Multiple Choice

is a senior editor at The American Prospect. When Amy got pregnant during her freshman year of college, she knew that, at 18, she wasn't ready to be a mother. So she had an abortion. "That was a very easy decision to get to, but a very difficult emotional experience, both before and after," she says from San Francisco, where she now lives. "I wouldn't wish it on anyone else." Six years later, she says, she was living and working in New York City when, after a condom failure, she found herself with a second unwanted pregnancy. "That time, it was like, `Oh, no! This sucks. Let me just take care of this.'" She had another abortion. "Oh well, that's over," she recalls thinking immediately afterward. "And then I didn't think about it very much." She didn't talk about it very much either, and, even today, she is loath to reveal it. "I rarely talk about the second abortion because of society's judgments about women who have a second abortion," she says. "It's like, `Oh, you're allowed one mistake.'" But not two.Amy's experience with multiple abortions was lifechanging enough that she decided to volunteer at Exhale, a telephone hotline where women who have had abortions can speak openly about their experiences. Exhale, which calls itself "pro-voice," is part of a new approach to abortion that eschews dogmas, left and right. Through the organization, which went national in June, Amy counsels women like herself, some of whom have been through multiple abortions. Their numbers are growing. According to the Guttmacher Institute, an abortion-rights organization respected for its data collection, close to half of the 1.3 million abortions performed in the United States each year are repeat abortions, up from just 12 percent in 1973. Most repeat abortions are, like Amy's, a woman's second, yet the number of third abortions is not insubstantial. In 2000, the Centers for Disease Control (CDC) reported that 18 percent of abortions were performed on women seeking at least their third pregnancy termination. In contrast, studies have shown that rape and incest victims, the most politically sympathetic and high-profile group of abortion-seekers, account for about 1 percent of abortions. Despite its prevalence, repeat abortion is the least discussed or researched aspect of abortion in the United States. In the past year, liberals and Democrats have increasingly focused on preventing unwanted pregnancies as a means of preventing abortion. But they have yet to address the specific needs of women who have already had abortions, partly out of fear of affirming conservative stereotypes about why women abort or how they react to an abortion. Asked about repeat abortions, a spokesman for naral Pro-Choice America declined several requests for comment. Yet the reluctance of liberals and pro-choice advocates to shine a spotlight on the troubling repeat-abortion phenomenon has obscured a growing public health issue. Studies suggest that women having repeat abortions as compared with those having first-time abortions are more likely to be minorities, poor, and victims of sexual abuse--in short, among society's most vulnerable. Liberals have always sought to aid the neediest, but their fear of undermining abortion rights has paralyzed them when it comes to helping women at risk of repeat abortion. The sad fact is that, three decades after legalization, abortion is no longer mainly a tool women use to shape their own destinies, but rather a symptom of larger social problems that ought to be addressed by policymakers. Realizing this may just mean accepting that there's some credibility to conservative views on abortion. The U.S. abortion rate has declined since its peak in 1980, so that, today, only 2 percent of women between the ages of 15 and 44, or roughly 1.3 million women, have abortions each year. This is good news for liberals--especially the "safe, legal, and rare" crowd that is eager to show that the abortion rate is declining--but these numbers also conceal a meaningful demographic shift. In 1973, the majority of American women who obtained abortions were white and childless. Since then, tremendous advances in birth control options--coupled with an upsurge in condom use in response to the aids epidemic, approval of the morning-after pill, and anti-teen pregnancy programs--have contributed to an overall decline in abortions, especially among the very young women most likely to have sought abortions in the past. Defying the pregnant-teen stereotype, only 19 percent of women getting abortions in 2000 were adolescents, according to Guttmacher, down from 33 percent in 1972. But the trends aren't quite so propitious for other groups of women. While the overall U.S. abortion rate declined between 1994 and 2000 for nearly all population groups, it continued to rise among low-income women and women on Medicaid. And a growing proportion of women getting abortions are members of a minority group. During that same time period, the abortion rate fell 20 percent among white women but only 10 percent among Latinas and 8 percent among black women. Although they account for roughly 30 percent of the population, minorities represented fully 59 percent of women getting abortions in 2000. In contrast to the mostly childless women getting abortions in the '70s, 60 percent of women getting abortions today are already mothers. If the goal is to decrease abortion rates, then the social and medical changes driving today's lower overall abortion rate are leaving these women behind. The whole point of defending abortion rights is so women can have control over their own destinies. The data, however, clearly show that a lot of women getting abortions are doing so precisely because they don't have control over their destinies, and perhaps never did. What few studies there have been of women who have repeat abortions paint a particularly disturbing picture. Rather than being the free choice of a woman controlling her own fate, repeat abortion operates as a kind of surrogate marker in women's lives for many other things that have gone awry. A Canadian study of 1,145 women found that those getting repeat abortions in 1998-1999 were much more likely to have a history of sexual or physical abuse. "Presentation for abortion," the researchers concluded, "may be an important indication to screen for a current or past history of relationship violence or sexual abuse." Repeat patients were less likely to report they had "lots of friends" and "lots of plans for the future," and they reported significant conflict with their current partners. Given these realities, it is high time that pro-choice advocates and their political defenders begin to treat abortion as a public health issue, rather than just a philosophical or political problem. Pro-choice advocates argue that women need the fail-safe of legal abortion in order to be free. Pro-life groups argue that the recriminalization of abortion will force women and men to become more sexually conservative and socially traditional, to their mutual benefit. But what women who abort appear to really need is the kind of help and social support that neither side has been willing to give them. The great irony is that the reluctance to address repeat abortions has caused U.S. private sector abortion services to lag behind those offered elsewhere in the world. Since 1993, the leading international family planning and women's health groups have been trying to address the repeat abortion problem under the auspices of the Postabortion Care Consortium. The Consortium was motivated by concerns about unsafe abortions, among other things. The U.S. Agency for International Development works closely with the Consortium and has funded programs aimed, in part, to reduce repeat abortions in Turkey, Egypt, Russia, and several African and Latin American nations. The World Health Organization has advocated post-abortion care and counseling since 1991, and support for it was written into the 1995 U.N. Fourth World Conference on Women Platform for Action. Though U.S. abortion services are much safer from a medical standpoint, it's time to consider whether secular post-abortion care and counseling services ought to be made available domestically as a routine part of women's health care as well. Such services could help women who abort gain control of their lives after abortion, get linked up with an appropriate form of birth control, and--most importantly--avoid descending into crisis once again. Advocates brave enough to take on this subject will find broad support for it in the medical literature. A 1997 Guttmacher study recommended that "more intensive contraceptive counseling and services should be provided to first- time abortion patients who are young" or otherwise at high risk of repeat abortion. The Canadians who recommended screening for sexual or physical abuse posited that "such screening could result in offers for referral and counseling that might prove helpful to the woman ... and could potentially help avert a future abortion." There are some post-abortion services available already in the United States, though the efforts are mostly piecemeal. Atlanta's Feminist Women's Health Center, one of the oldest abortion providers in the country, offers a shot of the long-acting hormonal contraceptive Depo-Provera and post-abortion counseling to all women who obtain procedures there. Planned Parenthood also has begun to offer post-abortion counseling services at some of its clinics, and it has long made sure that all women who leave their standard post-abortion follow-up visit are provided with a form of birth control. But such efforts clearly have not been enough, and there has been little research into how to most effectively prevent repeat abortions. Indeed, it could reasonably be argued that providing poor women with job-training and life- counseling after abortion might do as much to reduce repeat abortions as providing birth control. Reaching out to men with post-abortion counseling and contraceptive information might also make a difference. Partly because they are older, women who get repeat abortions are less likely to be single, and one study at a Baltimore hospital found that one-third of women were accompanied to their abortion by the man who had impregnated them. If such men are "not included in counseling in any way, it constitutes a missed opportunity to reduce repeat abortions," Stan Becker, a professor at the Johns Hopkins Bloomberg School of Public Health and a study author, said when it was released in 2004. More research into what kinds of contraception are best for post- abortion women would also be beneficial. The high rate of daily birth control pill use reported among women seeking repeat abortions, for example, suggests that this method may be less effective for them than the weekly patch or Depo- Provera. Polarization on abortion has kept those who defend a woman's right to choose silent on this issue. But pro-choice liberals must protect women from the poverty and abuse that often lead to abortion as fiercely as they protect the procedure itself. The growth of groups like Exhale shows that women who have had abortions need to be able to talk honestly about their experiences, including repeat abortion. Three decades after Roe v. Wade, liberals should still follow women's leads.

By garance franke-ruta