summary essay about abortion

A Brief History of Abortion in the U.S.

Abortion wasn’t always a moral, political, and legal tinderbox. What changed?

A bortion laws have never been more contentious in the U.S. Yet for the first century of the country’s existence—and most of human history before that—abortion was a relatively uncontroversial fact of life.

“Abortion has existed for pretty much as long as human beings have existed,” says Joanne Rosen, JD, MA , a senior lecturer in Health Policy and Management who studies the impact of law and policy on access to abortion.

Until the mid-19th century, the U.S. attitude toward abortion was much the same as it had often been elsewhere throughout history: It was a quiet reality, legal until “quickening” (when fetal motion could be felt by the mother). In the eyes of the law, the fetus wasn’t a “separate distinct entity until then,” but rather an extension of the mother, Rosen explains.

What changed?

America’s first anti-abortion movement wasn’t driven primarily by moral or religious concerns like it is today. Instead, abortion’s first major foe in the U.S. was physicians on a mission to regulate medicine.

Until this point, abortion services had been “women’s work.” Most providers were midwives, many of whom made a good living selling abortifacient plants. They relied on methods passed down through generations, from herbal abortifacients and pessaries—a tampon-like device soaked in a solution to induce abortion—to catheter abortions that irritate the womb and force a miscarriage, to a minor surgical procedure called dilation and curettage (D&C), which remains one of the most common methods of terminating an early pregnancy.

The cottage abortion industry caught the attention of the fledgling American Medical Association, which was established in 1847 and, at the time, excluded women and Black people from membership. The AMA was keen to be taken seriously as a gatekeeper of the medical profession, and abortion services made midwives and other irregular practitioners—so-called quacks—an easy target. Their rhetoric was strategic, says Mary Fissell, PhD , the J. Mario Molina professor in the Department of the History of Medicine at Johns Hopkins University. “You have to link those midwives to providing abortion as a way of kind of getting them out of business,” Fissell says. “So organized medicine very much takes the anti-abortion position and stays with that for some time.”

Early 19th century and before

Abortion is legal in the U.S. until “quickening”

AMA campaigns to end abortion

At least 40 anti-abortion statutes are enacted in the U.S.

Comstock Act makes it illegal to sell or mail contraceptives or abortifacients

Late 19th century

OB-GYN emerges as a specialty

Griswold v. Connecticut decision finds that the Constitution guarantees a right to privacy, specifically in prescribing contraceptives, paving the way for Roe v. Wade

Supreme Court decision in Roe v. Wade enshrines abortion as a constitutional right

Planned Parenthood of Southeastern Pennsylvania v. Casey protects a woman's right to have an abortion prior to  fetal viability

Four states pass trigger laws making it a felony to perform, procure, or prescribe an abortion if Roe is ever overturned

Roe v. Wade and Planned Parenthood v. Casey overturned; 13 states ban abortion by October 2022

In 1857, the AMA took aim at unregulated abortion providers with a letter-writing campaign pushing state lawmakers to ban the practice. To make their case, they asserted that there was a medical consensus that life begins at conception, rather than at quickening.

The campaign succeeded. At least 40 anti-abortion laws went on the books between 1860 and 1880.

And yet some doctors continued to perform abortions in the late 19th and early 20th centuries. By then, abortion was illegal in almost all states and territories, but during the Depression era, “doctors could see why women wouldn’t want a child,” and many would perform them anyway, Fissell says. In the 1920s and through the 1930s, many cities had physicians who specialized in abortions, and other doctors would refer patients to them “off book.”

That leniency faded with the end of World War II. “All across America, it’s very much about gender roles, and women are supposed to be in the home, having babies,” Fissell says. This shift in the 1940s and ’50s meant that more doctors were prosecuted for performing abortions, which drove the practice underground and into less skilled hands. In the 1950s and 1960s, up to 1.2 million illegal abortions were performed each year in the U.S., according to the Guttmacher Institute . In 1965, 17% of reported deaths attributed to pregnancy and childbirth were associated with illegal abortion.

A rubella outbreak from 1963–1965 moved the dial again, back toward more liberal abortion laws. Catching rubella during pregnancy could cause severe birth defects, leading medical authorities to endorse therapeutic abortions . But these safe, legal abortions remained largely the preserve of the privileged. “Women who are well-to-do have always managed to get abortions, almost always without a penalty,” says Fissell. “But God help her if she was a single, Black, working-class woman.”

Women who could afford it brought their cases to court to fight for access to hospital abortions. Other women gained approval for abortions with proof from a physician that carrying the pregnancy would endanger her life or her physical or mental health. These cases set off a wave of abortion reform bills in state legislatures that helped set the stage for Roe v. Wade . By the time Roe was decided in 1973, legal abortions were already available in 17 states—and not just to save a woman’s life.

But raising the issue to the level of the Supreme Court and enshrining abortion rights for all Americans also galvanized opposition to it and mobilized anti-abortion groups. “ Roe was under attack virtually from the moment it was decided,” says Rosen.  

In 1992 another Supreme Court case, Planned Parenthood of Southeastern Pennsylvania v. Casey posed the most significant existential threat to Roe . Rosen calls it “the case that launched a thousand abortion regulations,” upholding Roe but giving states far greater scope to regulate abortion prior to fetal viability. However, defining that nebulous milestone a became a flashpoint for debate as medical advancements saw babies survive earlier and earlier outside the womb. Sonograms became routine around the same time, making fetal life easier to grasp and “putting wind in the sails of the ‘pro-life’ movement,” Rosen says. Then in June, the Supreme Court overturned both Roe and Casey .

For many Americans, that meant the return to the conundrum that led Norma McCorvey—a.k.a. Jane Roe—to the Supreme Court in 1971: being poor and pregnant, and seeking an abortion in a state that had banned them in all but the narrowest of circumstances.

The history of abortion in the U.S. suggests the tides will turn again. “We often see periods of toleration followed by periods of repression,” says Fissell. The current moment is unequivocally marked by the latter. What remains to be seen is how long it will last.

From Public Health On Call Podcast

The independent source for health policy research, polling, and news.

Key Facts on Abortion in the United States

Usha Ranji , Karen Diep , and Alina Salganicoff Published: Nov 21, 2023

Note: This brief was updated on January 4, 2024 to correct the description of the data collected by the federal CDC Abortion Surveillance System. On June 24, 2022, the Supreme Court issued a ruling in Dobbs v. Jackson Women’s Health Organization that overturned the constitutional right to abortion as well as the federal standards of abortion access, established by prior decisions in the cases Roe v. Wade and Planned Parenthood v. Casey . Prior to the Dobbs ruling, the federal standard was that abortions were permitted up to fetal viability. That federal standard has been eliminated, allowing states to set policies regarding the legality of abortions and establish limits. Access to and availability of abortions varies widely between states , with some states banning almost all abortions and some states protecting abortion access.

This issue brief answers some key questions about abortion in the United States and presents data collected before and new data that was published shortly after the overturn of Roe v. Wade .

What is abortion?

How safe are abortions, how often do abortions occur, who gets abortions, at what point in pregnancy do abortions occur, where do people get abortion care, how much do abortions cost, does private insurance or medicaid cover abortions, what are public opinions about abortion.

Abortion is the medical termination of a pregnancy. It is a common medical service that many women obtain at some point in their life. There are different types of abortion methods, which the National Academy of Sciences, Engineering, and Medicine (NASEM ) places in four categories:

• Medication Abortion – Medication abortion, also known as medical abortion or abortion with pills, is a pregnancy termination protocol that involves taking oral medications. There are two widely accepted protocols for medication abortion. In the U.S., the most common protocol involves taking two different drugs, Mifepristone and Misoprostol. Typically, an individual using medication abortion takes Mifepristone first, followed by misoprostol 24-48 hours later. In the U.S., the Food and Drug Administration (FDA) has approved this protocol of medication abortion for use up to the first 70 days (10 weeks) of pregnancy, and its use has been rising for years. Another medication abortion protocol uses misoprostol alone . Patients can take 800 µg (4 pills) of misoprostol sublingually or vaginally every three hours for a total of 12 pills. The regimen is also recommended for up to 70 days (10 weeks) of pregnancy, but it is not currently approved by the FDA and is more commonly used in other countries.

Guttmacher Institute estimates that in 2020, medication was used for more than half (53%) of all abortions. While medication abortion has been available in the U.S. for more than 20 years, studies have found that many adults and women of reproductive age have not heard of medication abortion. Many have confused emergency contraception ( EC ) pills with medication abortion pills, but EC does not terminate a pregnancy. EC works by delaying or inhibiting ovulation and will not affect an established pregnancy.

• Aspiration , a minimally invasive and commonly used gynecological procedure, is the most common form of procedural abortion. It can be used to conduct abortions up to 14-16 weeks of gestation. Aspiration is also commonly used in cases of early pregnancy loss (miscarriage).
• Dilation and evacuation abortions (D&E) are usually performed after the 14th week of pregnancy. The cervix is dilated, and the pregnancy tissue is evacuated using forceps or suction.
• Induction abortions are rare and conducted later in pregnancy. They involve the use of medications to induce labor and delivery of the fetus.

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Decades of research have shown that abortion is a very safe medical service.

Despite its strong safety profile, abortion is the most highly regulated medical service in the country and is now banned in several states. In addition to bans on abortion altogether and telehealth, many states impose other limitations on abortion that are not medically indicated, including waiting periods, ultrasound requirements, gestational age limits, and parental notification and consent requirements. These restrictions typically delay receipt of services.

• NASEM completed an exhaustive review on the safety and effectiveness of abortion care and concluded that complications from abortion are rare and occur far less frequently than during childbirth.
• NASEM also concluded that safety is enhanced when the abortion is performed earlier in the pregnancy. State level restrictions such as waiting periods, ultrasound requirements, and gestational limits that impede access and delay abortion provision likely make abortions less safe.
• When medication abortion pills, which account for the majority of abortions, are administered at 9 weeks’ gestation or less, the pregnancy is terminated successfully 99.6% of the time, with a 0.4% risk of major complications, and an associated mortality rate of less than 0.001 percent (0.00064%).
• Medication abortion pills can be provided in a clinical setting or via telehealth (without an in-person visit). Research has found that the provision of medication abortion via telehealth is as safe and effective as the provision of the pills at an in person visit.
• Studies on procedural abortions, which include aspiration and D&E, have also found that they are very safe. Research on aspiration abortions, the most common procedural method, have found the rate of major complications of less than 1%.

There are three major data sources on abortion incidence and the characteristics of people who obtain abortions in the U.S: the Centers for Disease Control and Prevention (CDC), the Guttmacher Institute, and most recently, the Society of Family Planning’s (SFP) #WeCount project.

The federal CDC Abortion Surveillance System requests data from the central health agencies of the 50 states, DC, and New York City to document the number and characteristics of women obtaining abortions. Most states collect data from facilities where abortions are provided on the demographic characteristics of patients, gestational age, and type of abortion procedure. Reporting these data to the CDC is voluntary and not all states participate in the surveillance system. Notably, California, Maryland, and New Hampshire have not reported data on abortions to the CDC system for years. CDC publishes available data from the surveillance system annually.

Guttmacher Institute , an independent research and advocacy organization, is another major source of data on abortions in the U.S. Prior to the Dobbs ruling, Guttmacher conducted the Abortion Provider Census (APC) periodically which has provided data on abortion incidence, abortion facilities, and characteristics of abortion patients. Data from this Census are based primarily on questionnaires collected from all known facilities that provide abortion in the country, information obtained from state health departments, and Guttmacher estimates for a small portion of facilities. The most recent APC reports data from 2020.

The CDC and Guttmacher data differ in terms of methods, timeframe, and completeness, but both have shown similar trends in abortion rates over the past decade. One notable difference is that Guttmacher’s study includes continuous reporting from California, D.C., Maryland, and New Hampshire, which explains at least in part the higher number of abortions in their data.

Since the Dobbs ruling, the Guttmacher Institute has established the Monthly Abortion Provision Study to track abortion volume within the formal United States health care system. This ongoing effort collects data on and provides national and state-level estimates on procedural and medication abortions while also tracking the changes in abortion volume since 2020. The Monthly Abortion Provision Study was designed to complement Guttmacher’s APC along with other data collection efforts to allow for quick snapshots of the changing abortion landscape in the United States.

Society of Family Planning’s (SFP) #WeCount is another national reporting effort that measures changes in abortion access following the Dobbs ruling. The project reports on the number of abortions per month by state and includes data on abortions provided through clinics, private practices, hospitals, and virtual-only providers. The report does not include data on self-managed abortions that are performed without clinical supervision. The most recent #WeCount report analyzes data from April 2022 to data from June 2023, marking one full year of abortion data since Dobbs. The effort represents 83% of all providers known to #WeCount who agreed to participate in their research.

This KFF issue brief uses data from the CDC, Guttmacher, and SFP as well as other research organizations.

How has the abortion rate changed over time?

For most of the decade prior to the Dobbs ruling, there was a steady decline in abortion rates nationally, but there was a slight increase in the years just before the ruling.

In their most recent national data, Guttmacher Institute reported 930,160 abortions in 2020 and a rate of 14.4 per 1,000 women. CDC reported 622,108 abortions in 2021 and a rate of 11.6 abortions per 1,000 women (excludes CA, DC, MD, NH). Guttmacher’s study showed an upward trend in abortion from 2017 to 2020 whereas CDC’s report showed an increase in abortions from 2017 to 2021 except for a slight decrease in 2020.

While most attribute the long-term decline in abortion rates to increased use of more effective methods of contraception , several states had reduced access to low- or no-cost contraceptive care as a result of reductions in the Title X network under the Trump Administration, which may have contributed to the slight rise in abortions prior to the Dobbs ruling. Other factors that may have contributed to the increase could include greater coverage under Medicaid that subsequently made abortions more affordable in some states and broader financial support from abortion funds to help individuals pay for the costs of abortion care.

Even prior to the Dobbs ruling, abortion rates varied widely between states.

National averages can mask local and more granular differences. Lower state-level abortion rates do not reflect less need. Some of the variation has been due to the wide differences in state policies, with some states historically placing restrictions on abortion that make access and availability to nearly out of reach and, on the other side, some states enshrining protections in state Constitutions and legislation.

• In 2020, the abortion rate (per 1,000 women ages 15-44) ranged from 0.1 in Missouri to 48.9 in the District of Columbia (DC). Trends also varied between states. While the national rate of abortion increased between 2017 and 2019, some states saw declines, with particularly sharp drops in states where heavy restrictions were put into place.

While the number of abortions in the U.S. dropped immediately following the Dobbs decision, new data show that the number of abortions increased overall one year following the ruling. However, the upswing obscures the declines in abortion care in states with bans.

SFP’s #WeCount estimates there were 2,200 cumulative more abortions in the year following Dobbs (July 2022 to June 2023) compared to the pre- Dobbs period (April 2022 and May 2022). Nationally, the number of abortions varied month-by-month, with the largest decrease observed in November 2022 (73,930 abortions; 8,185 fewer abortions than pre- Dobbs period ) and the largest increase in March 2023 (92,680 abortions; 10,565 more abortions than pre- Dobbs period). The states with the largest cumulative increases in the total number of abortions provided by a clinician during the 12-month period include Illinois, Florida, North Carolina, California, and New Mexico. States with abortion bans experienced the largest cumulative decreases in the number of abortions, including Texas, Georgia, Tennessee, and Louisiana (data varies by month in each state; data not shown).

States without abortion bans experienced an increase of abortions following the Dobbs ruling likely due to a combination of reasons: increased interstate travel for abortion access, expanded in-person and virtual/telehealth capacity to see patients, increased measures to protect and cover abortion care for residents and out-of-state patients, and potentially reduced abortion-related stigma as a result of community mobilization around abortion care.

However, the overall national increase in the number of abortions masks the absence and/or scarcity of abortion care in states with total abortion bans or severe restrictions. States with total bans experienced observed 94,930 fewer clinician-provided abortions a year following the ruling (data not shown). Note, this figure is an underestimate due several state policies that restricted abortion access during the pre- Dobbs period. These estimates do not include abortions that may have been performed through self-managed means.

Most of the information about people who receive abortions comes from data prior to the Dobbs ruling. In 2021, women across a range of age groups, socioeconomic status, and racial and ethnic backgrounds obtained abortions, but the majority were obtained by women who were in their twenties, low-income, and women of color.

• Women in their twenties accounted for more than half (57%) of abortions. Nearly one-third (31%) were among women in their thirties and a small share were among women in their 40s (4%) and teens (8%).
• Seven in ten abortion patients were of women of color. Black women comprised 42% of abortion recipients, White women 30% , Hispanic women 22%, and 7% women of other races/ethnicities.
• Many women who sought abortions have children. More than six in 10 (61%) abortion patients in 2021 had at least one previous birth.

The vast majority (94%) of abortions occur during the first trimester of pregnancy according to data available from before the Dobbs decision.

Before the 2022 ruling in Dobbs, there was a federal constitutional right to abortion before the pregnancy is considered to be viable, that is, can survive outside of a pregnant person’s uterus. Viability is generally considered around 24 weeks of pregnancy. Most abortions, though, occur well before the point of fetal viability.

• Data from 2021 found that more than four in ten (45%) abortions occurred by six weeks of gestation, a third (36%) occurred between seven and nine weeks, and 13% at 10-13 weeks. Just 7% of abortions occurred after the first trimester.
• Prior to the decision in the Dobbs case, almost half of states (22) had enacted laws that ban abortion at a certain gestational age. Most of these limits are in the second trimester, but some are in the first trimester, well before fetal viability. Many of these laws were blocked because they violated the federal standard established by Roe v Wade. Some states have enacted laws banning abortions after fetal cardiac activity can be detected, or around 6 weeks of pregnancy, which is often before a person knows they are pregnant. In addition to banning abortion, states can now establish pre-viability gestational restrictions because the federal standard has been overturned.

Just over half of abortions were provided at clinics that specialize in abortion care in 2020. Others were provided at clinics that offer abortion care in addition to other family planning services.

Guttmacher Institute estimated that 96% of abortions were provided at clinics and just 4% were provided in doctors’ offices or hospitals in 2020. Most clinic-based abortions were provided at clinics that specialize in providing abortion care, but many were provided at clinics that offer a wide range of other sexual and reproductive health services like contraception and STI care. Most abortions are provided by physicians. However, in 19 states and D.C., Advanced Practice Clinicians (APCs) such as Nurse Practitioners and midwives may provide medication abortions. Conversely, 31 states prohibit clinicians other than physicians from providing abortion care.

Even prior to the ruling in Dobbs , access to abortion services was very uneven across the country though. The proliferation of restrictions in many states, particularly in the South, had greatly shrunk the availability of services in some areas. In the wake of overturning Roe v. Wade , these geographic disparities are likely to widen as more states ban abortion services altogether.

Telehealth has grown as a delivery mechanism for abortion services.

While procedural abortions must be provided in a clinical setting, medication abortion can be provided in a clinical setting or via telehealth. Access to medication abortion via telehealth had been limited for many years by a Food and Drug Administration (FDA) restriction that had permitted only certified clinicians to dispense mifepristone in a health care setting. The drug could not be mailed or picked up at a retail pharmacy. However, in December 2021, the FDA permanently revised its policy and no longer requires clinicians to dispense the drug in person. Additionally, in January 2023, the FDA finalized a change that allows retail pharmacies to dispense medication abortion pills to patients with a prescription.

While some states are regulating the use of mifepristone as an abortion method, the Biden Administration has asserted that the FDA has regulatory power over all drugs, including mifepristone. This could result in future legal action as the authority of the state to regulate health care will be pitted against the authority of the federal government to regulate drugs through the FDA will be contested.

• In a telehealth abortion, the patient typically completes an online questionnaire to assess (1) confirmation of pregnancy, (2) gestational age and (3) blood type. If determined eligible by a remote clinician, the patient is mailed the medications. This model does not require an ultrasound for pregnancy dating if the patient has regular periods and is sure of the date of their last menstrual period (in line with  ACOG ’s guidelines for pregnancy dating). If the patient has irregular periods or is unsure how long they have been pregnant, they must obtain an ultrasound to confirm gestational age and rule out an ectopic pregnancy 3 and send in the images for review before receiving their medications. If the patient does not know their blood type or has Rh negative blood, the  provider  may prompt the patient to visit a nearby clinic for an injection to prevent adverse reactions between maternal and fetal blood ( RhoGAM ), The follow-up visit with a clinician can also happen via a telehealth visit.
• However, even in some of the states that have not banned abortion altogether, telehealth may not be available. Many states had established restrictions prior to the Dobbs ruling that limit the use of telehealth abortions by either requiring abortion patients to take the pills at a physical clinic, require ultrasounds for all abortions, set their own policies regarding the dispensing of the medications used for abortion care, or directly ban the use of telehealth for abortion care. As of November 2022, of the 33 states that have not banned abortion, eight had at least one of these restrictions, effectively prohibiting telehealth for medication abortion.
• Medication abortion has emerged as a major legal front in the battle over abortion access across the nation. Multiple cases have been filed in federal courts regarding aspects of the FDA’s regulation of medication abortion as well as the mailing of medications. One notable ongoing case is Alliance for Hippocratic Medicine v. FDA , where the plaintiffs are challenging the FDA’s authority and approval process for mifepristone. The plaintiffs also contend that an 1873 anti-obscenity law, the Comstock Act, prohibits the mailing of any medication used for abortion. In April 2023, a US Supreme Court ruling allowed current FDA rules to remain in effect as the case proceeds through the courts. This means that mifepristone remains available for medication abortion either in a clinic or via telehealth where state law permits.

Data from SFP’s October 2023 #WeCount report show that abortions provided by virtual-only clinics represent approximately 5% of all abortions post- Roe . The number of telehealth abortions increased 72% from a monthly average of 4,045 abortions in April and May 2022 to 6,950 abortions per month in the 12 months post- Dobbs . Nearly all of these abortions occurred in states that permit abortions.

Self-managed abortions are provided without a clinician visit.

Self-managed abortions typically involve obtaining medication abortion pills from an online pharmacy that will send the pills by mail or by purchasing the pills from a pharmacy in another country. This does not typically involve a direct consultation with a clinician either in person or via telehealth.

Research has found that prior to Dobbs , more than one in ten patients who obtained abortions at clinics had considered self-managing their abortions. This is likely to increase going forward since abortion care is not available in many states, and there have already been reports of people ordering pills from online markets outside the U.S. medical system. Tracking information on these online orders can help fill in gaps in abortion count estimates but can also be difficult. Some companies may not share data on purchases, and it would also be unclear whether patients take the abortion medication after receiving it in the mail.

The median costs of abortion services exceed $500.

Obtaining an abortion can be costly. On average, the costs are higher for abortions in the second trimester than in the first trimester. State restrictions can also raise the costs, as people may have to travel if abortions are prohibited or not available in their area. Many people pay for abortion services out of pocket, but some people can obtain assistance from local abortion funds.

• In 2021, the median costs for people paying out of pocket in the first trimester were $568 for a medication abortion and $625 for a procedural abortion. The Federal Reserve estimates that nationally about one-third of people do not have $400 on hand for unexpected expenses. For low-income people, who are more likely to need abortion care, these costs are often unaffordable.
• The costs of abortion are higher in the second trimester compared to the first, with median self-pay of $775. In the second trimester, more intensive procedures may be needed, more are likely to be conducted in a hospital setting (although still a minority), and local options are more limited in many communities that have fewer facilities. This results in additional nonmedical costs for transportation, childcare, lodging, and lost wages. nonmedical costs for transportation, childcare, lodging, and lost wages.
• Abortion funds are independent organizations that help some people pay for the costs of abortion services. Most abortion funds are regional and have connections to clinics in their area. Funds vary, but they typically provide assistance with the costs of medical care, travel, and accommodations if needed. However, they do not reach all people seeking services, and many people are not able to afford the costs of obtaining an abortion because they cannot pay for the abortion itself or cover the costs of travel, lodging or missed work.

Insurance coverage for abortion services is heavily restricted in certain private insurance plans and public programs like Medicaid and Medicare.

Private insurance covers most women of reproductive age, and states have the responsibility to regulate fully insured private plans in their state, whereas the federal government regulates self-funded plans under the Employee Retirement Income Security Act (ERISA). States can choose whether abortion coverage is included or excluded in private plans that are not self-insured.

• Prior to the Dobbs ruling, several states had enacted private plan restrictions and banned abortion coverage from ACA Marketplace plans. Currently, there are 11 states that have policies restricting abortion coverage in private plans and 26 that ban coverage in any Marketplace plans. Since the Dobbs ruling, some of these states have also banned the provision of abortion services altogether.
• A handful of states ( 9 ), however, have enacted laws that require private plans to cover abortion.
• The Medicaid program covers approximately one in five women of reproductive age and four in ten who are low-income. For decades, the Hyde Amendment has banned the use of federal funds for abortion in Medicaid and other public programs unless the pregnancy is a result of rape, incest, or it endangers the woman’s life.
• States have the option to use state-only funds to cover abortions under other circumstances for women on Medicaid, which 16 states do currently. However, more than half (56% ) of women covered by Medicaid live in Hyde states.
• According to a Guttmacher Institute survey of patients in the year prior to the Dobbs ruling, a quarter (26%) of abortion patients in the study used Medicaid to pay for abortion services, 11% used private insurance, and 60% paid out of pocket. People in states with more restrictive abortion policies were less likely to use Medicaid or private insurance and more likely to pay out of pocket compared to people living in less restrictive states.
• Federal law also restricts abortion funding under the Indian Health Service, Medicare, and the Children’s Health Insurance Program. Over the years, language similar to that in the Hyde Amendment has been incorporated into a range of other federal programs that provide or pay for health services to women including: the military’s TRICARE program, federal prisons, the Peace Corps, and the Federal Employees Health Benefits Program.

National polls have consistently found that a majority of the public did not want to see Roe v . Wade overturned and that most people feel that abortion is a personal medical decision. The public also strongly opposes the criminalization of abortion both among people who get abortion and the clinicians who provide abortion services. Nearly three quarters of adults (74%) and 79% of reproductive age women say that obtaining an abortion should be a personal choice rather than regulated by law (data not shown). For example, two-thirds of the public are concerned that bans on abortion may lead to unnecessary health problems for people experiencing pregnancy complications.

Additional KFF resources:

Abortion in the US Dashboard

Access and Coverage of Abortion Services

Issue Brief: Abortion at SCOTUS: Dobbs v. Jackson Women’s Health

Issue Brief: State Actions to Protect and Expand Access to Abortion Services

Policy Watch: A Year After Dobbs: Policies Restricting Access to Abortion in States Even Where It’s Not Banned

Policy Watch: Employer Coverage of Travel Costs for Out-of-State Abortion

Issue Brief: Exclusion of Abortion Coverage from Employer-Sponsored Health Plans

Interactive: How State Policies Shape Access to Abortion Coverage

Medication Abortion

Issue Brief: Legal Challenges to the FDA Approval of Medication Abortion Pills

Infographic: The Availability and Use of Medication Abortion Care

Fact Sheet: The Availability and Use of Medication Abortion

Issue Brief: The Intersection of State and Federal Policies on Access to Medication Abortion Via Telehealth

Public Opinion on Abortion

Web Event: Americans’ Knowledge and Attitudes About Abortion Access and The Pending Supreme Court Ruling

KFF Health Tracking Poll: Early 2023 Update On Public Awareness On Abortion and Emergency Contraception

KFF Health Tracking Poll: Views on and Knowledge about Abortion in Wake of Leaked Supreme Court Opinion

Other Resources on Women’s Health

Interactive: State Profiles for Women’s Health

Interactive: State Health Facts on Women’s Health Indicators

Homepage: Women’s Health Policy

• Women's Health Policy
• Access to Care

Also of Interest

• The Availability and Use of Medication Abortion
• State Actions to Protect and Expand Access to Abortion Services
• Legal Challenges to State Abortion Bans Since the Dobbs Decision
• Legal Challenges to the FDA Approval of Medication Abortion Pills
• Employer Coverage of Travel Costs for Out-of-State Abortion
• Abortion in the United States Dashboard

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Is Abortion Sacred?

By Jia Tolentino

Twenty years ago, when I was thirteen, I wrote an entry in my journal about abortion, which began, “I have this huge thing weighing on me.” That morning, in Bible class, which I’d attended every day since the first grade at an evangelical school, in Houston, my teacher had led us in an exercise called Agree/Disagree. He presented us with moral propositions, and we stood up and physically chose sides. “Abortion is always wrong,” he offered, and there was no disagreement. We all walked to the wall that meant “agree.”

Then I raised my hand and, according to my journal, said, “I think it is always morally wrong and absolutely murder, but if a woman is raped, I respect her right to get an abortion.” Also, I said, if a woman knew the child would face a terrible life, the child might be better off. “Dead?” the teacher asked. My classmates said I needed to go to the other side, and I did. “I felt guilty and guilty and guilty,” I wrote in my journal. “I didn’t feel like a Christian when I was on that side of the room. I felt terrible, actually. . . . But I still have that thought that if a woman was raped, she has her right. But that’s so strange—she has a right to kill what would one day be her child? That issue is irresolved in my mind and it will eat at me until I sort it out.”

I had always thought of abortion as it had been taught to me in school: it was a sin that irresponsible women committed to cover up another sin, having sex in a non-Christian manner. The moral universe was a stark battle of virtue and depravity, in which the only meaningful question about any possible action was whether or not it would be sanctioned in the eyes of God. Men were sinful, and the goodness of women was the essential bulwark against the corruption of the world. There was suffering built into this framework, but suffering was noble; justice would prevail, in the end, because God always provided for the faithful. It was these last tenets, prosperity-gospel principles that neatly erase the material causes of suffering in our history and our social policies—not only regarding abortion but so much else—which toppled for me first. By the time I went to college, I understood that I was pro-choice.

America is, in many ways, a deeply religious country—the only wealthy Western democracy in which more than half of the population claims to pray every day. (In Europe, the figure is twenty-two per cent.) Although seven out of ten American women who get abortions identify as Christian, the fight to make the procedure illegal is an almost entirely Christian phenomenon. Two-thirds of the national population and nearly ninety per cent of Congress affirm a tradition in which a teen-age girl continuing an unplanned pregnancy allowed for the salvation of the world, in which a corrupt government leader who demanded a Massacre of the Innocents almost killed the baby Jesus and damned us all in the process, and in which the Son of God entered the world as what the godless dare to call a “clump of cells.”

For centuries, most Christians believed that human personhood began months into the long course of pregnancy. It was only in the twentieth century that a dogmatic narrative, in which every pregnancy is an iteration of the same static story of creation, began both to shape American public policy and to occlude the reality of pregnancy as volatile and ambiguous—as a process in which creation and destruction run in tandem. This newer narrative helped to erase an instinctive, long-held understanding that pregnancy does not begin with the presence of a child, and only sometimes ends with one. Even within the course of the same pregnancy, a person and the fetus she carries can shift between the roles of lover and beloved, host and parasite, vessel and divinity, victim and murderer; each body is capable of extinguishing the other, although one cannot survive alone. There is no human relationship more complex, more morally unstable than this.

The idea that a fetus is not just a full human but a superior and kinglike one—a being whose survival is so paramount that another person can be legally compelled to accept harm, ruin, or death to insure it—is a recent invention. For most of history, women ended unwanted pregnancies as they needed to, taking herbal or plant-derived preparations on their own or with the help of female healers and midwives, who presided over all forms of treatment and care connected with pregnancy. They were likely enough to think that they were simply restoring their menstruation, treating a blockage of blood. Pregnancy was not confirmed until “quickening,” the point at which the pregnant person could feel fetal movement, a measurement that relied on her testimony. Then as now, there was often nothing that distinguished the result of an abortion—the body expelling fetal tissue—from a miscarriage.

Ancient records of abortifacient medicine are plentiful; ancient attempts to regulate abortion are rare. What regulations existed reflect concern with women’s behavior and marital propriety, not with fetal life. The Code of the Assura, from the eleventh century B.C.E., mandated death for married women who got abortions without consulting their husbands; when husbands beat their wives hard enough to make them miscarry, the punishment was a fine. The first known Roman prohibition on abortion dates to the second century and prescribes exile for a woman who ends her pregnancy, because “it might appear scandalous that she should be able to deny her husband of children without being punished.” Likewise, the early Christian Church opposed abortion not as an act of murder but because of its association with sexual sin. (The Bible offers ambiguous guidance on the question of when life begins: Genesis 2:7 arguably implies that it begins at first breath; Exodus 21:22-24 suggests that, in Old Testament law, a fetus was not considered a person; Jeremiah 1:5 describes God’s hand in creation even “before I formed you in the womb.” Nowhere does the Bible clearly and directly address abortion.) Augustine, in the fourth century, favored the idea that God endowed a fetus with a soul only after its body was formed—a point that Augustine placed, in line with Aristotelian tradition, somewhere between forty and eighty days into its development. “There cannot yet be a live soul in a body that lacks sensation when it is not formed in flesh, and so not yet endowed with sense,” he wrote. This was more or less the Church’s official position; it was affirmed eight centuries later by Thomas Aquinas.

In the early modern era, European attitudes began to change. The Black Death had dramatically lowered the continent’s population, and dealt a blow to most forms of economic activity; the Reformation had weakened the Church’s position as the essential intermediary between the layman and God. The social scientist Silvia Federici has argued, in her book “ Caliban and the Witch ,” that church and state waged deliberate campaigns to force women to give birth, in service of the emerging capitalist economy. “Starting in the mid-16th century, while Portuguese ships were returning from Africa with their first human cargoes, all the European governments began to impose the severest penalties against contraception, abortion, and infanticide,” Federici notes. Midwives and “wise women” were prosecuted for witchcraft, a catchall crime for deviancy from procreative sex. For the first time, male doctors began to control labor and delivery, and, Federici writes, “in the case of a medical emergency” they “prioritized the life of the fetus over that of the mother.” She goes on: “While in the Middle Ages women had been able to use various forms of contraceptives, and had exercised an undisputed control over the birthing process, from now on their wombs became public territory, controlled by men and the state.”

Martin Luther and John Calvin, the most influential figures of the Reformation, did not address abortion at any length. But Catholic doctrine started to shift, albeit slowly. In 1588, Pope Sixtus V labelled both abortion and contraception as homicide. This pronouncement was reversed three years later, by Pope Gregory XIV, who declared that abortion was only homicide if it took place after ensoulment, which he identified as occurring around twenty-four weeks into a pregnancy. Still, theologians continued to push the idea of embryonic humanity; in 1621, the physician Paolo Zacchia, an adviser to the Vatican, proclaimed that the soul was present from the moment of conception. Still, it was not until 1869 that Pope Pius IX affirmed this doctrine, proclaiming abortion at any point in pregnancy to be a sin punishable by excommunication.

When I found out I was pregnant, at the beginning of 2020, I wondered how the experience would change my understanding of life, of fetal personhood, of the morality of reproduction. It’s been years since I traded the echo chamber of evangelical Texas for the echo chamber of progressive Brooklyn, but I can still sometimes feel the old world view flickering, a photographic negative underneath my vision. I have come to believe that abortion should be universally accessible, regulated only by medical codes and ethics, and not by the criminal-justice system. Still, in passing moments, I can imagine upholding the idea that our sole task when it comes to protecting life is to end the practice of abortion; I can imagine that seeming profoundly moral and unbelievably urgent. I would only need to think of the fetus in total isolation—to imagine that it were not formed and contained by another body, and that body not formed and contained by a family, or a society, or a world.

As happens to many women, though, I became, if possible, more militant about the right to an abortion in the process of pregnancy, childbirth, and caregiving. It wasn’t just the difficult things that had this effect—the paralyzing back spasms, the ragged desperation of sleeplessness, the thundering doom that pervaded every cell in my body when I weaned my child. And it wasn’t just my newly visceral understanding of the anguish embedded in the facts of American family life. (A third of parents in one of the richest countries in the world struggle to afford diapers ; in the first few months of the pandemic , as Jeff Bezos’s net worth rose by forty-eight billion dollars, sixteen per cent of households with children did not have enough to eat.) What multiplied my commitment to abortion were the beautiful things about motherhood: in particular, the way I felt able to love my baby fully and singularly because I had chosen to give my body and life over to her. I had not been forced by law to make another person with my flesh, or to tear that flesh open to bring her into the world; I hadn’t been driven by need to give that new person away to a stranger in the hope that she would never go to bed hungry. I had been able to choose this permanent rearrangement of my existence. That volition felt sacred.

Abortion is often talked about as a grave act that requires justification, but bringing a new life into the world felt, to me, like the decision that more clearly risked being a moral mistake. The debate about abortion in America is “rooted in the largely unacknowledged premise that continuing a pregnancy is a prima facie moral good,” the pro-choice Presbyterian minister Rebecca Todd Peters writes . But childbearing, Peters notes, is a morally weighted act, one that takes place in a world of limited and unequally distributed resources. Many people who get abortions—the majority of whom are poor women who already have children—understand this perfectly well. “We ought to take the decision to continue a pregnancy far more seriously than we do,” Peters writes.

I gave birth in the middle of a pandemic that previewed a future of cross-species viral transmission exacerbated by global warming, and during a summer when ten million acres on the West Coast burned . I knew that my child would not only live in this degrading world but contribute to that degradation. (“Every year, the average American emits enough carbon to melt ten thousand tons of ice in the Antarctic ice sheets,” David Wallace-Wells writes in his book “ The Uninhabitable Earth .”) Just before COVID arrived, the science writer Meehan Crist published an essay in the London Review of Books titled “Is it OK to have a child?” (The title alludes to a question that Alexandria Ocasio-Cortez once asked in a live stream, on Instagram.) Crist details the environmental damage that we are doing, and the costs for the planet and for us and for those who will come after. Then she turns the question on its head. The idea of choosing whether or not to have a child, she writes, is predicated on a fantasy of control that “quickly begins to dissipate when we acknowledge that the conditions for human flourishing are distributed so unevenly, and that, in an age of ecological catastrophe, we face a range of possible futures in which these conditions no longer reliably exist.”

In late 2021, as Omicron brought New York to another COVID peak, a Gen Z boy in a hoodie uploaded a TikTok , captioned “yall better delete them baby names out ya notes its 60 degrees in december.” By then, my baby had become a toddler. Every night, as I set her in the crib, she chirped good night to the elephants, koalas, and tigers on the wall, and I tried not to think about extinction. My decision to have her risked, or guaranteed, additional human suffering; it opened up new chances for joy and meaning. There is unknowability in every reproductive choice.

As the German historian Barbara Duden writes in her book “ Disembodying Women ,” the early Christians believed that both the bodies that created life and the world that sustained it were proof of the “continual creative activity of God.” Women and nature were aligned, in this view, as the material sources of God’s plan. “The word nature is derived from nascitura , which means ‘birthing,’ and nature is imagined and felt to be like a pregnant womb, a matrix, a mother,” Duden writes. But, in recent decades, she notes, the natural world has begun to show its irreparable damage. The fetus has been left as a singular totem of life and divinity, to be protected, no matter the costs, even if everything else might fall.

The scholar Katie Gentile argues that, in times of cultural crisis and upheaval, the fetus functions as a “site of projected and displaced anxieties,” a “fantasy of wholeness in the face of overwhelming anxiety and an inability to have faith in a progressive, better future.” The more degraded actual life becomes on earth, the more fervently conservatives will fight to protect potential life in utero. We are locked into the destruction of the world that birthed all of us; we turn our attention, now, to the worlds—the wombs—we think we can still control.

By the time that the Catholic Church decided that abortion at any point, for any reason, was a sin, scientists had identified the biological mechanism behind human reproduction, in which a fetus develops from an embryo that develops from a zygote, the single-celled organism created by the union of egg and sperm. With this discovery, in the mid-nineteenth century, women lost the most crucial point of authority over the stories of their pregnancies. Other people would be the ones to tell us, from then on, when life began.

At the time, abortion was largely unregulated in the United States, a country founded and largely populated by Protestants. But American physicians, through the then newly formed American Medical Association, mounted a campaign to criminalize it, led by a gynecologist named Horatio Storer, who once described the typical abortion patient as a “wretch whose account with the Almighty is heaviest with guilt.” (Storer was raised Unitarian but later converted to Catholicism.) The scholars Paul Saurette and Kelly Gordon have argued that these doctors, whose profession was not as widely respected as it would later become, used abortion “as a wedge issue,” one that helped them portray their work “as morally and professionally superior to the practice of midwifery.” By 1910, abortion was illegal in every state, with exceptions only to save the life of “the mother.” (The wording of such provisions referred to all pregnant people as mothers, whether or not they had children, thus quietly inserting a presumption of fetal personhood.) A series of acts known as the Comstock laws had rendered contraception, abortifacient medicine, and information about reproductive control widely inaccessible, by criminalizing their distribution via the U.S. Postal Service. People still sought abortions, of course: in the early years of the Great Depression, there were as many as seven hundred thousand abortions annually. These underground procedures were dangerous; several thousand women died from abortions every year.

This is when the contemporary movements for and against the right to abortion took shape. Those who favored legal abortion did not, in these years, emphasize “choice,” Daniel K. Williams notes in his book “ Defenders of the Unborn .” They emphasized protecting the health of women, protecting doctors, and preventing the births of unwanted children. Anti-abortion activists, meanwhile, argued, as their successors do, that they were defending human life and human rights. The horrors of the Second World War gave the movement a lasting analogy: “Logic would lead us from abortion to the gas chamber,” a Catholic clergyman wrote, in October, 1962.

Ultrasound imaging, invented in the nineteen-fifties, completed the transformation of pregnancy into a story that, by default, was narrated to women by other people—doctors, politicians, activists. In 1965, Life magazine published a photo essay by Lennart Nilsson called “ Drama of Life Before Birth ,” and put the image of a fetus at eighteen weeks on its cover. The photos produced an indelible, deceptive image of the fetus as an isolated being—a “spaceman,” as Nilsson wrote, floating in a void, entirely independent from the person whose body creates it. They became totems of the anti-abortion movement; Life had not disclosed that all but one had been taken of aborted fetuses, and that Nilsson had lit and posed their bodies to give the impression that they were alive.

In 1967, Colorado became the first state to allow abortion for reasons other than rape, incest, or medical emergency. A group of Protestant ministers and Jewish rabbis began operating an abortion-referral service led by the pastor of Judson Memorial Church, in Manhattan; the resulting network of pro-choice clerics eventually spanned the country, and referred an estimated four hundred and fifty thousand women to safe abortions. The evangelical magazine Christianity Today held a symposium of prominent theologians, in 1968, which resulted in a striking statement: “Whether or not the performance of an induced abortion is sinful we are not agreed, but about the necessity and permissibility for it under certain circumstances we are in accord.” Meanwhile, the priest James McHugh became the director of the National Right to Life Committee, and equated fetuses to the other vulnerable people whom faithful Christians were commanded to protect: the old, the sick, the poor. As states began to liberalize their abortion laws, the anti-abortion movement attracted followers—many of them antiwar, pro-welfare Catholics—using the language of civil rights, and adopted the label “pro-life.”

W. A. Criswell, a Dallas pastor who served as president of the Southern Baptist Convention from 1968 to 1970, said, shortly after the Supreme Court issued its decision in Roe v. Wade , that “it was only after a child was born and had life separate from his mother that it became an individual person,” and that “it has always, therefore, seemed to me that what is best for the mother and the future should be allowed.” But the Court’s decision accelerated a political and theological transformation that was already under way: by 1979, Criswell, like the S.B.C., had endorsed a hard-line anti-abortion stance. Evangelical leadership, represented by such groups as Jerry Falwell’s Moral Majority , joined with Catholics to oppose the secularization of popular culture, becoming firmly conservative—and a powerful force in Republican politics. Bible verses that express the idea of divine creation, such as Psalm 139 (“For you created my innermost being; you knit me together in my mother’s womb,” in the New International Version’s translation), became policy explanations for prohibiting abortion.

In 1984, scientists used ultrasound to detect fetal cardiac activity at around six weeks’ gestation—a discovery that has been termed a “fetal heartbeat” by the anti-abortion movement, though a six-week-old fetus hasn’t yet formed a heart, and the electrical pulses are coming from cell clusters that can be replicated in a petri dish. At six weeks, in fact, medical associations still call the fetus an embryo; as I found out in 2020, you generally can’t even schedule a doctor’s visit to confirm your condition until you’re eight weeks along.

So many things that now shape the cultural experience of pregnancy in America accept and reinforce the terms of the anti-abortion movement, often with the implicit goal of making pregnant women feel special, or encouraging them to buy things. “Your baby,” every app and article whispered to me sweetly, wrongly, many months before I intuited personhood in the being inside me, or felt that the life I was forming had moved out of a liminal realm.

I tried to learn from that liminality. Hope was always predicated on uncertainty; there would be no guarantees of safety in this or any other part of life. Pregnancy did not feel like soft blankets and stuffed bunnies—it felt cosmic and elemental, like volcanic rocks grinding, or a wild plant straining toward the sun. It was violent even as I loved it. “Even with the help of modern medicine, pregnancy still kills about 800 women every day worldwide,” the evolutionary biologist Suzanne Sadedin points out in an essay titled “War in the womb.” Many of the genes that activate during embryonic development also activate when a body has been invaded by cancer, Sadedin notes; in ectopic pregnancies, which are unviable by definition and make up one to two per cent of all pregnancies, embryos become implanted in the fallopian tube rather than the uterus, and “tunnel ferociously toward the richest nutrient source they can find.” The result, Sadedin writes, “is often a bloodbath.”

The Book of Genesis tells us that the pain of childbearing is part of the punishment women have inherited from Eve. The other part is subjugation to men: “Your desire will be for your husband and he will rule over you,” God tells Eve. Tertullian, a second-century theologian, told women, “You are the devil’s gateway: you are the unsealer of the (forbidden) tree: you are the first deserter of the divine law: you are she who persuaded him whom the devil was not valiant enough to attack.” The idea that guilt inheres in female identity persists in anti-abortion logic: anything a woman, or a girl, does with her body can justify the punishment of undesired pregnancy, including simply existing.

If I had become pregnant when I was a thirteen-year-old Texan , I would have believed that abortion was wrong, but I am sure that I would have got an abortion. For one thing, my Christian school did not allow students to be pregnant. I was aware of this, and had, even then, a faint sense that the people around me grasped, in some way, the necessity of abortion—that, even if they believed that abortion meant taking a life, they understood that it could preserve a life, too.

One need not reject the idea that life in the womb exists or that fetal life has meaning in order to favor the right to abortion; one must simply allow that everything, not just abortion, has a moral dimension, and that each pregnancy occurs in such an intricate web of systemic and individual circumstances that only the person who is pregnant could hope to evaluate the situation and make a moral decision among the options at hand. A recent survey found that one-third of Americans believe life begins at conception but also that abortion should be legal. This is the position overwhelmingly held by American Buddhists, whose religious tradition casts abortion as the taking of a human life and regards all forms of life as sacred but also warns adherents against absolutism and urges them to consider the complexity of decreasing suffering, compelling them toward compassion and respect.

There is a Buddhist ritual practiced primarily in Japan, where it is called mizuko kuyo : a ceremony of mourning for miscarriages, stillbirths, and aborted fetuses. The ritual is possibly ersatz; critics say that it fosters and preys upon women’s feelings of guilt. But the scholar William LaFleur argues, in his book “ Liquid Life ,” that it is rooted in a medieval Japanese understanding of the way the unseen world interfaces with the world of humans—in which being born and dying are both “processes rather than fixed points.” An infant was believed to have entered the human world from the realm of the gods, and move clockwise around a wheel as she grew older, eventually passing back into the spirit realm on the other side. But some infants were mizuko , or water babies: floating in fluids, ontologically unstable. These were the babies who were never born. A mizuko , whether miscarried or aborted—and the two words were similar: kaeru , to go back, and kaesu , to cause to go back—slipped back, counterclockwise, across the border to the realm of the gods.

There is a loss, I think, entailed in abortion—as there is in miscarriage, whether it occurs at eight or twelve or twenty-nine weeks. I locate this loss in the irreducible complexity of life itself, in the terrible violence and magnificence of reproduction, in the death that shimmered at the edges of my consciousness in the shattering moment that my daughter was born. This understanding might be rooted in my religious upbringing—I am sure that it is. But I wonder, now, how I would square this: that fetuses were the most precious lives in existence, and that God, in His vision, already chooses to end a quarter of them. The fact that a quarter of women, regardless of their beliefs, also decide to end pregnancies at some point in their lifetimes: are they not acting in accordance with God’s plan for them, too? ♦

More on Abortion and Roe v. Wade

In the post-Roe era, letting pregnant patients get sicker— by design .

The study that debunks most anti-abortion arguments .

Of course the Constitution has nothing to say about abortion .

How the real Jane Roe shaped the abortion wars.

Black feminists defined abortion rights as a matter of equality, not just “choice.”

Recent data suggest that taking abortion pills at home is as safe as going to a clinic. 

When abortion is criminalized, women make desperate choices .

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Abortion Argumentative Essay: Definitive Guide

Academic writing

Abortion remains a debatable issue even today, especially in countries like the USA, where a controversial ban was upheld in 13 states at the point this article was written. That’s why an essay on abortion has become one of the most popular tasks in schools, colleges, and universities. When writing this kind of essay, students learn to express their opinion, find and draw arguments and examples, and conduct research.

It’s very easy to speculate on topics like this. However, this makes it harder to find credible and peer-reviewed information on the topic that isn’t merely someone’s opinion. If you were assigned this kind of academic task, do not lose heart. In this article, we will provide you with all the tips and tricks for writing about abortion.

Where to begin?

Conversations about abortion are always emotional. Complex stories, difficult decisions, bitter moments, and terrible diagnoses make this topic hard to cover. Some young people may be shocked by this assignment, while others would be happy to express their opinion on the matter.

One way or another, this topic doesn't leave anyone indifferent. However, it shouldn’t have an effect on the way you approach the research and writing process. What should you remember when working on an argumentative essay about abortion?

• Don’t let your emotions take over. As this is an academic paper, you have to stay impartial and operate with facts. The topic is indeed sore and burning, causing thousands of scandals on the Internet, but you are writing it for school, not a Quora thread.
• Try to balance your opinions. There are always two sides to one story, even if the story is so fragile. You need to present an issue from different angles. This is what your tutors seek to teach you.
• Be tolerant and mind your language. It is very important not to hurt anybody with the choice of words in your essay. So make sure you avoid any possible rough words. It is important to respect people with polar opinions, especially when it comes to academic writing. 
• Use facts, not claims. Your essay cannot be based solely on your personal ideas – your conclusions should be derived from facts. Roe v. Wade case, WHO or Mayo Clinic information, and CDC are some of the sources you can rely on.

Speaking of Outline

An argumentative essay on abortion outline is a must-have even for experienced writers. In general, each essay, irrespective of its kind or topic, has a strict outline. It may be brief or extended, but the major parts are always the same:

• Introduction. This is a relatively short paragraph that starts with a hook and presents the background information on the topic. It should end with a thesis statement telling your reader what your main goal or idea is.
• Body. This section usually consists of 2-4 paragraphs. Each one has its own structure: main argument + facts to support it + small conclusion and transition into the next paragraph.
• Conclusion. In this part, your task is to summarize all your thoughts and come to a general conclusive idea. You may have to restate some info from the body and your thesis statement and add a couple of conclusive statements without introducing new facts.

Why is it important to create an outline?

• You will structure your ideas. We bet you’ve got lots on your mind. Writing them down and seeing how one can flow logically into the other will help you create a consistent paper. Naturally, you will have to abandon some of the ideas if they don’t fit the overall narrative you’re building.
• You can get some inspiration. While creating your outline, which usually consists of some brief ideas, you can come up with many more to research. Some will add to your current ones or replace them with better options.
• You will find the most suitable sources. Argumentative essay writing requires you to use solid facts and trustworthy arguments built on them. When the topic is as controversial as abortion, these arguments should be taken from up-to-date, reliable sources. With an outline, you will see if you have enough to back up your ideas.
• You will write your text as professionals do. Most expert writers start with outlines to write the text faster and make it generally better. As you will have your ideas structured, the general flow of thoughts will be clear. And, of course, it will influence your overall grade positively.

Abortion Essay Introduction

The introduction is perhaps the most important part of the whole essay. In this relatively small part, you will have to present the issue under consideration and state your opinion on it. Here is a typical introduction outline:

• The first sentence is a hook grabbing readers' attention.
• A few sentences that go after elaborate on the hook. They give your readers some background and explain your research.
• The last sentence is a thesis statement showing the key idea you are building your text around.

Before writing an abortion essay intro, first thing first, you will need to define your position. If you are in favor of this procedure, what exactly made you think so? If you are an opponent of abortion, determine how to argue your position. In both cases, you may research the point of view in medicine, history, ethics, and other fields.

When writing an introduction, remember:

• Never repeat your title. First of all, it looks too obvious; secondly, it may be boring for your reader right from the start. Your first sentence should be a well-crafted hook. The topic of abortion worries many people, so it’s your chance to catch your audience’s attention with some facts or shocking figures.
• Do not make it too long. Your task here is to engage your audience and let them know what they are about to learn. The rest of the information will be disclosed in the main part. Nobody likes long introductions, so keep it short but informative.
• Pay due attention to the thesis statement. This is the central sentence of your introduction. A thesis statement in your abortion intro paragraph should show that you have a well-supported position and are ready to argue it. Therefore, it has to be strong and convey your idea as clearly as possible. We advise you to make several options for the thesis statement and choose the strongest one.

Hooks for an Abortion Essay

Writing a hook is a good way to catch the attention of your audience, as this is usually the first sentence in an essay. How to start an essay about abortion? You can begin with some shocking fact, question, statistics, or even a quote. However, always make sure that this piece is taken from a trusted resource.

Here are some examples of hooks you can use in your paper:

• As of July 1, 2022, 13 states banned abortion, depriving millions of women of control of their bodies.
• According to WHO, 125,000 abortions take place every day worldwide.
• Is abortion a woman’s right or a crime?
• Since 1994, more than 40 countries have liberalized their abortion laws.
• Around 48% of all abortions are unsafe, and 8% of them lead to women’s death.
• The right to an abortion is one of the reproductive and basic rights of a woman.
• Abortion is as old as the world itself – women have resorted to this method since ancient times.
• Only 60% of women in the world live in countries where pregnancy termination is allowed.

Body Paragraphs: Pros and Cons of Abortion

The body is the biggest part of your paper. Here, you have a chance to make your voice concerning the abortion issue heard. Not sure where to start? Facts about abortion pros and cons should give you a basic understanding of which direction to move in.

First things first, let’s review some brief tips for you on how to write the best essay body if you have already made up your mind.

Make a draft

It’s always a good idea to have a rough draft of your writing. Follow the outline and don’t bother with the word choice, grammar, or sentence structure much at first. You can polish it all later, as the initial draft will not likely be your final. You may see some omissions in your arguments, lack of factual basis, or repetitiveness that can be eliminated in the next versions.

Trust only reliable sources

This part of an essay includes loads of factual information, and you should be very careful with it. Otherwise, your paper may look unprofessional and cost you precious points. Never rely on sources like Wikipedia or tabloids – they lack veracity and preciseness.

Edit rigorously

It’s best to do it the next day after you finish writing so that you can spot even the smallest mistakes. Remember, this is the most important part of your paper, so it has to be flawless. You can also use editing tools like Grammarly.

Determine your weak points

Since you are writing an argumentative essay, your ideas should be backed up by strong facts so that you sound convincing. Sometimes it happens that one argument looks weaker than the other. Your task is to find it and strengthen it with more or better facts.

Add an opposing view

Sometimes, it’s not enough to present only one side of the discussion. Showing one of the common views from the opposing side might actually help you strengthen your main idea. Besides, making an attempt at refuting it with alternative facts can show your teacher or professor that you’ve researched and analyzed all viewpoints, not just the one you stand by.

If you have chosen a side but are struggling to find the arguments for or against it, we have complied abortion pro and cons list for you. You can use both sets if you are writing an abortion summary essay covering all the stances.

Why Should Abortion Be Legal

If you stick to the opinion that abortion is just a medical procedure, which should be a basic health care need for each woman, you will definitely want to write the pros of abortion essay. Here is some important information and a list of pros about abortion for you to use:

• Since the fetus is a set of cells – not an individual, it’s up to a pregnant woman to make a decision concerning her body. Only she can decide whether she wants to keep the pregnancy or have an abortion. The abortion ban is a violation of a woman’s right to have control over her own body.
• The fact that women and girls do not have access to effective contraception and safe abortion services has serious consequences for their own health and the health of their families.
• The criminalization of abortion usually leads to an increase in the number of clandestine abortions. Many years ago, fetuses were disposed of with improvised means, which included knitting needles and half-straightened metal hangers. 13% of women’s deaths are the result of unsafe abortions.
• Many women live in a difficult financial situation and cannot support their children financially. Having access to safe abortion takes this burden off their shoulders. This will also not decrease their quality of life as the birth and childcare would.
• In countries where abortion is prohibited, there is a phenomenon of abortion tourism to other countries where it can be done without obstacles. Giving access to this procedure can make the lives of women much easier.
• Women should not put their lives or health in danger because of the laws that were adopted by other people.
• Girls and women who do not have proper sex education may not understand pregnancy as a concept or determine that they are pregnant early on. Instead of educating them and giving them a choice, an abortion ban forces them to become mothers and expects them to be fit parents despite not knowing much about reproduction.
• There are women who have genetic disorders or severe mental health issues that will affect their children if they're born. Giving them an option to terminate ensures that there won't be a child with a low quality of life and that the woman will not have to suffer through pregnancy, birth, and raising a child with her condition.
• Being pro-choice is about the freedom to make decisions about your body so that women who are for termination can do it safely, and those who are against it can choose not to do it. It is an inclusive option that caters to everyone.
• Women and girls who were raped or abused by their partner, caregiver, or stranger and chose to terminate the pregnancy can now be imprisoned for longer than their abusers. This implies that the system values the life of a fetus with no or primitive brain function over the life of a living woman.
• People who lived in times when artificial termination of pregnancy was scarcely available remember clandestine abortions and how traumatic they were, not only for the physical but also for the mental health of women. Indeed, traditionally, in many countries, large families were a norm. However, the times have changed, and supervised abortion is a safe and accessible procedure these days. A ban on abortion will simply push humanity away from the achievements of the civilized world.

Types of abortion

There are 2 main types of abortions that can be performed at different pregnancy stages and for different reasons:

• Medical abortion. It is performed by taking a specially prescribed pill. It does not require any special manipulations and can even be done at home (however, after a doctor’s visit and under supervision). It is considered very safe and is usually done during the very first weeks of pregnancy.
• Surgical abortion. This is a medical operation that is done with the help of a suction tube. It then removes the fetus and any related material. Anesthesia is used for this procedure, and therefore, it can only be done in a hospital. The maximum time allowed for surgical abortion is determined in each country specifically.

Cases when abortion is needed

Center for Reproductive Rights singles out the following situations when abortion is required:

• When there is a risk to the life or physical/mental health of a pregnant woman.
• When a pregnant woman has social or economic reasons for it.
• Upon the woman's request.
• If a pregnant woman is mentally or cognitively disabled.
• In case of rape and/or incest.
• If there were congenital anomalies detected in the fetus.

Countries and their abortion laws

• Countries where abortion is legalized in any case: Australia, Albania, Bosnia and Herzegovina, Belgium, Canada, Denmark, Sweden, France, Germany, Greece, Italy, Hungary, the Netherlands, Norway, Ukraine, Moldova, Latvia, Lithuania, etc.
• Countries where abortion is completely prohibited: Angola, Venezuela, Egypt, Indonesia, Iraq, Lebanon, Nicaragua, Oman, Paraguay, Palau, Jamaica, Laos, Haiti, Honduras, Andorra, Aruba, El Salvador, Dominican Republic, Sierra Leone, Senegal, etc.
• Countries where abortion is allowed for medical reasons: Afghanistan, Israel, Argentina, Nigeria, Bangladesh, Bolivia, Ghana, Israel, Morocco, Mexico, Bahamas, Central African Republic, Ecuador, Ghana, Algeria, Monaco, Pakistan, Poland, etc. 
• Countries where abortion is allowed for both medical and socioeconomic reasons: England, India, Spain, Luxembourg, Japan, Finland, Taiwan, Zambia, Iceland, Fiji, Cyprus, Barbados, Belize, etc.

Why Abortion Should Be Banned

Essays against abortions are popular in educational institutions since we all know that many people – many minds. So if you don’t want to support this procedure in your essay, here are some facts that may help you to argument why abortion is wrong:

• Abortion at an early age is especially dangerous because a young woman with an unstable hormonal system may no longer be able to have children throughout her life. Termination of pregnancy disrupts the hormonal development of the body.
• Health complications caused by abortion can occur many years after the procedure. Even if a woman feels fine in the short run, the situation may change in the future.
• Abortion clearly has a negative effect on reproductive function. Artificial dilation of the cervix during an abortion leads to weak uterus tonus, which can cause a miscarriage during the next pregnancy.
• Evidence shows that surgical termination of pregnancy significantly increases the risk of breast cancer.
• In December 1996, the session of the Council of Europe on bioethics concluded that a fetus is considered a human being on the 14th day after conception.

You are free to use each of these arguments for essays against abortions. Remember that each claim should not be supported by emotions but by facts, figures, and so on.

Health complications after abortion

One way or another, abortion is extremely stressful for a woman’s body. Apart from that, it can even lead to various health problems in the future. You can also cover them in your cons of an abortion essay:

• Continuation of pregnancy. If the dose of the drug is calculated by the doctor in the wrong way, the pregnancy will progress.
• Uterine bleeding, which requires immediate surgical intervention.
• Severe nausea or even vomiting occurs as a result of a sharp change in the hormonal background.
• Severe stomach pain. Medical abortion causes miscarriage and, as a result, strong contractions of the uterus.
• High blood pressure and allergic reactions to medicines.
• Depression or other mental problems after a difficult procedure.

Abortion Essay Conclusion

After you have finished working on the previous sections of your paper, you will have to end it with a strong conclusion. The last impression is no less important than the first one. Here is how you can make it perfect in your conclusion paragraph on abortion:

• It should be concise. The conclusion cannot be as long as your essay body and should not add anything that cannot be derived from the main section. Reiterate the key ideas, combine some of them, and end the paragraph with something for the readers to think about.
• It cannot repeat already stated information. Restate your thesis statement in completely other words and summarize your main points. Do not repeat anything word for word – rephrase and shorten the information instead.
• It should include a call to action or a cliffhanger. Writing experts believe that a rhetorical question works really great for an argumentative essay. Another good strategy is to leave your readers with some curious ideas to ponder upon.

Abortion Facts for Essay

Abortion is a topic that concerns most modern women. Thousands of books, research papers, and articles on abortion are written across the world. Even though pregnancy termination has become much safer and less stigmatized with time, it still worries millions. What can you cover in your paper so that it can really stand out among others? You may want to add some shocking abortion statistics and facts:

• 40-50 million abortions are done in the world every year (approximately 125,000 per day).
• According to UN statistics, women have 25 million unsafe abortions each year. Most of them (97%) are performed in the countries of Africa, Asia, and Latin America. 14% of them are especially unsafe because they are done by people without any medical knowledge.
• Since 2017, the United States has shown the highest abortion rate in the last 30 years.
• The biggest number of abortion procedures happen in the countries where they are officially banned. The lowest rate is demonstrated in the countries with high income and free access to contraception.
• Women in low-income regions are three times more susceptible to unplanned pregnancies than those in developed countries.
• In Argentina, more than 38,000 women face dreadful health consequences after unsafe abortions.
• The highest teen abortion rates in the world are seen in 3 countries: England, Wales, and Sweden.
• Only 31% of teenagers decide to terminate their pregnancy. However, the rate of early pregnancies is getting lower each year.
• Approximately 13 million children are born to mothers under the age of 20 each year.
• 5% of women of reproductive age live in countries where abortions are prohibited.

We hope that this abortion information was useful for you, and you can use some of these facts for your own argumentative essay. If you find some additional facts, make sure that they are not manipulative and are taken from official medical resources.

Abortion Essay Topics

Do you feel like you are lost in the abundance of information? Don’t know what topic to choose among the thousands available online? Check our short list of the best abortion argumentative essay topics:

• Why should abortion be legalized essay
• Abortion: a murder or a basic human right?
• Why we should all support abortion rights
• Is the abortion ban in the US a good initiative?
• The moral aspect of teen abortions
• Can the abortion ban solve birth control problems?
• Should all countries allow abortion?
• What consequences can abortion have in the long run?
• Is denying abortion sexist?
• Why is abortion a human right?
• Are there any ethical implications of abortion?
• Do you consider abortion a crime?
• Should women face charges for terminating a pregnancy?

Want to come up with your own? Here is how to create good titles for abortion essays:

• Write down the first associations. It can be something that swirls around in your head and comes to the surface when you think about the topic. These won’t necessarily be well-written headlines, but each word or phrase can be the first link in the chain of ideas that leads you to the best option.
• Irony and puns are not always a good idea. Especially when it comes to such difficult topics as abortion. Therefore, in your efforts to be original, remain sensitive to the issue you want to discuss.
• Never make a quote as your headline. First, a wordy quote makes the headline long. Secondly, readers do not understand whose words are given in the headline. Therefore, it may confuse them right from the start. If you have found a great quote, you can use it as your hook, but don’t forget to mention its author.
• Try to briefly summarize what is said in the essay. What is the focus of your paper? If the essence of your argumentative essay can be reduced to one sentence, it can be used as a title, paraphrased, or shortened.
• Write your title after you have finished your text. Before you just start writing, you might not yet have a catchy phrase in mind to use as a title. Don’t let it keep you from working on your essay – it might come along as you write.

Abortion Essay Example

We know that it is always easier to learn from a good example. For this reason, our writing experts have complied a detailed abortion essay outline for you. For your convenience, we have created two options with different opinions.

Topic: Why should abortion be legal?

Introduction – hook + thesis statement + short background information

Essay hook: More than 59% of women in the world do not have access to safe abortions, which leads to dreading health consequences or even death.

Thesis statement: Since banning abortions does not decrease their rates but only makes them unsafe, it is not logical to ban abortions.

Body – each paragraph should be devoted to one argument

Argument 1: Woman’s body – women’s rules. + example: basic human rights.

Argument 2: Banning abortion will only lead to more women’s death. + example: cases of Polish women.

Argument 3: Only women should decide on abortion. + example: many abortion laws are made by male politicians who lack knowledge and first-hand experience in pregnancies.

Conclusion – restated thesis statement + generalized conclusive statements + cliffhanger

Restated thesis: The abortion ban makes pregnancy terminations unsafe without decreasing the number of abortions, making it dangerous for women.

Cliffhanger: After all, who are we to decide a woman’s fate?

Topic: Why should abortion be banned?

Essay hook: Each year, over 40 million new babies are never born because their mothers decide to have an abortion.

Thesis statement: Abortions on request should be banned because we cannot decide for the baby whether it should live or die.

Argument 1: A fetus is considered a person almost as soon as it is conceived. Killing it should be regarded as murder. + example: Abortion bans in countries such as Poland, Egypt, etc.

Argument 2: Interrupting a baby’s life is morally wrong. + example: The Bible, the session of the Council of Europe on bioethics decision in 1996, etc.

Argument 3: Abortion may put the reproductive health of a woman at risk. + example: negative consequences of abortion.

Restated thesis: Women should not be allowed to have abortions without serious reason because a baby’s life is as priceless as their own.

Cliffhanger: Why is killing an adult considered a crime while killing an unborn baby is not?

Examples of Essays on Abortion

There are many great abortion essays examples on the Web. You can easily find an argumentative essay on abortion in pdf and save it as an example. Many students and scholars upload their pieces to specialized websites so that others can read them and continue the discussion in their own texts.

In a free argumentative essay on abortion, you can look at the structure of the paper, choice of the arguments, depth of research, and so on. Reading scientific papers on abortion or essays of famous activists is also a good idea. Here are the works of famous authors discussing abortion.

A Defense of Abortion by Judith Jarvis Thomson

Published in 1971, this essay by an American philosopher considers the moral permissibility of abortion. It is considered the most debated and famous essay on this topic, and it’s definitely worth reading no matter what your stance is.

Abortion and Infanticide by Michael Tooley

It was written in 1972 by an American philosopher known for his work in the field of metaphysics. In this essay, the author considers whether fetuses and infants have the same rights. Even though this work is quite complex, it presents some really interesting ideas on the matter.

Some Biological Insights into Abortion by Garret Hardin

This article by American ecologist Garret Hardin, who had focused on the issue of overpopulation during his scholarly activities, presents some insights into abortion from a scientific point of view. He also touches on non-biological issues, such as moral and economic. This essay will be of great interest to those who support the pro-choice stance.

H4 Hidden in Plain View: An Overview of Abortion in Rural Illinois and Around the Globe by Heather McIlvaine-Newsad 

In this study, McIlvaine-Newsad has researched the phenomenon of abortion since prehistoric times. She also finds an obvious link between the rate of abortions and the specifics of each individual country. Overall, this scientific work published in 2014 is extremely interesting and useful for those who want to base their essay on factual information.

H4 Reproduction, Politics, and John Irving’s The Cider House Rules: Women’s Rights or “Fetal Rights”? by Helena Wahlström

In her article of 2013, Wahlström considers John Irving’s novel The Cider House Rules published in 1985 and is regarded as a revolutionary work for that time, as it acknowledges abortion mostly as a political problem. This article will be a great option for those who want to investigate the roots of the abortion debate.

FAQs On Abortion Argumentative Essay

• Is abortion immoral?

This question is impossible to answer correctly because each person independently determines their own moral framework. One group of people will say that abortion is a woman’s right because only she has power over her body and can make decisions about it. Another group will argue that the embryo is also a person and has the right to birth and life.

In general, the attitude towards abortion is determined based on the political and religious views of each person. Religious people generally believe that abortion is immoral because it is murder, while secular people see it as a normal medical procedure. For example, in the US, the ban on abortion was introduced in red states where the vast majority have conservative views, while blue liberal states do not support this law. Overall, it’s up to a person to decide whether they consider abortion immoral based on their own values and beliefs.

• Is abortion legal?

The answer to this question depends on the country in which you live. There are countries in which pregnancy termination is a common medical procedure and is performed at the woman's request. There are also states in which there must be a serious reason for abortion: medical, social, or economic. Finally, there are nations in which abortion is prohibited and criminalized. For example, in Jamaica, a woman can get life imprisonment for abortion, while in Kenya, a medical worker who volunteers to perform an abortion can be imprisoned for up to 14 years.

• Is abortion safe?

In general, modern medicine has reached such a level that abortion has become a common (albeit difficult from various points of view) medical procedure. There are several types of abortion, as well as many medical devices and means that ensure the maximum safety of the pregnancy termination. Like all other medical procedures, abortion can have various consequences and complications.

Abortions – whether safe or not - exist in all countries of the world. The thing is that more than half of them are dangerous because women have them in unsuitable conditions and without professional help. Only universal access to abortion in all parts of the world can make it absolutely safe. In such a case, it will be performed only after a thorough assessment and under the control of a medical professional who can mitigate the potential risks.

• How safe is abortion?

If we do not talk about the ethical side of the issue related to abortion, it still has some risks. In fact, any medical procedure has them to a greater or lesser extent.

The effectiveness of the safe method in a medical setting is 80-99%. An illegal abortion (for example, the one without special indications after 12 weeks) can lead to a patient’s death, and the person who performed it will be criminally liable in this case.

Doctors do not have universal advice for all pregnant women on whether it is worth making this decision or not. However, many of them still tend to believe that any contraception - even one that may have negative side effects - is better than abortion. That’s why spreading awareness on means of contraception and free access to it is vital.

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The Landmark Decision: Understanding Roe V. Wade

This essay about Roe v. Wade explores the landmark Supreme Court decision of 1973, which affirmed a woman’s constitutional right to choose whether to terminate her pregnancy. It discusses the case’s origins, the Court’s ruling on the right to privacy, and the framework established for regulating abortion. Highlighting the societal impact and ongoing debate surrounding the decision, the essay emphasizes its significance in shaping reproductive rights, political discourse, and American culture. Roe v. Wade remains a polarizing issue, symbolizing the tension between individual autonomy and state interests in matters of personal morality and medical ethics.

How it works

In the realm of American jurisprudence, few cases have had as profound an impact as Roe v. Wade. This landmark decision, handed down by the United States Supreme Court in 1973, fundamentally altered the landscape of reproductive rights in the country. At its core, Roe v. Wade addressed the constitutionality of laws that criminalized or restricted access to abortion, sparking a national dialogue that continues to resonate to this day.

The case originated in Texas, where a woman identified as “Jane Roe” challenged the state’s abortion laws, which prohibited the procedure except to save the life of the mother.

Roe argued that these restrictions violated her constitutional right to privacy. The Supreme Court, in a 7-2 decision, agreed with Roe, asserting that the right to privacy encompassed a woman’s right to choose whether to terminate her pregnancy.

Central to the Court’s ruling was the concept of viability, referring to the point at which a fetus could potentially survive outside the womb. The Court established a framework that divided pregnancy into three trimesters, with different levels of state interest and regulation permitted at each stage. During the first trimester, the decision to terminate a pregnancy was deemed solely within the realm of the woman and her physician. As the pregnancy progressed, the state’s interest in regulating abortion became more substantial, but could not override the woman’s right to choose until the point of viability.

Roe v. Wade ignited a firestorm of debate and controversy that continues to shape American politics and culture. Proponents hailed the decision as a victory for women’s rights and reproductive freedom, while opponents decried it as an assault on the sanctity of life and the traditional family unit. In the decades since the ruling, Roe v. Wade has faced numerous legal challenges and attempts to undermine or overturn it, yet it remains the law of the land.

Beyond its immediate legal implications, Roe v. Wade has had far-reaching societal effects. It has fueled ongoing debates over the role of government in regulating personal medical decisions, the intersection of morality and law, and the definition of personhood. The case has also become a rallying cry for activists on both sides of the abortion issue, shaping electoral politics, judicial appointments, and public policy at all levels of government.

Despite its significance, Roe v. Wade remains a contentious and divisive issue in American society. Public opinion on abortion rights fluctuates, reflecting shifting cultural attitudes, religious beliefs, and political ideologies. Yet, the decision’s enduring legacy lies in its recognition of a woman’s autonomy over her own body and the recognition of reproductive rights as fundamental to gender equality and individual liberty.

In conclusion, Roe v. Wade stands as a pivotal moment in American legal history, reshaping the landscape of reproductive rights and sparking a national conversation that endures to this day. Whether viewed as a triumph of individual freedom or a challenge to traditional values, the decision continues to shape the contours of American society and inspire passionate advocacy on all sides of the issue.

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• v.61(1); Jan-Mar 2020

A research on abortion: ethics, legislation and socio-medical outcomes. Case study: Romania

Andreea mihaela niţă.

1 Faculty of Social Sciences, University of Craiova, Romania

Cristina Ilie Goga

This article presents a research study on abortion from a theoretical and empirical point of view. The theoretical part is based on the method of social documents analysis, and presents a complex perspective on abortion, highlighting items of medical, ethical, moral, religious, social, economic and legal elements. The empirical part presents the results of a sociological survey, based on the opinion survey method through the application of the enquiry technique, conducted in Romania, on a sample of 1260 women. The purpose of the survey is to identify Romanians perception on the decision to voluntary interrupt pregnancy, and to determine the core reasons in carrying out an abortion.

The analysis of abortion by means of medical and social documents

Abortion means a pregnancy interruption “before the fetus is viable” [ 1 ] or “before the fetus is able to live independently in the extrauterine environment, usually before the 20 th week of pregnancy” [ 2 ]. “Clinical miscarriage is both a common and distressing complication of early pregnancy with many etiological factors like genetic factors, immune factors, infection factors but also psychological factors” [ 3 ]. Induced abortion is a practice found in all countries, but the decision to interrupt the pregnancy involves a multitude of aspects of medical, ethical, moral, religious, social, economic, and legal order.

In a more simplistic manner, Winston Nagan has classified opinions which have as central element “abortion”, in two major categories: the opinion that the priority element is represented by fetus and his entitlement to life and the second opinion, which focuses around women’s rights [ 4 ].

From the medical point of view, since ancient times there have been four moments, generally accepted, which determine the embryo’s life: ( i ) conception; ( ii ) period of formation; ( iii ) detection moment of fetal movement; ( iv ) time of birth [ 5 ]. Contemporary medicine found the following moments in the evolution of intrauterine fetal: “ 1 . At 18 days of pregnancy, the fetal heartbeat can be perceived and it starts running the circulatory system; 2 . At 5 weeks, they become more clear: the nose, cheeks and fingers of the fetus; 3 . At 6 weeks, they start to function: the nervous system, stomach, kidneys and liver of the fetus, and its skeleton is clearly distinguished; 4 . At 7 weeks (50 days), brain waves are felt. The fetus has all the internal and external organs definitively outlined. 5 . At 10 weeks (70 days), the unborn child has all the features clearly defined as a child after birth (9 months); 6 . At 12 weeks (92 days, 3 months), the fetus has all organs definitely shaped, managing to move, lacking only the breath” [ 6 ]. Even if most of the laws that allow abortion consider the period up to 12 weeks acceptable for such an intervention, according to the above-mentioned steps, there can be defined different moments, which can represent the beginning of life. Nowadays, “abortion is one of the most common gynecological experiences and perhaps the majority of women will undergo an abortion in their lifetimes” [ 7 ]. “Safe abortions carry few health risks, but « every year, close to 20 million women risk their lives and health by undergoing unsafe abortions » and 25% will face a complication with permanent consequences” [ 8 , 9 ].

From the ethical point of view, most of the times, the interruption of pregnancy is on the border between woman’s right over her own body and the child’s (fetus) entitlement to life. Judith Jarvis Thomson supported the supremacy of woman’s right over her own body as a premise of freedom, arguing that we cannot force a person to bear in her womb and give birth to an unwanted child, if for different circumstances, she does not want to do this [ 10 ]. To support his position, the author uses an imaginary experiment, that of a violinist to which we are connected for nine months, in order to save his life. However, Thomson debates the problem of the differentiation between the fetus and the human being, by carrying out a debate on the timing which makes this difference (period of conception, 10 weeks of pregnancy, etc.) and highlighting that for people who support abortion, the fetus is not an alive human being [ 10 ].

Carol Gilligan noted that women undergo a true “moral dilemma”, a “moral conflict” with regards to voluntary interruption of pregnancy, such a decision often takes into account the human relationships, the possibility of not hurting the others, the responsibility towards others [ 11 ]. Gilligan applied qualitative interviews to a number of 29 women from different social classes, which were put in a position to decide whether or not to commit abortion. The interview focused on the woman’s choice, on alternative options, on individuals and existing conflicts. The conclusion was that the central moral issue was the conflict between the self (the pregnant woman) and others who may be hurt as a result of the potential pregnancy [ 12 ].

From the religious point of view, abortion is unacceptable for all religions and a small number of abortions can be seen in deeply religious societies and families. Christianity considers the beginning of human life from conception, and abortion is considered to be a form of homicide [ 13 ]. For Christians, “at the same time, abortion is giving up their faith”, riot and murder, which means that by an abortion we attack Jesus Christ himself and God [ 14 ]. Islam does not approve abortion, relying on the sacral life belief as specified in Chapter 6, Verse 151 of the Koran: “Do not kill a soul which Allah has made sacred (inviolable)” [ 15 ]. Buddhism considers abortion as a negative act, but nevertheless supports for medical reasons [ 16 ]. Judaism disapproves abortion, Tanah considering it to be a mortal sin. Hinduism considers abortion as a crime and also the greatest sin [ 17 ].

From the socio-economic point of view, the decision to carry out an abortion is many times determined by the relations within the social, family or financial frame. Moreover, studies have been conducted, which have linked the legalization of abortions and the decrease of the crime rate: “legalized abortion may lead to reduced crime either through reductions in cohort sizes or through lower per capita offending rates for affected cohorts” [ 18 ].

Legal regulation on abortion establishes conditions of the abortion in every state. In Europe and America, only in the XVIIth century abortion was incriminated and was considered an insignificant misdemeanor or a felony, depending on when was happening. Due to the large number of illegal abortions and deaths, two centuries later, many states have changed legislation within the meaning of legalizing voluntary interruption of pregnancy [ 6 ]. In contemporary society, international organizations like the United Nations or the European Union consider sexual and reproductive rights as fundamental rights [ 19 , 20 ], and promotes the acceptance of abortion as part of those rights. However, not all states have developed permissive legislation in the field of voluntary interruption of pregnancy.

Currently, at national level were established four categories of legislation on pregnancy interruption area:

( i )  Prohibitive legislations , ones that do not allow abortion, most often outlining exceptions in abortion in cases where the pregnant woman’s life is endangered. In some countries, there is a prohibition of abortion in all circumstances, however, resorting to an abortion in the case of an imminent threat to the mother’s life. Same regulation is also found in some countries where abortion is allowed in cases like rape, incest, fetal problems, etc. In this category are 66 states, with 25.5% of world population [ 21 ].

( ii )  Restrictive legislation that allow abortion in cases of health preservation . Loosely, the term “health” should be interpreted according to the World Health Organization (WHO) definition as: “health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” [ 22 ]. This type of legislation is adopted in 59 states populated by 13.8% of the world population [ 21 ].

( iii )  Legislation allowing abortion on a socio-economic motivation . This category includes items such as the woman’s age or ability to care for a child, fetal problems, cases of rape or incest, etc. In this category are 13 countries, where we have 21.3% of the world population [ 21 ].

( iv )  Legislation which do not impose restrictions on abortion . In the case of this legislation, abortion is permitted for any reason up to 12 weeks of pregnancy, with some exceptions (Romania – 14 weeks, Slovenia – 10 weeks, Sweden – 18 weeks), the interruption of pregnancy after this period has some restrictions. This type of legislation is adopted in 61 countries with 39.5% of the world population [21].

The Centre for Reproductive Rights has carried out from 1998 a map of the world’s states, based on the legislation typology of each country (Figure ​ (Figure1 1 ).

The analysis of states according to the legislation regarding abortion. Source: Centre for Reproductive Rights. The World’s Abortion Laws, 2018 [ 23 ]

An unplanned pregnancy, socio-economic context or various medical problems [ 24 ], lead many times to the decision of interrupting pregnancy, regardless the legislative restrictions. In the study “Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008” issued in 2011 by the WHO , it was determined that within the states with restrictive legislation on abortion, we may also encounter a large number of illegal abortions. The illegal abortions may also be resulting in an increased risk of woman’s health and life considering that most of the times inappropriate techniques are being used, the hygienic conditions are precarious and the medical treatments are incorrectly administered [ 25 ]. Although abortions done according to medical guidelines carry very low risk of complications, 1–3 unsafe abortions contribute substantially to maternal morbidity and death worldwide [ 26 ].

WHO has estimated for the year 2008, the fact that worldwide women between the ages of 15 and 44 years carried out 21.6 million “unsafe” abortions, which involved a high degree of risk and were distributed as follows: 0.4 million in the developed regions and a number of 21.2 million in the states in course of development [ 25 ].

Case study: Romania

Legal perspective on abortion

In Romania, abortion was brought under regulation by the first Criminal Code of the United Principalities, from 1864.

The Criminal Code from 1864, provided the abortion infringement in Article 246, on which was regulated as follows: “Any person, who, using means such as food, drinks, pills or any other means, which will consciously help a pregnant woman to commit abortion, will be punished to a minimum reclusion (three years).

The woman who by herself shall use the means of abortion, or would accept to use means of abortion which were shown or given to her for this purpose, will be punished with imprisonment from six months to two years, if the result would be an abortion. In a situation where abortion was carried out on an illegitimate baby by his mother, the punishment will be imprisonment from six months to one year.

Doctors, surgeons, health officers, pharmacists (apothecary) and midwives who will indicate, will give or will facilitate these means, shall be punished with reclusion of at least four years, if the abortion took place. If abortion will cause the death of the mother, the punishment will be much austere of four years” (Art. 246) [ 27 ].

The Criminal Code from 1864, reissued in 1912, amended in part the Article 246 for the purposes of eliminating the abortion of an illegitimate baby case. Furthermore, it was no longer specified the minimum of four years of reclusion, in case of abortion carried out with the help of the medical staff, leaving the punishment to the discretion of the Court (Art. 246) [ 28 ].

The Criminal Code from 1936 regulated abortion in the Articles 482–485. Abortion was defined as an interruption of the normal course of pregnancy, being punished as follows:

“ 1 . When the crime is committed without the consent of the pregnant woman, the punishment was reformatory imprisonment from 2 to 5 years. If it caused the pregnant woman any health injury or a serious infirmity, the punishment was reformatory imprisonment from 3 to 6 years, and if it has caused her death, reformatory imprisonment from 7 to 10 years;

2 . When the crime was committed by the unmarried pregnant woman by herself, or when she agreed that someone else should provoke the abortion, the punishment is reformatory imprisonment from 3 to 6 months, and if the woman is married, the punishment is reformatory imprisonment from 6 months to one year. Same penalty applies also to the person who commits the crime with the woman’s consent. If abortion was committed for the purpose of obtaining a benefit, the punishment increases with another 2 years of reformatory imprisonment.

If it caused the pregnant woman any health injuries or a severe disablement, the punishment will be reformatory imprisonment from one to 3 years, and if it has caused her death, the punishment is reformatory imprisonment from 3 to 5 years” (Art. 482) [ 29 ].

The criminal legislation from 1936 specifies that it is not considered as an abortion the interruption from the normal course of pregnancy, if it was carried out by a doctor “when woman’s life was in imminent danger or when the pregnancy aggravates a woman’s disease, putting her life in danger, which could not be removed by other means and it is obvious that the intervention wasn’t performed with another purpose than that of saving the woman’s life” and “when one of the parents has reached a permanent alienation and it is certain that the child will bear serious mental flaws” (Art. 484, Par. 1 and Par. 2) [ 29 ].

In the event of an imminent danger, the doctor was obliged to notify prosecutor’s office in writing, within 48 hours after the intervention, on the performance of the abortion. “In the other cases, the doctor was able to intervene only with the authorization of the prosecutor’s office, given on the basis of a medical certificate from hospital or a notice given as a result of a consultation between the doctor who will intervene and at least a professor doctor in the disease which caused the intervention. General’s Office Prosecutor, in all cases provided by this Article, shall be obliged to maintain the confidentiality of all communications or authorizations, up to the intercession of any possible complaints” (Art. 484) [ 29 ].

The legislation of 1936 provided a reformatory injunction from one to three years for the abortions committed by doctors, sanitary agents, pharmacists, apothecary or midwives (Art. 485) [ 29 ].

Abortion on demand has been legalized for the first time in Romania in the year 1957 by the Decree No. 463, under the condition that it had to be carried out in a hospital and to be carried out in the first quarter of the pregnancy [ 30 ]. In the year 1966, demographic policy of Romania has dramatically changed by introducing the Decree No. 770 from September 29 th , which prohibited abortion. Thus, the voluntary interruption of pregnancy became a crime, with certain exceptions, namely: endangering the mother’s life, physical or mental serious disability; serious or heritable illness, mother’s age over 45 years, if the pregnancy was a result of rape or incest or if the woman gave birth to at least four children who were still in her care (Art. 2) [ 31 ].

In the Criminal Code from 1968, the abortion crime was governed by Articles 185–188.

The Article 185, “the illegal induced abortion”, stipulated that “the interruption of pregnancy by any means, outside the conditions permitted by law, with the consent of the pregnant woman will be punished with imprisonment from one to 3 years”. The act referred to above, without the prior consent from the pregnant woman, was punished with prison from two to five years. If the abortion carried out with the consent of the pregnant woman caused any serious body injury, the punishment was imprisonment from two to five years, and when it caused the death of the woman, the prison sentence was from five to 10 years. When abortion was carried out without the prior consent of the woman, if it caused her a serious physical injury, the punishment was imprisonment from three to six years, and if it caused the woman’s death, the punishment was imprisonment from seven to 12 years (Art. 185) [ 32 ].

“When abortion was carried out in order to obtain a material benefit, the maximum punishment was increased by two years, and if the abortion was made by a doctor, in addition to the prison punishment could also be applied the prohibition to no longer practice the profession of doctor”.

Article 186, “abortion caused by the woman”, stipulated that “the interruption of the pregnancy course, committed by the pregnant woman, was punished with imprisonment from 6 months to 2 years”, quoting the fact that by the same punishment was also sanctioned “the pregnant woman’s act to consent in interrupting the pregnancy course made out by another person” (Art. 186) [ 26 ].

The Regulations of the Criminal Code in 1968, also provided the crime of “ownership of tools or materials that can cause abortion”, the conditions of this holding being met when these types of instruments were held outside the hospital’s specialized institutions, the infringement shall be punished with imprisonment from three months to one year (Art. 187) [ 32 ].

Furthermore, the doctors who performed an abortion in the event of extreme urgency, without prior legal authorization and if they did not announce the competent authority within the legal deadline, they were punished by imprisonment from one month to three months (Art. 188) [ 32 ].

In the year 1985, it has been issued the Decree No. 411 of December 26 th , by which the conditions imposed by the Decree No. 770 of 1966 have been hardened, meaning that it has increased the number of children, that a woman could have in order to request an abortion, from four to five children [ 33 ].

The Articles 185–188 of the Criminal Code and the Decree No. 770/1966 on the interruption of the pregnancy course have been abrogated by Decree-Law No. 1 from December 26 th , 1989, which was published in the Official Gazette No. 4 of December 27 th , 1989 (Par. 8 and Par. 12) [ 34 ].

The Criminal Code from 1968, reissued in 1997, maintained Article 185 about “the illegal induced abortion”, but drastically modified. Thus, in this case of the Criminal Code, we identify abortion as “the interruption of pregnancy course, by any means, committed in any of the following circumstances: ( a ) outside medical institutions or authorized medical practices for this purpose; ( b ) by a person who does not have the capacity of specialized doctor; ( c ) if age pregnancy has exceeded 14 weeks”, the punishment laid down was the imprisonment from 6 months to 3 years” (Art. 185, Par. 1) [ 35 ]. For the abortion committed without the prior consent of the pregnant woman, the punishment consisted in strict prison conditions from two to seven years and with the prohibition of certain rights (Art. 185, Par. 2) [ 35 ].

For the situation of causing serious physical injury to the pregnant woman, the punishment was strict prison from three to 10 years and the removal of certain rights, and if it had as a result the death of the pregnant woman, the punishment was strict prison from five to 15 years and the prohibition of certain rights (Art. 185, Par. 3) [ 35 ].

The attempt was punished for the crimes specified in the various cases of abortion.

Consideration should also be given in the Criminal Code reissued in 1997 for not punishing the interruption of the pregnancy course carried out by the doctor, if this interruption “was necessary to save the life, health or the physical integrity of the pregnant woman from a grave and imminent danger and that it could not be removed otherwise; in the case of a over fourteen weeks pregnancy, when the interruption of the pregnancy course should take place from therapeutic reasons” and even in a situation of a woman’s lack of consent, when it has not been given the opportunity to express her will, and abortion “was imposed by therapeutic reasons” (Art. 185, Par. 4) [ 35 ].

Criminal Code from 2004 covers abortion in Article 190, defined in the same way as in the prior Criminal Code, with the difference that it affects the limits of the punishment. So, in the event of pregnancy interruption, in accordance with the conditions specified in Paragraph 1, “the penalty provided was prison time from 6 months to one year or days-fine” (Art. 190, Par. 1) [ 36 ].

Nowadays, in Romania, abortion is governed by the criminal law of 2009, which entered into force in 2014, by the section called “aggression against an unborn child”. It should be specified that current criminal law does not punish the woman responsible for carrying out abortion, but only the person who is involved in carrying out the abortion. There is no punishment for the pregnant woman who injures her fetus during pregnancy.

In Article 201, we can find the details on the pregnancy interruption infringement. Thus, the pregnancy interruption can be performed in one of the following circumstances: “outside of medical institutions or medical practices authorized for this purpose; by a person who does not have the capacity of specialist doctor in Obstetrics and Gynecology and the right of free medical practice in this specialty; if gestational age has exceeded 14 weeks”, the punishment is the imprisonment for six months to three years, or fine and the prohibition to exercise certain rights (Art. 201, Par. 1) [ 37 ].

Article 201, Paragraph 2 specifies that “the interruption of the pregnancy committed under any circumstances, without the prior consent of the pregnant woman, can be punished with imprisonment from 2 to 7 years and with the prohibition to exercise some rights” (Art. 201, Par. 1) [ 37 ].

If by facts referred to above (Art. 201, Par. 1 and Par. 2) [ 37 ] “it has caused the pregnant woman’s physical injury, the punishment is the imprisonment from 3 to 10 years and the prohibition to exercise some rights, and if it has had as a result the pregnant woman’s death, the punishment is the imprisonment from 6 to 12 years and the prohibition to exercise some rights” (Art. 201, Par. 3) [ 37 ]. When the facts have been committed by a doctor, “in addition to the imprisonment punishment, it will also be applied the prohibition to exercise the profession of doctor (Art. 201, Par. 4) [ 37 ].

Criminal legislation specifies that “the interruption of pregnancy does not constitute an infringement with the purpose of a treatment carried out by a specialist doctor in Obstetrics and Gynecology, until the pregnancy age of twenty-four weeks is reached, or the subsequent pregnancy interruption, for the purpose of treatment, is in the interests of the mother or the fetus” (Art. 201, Par. 6) [ 37 ]. However, it can all be found in the phrases “therapeutic purposes” and “the interest of the mother and of the unborn child”, which predisposes the text of law to an interpretation, finally the doctors are the only ones in the position to decide what should be done in such cases, assuming direct responsibility [ 38 ].

Article 202 of the Criminal Code defines the crime of harming an unborn child, pointing out the punishments for the various types of injuries that can occur during pregnancy or in the childbirth period and which can be caused by the mother or by the persons who assist the birth, with the specification that the mother who harms her fetus during pregnancy is not punished and does not constitute an infringement if the injury has been committed during pregnancy or during childbirth period if the facts have been “committed by a doctor or by an authorized person to assist the birth or to follow the pregnancy, if they have been committed in the course of the medical act, complying with the specific provisions of his profession and have been made in the interest of the pregnant woman or fetus, as a result of the exercise of an inherent risk in the medical act” (Art. 202, Par. 6) [ 37 ].

The fact situation in Romania

During the period 1948–1955, called “the small baby boom” [ 39 ], Romania registered an average fertility rate of 3.23 children for a woman. Between 1955 and 1962, the fertility rate has been less than three children for a woman, and in 1962, fertility has reached an average of two children for a woman. This phenomenon occurred because of the Decree No. 463/1957 on liberalization of abortion. After the liberalization from 1957, the abortion rate has increased from 220 abortions per 100 born-alive children in the year 1960, to 400 abortions per 100 born-alive children, in the year 1965 [ 40 ].

The application of provisions of Decrees No. 770 of 1966 and No. 411 of 1985 has led to an increase of the birth rate in the first three years (an average of 3.7 children in 1967, and 3.6 children in 1968), followed by a regression until 1989, when it was recorded an average of 2.2 children, but also a maternal death rate caused by illegal abortions, raising up to 85 deaths of 100 000 births in the year of 1965, and 170 deaths in 1983. It was estimated that more than 80% of maternal deaths between 1980–1989 was caused by legal constraints [ 30 ].

After the Romanian Revolution in December 1989 and after the communism fall, with the abrogation of Articles 185–188 of the Criminal Code and of the Decree No. 770/1966, by the Decree of Law No. 1 of December 26 th , 1989, abortion has become legal in Romania and so, in the following years, it has reached the highest rate of abortion in Europe. Subsequently, the number of abortion has dropped gradually, with increasing use of birth control [ 41 ].

Statistical data issued by the Ministry of Health and by the National Institute of Statistics (INS) in Romania show corresponding figures to a legally carried out abortion. The abortion number is much higher, if it would take into account the number of illegal abortion, especially those carried out before 1989, and those carried out in private clinics, after the year 1990. Summing the declared abortions in the period 1958–2014, it is to be noted the number of them, 22 037 747 exceeds the current Romanian population. A detailed statistical research of abortion rate, in terms of years we have exposed in Table ​ Table1 1 .

The number of abortions declared in Romania in the period 1958–2016

Source: Pro Vita Association (Bucharest, Romania), National Institute of Statistics (INS – Romania), EUROSTAT [ 42 , 43 , 44 ]

Data issued by the United Nations International Children’s Emergency Fund (UNICEF) in June 2016, for the period 1989–2014, in matters of reproductive behavior, indicates a fertility rate for Romania with a continuous decrease, in proportion to the decrease of the number of births, but also a lower number of abortion rate reported to 100 deliveries (Table ​ (Table2 2 ).

Reproductive behavior in Romania in 1989–2014

Source: United Nations International Children’s Emergency Fund (UNICEF), Transformative Monitoring for Enhanced Equity (TransMonEE) Data. Country profiles: Romania, 1989–2015 [ 45 ].

By analyzing data issued for the period 1990–2015 by the International Organization of Health , UNICEF , United Nations Fund for Population Activity (UNFPA), The World Bank and the United Nations Population Division, it is noticed that maternal mortality rate has currently dropped as compared with 1990 (Table ​ (Table3 3 ).

Maternal mortality estimation in Romania in 1990–2015

Source: World Health Organization (WHO), Global Health Observatory Data. Maternal mortality country profiles: Romania, 2015 [ 46 ].

Opinion survey: women’s opinion on abortion

Argument for choosing the research theme

Although the problematic on abortion in Romania has been extensively investigated and debated, it has not been carried out in an ample sociological study, covering Romanian women’s perception on abortion. We have assumed making a study at national level, in order to identify the opinion on abortion, on the motivation to carry out an abortion, and to identify the correlation between religious convictions and the attitude toward abortion.

Examining the literature field of study

In the conceptual register of the research, we have highlighted items, such as the specialized literature, legislation, statistical documents.

Formulation of hypotheses and objectives

The first hypothesis was that Romanian women accept abortion, having an open attitude towards this act. Thus, the first objective of the research was to identify Romanian women’s attitude towards abortion.

The second hypothesis, from which we started, was that high religious beliefs generate a lower tolerance towards abortion. Thus, the second objective of our research has been to identify the correlation between the religious beliefs and the attitude towards abortion.

The third hypothesis of the survey was that, the main motivation in carrying out an abortion is the fact that a woman does not want a baby, and the main motivation for keeping the pregnancy is that the person wants a baby. In this context, the third objective of the research was to identify main motivation in carrying out an abortion and in maintaining a pregnancy.

Another hypothesis was that modern Romanian legislation on the abortion is considered fair. Based on this hypothesis, we have assumed the fourth objective, which is to identify the degree of satisfaction towards the current regulatory provisions governing the abortion.

Research methodology

The research method is that of a sociological survey by the application of the questionnaire technique. We used the sampling by age and residence looking at representative numbers of population from more developed as well as underdeveloped areas.

Determination of the sample to be studied

Because abortion is a typical women’s experience, we have chosen to make the quantitative research only among women. We have constructed the sample by selecting a number of 1260 women between the ages of 15 and 44 years (the most frequently encountered age among women who give birth to a child). We also used the quota sampling techniques, taking into account the following variables: age group and the residence (urban/rural), so that the persons included in the sample could retain characteristic of the general population.

By the sample of 1260 women, we have made a percentage of investigation of 0.03% of the total population.

The Questionnaires number applied was distributed as follows (Table ​ (Table4 4 ).

The sampling rates based on the age, and the region of residence

Source: Sample built, based on the population data issued by the National Institute of Statistics (INS – Romania) based on population census conducted in 2011 [ 47 ].

Data collection

Data collection was carried out by questionnaires administered by 32 field operators between May 1 st –May 31 st , 2018.

The analysis of the research results

In the next section, we will present the main results of the quantitative research carried out at national level.

Almost three-quarters of women included in the sample agree with carrying out an abortion in certain circumstances (70%) and only 24% have chosen to support the answer “ No, never ”. In modern contemporary society, abortion is the first solution of women for which a pregnancy is not desired. Even if advanced medical techniques are a lot safer, an abortion still carries a health risk. However, 6% of respondents agree with carrying out abortion regardless of circumstances (Table ​ (Table5 5 ).

Opinion on the possibility of carrying out an abortion

Although abortions carried out after 14 weeks are illegal, except for medical reasons, more than half of the surveyed women stated they would agree with abortion in certain circumstances. At the opposite pole, 31% have mentioned they would never agree on abortions after 14 weeks. Five percent were totally accepting the idea of abortion made to a pregnancy that has exceeded 14 weeks (Table ​ (Table6 6 ).

Opinion on the possibility of carrying out an abortion after the period of 14 weeks of pregnancy

For 53% of respondents, abortion is considered a crime as well as the right of a women. On the other hand, 28% of the women considered abortion as a crime and 16% associate abortion with a woman’s right (Table ​ (Table7 7 ).

Opinion on abortion: at the border between crime and a woman’s right

Opinions on what women abort at the time of the voluntary pregnancy interruption are split in two: 59% consider that it depends on the time of the abortion, and more specifically on the pregnancy development stage, 24% consider that regardless of the period in which it is carried out, women abort a child, and 14% have opted a fetus (Table ​ (Table8 8 ).

Abortion of a child vs. abortion of a fetus

Among respondents who consider that women abort a child or a fetus related to the time of abortion, 37.5% have considered that the difference between a baby and a fetus appears after 14 weeks of pregnancy (the period legally accepted for abortion). Thirty-three percent of them have mentioned that the distinction should be performed at the first few heartbeats; 18.1% think it is about when the child has all the features definitively outlined and can move by himself; 2.8% consider that the difference appears when the first encephalopathy traces are being felt and the child has formed all internal and external organs. A percentage of 1.7% of respondents consider that this difference occurs at the beginning of the central nervous system, and 1.4% when the unborn child has all the features that we can clearly see to a newborn child (Table ​ (Table9 9 ).

The opinion on the moment that makes the difference between a fetus and a child

We noticed that highly religious people make a clear association between abortion and crime. They also consider that at the time of pregnancy interruption it is aborted a child and not a fetus. However, unexpectedly, we noticed that 27% of the women, who declare themselves to be very religious, have also stated that they see abortion as a crime but also as a woman’s right. Thirty-one percent of the women, who also claimed profound religious beliefs, consider that abortion may be associated with the abortion of a child but also of a fetus, this depending on the time of abortion (Tables ​ (Tables10 10 and ​ and11 11 ).

The correlation between the level of religious beliefs and the perspective on abortion seen as a crime or a right

The correlation between the level of religious beliefs and the perspective on abortion procedure conducted on a fetus or a child

More than half of the respondents have opted for the main reason for abortion the appearance of medical problems to the child. Baby’s health represents the main concern of future mothers, and of each parent, and the birth of a child with serious health issues, is a factor which frightens any future parent, being many times, at least theoretically, one good reason for opting for abortion. At the opposite side, 12% of respondents would not choose abortion under any circumstances. Other reasons for which women would opt for an abortion are: if the woman would have a medical problem (22%) or would not want the child (10%) (Table ​ (Table12 12 ).

Potential reasons for carrying out an abortion

Most of the women want to give birth to a child, 56% of the respondents, representing also the reason that would determine them to keep the child. Morality (26%), faith (10%) or legal restrictions (4%), are the three other reasons for which women would not interrupt a pregnancy. Only 2% of the respondents have mentioned other reasons such as health or age.

A percentage of 23% of the surveyed people said that they have done an abortion so far, and 77% did not opted for a surgical intervention either because there was no need, or because they have kept the pregnancy (Table ​ (Table13 13 ).

Rate of abortion among women in the sample

Most respondents, 87% specified that they have carried out an abortion during the first 14 weeks – legally accepted limit for abortion: 43.6% have made abortion in the first four weeks, 39.1% between weeks 4–8, and 4.3% between weeks 8–14. It should be noted that 8.7% could not appreciate the pregnancy period in which they carried out abortion, by opting to answer with the option “ I don’t know ”, and a percentage of 4.3% refused to answer to this question.

Performing an abortion is based on many reasons, but the fact that the women have not wanted a child is the main reason mentioned by 47.8% of people surveyed, who have done minimum an abortion so far. Among the reasons for the interruption of pregnancy, it is also included: women with medical problems (13.3%), not the right time to be a mother (10.7%), age motivation (8.7%), due to medical problems of the child (4.3%), the lack of money (4.3%), family pressure (4.3%), partner/spouse did not wanted. A percentage of 3.3% of women had different reasons for abortion, as follows: age difference too large between children, career, marital status, etc. Asked later whether they regretted the abortion, a rate of 69.6% of women who said they had at least one abortion regret it (34.8% opted for “ Yes ”, and 34.8% said “ Yes, partially ”). 26.1% of surveyed women do not regret the choice to interrupted the pregnancy, and 4.3% chose to not answer this question. We noted that, for women who have already experienced abortion, the causes were more diverse than the grounds on which the previous question was asked: “What are the reasons that determined you to have an abortion?” (Table ​ (Table14 14 ).

The reasons that led the women in the sample to have an abortion

The majority of the respondents (37.5%) considered that “nervous depression” is the main consequence of abortion, followed by “insomnia and nightmares” (24.6%), “disorders in alimentation” and “affective disorders” (each for 7.7% of respondents), “deterioration of interpersonal relationships” and “the feeling of guilt”(for 6.3% of the respondents), “sexual disorders” and “panic attacks” (for 6.3% of the respondents) (Table ​ (Table15 15 ).

Opinion on the consequences of abortion

Over half of the respondents believe that abortion should be legal in certain circumstances, as currently provided by law, 39% say it should be always legal, and only 6% opted for the illegal option (Table ​ (Table16 16 ).

Opinion on the legal regulation of abortion

Although the current legislation does not punish pregnant women who interrupt pregnancy or intentionally injured their fetus, survey results indicate that 61% of women surveyed believe that the national law should punish the woman and only 28% agree with the current legislation (Table ​ (Table17 17 ).

Opinion on the possibility of punishing the woman who interrupts the course of pregnancy or injures the fetus

For the majority of the respondents (40.6%), the penalty provided by the current legislation, the imprisonment between six months and three years or a fine and deprivation of certain rights for the illegal abortion is considered fair, for a percentage of 39.6% the punishment is too small for 9.5% of the respondents is too high. Imprisonment between two and seven years and deprivation of certain rights for an abortion performed without the consent of the pregnant woman is considered too small for 65% of interviewees. Fourteen percent of them think it is fair and only 19% of respondents consider that Romanian legislation is too severe with people who commit such an act considering the punishment as too much. The imprisonment from three to 10 years and deprivation of certain rights for the facts described above, if an injury was caused to the woman, is considered to be too small for more than half of those included in the survey, 64% and almost 22% for nearly a quarter of them. Only 9% of the respondents mentioned that this legislative measure is too severe for such actions (Table ​ (Table18 18 ).

Opinion on the regulation of abortion of the Romanian Criminal Code (Art. 201)

Conclusions

After analyzing the results of the sociological research regarding abortion undertaken at national level, we see that 76% of the Romanian women accept abortion, indicating that the majority accepts only certain circumstances (a certain period after conception, for medical reasons, etc.). A percentage of 64% of the respondents indicated that they accept the idea of abortion after 14 weeks of pregnancy (for solid reasons or regardless the reason). This study shows that over 50% of Romanian women see abortion as a right of women but also a woman’s crime and believe that in the moment of interruption of a pregnancy, a fetus is aborted. Mostly, the association of abortion with crime and with the idea that a child is aborted is frequently found within very religious people. The main motivation for Romanian women in taking the decision not to perform an abortion is that they would want the child, and the main reason to perform an abortion is the child’s medical problems. However, it is noted that, in real situations, in which women have already done at least one abortion, most women resort to abortion because they did not want the child towards the hypothetical situation in which women felt that the main reason of abortion is a medical problem. Regarding the satisfaction with the current national legislation of the abortion, the situation is rather surprising. A significant percentage (61%) of respondents felt as necessary to punish the woman who performs an illegal abortion, although the legislation does not provide a punishment. On the other hand, satisfaction level to the penalties provided by law for various violations of the legal conditions for conducting abortion is low, on average only 25.5% of respondents are being satisfied with these, the majority (average 56.2%) considering the penalties as unsatisfactory. Understood as a social phenomenon, intensified by human vulnerabilities, of which the most obvious is accepting the comfort [ 48 ], abortion today is no longer, in Romanian society, from a legal or religious perspective, a problem. Perceptions on the legislative sanction, moral and religious will perpetual vary depending on beliefs, environment, education, etc. The only and the biggest social problem of Romania is truly represented by the steadily falling birth rate.

Conflict of interests

The authors declare that they have no conflict of interests.

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Chapter 42 Chapter Summary

Hursthouse argues that the considerations that dominate the discussion of abortion—namely, women’s rights and the status of the fetus—are fundamentally irrelevant to the morality of abortion. Answering the question of whether women have a right to abortion does nothing to determine whether a particular woman who terminates a pregnancy in particular circumstances is acting virtuously or viciously. Moreover, the status of the fetus is relevant only in the way that the undisputed biological facts—for example, that human reproduction follows sexual intercourse, that only women become pregnant, that human parents tend to care deeply about their offspring—figure into the feelings, actions, and practical reasoning of virtuous and vicious agents confronted with an undesired pregnancy. Some abortions done for some reasons would be viciously callous or foolish, Hursthouse claims, whereas others might indicate an appropriate humility. No general rule can be laid down in advance for correctly applying the virtue- and vice-related terms of the sort Hursthouse advocates. This is not a failing of a virtue-theory approach to abortion, however, but an acknowledgment that a genuine understanding of moral issues cannot proceed in abstraction from the concrete facts or from difficult issues about what is worthwhile, serious, and important in human lives.

Select your Country

The Perplexing Geography of Abortion Opinion

I n November, Ohioans gave Republican legislators a shellacking on abortion rights, enshrining the right to the procedure (as well as rights to contraception, in-vitro fertilization and miscarriage care) in the state’s constitution. Though Ohio voters consistently elect Republicans in statewide races, the referendum passed by a margin of 14 percentage points. The vote — together with similar results in Kansas and Kentucky — has rightly been seen as a warning that Republicans in state legislatures, Congress and on the Supreme Court bench are radically out of step with the citizenry on this issue, even in reliably red states.

The vote on Ohio’s referendum was geographically split along patterns the pioneering Midwestern political geographer Frederick Jackson Turner would have recognized in 1895. Every county in the New England-settled northeast voted overwhelmingly in favor, rural and urban alike. A middle section of the state, where colonization was led by Pennsylvania “Dutch” and German immigrant farmers, opposed the measure, which only barely passed in its cities. The Scots-Irish-settled south of the state, first colonized via western Virginia and Kentucky, left Columbus, Cincinnati, and Ohio University as islands poking from a sea of opposition.

To understand why so many red state leaders, in defiance of their own electorates, have moved to enact laws to ban abortion or even to prosecute people seeking or providing the procedure, you need to take a plunge into geography, history, and centuries-old settlement patterns that created the cross-wired political world we live in today. Absent a national abortion ban, the states in which women can terminate an unwanted pregnancy will largely be determined by the legacy of events, migrations, and conquests in the 17th, 18th, and 19th centuries and the political science incentives they created in some places and not in others.

Modern politics and policies make more sense when viewed through the regional identities that are the legacy of America’s early colonial projects. In my 2011 book,  American Nations: A History of the Eleven Rival Regional Cultures of North America , I explained how mutually exclusive bands of immigration imbued their respective regions with civic and religious institutions, cultural norms and ideas about freedom, social responsibility and the provision of public goods that later arrivals would encounter and, by and large, assimilate into. These settlement streams — whose members were often repelled by one another’s values and practices — spread with little regard for today’s state (or even international) boundaries.

Those colonial projects — Puritan-controlled New England; the Dutch-settled area around what is now New York City; the Quaker-founded Delaware Valley; the Scots-Irish-dominated upland backcountry of the Appalachians; the West Indies-style slave society in the Deep South; the Spanish project in the southwest and so on — had different religious, economic and ideological characteristics. They settled much of the eastern half and southwestern third of what is now the U.S. in mutually exclusive settlement bands before significant third party in-migration picked up steam in the 1840s. In the process — as I unpacked in American Nations  — they laid down the institutions, cultural norms and ideas about freedom, social responsibility and the provision of public goods that later arrivals would encounter and, by and large, assimilate into. Some states lie entirely or almost entirely within one of these regional cultures (Mississippi, Vermont, Minnesota and Montana, for instance). Other states are split between the regions , propelling constant and profound internal disagreements on politics and policy alike in places like Pennsylvania, Illinois, California, Oregon and, yes, Ohio.

The American Nations model of U.S. Regions

In the book  American Nations , I argued that there has never been one America but rather several Americas, most of them developing from one or another of the rival colonial projects that formed on the eastern and southwestern rims of what is now the United States. These regional cultures — “nations,” if you will — had their own ethnographic, religious and political characteristics, distinct ideas about the balance between individual liberty and the common good and what the United States should become.

The nine large regions — with  populations today ranging from 13 and 63 million — are:

Yankeedom (pop. 55.8 million)

Founded by Puritans who sought to perfect earthly society through social engineering, individual denial for the common good, and the assimilation of outsiders. The common good — ensured by popular government — took precedence over individual liberty when the two were in conflict.

New Netherland (pop. 18.8 million)

Dutch-founded and retains characteristics of 17th century Amsterdam: a global commercial trading culture, materialistic, multicultural and committed to tolerance and the freedom of inquiry and conscience.

Tidewater (pop. 12.6 million)

Founded by lesser sons of landed gentry seeking to recreate the semi-feudal manorial society of the English countryside. Conservative with strong respect for authority and tradition, this culture is rapidly eroding because of its small physical size and the massive federal presence around D.C. and Hampton Roads.

Greater Appalachia (pop. 59 million)

Settlers came overwhelmingly from war-ravaged Northern Ireland, Northern England and the Scottish lowlands, and were deeply committed to personal sovereignty and intensely suspicious of external authority.

The Midlands (pop. 37.7 million)

Founded by English Quakers, who believed in humans’ inherent goodness and welcomed people of many nations and creeds. Pluralistic and organized around the middle class; ethnic and ideological purity is never a priority; government is seen as an unwelcome intrusion.

Deep South (pop. 43.5 million)

Established by English Barbadian slave lords who championed classical republicanism modeled on slave states of the ancient world, where democracy was the privilege of the few and subjugation and enslavement the natural lot of the many.

El Norte (pop. 33.3 million)

Borderlands of the Spanish-American empire, so far from Mexico City and Madrid that it developed its own characteristics: independent, self-sufficient, adaptable and work-centered. Though it often sought to break away from Mexico to become an independent buffer state, it was annexed into the U.S. instead.

Left Coast (pop. 17.9 million)

Founded by New Englanders (who came by ship) and farmers, prospectors and fur traders from the lower Midwest (by wagon), it’s a fecund hybrid of Yankee utopianism and the Appalachian emphasis on self-expression and exploration.

Far West (pop. 28.7 million)

An extreme environment stopped eastern cultures in their path, so settlement largely was controlled by distant corporations or the federal government via deployment of railroads, dams, irrigation, and mines; exploited as an internal colony, with lasting resentments.

You can find a more detailed summary here, at the Nationhood Lab .

The pattern of Ohio’s vote was almost pre-ordained by this colonization history and the regional cultures it created, just as were the results of other post- Dobbs abortion measures in Michigan, Kansas, Kentucky, California, and Vermont. The same can be said of the states in which political elites have enacted unpopular and often extreme anti-abortion policies sought by a focused and influential minority that’s successfully hacked local political establishments in ways that would be impossible in other regions.

At  Nationhood Lab , a project I founded at Salve Regina University’s Pell Center for International Relations and Public Policy, we use  this regional framework to analyze all manner of phenomena in American society and how one might go about responding to them. We’ve looked at everything from  gun violence  and  attitudes toward threats to democracy  to  Covid-19 vaccination rates , life expectancy , the prevalence of diabetes and obesity ,  rural vs. urban political behavior  and  the geography of the 2022 midterm elections . This spring we’ve been parsing abortion opinion via the massive Democracy Fund + UCLA Nationscape poll , which from late 2019 to early 2021 asked a half million Americans about their stance on a wide range of social, political and economic questions, including abortion; we’ve dug into the county-level results of the post- Dobbs abortion initiatives across the country and overlaid them with the American Nations settlement model and the closely related religious makeup of each county as calculated by the Public Religion Research Institute in their 2020 Census of American Religion. The results – which we’ve published in wonky detail at the project website — provide a Rosetta Stone for understanding an issue that is propelling inter-regional animosity at a time when the sinews holding our federation together are weakening.

In terms of policy implementation, the geographic divide is stark. Since the Dobbs decision came down, 14 states have fully banned abortion and seven others have restricted the procedure to earlier in the pregnancy than allowed by Roe v. Wade . Together they include every state controlled, in the American Nations settlement model, by the Deep South or Greater Appalachia, plus two Far Western-controlled states and four (Missouri, the Dakotas, and Nebraska) with mixed Midlands and Far Western control. By contrast, abortion remains legal and unchallenged in every state controlled by Yankeedom, New Netherland, Tidewater, Left Coast and Greater Polynesia, and most of those states have increased protections for abortion access since the Dobbs ruling. Lawmakers in Midlands-controlled Kansas and in Ohio — with those large Yankee and Midlands sections but a Greater Appalachian plurality — wanted a ban too, but were stopped by their citizens via ballot referendum, an option most Deep Southern and Greater Appalachian states do not allow.

Officials in some states controlled by the Deep South, Greater Appalachia, the Midlands or some combination thereof want to make it a crime for one of their residents to get an abortion in another state where it’s legal, a move that encumbers women’s right to travel. Texas now allows civil suits against any entity that provides funds or assistance to someone trying to obtain an out-of-state abortion and South Dakota law opens the possibility that out-of-state medical providers could face criminal charges for filling a mail-order prescription for federally approved abortion drugs. Alabama attorney general Steve Marshall says anyone helping an Alabaman to obtain an out-of-state abortion has engaged in a criminal conspiracy. “Alabama can criminalize Alabama-based conspiracies to commit abortions elsewhere,” his office has asserted in court filings .

Meanwhile, states dominated by Yankeedom, New Netherland and Left Coast have added reproductive rights protections and declared other states’ anti-abortion laws to be inapplicable in their courts. Maine, Massachusetts, Rhode Island, New Jersey and Delaware now prohibit law enforcement from cooperating with abortion investigations or answering legal summons by anti-abortion states. Maine Gov. Janet Mills —  a career state prosecutor and former state attorney general — issued an executive order prohibiting authorities from arresting or surrendering an individual for these new crimes on behalf of an anti-abortion state’s government. California lawmakers have prohibited companies, tech goliaths, and government agencies from providing personal data or medical data to out-of-state abortion investigators.

Together, these regional divides amount to what George Washington University law professor Paul Berman has called “the biggest set of nationwide conflicts-of-law problems since the era of the Fugitive Slave Act before the Civil War,” when southern states began forcing northerners to apprehend any Black person they claimed had escaped from slavery and, without due process, return them to bondage.

The Nationscape survey shows the public favors abortion being legal in every state and region, but the depth of that support varies in a pattern mirroring the policy divide we just described.

Supermajorities in every American Nations region reject an outright ban on abortion, and large majorities everywhere believe the procedure should be legal for reasons beyond incest, rape, and the life of the mother. But support for a total ban is nearly twice as high in New France — that’s southern Louisiana — (at 30.9 percent) than in the Left Coast (15.5 percent). The block wanting a ban is about a quarter greater in the Deep South and Greater Appalachia (where it’s a bit more than a quarter of the population) than in Yankeedom, Tidewater, El Norte, New Netherland, or Spanish Caribbean (all between 17 percent and 20 percent). We found a very similar pattern when probing opposition to abortions for reasons other than rape, incest, or saving the life of the mother.

Abortion ban support by regional culture

Who are these abortion opponents? Far and away the biggest predictor, no matter what region we looked at , was being a white Evangelical. Depending on region, 38 to 47 percent of this cohort supports a total ban, compared to 19 to 34 percent for Catholics and 6 to 14 percent for mainline Protestants (with New France as an outlier among Protestants at 25 percent). We found one’s religious affiliation has a much greater effect on abortion opinion than their gender — indeed, in the South there’s hardly any gender gap at all. And the religious geography of this country has, to a degree seldom appreciated, been determined by the distinct value systems of the settlement

White Evangelicals, the PRRI data reveals , are overwhelmingly concentrated in the Deep South and Greater Appalachia, where they constitute 31 and 24 percent of the overall population respectively. (They are 14 percent of the national population and only three percent of New Netherland’s.) That Evangelicals dominate in the Bible Belt probably comes as no surprise, but it’s the way Evangelical Protestantism took root in the South that has made such a difference in modern abortion politics.

In the 18th century, most of the South was, in fact, the least likely place for Evangelicals to find favor. In Virginia (which included today’s West Virginia), the Carolinas and Georgia, the Church of England (rebranded as the Episcopal church after the Revolution) was the official, taxpayer-financed church. Few people responded well to Evangelical Baptist and Methodist preachers from Yankeedom, the Midlands, New Netherland and Great Britain who demanded that followers stop drinking, gambling, swearing and fighting. These early Evangelicals were even more unpopular in the lowlands because they threatened that region’s power structure, casting aspersions on slavery, welcoming African-Americans into fellowship and encouraging followers to regard one another as family, regardless of race, class or marital status.

“Evangelicals, far from dominating the South, were viewed by most whites as odd at best and subversive at worse,” writes University of Delaware historian Christine Leigh Heyrman, author of Southern Cross: The Beginnings of the Bible Belt .

In the early 19th century, however, Evangelical missionaries adapted to the southern cultures, accepting slavery, the racial segregation of churches, strong patriarchal family dynamics, and the private misconduct of men. Southern Evangelical camp meetings adopted a manly, martial vibe that accorded with the southern “culture of honor,” with morning bugle calls, marches to the altar, and posted rules enforced by “dog-whippers,” guards with special insignia attached to their coats who patrolled the grounds. In the Antebellum Era, southern Baptists and Methodists would break from their northern counterparts over their support of slavery, which is why there’s a Southern Baptist Convention in the first place. These adaptations caused their religion to spread rapidly across these cultural regions, helped by the fact most Anglican priests had fled to England when the American Revolution broke out, leaving their congregations ripe for poaching.

“It’s not too much of an oversimplification to say that what happens in the South between 1780 and the Civil War is that the religion, Evangelicalism, adapts to the culture,” Heyrman told me. “The Evangelicalism in the North is in many ways a very different animal than in the Evangelical South.”

In Yankeedom, the Midlands and New Netherland, Evangelicals faced ever-increasing competition from other groups, both home-grown rivals like the Mormons, Seventh Day Adventists, or Christian Scientists and immigrant-powered Catholic, Lutheran, Orthodox Christian, and Jewish congregations. And without the same cultural incentives as their southern co-religionists faced, many northern Baptist and Methodist groups became “mainline” Protestant over time, in that they read many Biblical passages as allegory and metaphor rather than being literally true. The gulf between the regions grew dramatically during the great immigration wave of 1880 to 1924 because the three southern regions’ feudal nature repelled the newcomers, causing them to be nearly bereft of Catholics, Jews, Orthodox Christians and other non-Evangelicals until the 1980s. Right into the late 1960s, Evangelicalism was practically the only show in town, and enjoyed the power of incumbency to a degree unmatched elsewhere.

Immigrants per capita, 1900

Dominant religion, U.S. counties, 2020

There is one big American Nations region — the Midlands — whose settlement history and underlying cultural ethos presents something of a wild card in mapping abortion opinion.

This region has always had an extremely heterogenous religious identity thanks to its Quaker founders, who welcomed people of many nationalities and religious denominations — some conservative, some liberal — to their multicultural colonies on Delaware Bay. That multicultural ethos was enhanced by new streams of religious refugees in the mid- to late-19th century. The result was that in the Midlands, more so than any other region, different ethno-religious communities were encouraged to erect their own villages, towns and neighborhoods and maintain their linguistic, cultural and spiritual practices, with a lasting imprint you can see today, from Pennsylvania to Iowa.

This matters for today’s abortion politics because it has made the Midlands more like a chunky stew than a melting pot. The presence of white Evangelicals is still your best tool for predicting how a given Midlands county will vote, but there are concentrations of centuries-old religious communities of surprising homogeneity that sometimes have very strong opinions on abortion. That’s why the Midlands band in Ohio, which features a constellation of deeply conservative German Catholic settlements combined with a percentage of white Evangelicals, voted to reject the abortion initiative by seven points .

But in Kansas, 8 out of 10 Midlanders live in metropolitan areas, and in Kansas City, Wichita and Topeka (unlike Toledo and Youngstown in Ohio), pro-life mainline Protestants outnumber both Catholics and white Evangelicals. In the 2022 vote, the Kansas Midlands supported abortion by double digits, spearheading its passage over the objections of the state’s much less populous Greater Appalachian and Far Western sections. In this regard, the Missouri Midlands look a lot more like Kansas than Ohio and, given that that section of the state makes up two-thirds of the electorate , abortion restrictions will almost certainly lose at the ballot box when Missourians vote on their state’s referendum this coming November.

Republicans’ aggressive pro-life stance in Arizona may be based on moral conviction but makes absolutely no political sense. The state — divided between El Norte and Far West sections — has relatively few white (or Hispanic) Evangelicals, lots of (generally pro-choice) mainline Protestants and (ambivalent) Spanish Catholics, and even a substantial indigenous population. It’s no surprise that polls show supermajority support for abortion being legal in most cases , which wasn’t the case for Kentucky or Kansas before they voted on the issue. The Arizona state Supreme Court’s ruling earlier this spring to put back into force a total abortion ban passed by the territorial legislature in 1864 — a time when Arizona wasn’t a state and women didn’t have the right to vote — was overturned earlier this month by Democratic legislators with the help of a handful of Republican defectors, but could still go into effect for some weeks due to the quirks of state law. None of this will help GOP candidates in this fall’s elections.

Abortion will likely prevail in any state that allows ballot measures, but many states that have banned or severely restricted the procedure don’t allow citizen initiated-ballot referenda, including almost every one in the Deep South, Greater Appalachia and New France. Which leaves a big political question: If most people in these regions don’t want abortion banned or restricted, how has a white Evangelical minority been able to get their way nonetheless?

Academics have been asking this question for decades and have come to some broad conclusions. From their fight against gay marriage in the early 2000s to wanting to ban abortion today, white Evangelicals succeed in states where they’ve been able to capture intermediary institutions like state (Republican) parties, (the Republican caucuses of) legislatures, or the state’s executive branch. “Successes have been achieved,” sociologists Rebecca Sager and Keith Bentele concluded in a study of how and where faith-based legislation passed between 1996 and 2009, primarily “through effective utilization of an existing political institution, the Republican Party.”

It turns out Evangelical churches are excellent training grounds for political organizing. “Places of worship provide a natural foundation for organizing, a place where people are showing up every week and maybe serving on a board or volunteering at all sorts of events,” says Christopher Scheitle, assistant professor of sociology at West Virginia University, who found Christian Right influence within state GOPs had an even greater influence on the passage of anti-LGBTQ adoption, discrimination, hate crime and marriage laws from 2005 to 2008 than the proportion of a state’s population that were Evangelical. “And Evangelical churches have this entrepreneurial spirit and they don’t have to seek approval from a hierarchy of a bishop to set up associated non-profits like sports camps or publishing houses, which get people in the pews involved,” Scheitle says.

An organized minority can get a long way, but numbers still matter. It’s one thing to capture a state political party, legislative majority, or gubernatorial administration if you’re group represents 20 or 30 percent of the population, quite another if it’s only 2, 8 or 10 percent, which is why white Evangelicals are not getting their way in New Netherland and Yankeedom.

“It doesn’t matter if you want something if those in power who can make that happen aren’t willing to listen to you,” Scheitle adds. “But if those in power have an affinity with or, for whatever reason, find it useful to listen to a particular part of the population, that’s where you see these social movements succeed.”

This story originally appeared on Talking Points Memo .

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• America’s Abortion Quandary

2. Social and moral considerations on abortion

Table of contents.

• Abortion at various stages of pregnancy 
• Abortion and circumstances of pregnancy 
• Parental notification for minors seeking abortion
• Penalties for abortions performed illegally 
• Public views of what would change the number of abortions in the U.S.
• A majority of Americans say women should have more say in setting abortion policy in the U.S.
• How do certain arguments about abortion resonate with Americans?
• In their own words: How Americans feel about abortion 
• Personal connections to abortion 
• Religion’s impact on views about abortion
• Acknowledgments
• The American Trends Panel survey methodology

Relatively few Americans view the morality of abortion in stark terms: Overall, just 7% of all U.S. adults say abortion is morally acceptable in all cases, and 13% say it is morally wrong in all cases. A third say that abortion is morally wrong in  most  cases, while about a quarter (24%) say it is morally acceptable most of the time. About an additional one-in-five do not consider abortion a moral issue.

There are wide differences on this question by political party and religious affiliation. Among Republicans and independents who lean toward the Republican Party, most say that abortion is morally wrong either in most (48%) or all cases (20%). Among Democrats and Democratic leaners, meanwhile, only about three-in-ten (29%) hold a similar view. About four-in-ten Democrats say abortion is morally  acceptable  in most (32%) or all (11%) cases, while an additional 28% say abortion is not a moral issue. 

White evangelical Protestants overwhelmingly say abortion is morally wrong in most (51%) or all cases (30%). A slim majority of Catholics (53%) also view abortion as morally wrong, but many also say it is morally acceptable in most (24%) or all cases (4%), or that it is not a moral issue (17%). And among religiously unaffiliated Americans, about three-quarters see abortion as morally acceptable (45%) or not a moral issue (32%).

There is strong alignment between people’s views of whether abortion is morally wrong and whether it should be illegal. For example, among U.S. adults who take the view that abortion should be illegal in all cases without exception, fully 86% also say abortion is always morally wrong. The prevailing view among adults who say abortion should be legal in all circumstances is that abortion is not a moral issue (44%), though notable shares of this group also say it is morally acceptable in all (27%) or most (22%) cases. 

Most Americans who say abortion should be illegal with some exceptions take the view that abortion is morally wrong in  most  cases (69%). Those who say abortion should be legal with some exceptions are somewhat more conflicted, with 43% deeming abortion morally acceptable in most cases and 26% saying it is morally wrong in most cases; an additional 24% say it is not a moral issue. 

The survey also asked respondents who said abortion is morally wrong in at least some cases whether there are situations where abortion should still be legal  despite  being morally wrong. Roughly half of U.S. adults (48%) say that there are, in fact, situations where abortion is morally wrong but should still be legal, while just 22% say that whenever abortion is morally wrong, it should also be illegal. An additional 28% either said abortion is morally acceptable in all cases or not a moral issue, and thus did not receive the follow-up question.

Across both political parties and all major Christian subgroups – including Republicans and White evangelicals – there are substantially more people who say that there are situations where abortion should still be  legal  despite being morally wrong than there are who say that abortion should always be  illegal  when it is morally wrong.

Asked about the impact a number of policy changes would have on the number of abortions in the U.S., nearly two-thirds of Americans (65%) say “more support for women during pregnancy, such as financial assistance or employment protections” would reduce the number of abortions in the U.S. Six-in-ten say the same about expanding sex education and similar shares say more support for parents (58%), making it easier to place children for adoption in good homes (57%) and passing stricter abortion laws (57%) would have this effect. 

While about three-quarters of White evangelical Protestants (74%) say passing stricter abortion laws would reduce the number of abortions in the U.S., about half of religiously unaffiliated Americans (48%) hold this view. Similarly, Republicans are more likely than Democrats to say this (67% vs. 49%, respectively). By contrast, while about seven-in-ten unaffiliated adults (69%) say expanding sex education would reduce the number of abortions in the U.S., only about half of White evangelicals (48%) say this. Democrats also are substantially more likely than Republicans to hold this view (70% vs. 50%). 

Democrats are somewhat more likely than Republicans to say support for parents – such as paid family leave or more child care options – would reduce the number of abortions in the country (64% vs. 53%, respectively), while Republicans are more likely than Democrats to say making adoption into good homes easier would reduce abortions (64% vs. 52%).

Majorities across both parties and other subgroups analyzed in this report say that more support for women during pregnancy would reduce the number of abortions in America.

More than half of U.S. adults (56%) say women should have more say than men when it comes to setting policies around abortion in this country – including 42% who say women should have “a lot” more say. About four-in-ten (39%) say men and women should have equal say in abortion policies, and 3% say men should have more say than women. 

Six-in-ten women and about half of men (51%) say that women should have more say on this policy issue. 

Democrats are much more likely than Republicans to say women should have more say than men in setting abortion policy (70% vs. 41%). Similar shares of Protestants (48%) and Catholics (51%) say women should have more say than men on this issue, while the share of religiously unaffiliated Americans who say this is much higher (70%).

Seeking to gauge Americans’ reactions to several common arguments related to abortion, the survey presented respondents with six statements and asked them to rate how well each statement reflects their views on a five-point scale ranging from “extremely well” to “not at all well.” 

The list included three statements sometimes cited by individuals wishing to protect a right to abortion: “The decision about whether to have an abortion should belong solely to the pregnant woman,” “If legal abortions are too hard to get, then women will seek out unsafe abortions from unlicensed providers,” and “If legal abortions are too hard to get, then it will be more difficult for women to get ahead in society.” The first two of these resonate with the greatest number of Americans, with about half (53%) saying each describes their views “extremely” or “very” well. In other words, among the statements presented in the survey, U.S. adults are most likely to say that women alone should decide whether to have an abortion, and that making abortion illegal will lead women into unsafe situations.

The three other statements are similar to arguments sometimes made by those who wish to restrict access to abortions: “Human life begins at conception, so a fetus is a person with rights,” “If legal abortions are too easy to get, then people won’t be as careful with sex and contraception,” and “If legal abortions are too easy to get, then some pregnant women will be pressured into having an abortion even when they don’t want to.” 

Fewer than half of Americans say each of these statements describes their views extremely or very well. Nearly four-in-ten endorse the notion that “human life begins at conception, so a fetus is a person with rights” (26% say this describes their views extremely well, 12% very well), while about a third say that “if legal abortions are too easy to get, then people won’t be as careful with sex and contraception” (20% extremely well, 15% very well).

When it comes to statements cited by proponents of abortion rights, Democrats are much more likely than Republicans to identify with all three of these statements, as are religiously unaffiliated Americans compared with Catholics and Protestants. Women also are more likely than men to express these views – and especially more likely to say that decisions about abortion should fall solely to pregnant women and that restrictions on abortion will put women in unsafe situations. Younger adults under 30 are particularly likely to express the view that if legal abortions are too hard to get, then it will be difficult for women to get ahead in society.

In the case of the three statements sometimes cited by opponents of abortion, the patterns generally go in the opposite direction. Republicans are more likely than Democrats to say each statement reflects their views “extremely” or “very” well, as are Protestants (especially White evangelical Protestants) and Catholics compared with the religiously unaffiliated. In addition, older Americans are more likely than young adults to say that human life begins at conception and that easy access to abortion encourages unsafe sex.

Gender differences on these questions, however, are muted. In fact, women are just as likely as men to say that human life begins at conception, so a fetus is a person with rights (39% and 38%, respectively).

Analyzing certain statements together allows for an examination of the extent to which individuals can simultaneously hold two views that may seem to some as in conflict. For instance, overall, one-in-three U.S. adults say that  both  the statement “the decision about whether to have an abortion should belong solely to the pregnant woman” and the statement “human life begins at conception, so the fetus is a person with rights” reflect their own views at least somewhat well. This includes 12% of adults who say both statements reflect their views “extremely” or “very” well. 

Republicans are slightly more likely than Democrats to say both statements reflect their own views at least somewhat well (36% vs. 30%), although Republicans are much more likely to say  only  the statement about the fetus being a person with rights reflects their views at least somewhat well (39% vs. 9%) and Democrats are much more likely to say  only  the statement about the decision to have an abortion belonging solely to the pregnant woman reflects their views at least somewhat well (55% vs. 19%).

Additionally, those who take the stance that abortion should be legal in all cases with no exceptions are overwhelmingly likely (76%) to say only the statement about the decision belonging solely to the pregnant woman reflects their views extremely, very or somewhat well, while a nearly identical share (73%) of those who say abortion should be  illegal  in all cases with no exceptions say only the statement about human life beginning at conception reflects their views at least somewhat well.

When asked to describe whether they had any other additional views or feelings about abortion, adults shared a range of strong or complex views about the topic. In many cases, Americans reiterated their strong support – or opposition to – abortion in the U.S. Others reflected on how difficult or nuanced the issue was, offering emotional responses or personal experiences to one of two open-ended questions asked on the survey. 

One open-ended question asked respondents if they wanted to share any other views or feelings about abortion overall. The other open-ended question asked respondents about their feelings or views regarding abortion restrictions. The responses to both questions were similar. 

Overall, about three-in-ten adults offered a response to either of the open-ended questions. There was little difference in the likelihood to respond by party, religion or gender, though people who say they have given a “lot” of thought to the issue were more likely to respond than people who have not. 

Of those who did offer additional comments, about a third of respondents said something in support of legal abortion. By far the most common sentiment expressed was that the decision to have an abortion should be solely a personal decision, or a decision made jointly with a woman and her health care provider, with some saying simply that it “should be between a woman and her doctor.” Others made a more general point, such as one woman who said, “A woman’s body and health should not be subject to legislation.” 

About one-in-five of the people who responded to the question expressed disapproval of abortion – the most common reason being a belief that a fetus is a person or that abortion is murder. As one woman said, “It is my belief that life begins at conception and as much as is humanly possible, we as a society need to support, protect and defend each one of those little lives.” Others in this group pointed to the fact that they felt abortion was too often used as a form of birth control. For example, one man said, “Abortions are too easy to obtain these days. It seems more women are using it as a way of birth control.” 

About a quarter of respondents who opted to answer one of the open-ended questions said that their views about abortion were complex; many described having mixed feelings about the issue or otherwise expressed sympathy for both sides of the issue. One woman said, “I am personally opposed to abortion in most cases, but I think it would be detrimental to society to make it illegal. I was alive before the pill and before legal abortions. Many women died.” And one man said, “While I might feel abortion may be wrong in some cases, it is never my place as a man to tell a woman what to do with her body.” 

The remaining responses were either not related to the topic or were difficult to interpret.

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The Unlikely Women Fighting for Abortion Rights

The end of Roe has turned women who terminated pregnancies for medical reasons into a political force.

Riata Little Walker, right, with her husband, Ian Walker, and their family in Casper, Wyo. Credit... Jimena Peck for The New York Times

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By Kate Zernike

Kate Zernike covers abortion for The Times.

• May 27, 2024

For a long time, many women who had abortions because of catastrophic fetal diagnoses told their stories only privately. Grieving pregnancies they dearly wanted and fearing the stigma of abortion, they sought the closely guarded comfort of online communities identified by the way many doctors had described the procedure — TFMR, or “termination for medical reasons.”

In the two years since the Supreme Court overturned Roe v. Wade, their pain has been compounded into anger by new abortion bans across the country. While these women account for a fraction of abortions in the United States, they have emerged as the most powerful voices in the nation’s post-Roe debate, speaking out against bans with their stories of being forced across state lines and left to feel like criminals in seeking care.

Many of these women started out opposing abortion, but as they have changed their minds, they have changed the way Americans speak about it. Shifting from private anguish to public outrage, they have also helped shift public opinion toward more support for abortion.

“After going through all this I wondered, why are we not the poster child for abortion rights?” said Riata Little Walker, who traveled from her home in Casper, Wyo., for an abortion in Colorado at 22 weeks, after doctors diagnosed Down syndrome and a heart defect in her fetus, which they said would require surgery and later a transplant if it survived until delivery.

“Yes, your body, your choice, but that’s not the story that pulls people in,” she said. “We have to bring our stories to the front because otherwise it’s so easy for those over here to do, ‘But they’re killing babies.’”

Ms. Walker is Catholic and had worked for Wyoming Republicans, including Senator John Barrasso. She opposed abortion, and did not realize she was having one because doctors called it “termination.” In the months that followed, she came to support abortion whatever the reason, and after Roe was overturned in June 2022, she testified against the ban on abortion passed by the Wyoming Legislature.

Although most bans allow abortions to save the life or health of the pregnant woman, few women have been granted these exceptions, and only a handful of bans allow abortions for fatal fetal anomalies. There are no bright lines to define “fatal,” or “medical reason,” and the procedure is the same whether it’s described as termination, TFMR, or abortion.

That makes these cases complicated for doctors, lawmakers, and for the women themselves: What qualifies as a medical reason?

The women speaking out say their experiences made them believe that the law can’t and shouldn’t try to address complex and endlessly varying medical cases. In this, they appeal to rare common ground in what has been a bitter, decades-long debate: Regardless of whether they identify as “pro-life” or “pro-choice” in polls, Americans overwhelmingly say that the decision to have an abortion should be up to women and doctors, not the government.

These women say they now feel compelled not only to speak out but to use the word “abortion,” to remove the stigma they themselves put on it.

“All these things we never even knew before, because before all of this it was never spoken about,” said Kimberly Manzano, who flew from Texas for an abortion in New Mexico at 18 weeks after scans showed her fetus was missing limbs, organs and genitalia.

Ms. Manzano describes herself and her husband as “big Christians,” who thought abortion was something “promiscuous women” did to end unwanted pregnancies. Their pastor assumed they would qualify as a medical exception to Texas’ ban. They did not.

“We feel it’s our calling to our child that we lost that we do need to talk about it, to educate people, because I feel that we were so uneducated,” she said.

Some of the women are appearing in ads in favor of abortion rights ballot measures or candidates . Others are confronting politicians on the campaign trail, testifying or joining lawsuits . But mostly, they are talking to friends, family members and colleagues.

Polls show that people who have heard stories about women who had to cross state lines for abortions because of severe pregnancy complications are more likely to support legalized abortion. That is true even for Republicans or those who think that abortion should be illegal in most cases. Stories like these have also moved voters who oppose abortion to support ballot measures that have enshrined broad abortion rights in conservative states like Ohio and Kansas.

“By telling people’s stories, it makes it reality,” said Megan Kling, who traveled from her home in Wisconsin to Minnesota for an abortion at 23 weeks after a scan revealed that her fetus had no kidneys , so was not creating amniotic fluid, and would die after delivery, if not in utero. “You want to think every woman is perfectly healthy, every pregnancy is perfectly healthy, when in reality there’s a lot of things that can go wrong.”

Ms. Kling said some family members have argued that her situation is different: They support abortion if the fetus has a devastating condition, they just don’t want women using it as birth control. She understands, because she never thought of herself as someone who would choose abortion. “But women need health care options, and that’s what they don’t understand: Abortion is health care,” she said. “That’s what these stories raise up.”

Researchers say it’s not clear how many of the roughly one million abortions each year in the United States would be considered “for medical reasons,” but that they are rare.

Still, TFMR or “ending wanted pregnancy” communities have flourished online, with websites , private groups on social media where thousands of women share their stories — and separate sites for their partners — as well as podcasts and psychotherapists devoted solely to TFMR, and an awareness day in early May.

Many of these women don’t fit the usual angles of the abortion debate. They bristle at the clinical language of abortion rights groups; instead of saying “fetus,” they speak of the pregnancies they lost as unborn children. They name them, mark birthdays and imprint their tiny feet on keepsakes.

Ms. Kling found herself in an awkward position after she wrote letters to her state legislators, including the Republicans who represent her, in an attempt to move beyond her grief and anger after losing her pregnancy. She heard back only from a Democrat, and later, from Planned Parenthood and other groups who asked her to speak at events in support of President Biden. She agreed, but explained that she did not necessarily support him. She doesn’t think of herself as a Democrat, but she doesn’t feel like a Republican anymore, either.

“I feel like most people feel that way,” she said. “All the extremists are so loud you almost feel like you can’t speak up.”

Anti-abortion groups argue that bans prohibit only what they call “elective abortions” for unwanted pregnancies, and that any woman who needs an abortion for medical reasons can get one under the exceptions in those bans. They accuse Democrats of manipulating medical patients for political ends.

“Women have been falsely told this is a compassionate option, however, it feeds into the growing trend of disability discrimination and the pressure women face from the medical community to abort children who might have a disability,” said Dr. Ingrid Skop, of the American Association of Pro-Life Obstetricians and Gynecologists.

On the other side, abortion rights groups fear that elevating TFMR stories promotes the message that abortion should be protected only if it is “justified,” not that it should be every woman’s right. “People need abortions for all kinds of reasons — financial, medical, life circumstances — and none should be stigmatized,” said Nancy Northup, the president of the Center for Reproductive Rights.

Even within online communities, there is debate: Is it acceptable to terminate if a child would live only a few hours? A few days, a few years? What about the “gray” diagnoses — where a fetus is likely to survive into childhood but live a life severely constrained by surgeries, medications, machinery and hospitalizations?

Women describe weeks of waiting for additional scans, hoping for miracles, poring over statistics on survival rates and research on quality of life. Some elect to continue their pregnancies.

“Theoretically, if I had a Down syndrome diagnosis, I would keep them,” said Martha Sheppard. She and her husband, a teacher, learned on a 20-week anatomy scan that their daughter’s spine had not fused — the diagnosis was spina bifida — and would require an unknown number of surgeries, the first in utero. They moved from their home in Virginia to a Ronald McDonald House near a hospital in North Carolina for further tests, and researched. Three weeks later, they decided to terminate.

“To keep a child with spina bifida is also a loving decision,” Ms. Sheppard said, “but my husband and I decided that it was a loving decision not to bring her into the world with the body that she had.”

The women might seem to be making the case for medical exceptions — dozens have joined lawsuits filed by the Center for Reproductive Rights in four states , seeking to clarify what conditions qualify as exceptions under abortion bans. Instead, “Exceptions don’t work, is what we’re proving,” said Ashley Brandt, a plaintiff in Texas.

Ms. Brandt traveled to Colorado to abort a twin that had acrania — it had no skull — and posed a threat to her other fetus. “It wasn’t just me at risk, it was my viable daughter,” she said. “We still were not an exception.”

She learned of the option to selectively abort only from a TFMR group online; her doctors had been afraid to mention termination for fear of prosecution. She saw the shame and isolation that women in those groups felt, and felt it herself. Some of the harshest comments, Ms. Brandt said, came from women struggling with infertility who cannot imagine choosing to end any pregnancy. Like many of the women now telling their stories in public, she said her experience has made her feel more compassion for women who choose abortion no matter what the reason.

“Picking and choosing, it has to stop,” she said. “We need to trust people to make their own decisions.”

But the women say it remains a fight simply to explain that what they had was an abortion.

Months after Ms. Manzano’s abortion, she noticed her doctor had recorded it as “spontaneous miscarriage” on her chart.

“We had to travel to New Mexico,” Ms. Manzano said. “There was nothing spontaneous about it.”

She has been seeing a grief counselor, who refers to it as her “medical miscarriage,” even after Ms. Manzano told him she prefers to say “abortion.”

“Neither one of us corrects the other,” she said. Still, “for me to be able to grieve and heal through the process, I have to be able to say what it is.”

Kate Zernike is a national reporter at The Times. More about Kate Zernike

Advertisement

Opinion Abortion was already a top issue. Alito made the Supreme Court one, too.

A Democratic agenda: Lose the filibuster, reform the court and revive Roe.

Failure to appreciate the salience of the abortion issue is one reason so many pundits, reporters and pollsters wrongly predicted a “red wave” in 2022. It’s one thing to poll a specific congressional race in, say, September; it’s another when voters finally enter the voting booth to register their views.

This year, abortion remains a powerful issue for Democrats. And the focus on abortion might also make the Supreme Court itself a top issue for Democrats in a presidential campaign for the first time in a generation. The radical Supreme Court that reversed Roe v. Wade is increasingly unpopular and scandal-ridden.

The importance of abortion — and, in turn, the Supreme Court responsible for overturning Roe in Dobbs v. Jackson Women’s Health Organization — marks a dramatic shift in the political landscape. In election after election going back to the early 1980s, Republicans used the Supreme Court to gin up their voters on a variety of issues, but especially on abortion. Democrats never really expected abortion access to disappear, so their presidential nominees did not rely as much on the Supreme Court to turn out their base. Now the tables are turned, at the very time the court has made a spectacle of itself.

Angst over the Supreme Court’s serial ethical blunders remind Democrats and Democratic-leaning independents that the problem is not just abortion but the court itself. Justice Samuel A. Alito Jr. — who authored Dobbs and also committed arguably the worst ethical lapse on the court in memory — helps connect the dots for voters.

This month, NPR reported on a Public Religion Research Institute poll showing that abortion rights remain extremely popular in the United States. “Nationwide, 64% percent of voters said abortion should be always or mostly legal; 35% said it should be always or mostly illegal. In most states — including states with Republican-controlled state governments — a majority of voters support legal abortion, and very few favor total bans.” Pro-choice advocates have won every abortion referendum since Dobbs , even in red states such as Ohio and Kansas.

Abortion has outsize importance as an electoral matter, as the poll’s executive summary explains:

Democrats are 12 percentage points more likely than Republicans in battleground states to say that they will only vote for a candidate who shares their abortion views (46% vs. 34%). Women in battleground states are 9 points more likely than men (41% vs. 32%) to say that they will only vote for a candidate who shares their views on abortion. Half of Democratic women in battleground states (50%) say they will only vote for a candidate who shares their views on abortion, compared with 42% of Democratic men in battleground states.

When it comes to the Comstock Act, which some Republicans are eyeing as a means to criminalize abortion medication or literature sent through the mail, the numbers are even more stunning. “Among all Americans, over two-thirds (68%) oppose laws that make it illegal to use or receive through the mail FDA-approved drugs for medical abortion, often called abortion pills, while about three in ten (29%) favor these laws,” the pollsters found . “Democrats (79%) and independents (71%) are significantly more likely than Republicans (54%) to oppose laws that make it illegal to use or receive abortion pills through the mail.”

The renewed focus on abortion should hardly be a surprise. From tragedies caused by forced birth laws to attempts to ban in vitro fertilization and mifepristone , voters have been reminded continually of the damage wrought by Dobbs . Abortion might be one of the few issues that permeates every race in every state.

Abortion bans are the manifestation of the underlying problem: a reckless Supreme Court accountable to no one. The rogue right-wing court that took away millions of women’s reproductive rights is the same court that is in dire need of ethical reform and, most Americans believe, term limits.

Democrats, as a result, are willing to be daring when it comes to ending the filibuster. “Democratic incumbents and challengers running for the Senate this year say they want to restore a national right to abortion, and many, like [Wisconsin Democratic Sen. Tammy] Baldwin, openly say they would support suspending the filibuster to do so,” the Associated Press reports . “It’s become a key talking point as they try to capitalize on the nationwide battle over abortion rights.” With Sens. Joe Manchin III ( D-W.Va .) and Kyrsten Sinema (I-Ariz.) gone next year, filibuster reform might finally come to pass if Democrats hold the Senate.

The choice is stark. If voters reelect President Biden , new justices with pristine ethical records might replace aging, corrupt radicals. Long-term court reform would also be possible. Elect four-times indicted former president Donald Trump (who brags about ending Roe ) and he will look to put younger, and even more radical, justices (not to mention lower court judges) who will control Americans’ lives for decades. In other words, abortion will be the impetus, but a wider battle about the future of the court is inevitable.

Democrats are more than happy to make abortion and the Supreme Court central issues in the campaign. In certain states the attention might be particularly intense. Last week, abortion measures qualified for the November ballot in Colorado and South Dakota . Those join Florida, New York and Maryland as states with measures to protect abortion rights on the ballot. Others might qualify in Nevada, Arizona, Montana and Nebraska. (A Missouri measure has qualified but the Republican governor might put it on the Aug. 6 primary ballot.) That will ensure abortion — and the Supreme Court — is front and center in debates, ads, interviews and coverage for state and federal office in multiple states as well as national coverage.

The MAGA GOP, which created the most radical court in history, is wildly out of step with voters who want access to abortion, ethical rules and term limits for the court. Republicans need to be forced to defend grossly unpopular abortion bans, a disgraced court and unending judicial imperialism. No wonder they’d rather talk about Hunter Biden or troop up to New York to support criminal defendant Trump.

The Safety and Quality of Abortion Care in the United States (2018)

Chapter: 5 conclusions, 5 conclusions.

This report provides a comprehensive review of the state of the science on the safety and quality of abortion services in the United States. The committee was charged with answering eight specific research questions. This chapter presents the committee’s conclusions by responding individually to each question. The research findings that are the basis for these conclusions are presented in the previous chapters. The committee was also asked to offer recommendations regarding the eight questions. However, the committee decided that its conclusions regarding the safety and quality of U.S. abortion care responded comprehensively to the scope of this study. Therefore, the committee does not offer recommendations for specific actions to be taken by policy makers, health care providers, and others.

1. What types of legal abortion services are available in the United States? What is the evidence regarding which services are appropriate under different clinical circumstances (e.g., based on patient medical conditions such as previous cesarean section, obesity, gestational age)?

Four legal abortion methods—medication, 1 aspiration, dilation and evacuation (D&E), and induction—are used in the United States. Length of gestation—measured as the amount of time since the first day of the last

___________________

1 The terms “medication abortion” and “medical abortion” are used interchangeably in the literature. This report uses “medication abortion” to describe the U.S. Food and Drug Administration (FDA)-approved prescription drug regimen used up to 10 weeks’ gestation.

menstrual period—is the primary factor in deciding what abortion procedure is the most appropriate. Both medication and aspiration abortions are used up to 10 weeks’ gestation. Aspiration procedures may be used up to 14 to 16 weeks’ gestation.

Mifepristone, sold under the brand name Mifeprex, is the only medication specifically approved by the FDA for use in medication abortion. The drug’s distribution has been restricted under the requirements of the FDA Risk Evaluation and Mitigation Strategy program since 2011—it may be dispensed only to patients in clinics, hospitals, or medical offices under the supervision of a certified prescriber. To become a certified prescriber, eligible clinicians must register with the drug’s distributor, Danco Laboratories, and meet certain requirements. Retail pharmacies are prohibited from distributing the drug.

When abortion by aspiration is no longer feasible, D&E and induction methods are used. D&E is the superior method; in comparison, inductions are more painful for women, take significantly more time, and are more costly. However, D&Es are not always available to women. The procedure is illegal in Mississippi 2 and West Virginia 3 (both states allow exceptions in cases of life endangerment or severe physical health risk to the woman). Elsewhere, access to the procedure is limited because many obstetrician/gynecologists (OB/GYNs) and other physicians lack the requisite training to perform D&Es. Physicians’ access to D&E training is very limited or nonexistent in many areas of the country.

Few women are medically ineligible for abortion. There are, however, specific contraindications to using mifepristone for a medication abortion or induction. The drug should not be used for women with confirmed or suspected ectopic pregnancy or undiagnosed adnexal mass; an intrauterine device in place; chronic adrenal failure; concurrent long-term systemic corticosteroid therapy; hemorrhagic disorders or concurrent anticoagulant therapy; allergy to mifepristone, misoprostol, or other prostaglandins; or inherited porphyrias.

Obesity is not a risk factor for women who undergo medication or aspiration abortions (including with the use of moderate intravenous sedation). Research on the association between obesity and complications during a D&E abortion is less certain—particularly for women with Class III obesity (body mass index ≥40) after 14 weeks’ gestation.

A history of a prior cesarean delivery is not a risk factor for women undergoing medication or aspiration abortions, but it may be associated

2 Mississippi Unborn Child Protection from Dismemberment Abortion Act, Mississippi HB 519, Reg. Sess. 2015–2016 (2016).

3 Unborn Child Protection from Dismemberment Abortion Act, West Virginia SB 10, Reg. Sess. 2015–2016 (2016).

with an increased risk of complications during D&E abortions, particularly for women with multiple cesarean deliveries. Because induction abortions are so rare, it is difficult to determine definitively whether a prior cesarean delivery increases the risk of complications. The available research suggests no association.

2. What is the evidence on the physical and mental health risks of these different abortion interventions?

Abortion has been investigated for its potential long-term effects on future childbearing and pregnancy outcomes, risk of breast cancer, mental health disorders, and premature death. The committee found that much of the published literature on these topics does not meet scientific standards for rigorous, unbiased research. Reliable research uses documented records of a prior abortion, analyzes comparable study and control groups, and controls for confounding variables shown to affect the outcome of interest.

Physical health effects The committee identified high-quality research on numerous outcomes of interest and concludes that having an abortion does not increase a woman’s risk of secondary infertility, pregnancy-related hypertensive disorders, abnormal placentation (after a D&E abortion), preterm birth, or breast cancer. Although rare, the risk of very preterm birth (<28 weeks’ gestation) in a woman’s first birth was found to be associated with having two or more prior aspiration abortions compared with first births among women with no abortion history; the risk appears to be associated with the number of prior abortions. Preterm birth is associated with pregnancy spacing after an abortion: it is more likely if the interval between abortion and conception is less than 6 months (this is also true of pregnancy spacing in general). The committee did not find well-designed research on abortion’s association with future ectopic pregnancy, miscarriage or stillbirth, or long-term mortality. Findings on hemorrhage during a subsequent pregnancy are inconclusive.

Mental health effects The committee identified a wide array of research on whether abortion increases women’s risk of depression, anxiety, and/or posttraumatic stress disorder and concludes that having an abortion does not increase a woman’s risk of these mental health disorders.

3. What is the evidence on the safety and quality of medical and surgical abortion care?

Safety The clinical evidence clearly shows that legal abortions in the United States—whether by medication, aspiration, D&E, or induction—are

safe and effective. Serious complications are rare. But the risk of a serious complication increases with weeks’ gestation. As the number of weeks increases, the invasiveness of the required procedure and the need for deeper levels of sedation also increase.

Quality Health care quality is a multidimensional concept. Six attributes of health care quality—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity—were central to the committee’s review of the quality of abortion care. Table 5-1 details the committee’s conclusions regarding each of these quality attributes. Overall, the committee concludes that the quality of abortion care depends to a great extent on where women live. In many parts of the country, state regulations have created barriers to optimizing each dimension of quality care. The quality of care is optimal when the care is based on current evidence and when trained clinicians are available to provide abortion services.

4. What is the evidence on the minimum characteristics of clinical facilities necessary to effectively and safely provide the different types of abortion interventions?

Most abortions can be provided safely in office-based settings. No special equipment or emergency arrangements are required for medication abortions. For other abortion methods, the minimum facility characteristics depend on the level of sedation that is used. Aspiration abortions are performed safely in office and clinic settings. If moderate sedation is used, the facility should have emergency resuscitation equipment and an emergency transfer plan, as well as equipment to monitor oxygen saturation, heart rate, and blood pressure. For D&Es that involve deep sedation or general anesthesia, the facility should be similarly equipped and also have equipment to provide general anesthesia and monitor ventilation.

Women with severe systemic disease require special measures if they desire or need deep sedation or general anesthesia. These women require further clinical assessment and should have their abortion in an accredited ambulatory surgery center or hospital.

5. What is the evidence on what clinical skills are necessary for health care providers to safely perform the various components of abortion care, including pregnancy determination, counseling, gestational age assessment, medication dispensing, procedure performance, patient monitoring, and follow-up assessment and care?

Required skills All abortion procedures require competent providers skilled in patient preparation (education, counseling, and informed consent);

TABLE 5-1 Does Abortion Care in the United States Meet the Six Attributes of Quality Health Care?

a These attributes of quality health care were first proposed by the Institute of Medicine’s Committee on Quality of Health Care in America in the 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century.

b Elsewhere in this report, effectiveness refers to the successful completion of the abortion without the need for a follow-up aspiration.

clinical assessment (confirming intrauterine pregnancy, determining gestation, taking a relevant medical history, and physical examination); pain management; identification and management of expected side effects and serious complications; and contraceptive counseling and provision. To provide medication abortions, the clinician should be skilled in all these areas. To provide aspiration abortions, the clinician should also be skilled in the technical aspects of an aspiration procedure. To provide D&E abortions, the clinician needs the relevant surgical expertise and sufficient caseload to maintain the requisite surgical skills. To provide induction abortions, the clinician requires the skills needed for managing labor and delivery.

Clinicians that have the necessary competencies Both trained physicians (OB/GYNs, family medicine physicians, and other physicians) and advanced practice clinicians (APCs) (physician assistants, certified nurse-midwives, and nurse practitioners) can provide medication and aspiration abortions safely and effectively. OB/GYNs, family medicine physicians, and other physicians with appropriate training and experience can perform D&E abortions. Induction abortions can be provided by clinicians (OB/GYNs,

family medicine physicians, and certified nurse-midwives) with training in managing labor and delivery.

The extensive body of research documenting the safety of abortion care in the United States reflects the outcomes of abortions provided by thousands of individual clinicians. The use of sedation and anesthesia may require special expertise. If moderate sedation is used, it is essential to have a nurse or other qualified clinical staff—in addition to the person performing the abortion—available to monitor the patient, as is the case for any other medical procedure. Deep sedation and general anesthesia require the expertise of an anesthesiologist or certified registered nurse anesthetist to ensure patient safety.

6. What safeguards are necessary to manage medical emergencies arising from abortion interventions?

The key safeguards—for abortions and all outpatient procedures—are whether the facility has the appropriate equipment, personnel, and emergency transfer plan to address any complications that might occur. No special equipment or emergency arrangements are required for medication abortions; however, clinics should provide a 24-hour clinician-staffed telephone line and have a plan to provide emergency care to patients after hours. If moderate sedation is used during an aspiration abortion, the facility should have emergency resuscitation equipment and an emergency transfer plan, as well as equipment to monitor oxygen saturation, heart rate, and blood pressure. D&Es that involve deep sedation or general anesthesia should be provided in similarly equipped facilities that also have equipment to monitor ventilation.

The committee found no evidence indicating that clinicians that perform abortions require hospital privileges to ensure a safe outcome for the patient. Providers should, however, be able to provide or arrange for patient access or transfer to medical facilities equipped to provide blood transfusions, surgical intervention, and resuscitation, if necessary.

7. What is the evidence on the safe provision of pain management for abortion care?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended to reduce the discomfort of pain and cramping during a medication abortion. Some women still report high levels of pain, and researchers are exploring new ways to provide prophylactic pain management for medication abortion. The pharmaceutical options for pain management during aspiration, D&E, and induction abortions range from local anesthesia, to minimal sedation/anxiolysis, to moderate sedation/analgesia, to deep sedation/

analgesia, to general anesthesia. Along this continuum, the physiological effects of sedation have increasing clinical implications and, depending on the depth of sedation, may require special equipment and personnel to ensure the patient’s safety. The greatest risk of using sedative agents is respiratory depression. The vast majority of abortion patients are healthy and medically eligible for all levels of sedation in office-based settings. As noted above (see Questions 4 and 6), if sedation is used, the facility should be appropriately equipped and staffed.

8. What are the research gaps associated with the provision of safe, high-quality care from pre- to postabortion?

The committee’s overarching task was to assess the safety and quality of abortion care in the United States. As noted in the introduction to this chapter, the committee decided that its findings and conclusions fully respond to this charge. The committee concludes that legal abortions are safe and effective. Safety and quality are optimized when the abortion is performed as early in pregnancy as possible. Quality requires that care be respectful of individual patient preferences, needs, and values so that patient values guide all clinical decisions.

The committee did not identify gaps in research that raise concerns about these conclusions and does not offer recommendations for specific actions to be taken by policy makers, health care providers, and others.

The following are the committee’s observations about questions that merit further investigation.

Limitation of Mifepristone distribution As noted above, mifepristone, sold under the brand name Mifeprex, is the only medication approved by the FDA for use in medication abortion. Extensive clinical research has demonstrated its safety and effectiveness using the FDA-recommended regimen. Furthermore, few women have contraindications to medication abortion. Nevertheless, as noted earlier, the FDA REMS restricts the distribution of mifepristone. Research is needed on how the limited distribution of mifepristone under the REMS process impacts dimensions of quality, including timeliness, patient-centeredness, and equity. In addition, little is known about pharmacist and patient perspectives on pharmacy dispensing of mifepristone and the potential for direct-to-patient models through telemedicine.

Pain management There is insufficient evidence to identify the optimal approach to minimizing the pain women experience during an aspiration procedure without sedation. Paracervical blocks are effective in decreasing procedural pain, but the administration of the block itself is painful, and

even with the block, women report experiencing moderate to significant pain. More research is needed to learn how best to reduce the pain women experience during abortion procedures.

Research on prophylactic pain management for women undergoing medication abortions is also needed. Although NSAIDs reduce the pain of cramping, women still report high levels of pain.

Availability of providers APCs can provide medication and aspiration abortions safely and effectively, but the committee did not find research assessing whether APCs can also be trained to perform D&Es.

Addressing the needs of women of lower income Women who have abortions are disproportionately poor and at risk for interpersonal and other types of violence. Yet little is known about the extent to which they receive needed social and psychological supports when seeking abortion care or how best to meet those needs. More research is needed to assess the need for support services and to define best clinical practice for providing those services.

Abortion is a legal medical procedure that has been provided to millions of American women. Since the Institute of Medicine first reviewed the health implications of national legalized abortion in 1975, there has been a plethora of related scientific research, including well-designed randomized clinical trials, systematic reviews, and epidemiological studies examining abortion care. This research has focused on examining the relative safety of abortion methods and the appropriateness of methods for different clinical circumstances. With this growing body of research, earlier abortion methods have been refined, discontinued, and new approaches have been developed.

The Safety and Quality of Abortion Care in the United States offers a comprehensive review of the current state of the science related to the provision of safe, high-quality abortion services in the United States. This report considers 8 research questions and presents conclusions, including gaps in research.

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