The New Abortion Providers

Terry understood that focusing on abortion providers was possible because they had become increasingly isolated from mainstream medicine. That was not what physicians themselves anticipated after the Supreme Court’s 1973 decision in Roe v. Wade. An open letter signed by 100 professors of obstetrics and gynecology predicted that free-standing clinics would be unnecessary if half of the 20,000 obstetricians in the country would do abortions for their patients, and if hospitals would handle “their proportionate share.” OB-GYNs at the time emphasized that abortion was a surgical procedure and fell under their purview.

But then most of the OB-GYNs left the stage. After Roe, the shadow of the greedy, butchering “abortionist” continued to hover, and many doctors didn’t want to stand in it. As mainstream medicine backed away, feminist activists stepped in. They set up stand-alone clinics to care for women in their moments of crisis. In many ways, the clinics were a rebel-sister success story. Instead of a sterile and expensive hospital operating room, patients could go to a low-cost clinic with pastel walls and sympathetic staff members. At a Planned Parenthood I visited recently in Rochester, while women were having abortions, they could look at photos of a Caribbean beach, taped above them on the ceiling.

But the clinics also truly came to stand alone. In 1973, hospitals made up 80 percent of the country’s abortion facilities. By 1981, however, clinics outnumbered hospitals, and 15 years later, 90 percent of the abortions in the U.S. were performed at clinics. The American Medical Association did not maintain standards of care for the procedure. Hospitals didn’t shelter them in their wings. Being a pro-choice doctor came to mean referring your patients to a clinic rather than doing abortions in your own office.

This was never the feminist plan. “The clinics’ founders didn’t intend them to become virtually the only settings for abortion services in many communities,” says Carole Joffe, a sociologist and author of a history of the era, “Doctors of Conscience,” and a new book, “Dispatches From the Abortion Wars.” When the clinics became the only place in town to have an abortion, they became an easy mark for extremists. As Joffe told me, “The violence was possible because the relationship of medicine to abortion was already tenuous.” The medical profession reinforced the outsider status of the clinics by not speaking out strongly after the first attacks. As abortion moved to the margins of medical practice, it also disappeared from residency programs that produced new doctors. In 1995, the number of OB-GYN residencies offering abortion training fell to a low of 12 percent.

“Under pressure and stigma, more doctors shun abortion,” wrote David Grimes, a leading researcher and abortion provider of 38 years, in a widely cited 1992 medical journal article called “Clinicians Who Provide Abortions: The Thinning Ranks.” In a 1992 survey of OB-GYNs, 59 percent of those age 65 and older said that they performed abortions, compared with 28 percent of those age 50 and younger. The National Abortion Federation started warning about “the graying of the abortion provider.” In the decade after Roe, the number of sites providing abortion across the country almost doubled from about 1,500 to more than 2,900, according to the Gutt­macher Institute. But by 2000 the number shrank back to about 1,800 — a decline of 37 percent from 1982.

There’s another side of the story, however — a deliberate and concerted counteroffensive that has gone largely unremarked. Over the last decade, abortion-rights advocates have quietly worked to reverse the marginalization encouraged by activists like Randall Terry. Abortion-rights proponents are fighting back on precisely the same turf that Terry demarcated: the place of abortion within mainstream medicine. This abortion-rights campaign, led by physicians themselves, is trying to recast doctors, changing them from a weak link of abortion to a strong one. Its leaders have built residency programs and fellowships at university hospitals, with the hope that, eventually, more and more doctors will use their training to bring abortion into their practices. The bold idea at the heart of this effort is to integrate abortion so that it’s a seamless part of health care for women — embraced rather than shunned.

This is the future. Or rather, one possible future. There’s a long way to go from here to there. Between 2000 and 2005, the last year that statistics are available, the number of abortion facilities in the U.S. dropped 2 percent — a smaller dip than those in the preceding five-year periods, but a decline nonetheless. “The ’90s were about getting abortion back into residency training and medical schools,” says Jody Steinauer, an OB-GYN professor at the University of California at San Francisco, the hub of the abortion-rights countermovement in medicine. “Now it’s about getting abortion into our practices.”

THE INITIAL PUSH TO lift the status of abortion in medicine came from the profession’s most junior members. In 1992, Steinauer started medical school at U.C.S.F. In the spring of her first year, she and thousands of other students received a mailing at home called “Bottom Feeder.” It made racist jokes and included this exchange: “Q: What would you do if you found yourself in a room with Hitler, Mussolini and an abortionist, and you had a gun with only two bullets? A: Shoot the abortionist twice.”

Distressed by the mailing, Steinauer started talking to students at other schools about how abortion wasn’t the topic of a single class. She took a year off and started the group Medical Students for Choice. Soon chapters throughout the country began pushing to add lectures about abortion to the medical-school curriculum. “Not everyone has to do abortion, but everyone has to think about it,” Steinauer says today of M.S.F.C.’s philosophy. The point is to recruit not only future abortion providers but also the supporters they’ll need inside medicine later in their professional lives. M.S.F.C. now has 10,000 members. “You know, all these students going into dermatology or radiology — if you’re an OB who wants to provide and your hospital won’t let you, they’re the ones you want as your allies on the hospital board,” Steinauer says.