提取 ;对数据不能合并进行分析时 ,则行定性系统评价。结果　共收集、纳入文献 10 1篇 ,病例 136 4例。其中为药物严重不良反应 115例 ( 8 4 3% ) ,包括药物过敏性和失血性休克、药物中毒性心律失常、抽搐及胎儿畸形等 ;一般不良反应 10 15例 ( 74 4 1% ) ,包括异常出血和轻、中度过敏反应等。系统评价提示 ,药物流产后出血量过多、腹痛、发热和眩晕的发生率比手术流产高 ,相对危险度(RR)及 95 %可信限 (CI)范围分别为 3 2 7,1 14～ 9 38;1 6 3,1 14～ 2 34;1 5 8,1 0 3～ 2 4 4 ;和1 36 ,1 0 6～ 1 75。药物流产后的出血时间比手术流产长 ,加权均数差 (WMD)为 6 4 9,95 %CI为6 0 8～ 7 80。药物流产有并发症者 177例 ( 12 98% ) ,包括滋养细胞疾病、宫腔粘连和继发不孕。为异位妊娠而误用药物流产者 5 7例 ( 4 18% )。结论　药物流产的严重不良反应发生率较低 ,不影响药物流产的临床应用 ,但需要健全监测药物流产不良反应的制度 ;减少药物流产后出血 ,是需要进一步研究的课题     

‘And they kill me,only because I am a girl’…a review of sex-selective abortions in South Asia

The low social status of women and the preference for sons determine a high rate of sex-selective abortion or, more specifically, female feticide, in South Asian countries. Although each of them, irrespective of its abortion policy, strictly condemns sex-selective abortion, data suggest high rates of such procedures in India, Nepal, China and Bangladesh. This paper reviews the current situation of sex-selective abortion, the laws related to it and the factors contributing to its occurrence within these countries. Based on this review, it is concluded that sex selective abortion is a public health issue as it contributes to high maternal mortality. Abortion policies of South Asian countries vary greatly and this influences the frequency of reporting of cases. Several socio-economic factors are responsible for sex-selective abortion including gender discriminating cultural practices, irrational national population policies and unethical use of technology. Wide social change promoting women's status in society should be instituted whereby women are offered more opportunities for better health, education and economic participation through gender sensitive policies and programmes. A self-regulation of the practices in the medical profession and among communities must be achieved through behavioural change campaigns.     

Making Abortions Safe: A Matter of Good Public Health Policy and Practice

Globally, abortion mortality constitutes at least 13% of maternal mortality. Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high mortality and morbidity from abortion tend to occur together. Preventing abortion mortality and morbidity in countries where they remain high is a matter of good public health policy, based on good medical practice, and an important part of initiatives to make pregnancy safer. This paper examines the changes in policy and health service provision required to make abortions safe. It is based on a wide-ranging review of published and unpublished sources. In order to be effective, public health measures must take into account the reasons why women have abortions, the kind of abortion services required and at what stages of pregnancy, the types of abortion service providers needed, and training, cost and counselling issues. The transition from unsafe to safe abortions demands: changes at national policy level; abortion training for service providers; the provision of services at the appropriate primary level health service delivery points; and ensuring that women access these services instead of those of untrained providers. Public awareness that abortion services are available is a crucial element of this transition, particularly among adolescent and single women, who tend to have less access to reproductive health services generally.     

The Tunisian experience in legal abortion

In 1965, Tunisia became the first Moslem country to liberalize abortion laws. This paper is a review of Tunisia's experience and is, therefore, significant to other Moslem countries. The experience is also of interest to the developing world, as it demonstrates that such liberalization does not lead to excessive use or abuse of abortion, nor does it burden hospital services. The study shows, a first for a developing country, that liberalization of abortion can improve contraceptive practice.