In 1967, a group of clergy in New York City founded the Clergy Consultation Service on Abortion (CCS) to “bring light and hope to the thousands of people who suffer — usually in quiet, and sometimes in death — the miseries and heartbreak of backstreet abortions.” In an era of back-alley butchers, prohibitively high-priced abortions from skilled physicians, and limited legal access to abortions at hospitals, the CCS enabled women to obtain safe and comparatively inexpensive abortions from licensed doctors and skilled practitioners. Over six years, the CCS expanded across the United States and Canada and helped upward of a quarter-to half-a-million women obtain abortions.
The history of the CCS remains instructive and offers a useful counterpoint to Cara Delay’s recent essay on Nursing Clio. Delay suggests that the repeal of Roe would have little effect on women given the current state of restricted abortion access in the United States. She speculates about a new era of reproductive rights “that focuses on rethinking the medicalized model [of abortion]” and “giving women themselves control over the process.” And she asserts that we simply don’t know what happened to women who procured illegal abortions. However, a careful examination of the American history of illegal abortion and of current research on abortion access reveals a substantially different story about the past and present.
Let’s begin with the dangers of illegal abortion — what Delay calls the “backstreet butcher myth.” A wealth of historical knowledge about illegal abortion before Roe, including the rich records of the CCS, gives us a clear picture of the burdens incurred and complications experienced by women who sought abortions. In fact, women’s lack of access to skilled abortion providers, the financially prohibitive abortion market, and above all, the pervasive presence of unscrupulous providers — the backstreet butchers — who both exploited and endangered women motivated the CCS’ efforts.
The CCS evaluated abortion providers in the United States, Canada, Mexico, Puerto Rico, England, and Japan. They preserved voluminous correspondence with clients seeking abortions, including patients’ assessments of providers. And they kept their own client records based on ongoing pastoral care in over 500 locations across the United States. What’s more, the CCS maintained and updated “Negative Lists” to warn women away from dangerous abortionists. This practice was common to other groups including Association to Repeal Abortion Laws in California and Women’s Liberation Coalition of Michigan.
Thus while some abortion providers were fastidious in their work, a significant number were not, and doctors regularly provided secondary care to women injured or abandoned by negligent providers.1 Abortions performed in non-sterile spaces, via unorthodox methods, and by incompetent providers sent women to emergency rooms with septic shock, peritonitis, uncontrolled hemorrhaging, or perforated uteri. Encountering these dangerous outcomes propelled some doctors to risk their careers and covertly offer illegal — but safe — abortions.2
Despite these efforts, the scarcity of conscientious providers endured. Even with abortion referral groups like the CCS successfully pressuring hospitals to provide abortions in some major cities and creating travel routes to channel women to safe providers, the number of known, reliable doctors remained small. The game changer was legalization. When England legalized abortion in 1967, it spurred an international medical migration to London. The cost of abortion dropped on both sides of the Atlantic. With the repeal of abortion laws in New York in 1970, prices for abortions fell further while the number of physician-providers increased dramatically.
Legalization resolved the problem of medical scarcity in the short term. However, as with American healthcare writ large, wealth continued to enable access while poverty limited it. The continued scarcity partly derives from the earliest battles over access post-Roe: Medicaid and Medicare coverage of abortion.
Since Roe, abortion opponents have deployed a “whittle away” strategy — using courtroom contests, legislative instruments, and clinic protests — to erode and obstruct abortion access. Since Planned Parenthood v. Casey (1992), abortion restrictions have proliferated at the state level — ranging from waiting periods, mandatory misleading counseling, prohibiting certain procedures, and ambulatory clinic requirements. One CCS leader, characterized these legislative efforts as the hallmark of “real medical and ethical indifference to the needs of thousands of American women who…will once again fall victim to those back alley butchers.”
We agree with Delay that first trimester abortion services, which have been curtailed by a number of factors including the medical establishment and anti-abortion forces, could be more accessible. A 1971 CCS study of 100,000 abortions reported, “in the area of professional competence, we have found medical success more correlative with experience than with institutional training, prestige, or specialty certification.” Thus the report concluded, “medical competence in abortion performance may be achieved through proper training of allied health specialists.”
Current research bolsters the CCS’ historical assessment: knowledgeable clinicians are the best indicator of safe abortion care. A recent California study demonstrated no difference in clinical outcomes between aspiration abortions provided by physicians, nurse practitioners, certified nurse midwives, and physician assistants, thus providing the data to support expanding abortion access by widening the provider population. And with the development of Mifeprex and thus medical rather than surgical abortion, there are greater options for safe abortions, including the use of telemedicine to connect patients to more distant providers. A spate of studies documented the safety of Mifeprex, leading to a recent call to “unburden Mifeprex” by enabling dispensation at pharmacies and eliminating the clinician certification process.
Notably, all of these possibilities — medical abortion, broader ranges of providers, new methods of provision — have occurred within the context of legal abortion and the infrastructure of the regulatory state. Legalization is the condition of possibility for these innovations, and the repeal of Roe would indeed have profound consequences for each. Data and experiences from state-level efforts to restrict abortion access underscore the difficulties and dangers women face when abortion access is severely curtailed.
In Indiana, Vice President Mike Pence’s home state, the main effect of such laws has shifted the location and timeline of abortions: women travel out-of-state and undergo later, more expensive, and potentially more complicated abortions. A study by the Center for Reproductive Rights predicts that should Roe be repealed, 37 million women in 33 states would be in jeopardy of losing abortion access, thereby exacerbating an already existent medical crisis.
At a moment when the already precarious access to abortion is threatened, trying to find a less dismal view of the past, present, and future of American reproductive rights access is understandable. But before we celebrate alternative healthcare schemas, we’d be wise to heed Justice Ruth Bader Ginsberg’s warning from Whole Woman’s Health (2016). Ginsberg noted that, “when a State severely limits access to safe and legal procedures, women in desperate circumstances may resort to unlicensed rogue practitioners, faute de mieux, at great risk to their health and safety.” Ginsburg’s concern reflects a harsh reality. A 2016 qualitative study of women who had sought abortions in Texas showed that about 7 percent (compared to 2 percent nationwide) tried to self-induce abortion because of prohibitive financial costs and distance to providers. Interviews with 18 of these women revealed that, relying on friends or the internet, they used the natural remedies or contraband medicine from Mexico to self-induce abortion. Those using natural supplements failed, as did three women who used pills.
However, almost half of the women interviewed reported successful abortions via illicitly procured pharmaceuticals. Yet even this success had costs: in addition to needing the means to acquire the drugs, many found the experience disconcerting because they did not know if their symptoms were normal, if they had succeeded, or if they could disclose their actions to their physicians without legal or emotional repercussions. These interviews underscore that clandestine abortion access enhances neither autonomy nor empowerment; rather, it fuels exploitation and fear.
Together, history and current research show that a shadow, unregulated system of abortion provision cannot safely substitute for legally-protected reproductive rights or effectively improve women’s healthcare. Giving women “control over the process” does not mean removing abortion from the world of medicine. Autonomy and choice don’t mean encouraging women to self-induce abortion. Shared decision-making between patients and licensed healthcare professionals enables women to fully consider their options and make decisions that reflect their particular values — a process that stands on a legal foundation.
- Carol Joffe, Doctors of Conscience: The Struggle to Provide Abortion Before and After Roe v. Wade (Boston: Beacon Press, 1995). Return to text.
- Joffe, 53-69. Leslie Reagan, When Abortion was a Crime: Women, Medicine, and the Law in the United States, 1867-1973 (Berkeley: University of California Press, 1998). Joffe and Reagan both document the serious complications, including death, women experienced at the hands of unsafe, illegal abortion providers, and the ways these encounters mobilized doctors to provide safe abortions and advocate for legalization. Both also highlight how disruptive police surveillance and interrogations were to patient care. Return to text.