In this season of presidential and vice presidential debates, those of us who work in reproductive health hold our breath for the inevitable moments when abortion becomes the topic of discussion. I keep waiting for a candidate to actually talk about the lifesaving significance of safe, legal, accessible abortion. But what I hear instead are scripted responses that completely and carefully ignore the messy reality of women's lives.
The reality is that 42 million women around the world have abortions each year regardless of any politician's religious beliefs or "moderated" position on abortion. Women put off bills, borrow money from friends, travel miles, sit through enforced waiting periods, and they have abortions. The reality is Jennie Linn McCormack.
You may have heard about McCormack, the mother of three from Pocatello, Idaho, who was arrested last year for causing her own abortion with pills she got over the Internet. She was unemployed, the father was in prison and she was already barely making ends meet -- she knew she couldn't support another child. Abortion may be nominally legal in the United States, but McCormack's story illustrates the many legal, practical and social barriers deliberately placed in a woman's path to make that legal right out of reach.
Let's first examine the legal and regulatory barriers. Idaho (where McCormack lives) and Utah (where the abortion clinic nearest her can be found) have laws that place burdensome requirements and restrictions on abortion providers (known as TRAP laws) that are not supported by medical evidence and that do not apply to other similar clinical centers. As a result there are few abortion providers in these very rural states.
What's more, both Utah and Idaho require women seeking abortions to undergo mandatory biased counseling, intended to shame and dissuade women from having an abortion, followed by a one- to three-day waiting period before returning for the procedure. Finally, the state health program for low-income women is legally barred from covering abortion, except in cases of rape or incest or threats to a woman's life. Most poor women seeking abortions must pay out of pocket.
Legal restrictions like these created serious practical barriers to abortion for McCormack. The closest clinic to McCormack was in Salt Lake City, more than 150 miles away. With nowhere to seek an abortion locally, and no car, McCormack would have had to borrow or rent a car for a whole day twice, find childcare twice and, perhaps hardest of all, come up with at least $400 to pay for the procedure -- more than her monthly income.
As if the legal and practical barriers weren't enough to overcome, McCormack faced intense social pressure, or stigma, that women around the world face when they decide to terminate pregnancy. She was raised Mormon, which condemns abortion in most cases. I grew up not far from Pocatello, in Ogden, Utah, and as a Hindu-Indian woman, I am well aware of the power of the closed Mormon culture, and the social shame that is experienced by those that don't fit in. Having decided to end her pregnancy, McCormack didn't have anyone she felt she could turn to -- not a close friend, not her mother, not even a health-care professional (and as a result, she greatly miscalculated how far along she was in her pregnancy).
Who did she talk to? Her sister, nearly 2,000 miles away in the equally conservative state of Mississippi. It was she who ordered the pills McCormack needed.
In the end, McCormack correctly understood the social stigma surrounding her act: When the fetus she delivered was larger than expected, she confided in a friend about her abortion. Her friend confided in another woman, and it was that woman who turned McCormack into the police. She was arrested and charged with having an abortion without a physician's assistance.
In the 1992 Supreme Court case Casey v. Planned Parenthood, the court ruled that legal restrictions on abortion were permissible as long as they did not impose an undue burden on women. Political forces opposed to abortion have deliberately pushed restrictions that, taken individually, may not seem to place an undue burden on any individual. But taken all together, compounded by the stigma they reinforce and experienced by real women in their real, indivisible lives, they become enormous, and yes, undue burdens.
Ultimately the charges against McCormack have been dismissed, and even the Ninth Circuit Court of Appeals recognizes that these layers are onerous. "There can be no doubt," the court said in a recent ruling on her case, "that requiring women to explore the intricacies of state abortion statutes to ensure that they and their provider act within the Idaho abortion statute framework, results in an 'undue burden' on a woman seeking an abortion of a nonviable fetus."
In the United States, these patchwork restrictions have evolved over the last two decades. But this week Uruguay passed a law that "legalizes" abortion while including many of these very same restrictions. As the result of political compromise needed to win passage of the law, women seeking abortions in Uruguay will have to go before a panel that made up of a gynecologist, a mental health professional and a social worker and ask permission to terminate an unwanted or unsafe pregnancy. The panel will also be required to provide biased counseling as in many U.S. states, after which the woman will have to wait five days before her procedure. Is the law change in Uruguay a victory for women's rights or further evidence that society is not ready to grant women moral agency?
Ironically, this legislation is considered an advance for women in Latin America, who otherwise would go to a pharmacist and ask for the ulcer medication Cytotec, the very medication that McCormack ordered over the Internet. In several countries, hotlines exist to give women the information they need to take the pills safely. Access to this medication has reduced the death rate from unsafe abortion around the region, making "unsafe" abortion a good deal safer. Will we begin seeing women in conservative and rural states -- like Idaho, Utah and Mississippi -- creating their own hotlines?
An Indian colleague, Dr. Nozer Sheriar, an Ipas board member and secretary general of the Federation of Obstetric and Gynecological Societies of India, is conscious of the religious and cultural pressure women around the world feel. He often notes that, "Anything 42 million women do every year can't be immoral." What I wouldn't give for a presidential candidate to assert the same thing.
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