Ever since the Supreme Court ruled that women have the constitutional right to decide whether to continue or terminate a pregnancy, Perspectives on Sexual and Reproductive Health has been a leading source of research on and analysis of the ramifications--public health, behavioral, social and political--of that ruling. With this issue of Perspectives going to press only days before the 30th anniversary of Roe v. Wade, and in a climate of great uncertainty among supporters of a woman's right to choose, it seems only natural for us to dedicate this issue to that anniversary. The articles and essays that follow highlight what has been accomplished and what remains to be done in the effort to ensure safe, accessible and affordable abortions for women who need them.
• The Alan Guttmacher Institute's 13th survey of all known U.S. abortion providers, conducted in 2001-2002, documents that the incidence of abortion and the number of providers declined during the late 1990s, although more gradually than in previous years. In the lead article (see article), researchers Lawrence B. Finer and Stanley K. Henshaw report that the proportion of counties lacking a provider and the proportion of women of reproductive age living in such counties both inched higher in the late 1990s. Early medical abortion has begun to play a role in helping women terminate unwanted pregnancies, but it is not yet widely offered by providers who have not already been performing abortions. In a second article based on the survey findings (page 16), the same authors describe some of the factors that may hamper women from obtaining abortions: gestational limits, distance from a provider, cost, a lack of choice of early medical abortion and intimidation by antiabortion protesters. While these barriers may be substantial, Henshaw and Finer point out that they are undoubtedly compounded by others for which the survey gathered no data, such as difficulties locating services and the prevalence of misinformation about abortion.
• The public health benefits of legalized abortion, as outlined by Willard Cates, Jr., and colleagues (see article), have been enormous. Reviewing data from relevant surveillance systems, the authors show that the shift away from illegal procedures gave women a safer option for terminating unwanted pregnancies, sharply reducing levels of abortion-related complications and deaths. Other benefits, too, have become clear over the years: Notably, as freestanding clinics developed track records for providing safe, economical abortion services, they became a new model for the provision of reproductive and other health care.
• Carole Joffe observes (see article) that while a conservative political agenda and a risk-averse medical culture with a long history of not supporting abortion provision threaten the availability of abortion services, there are some hopeful signs for abortion rights. Joffe points to recently implemented abortion training programs in public hospitals in New York City and California, medical and technological advances that may broaden access to services and increased political mobilization within the medical wing of the prochoice movement. Ultimately, as she sees it, the movement's greatest asset is the dedication of the health care professionals who are committed to providing abortions.
• In the years before Roe, some physicians treated women who had often life-threatening complications from unsafe, illegal abortions or got around the restrictions on abortion by documenting the medical necessity of a pregnancy termination. Physicians for Reproductive Choice and Health's Voices of Choice project captures the anger, frustration and defiance of some of these doctors. The interview excerpted in this issue (see article) paints a vivid picture of how the lack of safe, legal abortion services affected both women and clinicians who provided their health care.
• Felicia H. Stewart and Philip D. Darney argue (see article) that for medical educators and students, it is important to know not only how to provide abortion but why--beyond the public health benefits. In a viewpoint article, Stewart and Darney note that the decision to have an abortion has a profound impact on individual women's lives. In making that decision, a woman may have to weigh the impact on family members; health, relationship, financial and educational issues; and whether her circumstances will allow her to be the best parent she can be. Thus, according to the authors, by performing abortions, physicians provide "one of the few medical services...that can quickly and effectively resolve a major problem in an individual woman's life."
• "Complacency corrodes all freedoms," write Caitlin Borgmann and Catherine Weiss (see article), and it is "particularly dangerous to reproductive freedom" because of the fervor of abortion opponents. Unfortunately, in the authors' view, the prochoice movement has sometimes tried to goad the public into action either by pronouncing the imminent doom of Roe v. Wade or by shying away from open discussion about abortion. As an alternative, Borgmann and Weiss urge a "direct defense that recalls the reasons we fought for legal abortion in the first place": The right to choose promotes a woman's autonomy, equality, bodily integrity and health, and ensures that she will have children only when she feels prepared to welcome them.
• Medical abortion has the potential to expand women's access to abortion services, but only if providers offer the method. In interviews with health care providers in California, Francine Coeytaux, Kirsten Moore and Lillian Gelberg have found that providers often have misplaced fears about the method and receive inadequate professional support and training to offer it (see article). To increase providers' acceptance of the method, they recommend developing information and education materials for providers in specific specialties, disseminating the work of innovators and increasing demand for the service.