Safe, legal and rare. President Clinton first used this phrase, as early as 1992, to capture the essence of a desired national policy on abortion. For the most part, even the most ardent abortion rights supporters have come to embrace this notion and to accept the validity of its two-fold underlying premise: Abortion in the United States must remain legal in order to be safe, and at the same time, even with abortion services legal and accessible to women who need them, abortion can be rare—or at least far less common than it is now.

Most on the prochoice side would agree that lessening the need for abortion is a worthy goal, one both that reflects the fact that most American women try to control their fertility by using birth control rather than abortion and that recognizes the reality that even many of those who support legal abortion also have moral qualms about it. The evidence is strong that abortion’s legal status, however closely related to the conditions under which it is performed, is not the central determinant of its prevalence (related articles, March 2003, page 8, and May 2003, page 3). Prochoice advocates, therefore, assert that the route to rare depends primarily on a societal commitment to helping women be more successful at preventing unintended pregnancy. And this is impossible, they say, without a central emphasis on increasing and improving the use of contraception.

Most antiabortion activists have a different worldview. Their primary abortion-prevention strategy is to make the procedure harder to obtain by enacting ever more legal barriers to services, presumably until there is sufficient social and political will to outlaw abortion altogether. Positions on contraception among the country’s leading antiabortion organizations range from outright hostility to, at best, neutrality. (To the extent they have a pregnancy prevention agenda, it has involved mostly the promotion of abstinence outside of marriage and periodic abstinence within marriage.) Even in the new "95-10" strategy being touted by the self-described "centrist" group Democrats for Life, contraception is conspicuous by its absence. Instead, it is suggested, abortion can be reduced by 95% over 10 years largely through modest increases in social supports for pregnant women and parents of young children.

As the debate over abortion intensifies in the coming months and years, so too, it appears, will the debate over prevention. This is an opportune moment, then, to more closely examine what is likely to really make a difference in lowering the number of abortions in order to inform current policy directions before the new battle lines harden.

Abortion Legality, Safety and Incidence

Abortion was prevalent in the United States long before the U.S. Supreme Court’s 1973 decision in Roe v. Wade. One stark indicator, however, was the death toll. Especially prior to the introduction of antibiotics in the 1940s, thousands of American women died (abortion was listed as the official cause of death for almost 2,700 women in 1930) and many thousands more suffered serious health complications as a result of having unsafe, illegal abortions. Both deaths and serious complications are virtually unknown in the United States today.

Nationwide legality brought with it networks of professional providers operating in clinical settings, formalized training and simpler procedures. Following Roe, the proportion of abortions performed after the first trimester plummeted. Within only a few years, half of all abortions were occurring before eight weeks and nine in 10 before the end of the first trimester. Today, while death associated with childbirth is extremely rare, it is still some 10 times more likely than dying from a legal abortion.

Where abortion remains illegal and clandestine, however, women are still paying the ultimate price. Globally, about 70,000 pregnancy-related deaths each year are attributable to unsafe abortion. Romania provides a stark case study of the impact abortion’s legal status can have on women’s health and lives (see chart). In that country, abortion-related death rates soared after the Ceausescu regime outlawed abortion as part of its pronatalist policy. Deaths dropped dramatically when abortion was legalized one again after Ceausescu’s ouster.

LEGAL AND SAFE
When abortion was outlawed in Romania, abortion-related deaths soared, but they quickly dropped when abortion was made legal again.
Source: World Health Organization.

Just as laws banning abortion do not stop women from having them, it is equally true that permissive laws do not cause them to do so. Abortion is legal, free and widely available in the Netherlands, for example, yet that country is home to one of the world’s lowest abortion rates. By contrast, abortion is completely illegal in countries as diverse as Peru, the Philippines and Uganda, but all have abortion rates that far exceed the rate in the United States (see table).

The Common Thread: Unplanned Pregnancy

Put simply, abortion rates around the world are high where unplanned pregnancy is high, and they are low where women and couples are better equipped to prevent those pregnancies they wish to postpone or avoid altogether. In the industrialized world, unintended pregnancy rates are lowest in western and northern European countries, where sexual activity from the teen years on is generally accepted as a fact of life. In these countries, therefore, "personal responsibility" is equated much less with refraining from sex than it is with a commitment to using contraception consistently and correctly.

The impact of contraceptive use—and of public funding for contraceptive services—on the incidence of unintended pregnancy and abortion has been extensively documented over the years, both at the national level and in various states. According to data compiled by the Guttmacher Institute for the federal government, publicly supported family planning services prevent some 1.3 million unintended pregnancies each year. If these unplanned pregnancies had occurred, they would have resulted in some 632,000 abortions, increasing the U.S. abortion rate by 40%. University of California researchers estimated that in 2002 alone, their state’s effort to extend eligibility for Medicaid-subsidized family planning services to more lower-income women prevented 213,000 unintended pregnancies, averting 82,000 abortions.

Based on the evidence, then, and consistent with the value they place on self-determination, prochoice activists promote policies that support contraceptive access and use as the single most effective and acceptable way to bring about a large reduction in the number of abortions in the United States. This is the underlying principle of the Prevention First Act, an omnibus bill that Senate Minority Leader Harry Reid (NV), himself antiabortion, introduced with Sen. Hillary Clinton (D-NY) in 2005 as one of the Democrats’ top 10 legislative priorities (see box and related article, May 2005, page 1).

Making Abortions Harder to Obtain

Meanwhile, antiabortion activists are more intent than ever in pursuing a strategy to reduce and eventually eliminate abortion by law. Twenty years ago, while a lawyer for the Reagan administration’s Justice Department, U.S. Supreme Court Justice Samuel A. Alito Jr. wrote that he welcomed the "opportunity to advance the goals of bringing about the eventual overturning of Roe v. Wade, and, in the meantime, of mitigating its effects."

Undoubtedly, the array of restrictions on abortion that has been enacted since that time can and does amount to an absolute barrier for some women who may be young or have meager resources and who cannot easily travel to another state to find an abortion provider or to avoid a home-state’s burdensome requirements. Overall, though, with the exception of the cutoff of Medicaid funds for abortions for poor women, there is little evidence that "mitigating" Roe’s effects has had a significant impact on the incidence of abortion. The primary impact of the current array of legal barriers has been to delay the point in pregnancy when affected women obtain the procedure, needlessly adding to its risk.

This may not be the case in the future, however. Depending on how far and how fast the newly constituted U.S. Supreme Court proceeds toward unraveling Roe’s current protections, Congress and the states could probably find ways to make some greater inroads in stopping abortions (related article, page 18). Already, Missouri has enacted a law that criminalizes the provision of any assistance to a minor to cross state lines for the purpose of obtaining a confidential abortion. If antiabortion advocates in Congress have their way, such assistance would virtually be banned nationwide—essentially enacting a national parental notification requirement even in states that have explicitly rejected one. If this law and perhaps even more stringent ones are enacted and allowed to stand, inevitably more women will be thwarted from obtaining safe abortion services.

Providing Support for Parenting

As the legal tactics become harsher, Democrats for Life has emerged to soften the edges a bit. Overlaying the organization’s support for making abortion illegal is a new initiative that Rep. Tim Ryan (D-OH), who is working to translate it into legislation, has proclaimed will "provide the true long-term solution to reducing the number of abortions." Dubbed "95-10," it proposes to reduce abortion by 95% in 10 years largely by increasing the availability of supportive services for pregnant women and parents so as to make it more economically feasible for women confronting an unplanned pregnancy to choose childbirth over abortion (see box).

Proponents justify the "social-supports" approach to reducing abortion by citing Guttmacher Institute research showing that most women having an abortion say they are doing so for what could be considered "economic" reasons. According to the research, women say that they are not ready to have a child, or another child, at this point in their lives because becoming a parent would interfere with their educational goals, their job aspirations or their ability to care for their existing family. The theory behind the 95-10 strategy would seem to be that extending a limited and fairly hodgepodge array of benefits, mainly to young and lower-income women, during and shortly after pregnancy would remove the economic disincentives to raising a child or another child.

To be sure, the component parts of the 95-10 approach have merit in their own right, but the approach must be judged more dubious as an abortion-reduction strategy. First, its relatively modest, short-term offerings fail to address the much larger, longer-term economic issues that women, especially young and low-income women, face in raising families. These issues include obtaining a stable job and being able to pay for food, housing, medical care and childcare services and still save enough for children’s higher education and for retirement. Even if the proponents of the 95-10 idea, or similar social-supports strategies, were inclined to go much further to address some of these issues more broadly, the fact remains that doing so would run directly counter to the direction the federal government and most state governments are currently headed. In the current climate, and likely for years to come, advocates for the young and the poor will need to work overtime just to stave off draconian cuts to health and social welfare programs, let alone revolutionize the entire national approach to addressing the problems of poverty and disadvantage.

Moreover, the fact is that most women and couples around the world—at all income levels—want smaller families than their mothers and grandmothers did. Economic development and globalization increasingly are accompanied by the desire to time, space and, ultimately, limit childbearing so that parents can achieve a decent standard of living and ensure that their children are educated and healthy. It is doubtful that offering modest economic incentives to pregnant women would have much if any impact on an inexorable and universal trend that defines modern life.

The Role of Adoption

Whatever their impact as an abortion-reduction strategy might be, it should be recognized that incentives designed to make it easier for young women without much money to keep their babies are to some extent in conflict with another main goal of the antiabortion movement: to encourage these women to place their babies for adoption. In fact, relatively few women have chosen this option in modern times: As far back as the early 1970s, only about 9% of births to never-married women were placed for adoption. According to the National Center for Health Statistics (NCHS), this dropped to less than 1% during the years 1989–1995. In 2003, a total of about 14,000 children were placed for adoption.

Antiabortion advocates have long alleged that problem-pregnancy counseling in Title X–funded family planning clinics is biased against adoption and that this accounts for the country’s low adoption-placement rate. A federal audit found otherwise, however, reporting to Congress in 2002 that "infant adoption as part of non-directive counseling to pregnant women is an accepted and adhered-to standard amongclinicians in federally funded health clinics." Moreover, the availability of legal abortion itself, according to NCHS, "is not a significant factor in lower prevalence of relinquishment in recent years." (The abortion rate was declining at the same time.) Rather, the decline in adoption placement parallels a steady rise in births to unmarried women, itself a function of increased societal acceptance of single parenthood.

Which leaves the question: What more reasonably can be done to encourage women to choose adoption over abortion? Notably, the Democrats for Life’s main adoption-promotion idea is to guarantee tax credits to couples wishing to adopt. Again, while most would agree that easing the financial burden adoptive couples bear is justified on its own merits, this will have no effect on the availability of infants for adoption—let alone on the abortion rate.

Getting Real

When it comes to making abortion "rare," then, the evidence indicates strongly that not all interventions are created equal. Criminalization would reduce, but by no means eliminate, abortion’s incidence, and that might come at a price too high for most Americans to bear. While it is theoretically possible that increased social supports for pregnant women and even more "adoption-positive" problem-pregnancy counseling could have some impact, neither can hope to approach the real reductions in the abortion rate that could be achieved by preventing unintended pregnancy in the first place.

Moreover, while both abstinence and contraceptive use can prevent pregnancy, they also are unlikely to be equal partners in a strategy to lower the number of abortions. Even if more teenagers can be persuaded to practice abstinence more successfully, thereby reducing the teenage abortion rate, the fact remains that four in five abortions occur to adult women. Inevitably, for most people over the course of most of their lives, it is contraceptive use that is likely to have the greatest impact.

While the battle over legal abortion will continue to rage, it would seem that common ground could be reached by agreeing that it should, and could, be rarer. But the means to this end matter if all sides are sincere about the goal.

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