Elevate Difference

Willing and Unable: Doctors' Constraints in Abortion Care

Ninety-three percent of all abortions are done in abortion clinics. Only three percent of non-metropolitan counties in the United States had an abortion provider in 2005, while thirty-one percent of metropolitan counties had at least one. After completing their residency, half of physicians who plan to perform abortions as part of their practice actually do so.

These startling facts prompted Lori Freedman to embark on the study summarized in Willing and Unable: Doctors' Constraints in Abortion Care. Freedman is a sociologist working for Advancing New Standards in Reproductive Health (ANSIRH), a collective of researchers and scholars at the University of California, San Francisco. Through this study, she “primarily wanted to find out what keeps physicians who feel positive about providing abortion from doing so.” She interviewed thirty ob-gyns—twenty-two women and eight men—who graduated between 1996-2001 from four residency programs in which abortion training is routine. The interviews, along with historical context and analysis, make up the core of the book.

While some may assume that doctors don’t “have the guts” to do abortions or are primarily afraid of violent retaliation—which is understandable given that eight abortion clinic workers and/or doctors have been murdered since 1993—the reasons are more complex and wide-ranging. The reasons Freedman uncovers include the managed care currently regulating doctors’ services, the stigma attached to being labeled an “abortionist,” the fact that abortions do not often result in a significant amount of revenue, the efficiency and quality of care provided by abortion clinics, and the extent to which physicians see providing abortion as a professional duty.

Willing and Unable begins with the introduction of Freedman’s research question and methods, establishes the various factors influencing physician autonomy, and provides context for the debate over abortion. Most notably, Freedman points out that the loss of fetal life is not, in fact, the most morally offensive element of abortion for those who rabidly oppose it—despite their propensity to wave around graphic pictures of aborted fetuses—since many support abortion in the cases of rape, incest, and fetal anomaly. Rather, the element of abortion that rankles many anti-choicers is “the notion that women can shirk the mother role. Deeply embedded in American society is the belief that women who have sex implicitly become obligated toward parenthood more so than men.” Therefore, any woman who avoids this responsibility is assumed to be irredeemably selfish.

From here, Freedman’s book covers a wide span of topics. The next five chapters trace the history of abortion care in U.S. medicine, the various ideological reasons why doctors are willing or not to provide abortions, the choices surrounding “learning, doing, and having abortions,” the various manifestation of the “institutionalized buck-passing of abortion care,” and the dynamics of miscarriage management within Catholic-owned institutions. The concluding chapter recaps Freedman’s main points and outlines ways to increase the number of abortion providers and integrate abortion into mainstream practice, both of which would lessen the stigma attached to abortion.

Freedman’s balance between analysis and physicians’ interviews is highly engaging. In chapter four, she teases apart the variety of choices involved in abortion care—not simply a woman’s choice to have an abortion or not—through the prism of Dr. Rina Anderson’s experience. After initially opting out of abortion training, Dr. Anderson chose to re-enter the program, then chose to perform abortions in private practice primarily in the case of fetal anomalies, and finally, chose to carry her own pregnancy to term despite the fact that her baby had a fatal condition and would die soon after birth. Dr. Anderson’s story is not only moving but also reveals the layers of choice involved in abortion care for both provider and patient, especially when they are one in the same.

While Freedman’s book explores a unique perspective within the abortion debate, I couldn’t help but want more—more interviews and information pertaining to a wider sampling of physicians. Perhaps I wanted more because what Freedman provides is so compelling. These are memorable portraits of physicians who find themselves confronted with the “choice” of either providing abortions or practicing obstetrics and gynecology, which—like the options available for many women faced with an unwanted pregnancy—isn’t much of a choice at all.

Written by: Dr. Jennifer A. Smith, August 21st 2010

This turned into a bit of a rant and I apologize for that-- but this is a great post, I'm really interested in reading the book, and I wanted to share some of my views and experience.

Indeed, the stigma with abortions and "pro-life" campaigns is never about babies and children. (If it was, these people would be doing something about the millions of children out there who don't have homes/are in abusive domestic situations/starving etc...no, it's clearly never about the children.) It's about taking away womens' rights and agency and as it was worded in this article, "shirking motherhood just makes you selfish." Okay, it's the "selfish" bit that really gets at me.

If someone personally doesn't want to have an abortion or feels it's wrong, and would rather become a mom spontaneously or give the child up for adoption, it's not my business. Not my body. But people shouldn't be telling others what to do with their bodies though unforutnately they do. I recently had a pregnancy scare that was VERY realistic-- not like the occasional lateness I had in my teens; I mean we're talking swollen breasts, constant nausea and vomiting, the works. Although I am fortunate to have good health coverage and live in NYC that has always been known for its liberal laws regarding abortion, I was incredibly scared and freaked out. the only thought that went through my head was, "I'm a graduate student with no income living in the ghetto. I am way too much of a space cadet to be a mom. I need to go to a clinic as soon as I have an answer." And let me tell you, you don't really feel that stigma and judging until that realistic scare comes and you're calling clinics and your insurance company and hoping you don't get someone judgmental.

Fortunately the scare was just lateness combined with a stomach virus that had been going around. But the experience made me so much more adamant in my pro-choice stance-- even if I was finished with my Masters and working a good job, had a nicer place to live? I still would've gone to the clinic. Because I want to spend my thirties living in relative financial comfort and provide for my father in old age, and spend time on my career rather than childrearing. That and I want at least one nice vacation, dammit.

So just like how some people choose whether or not to have children, the REASON for why not may or may not be selfish-- but the choice itself is not.

If anything, it is more selfish to have a child you don't want and cannot/will not take care of.

But women in Western society are not supposed to be selfish; it's a higher standard we're held to that it's simply a given we give up everything to procreate and provide care-- god forbid we "shirk" that. I am so tired of this attitude!

Sorry about posting a book; but I just wanted to share that. I agree with Heather-- our abortion and wellwoman care providers are unsung heroes. We shouldn't take them for granted.

Lori Freedman's book sounds amazing, and it's interesting to imagine the stigma attached to abortion not being the fetus itself, but the individual choice a woman makes. If women are indeed looked at as "selfish", then women have been self-serving for thousands of years. Abortion and contraception are age-old practices found in Ancient Egypt, Ancient Greece and Rome, the East and the West throughout the middle-ages, and found within every indigenous culture ever studied. Women and men controlled their reproduction for thousands of years through the use of herbs and other basic technologies that proceeded Western medicine in the United States. Please check out http://www.4000yearsforchoice.com. Celebrate clinics and honor abortion providers, as they are our unsung heros!