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Choose or Lose

A Decade After Passing One of the Country's Strongest Abortion Laws, Maryland Faces New Challenges to Choice

Jefferson Jackson Steele
University of Maryland Medical student Kristen Patzkowsky is active in a campus pro-choice group but says she would be concerned about anti-abortion violence if she practiced the procedure: "It's a scary aspect of the job."
Jefferson Jackson Steele
"I don't know why [pro-choice groups] think there's a threat," says state Sen. Andrew Harris of Baltimore County, who was elected in 1998 on a pro-life platform. "There has been no change in Maryland abortion law since the [1991] referendum."
Jefferson Jackson Steele
Right-to-life activists Sharon Thomas and Dwight Hanauer protest outside Hillcrest, an abortion clinic in Catonsville.
Jefferson Jackson Steele
"People don't realize that we could have potentially lost the legal right to abortion in Maryland," says NARAL's Nancy Lineman of a 1999 bid by pro-life legislators to ban "partial-birth" abortion.
Jefferson Jackson Steele
Dispensing the abortion drug RU486 is one of several services provided by Gynemed Surgi-Center in Eastern Baltimore County.
Jefferson Jackson Steele
Clayton Lee Waagner is on the FBI's 10 Most Wanted list.

By Joyce Lombardi | Posted 10/3/2001

It's really none of your business why these two strangers are sitting in the mauve waiting room of Gynemed Surgi-Center, a tidy clinic tucked away in an office park near Golden Ring Mall in eastern Baltimore County. But they tell you anyway.

"We already have two kids, 2 and 6," says Tiffany, a slender 21-year-old just starting to get drowsy from a sedative she has been given. "She's still young," says her husband, Greg, a 34-year-old tile setter who grew up in Calvert County. "She wants to go to college, and a third child would stop her. We can't have another kid."

Like any other consumer, Greg searched the phone book and called around before settling on Gynemed, a 45-minute drive from their home, for his wife's abortion. "We liked the sound of this place best," he says. They got an appointment within days, and Greg's insurance picked up the tab.

On the face of it, abortion in Maryland looks like any other routine health-care service. As long as you, Medicaid, or your insurance company can cover the fee (which ranges from $350 to $3,000), you can get a simple first-trimester abortion from one of the state's 47 abortion providers, most likely within a week.

This is not how abortion looks in, say, South Dakota, where people face long drives and long waits to be seen at the state's one remaining abortion facility. Nor is it how it looks in Pennsylvania, where working women pay extra to have insurance cover abortion and those on Medicaid don't get coverage at all. In fact, this is not how abortion looks in most states, where patients must contend with obstacles ranging from laws requiring parental or spousal consent and 24-hour waiting periods between counseling and abortion to stringent clinic regulations and aggressive pro-life protesters.

Maryland is, by all accounts, a pro-choice leader, one of only five states to directly safeguard reproductive choice in state law, as the General Assembly did in 1991. Furious right-to-life groups petitioned the law to referendum the following year, but "Question 6" was passed with 62 percent of the vote, preserving the law. As a result, abortion would remain legal in Maryland even if the U.S. Supreme Court reverses Roe v. Wade, something many national pro-choice groups anticipate with the next High Court appointment.

The number of clinics and the tenor of our laws makes Maryland a destination for women seeking abortions from Pennsylvania, West Virginia, and beyond. "We got a call from Iceland today," says Sheryl Lamb*, community-affairs representative at Hillcrest Clinic in Catonsville.

So abortion is solidly legal, easily accessible, and reasonably affordable in Maryland. End of story, right?

Wrong. The real picture of abortion in Maryland is much more complex. For some women it is accessible, but for many others it is almost completely out of reach. And it is clouded by opposition, as abortion always is. But the nature of the opposition has changed. True, abortion foes still congregate, bloody-fetus posters held aloft, as did members of one pro-life group along Maryland roadways in August. But the most effective threats to reproductive choice today are more subtle. With legal abortion embedded in state law, Maryland pro-lifers, taking their cue from peers in other states, are trying to chip away at women's access to abortion, from a variety of directions. And they are getting inadvertent assistance from a medical establishment that largely favors abortion in theory but ignores it in practice. Here is a snapshot of what abortion looks like in Maryland in the four arenas that matter--politics, medical schools, hospitals, and clinics.

"People don't realize that we could have potentially lost the legal right to abortion in Maryland," says Nancy Lineman, executive director of the Maryland affiliate of National Abortion and Reproductive Rights Action League (NARAL), "and we only defeated the measure by three votes."

She's talking about a bill that went before the state legislature in 1999, a proposed ban on so-called "partial-birth abortion." The measure aimed to outlaw a rare procedure--for which there is no accepted medical term--in which a live fetus is pulled partially into the birth canal before it is aborted. Though many doctors argue that it's the safest way to perform an abortion after 20 weeks' gestation, the gruesome-sounding surgery has swayed even normally pro-choice lawmakers all over the country, and partial-birth bans have passed in 30 states and in Congress.

Amid emotional testimony and accusations of deception from both sides, the bill passed the Maryland Senate in 1999 and went to the House of Delegates, where it lost by three votes.

It wasn't just the bill's near success that alarmed its opponents; it was also the way the measure was written, in language critics say was so vague that it could have applied to all abortions.

"It's a game that's being played," says state Sen. Barbara Hoffman (D-Baltimore City/ County), who voted against the ban. "[The bill's sponsors] are not trying to make partial-birth abortion illegal, they're trying to make all abortion illegal."

If such assertions sound far-fetched, consider what happened in Wisconsin the year before. In 1998, that state's governor, Tommy Thompson (now secretary of the U.S. Department of Health and Human Services), signed into law a partial-birth-abortion ban so loosely worded that Wisconsin abortion clinics actually shut down for several days until they received legal assurance that doctors would not be prosecuted for performing routine first-trimester abortions, according to news accounts.

Proponents of the Maryland bill dismiss claims that the partial-birth-abortion ban is a stalking horse for outlawing abortion altogether. "The claim that we were trying to ban all abortions is absurd," says David Lam, executive director of Maryland Right to Life. The clinic closings in Wisconsin were, he says, "a publicity stunt."

Lam, whose group lobbied extensively for the '99 bill, says its language was clear but intentionally open-ended. "The law had to be written broadly enough to cover what we were trying to cover without allowing loopholes," he says.

For now, the point is moot. Gov. Parris Glendening said he'd have nixed the partial-birth ban had it reached his desk. And last year, the Supreme Court (narrowly) struck down Nebraska's partial-birth bill--in part because of its vague wording--thus rendering the bans passed in 30 other states and Congress unconstitutional or unenforceable. Pro-life Maryland legislators have put their bill on ice, waiting to see what language will pass muster in the nation's courts.

The debate is a glimpse into how the abortion battle really looks in Maryland--like it does in other states, with pro-life lawmakers drafting increasingly sophisticated bills aimed at testing just how far state and federal courts will allow abortion rights, as defined by Roe v. Wade, to be whittled away.

How did supposedly pro-choice, left-leaning Maryland--where Democrats outnumber Republicans by two to one in the state Senate and three to one in the House of Delegates--ever get to look this way? State Sen. Paula Hollinger (D-Baltimore County), a 23-year veteran of the General Assembly, traces the shift to the Reagan years and the simultaneous rise of the right-wing Christian groups. "Rural senators used to be pro-choice," she says, "but then the religious right started organizing, and when [legislators] would go home they'd be picketed at their church. Then they'd come to me and say, 'I have to vote with them on this.'"

Hollinger, a former emergency-room nurse, was one of the Senate's most vocal supporters of the 1991 law that "codified" Roe v. Wade, protecting abortion as a matter of state law. Through the remainder of the '90s, she and her pro-choice colleagues beat back a steady stream of pro-life bills, including the partial-birth-abortion ban proposed by Sen. Larry Haines (R-Carroll County) in 1997 and '98. But the state election in the fall of '98 changed the balance of power. That November, several Democrats and moderate, pro-choice Republican senators lost seats to pro-life challengers, including Andrew Harris (R-Baltimore County), Robert Hooper (R-Harford/Cecil counties), and Alex Mooney (R-Frederick/Washington counties), all of whom mounted aggressive campaigns that focused on abortion.

"He was very, very good, but he didn't reflect the district," Harris says of his predecessor, Towson Republican Vernon Boozer, who fought earlier versions of the partial-birth abortion ban. "It's one thing as a Republican to say, 'I'm pro-choice,'" Harris says, "but it's another to lead the fight against another Republican's bill."

Suddenly, the legislature's small but vocal pro-life faction got a tremendous boost and showed what a persistent but vocal minority can do. Pro-choice groups like NARAL, the National Organization for Women, and Planned Parenthood of Maryland started sounding the alarm. "There is a lot of voter apathy," Lineman says. "People think that we had Question 6, that Roe was codified and that's it, but it's not true. A freedom that you have, you always have to defend."

Harris--chatting comfortably in his scrubs and white coat at Johns Hopkins Hospital, where he is an M.D. who administers anesthesia to women in labor--downplays the impact he and his colleagues have in Annapolis. "I don't know why [pro-choice groups] think there's a threat," he says. "There has been no change in Maryland abortion law since the referendum."

It hasn't been for lack of trying. Pro-life legislators, including the delegation from Baltimore County's increasingly conservative 9th District, introduce abortion bills annually, including five in the 2001 legislative session. Among them were attempts to tighten Maryland's parental-notification law--echoing measures enacted in other states to curb abortion access--and a bill seeking to prevent the sale of fetal tissue for research. Most of the 2001 bills died in committee, but a budget amendment to curtail Medicaid funding of abortions made it to the Senate floor, where it was rejected by a 25-21 vote.

No abortion bills have yet been pre-filed for the 2002 session. Lam and Harris maintain there is enough support for their bills to get them to the Senate floor for a vote, but they accuse the leadership--Lam names Senate President Thomas V. Mike Miller Jr. (D-Prince George's/Anne Arundel/Calvert counties) and Sen. Walter Baker (D-Cecil County), chairperson of the Judicial Proceedings Committee--of bottling them up in committee.

Baker disputes the assertion. "Everyone accuses me of that when their bills aren't heard," he says. "There is no policy to restrict abortion bills, but the problem with many of these bills is that they're unconstitutional to begin with. And no, I'm not going to let an unconstitutional bill out of my committee."

Hollinger says she doubts Maryland will adopt abortion laws as stringent as those of other states. "Frankly, many of us who are pro-choice are more worried about the actions of the Supreme Court than about these bills," she says. But pro-life leaders are heartened by their recent inroads. Lam and Harris note the close vote on the 1999 partial-birth-abortion bill, which was backed by some normally pro-choice legislators. They also cite a 2000 poll of 627 Maryland voters indicating popular support for restricting minors' access to abortion.

Whether or not abortion ends up on the agenda for the 2002 legislative session, the more important battleground is likely to be the state election to follow that fall. With the legislature now nearly split on issues such as partial-birth abortion and Medicaid funding, right-to-life groups will be looking to add to their 1998 gains, while abortion-rights advocates attempt to maintain or even solidify their slim majority. Baltimore County's Harris notes that there is already a pro-choice challenger running for his seat.

In Cumberland, an old coal-mining city of 24,000 in mountainous Western Maryland, the legal and legislative debate over abortion is essentially moot. The Allegany County yellow pages list four abortion clinics, two in the Baltimore area and two out of state, all at least a two-hour drive away. Things are much the same on the Eastern Shore, where a referral operator at the Shore Health System of Maryland, which owns hospitals in Cambridge and Easton, directs those seeking abortions to Glen Burnie or Baltimore.

Outside central Maryland, the biggest obstacle to abortion is simply finding a doctor to perform one. According to the Alan Guttmacher Institute, a Planned Parenthood affiliate that researches reproductive-health issues, there are no abortion providers in 13 Maryland counties, most in Western Maryland and the Eastern Shore.

"I've been here 13 years, and the only abortion services ever available in Salisbury were a couple of private doctors," says Cissy Sanders, manager of the Wicomico County town's Planned Parenthood clinic, which provides contraceptive services only. "But people started complaining, and they stopped doing it."

It would likely come as no surprise to women and medical professionals on the Shore and in the western counties that, nationally, the number of abortion providers began to drop sharply in the '80s. Between 1982 and 1996, the number of providers nationwide fell 30 percent, from 2,908 to 2,042. Some states, such as New Mexico and Kansas, lost more than half of their providers during that period. Maryland lost 10 percent, a total of five providers--which doesn't sound like much, unless you happen to live in a place like Salisbury, which had only two providers to begin with.

In populous, medical-minded Baltimore, the decline seems illusory. The local phone book lists 10 private abortion clinics, seven of them in the city or just outside. A new clinic just opened up near Union Memorial Hospital. There are also five local hospitals in town that discreetly provide abortion services to women who need them. "I am solicited by physicians who would like to come in and to work," says Gynemed's owner, Dr. David O'Connor*.

But providers looking for full-time staff have a different view. They say that a shortage is making itself felt even here, and will worsen as doctors currently performing abortions retire.

"There is a paucity of providers, here and everywhere else," says Dr. Paul Blumenthal, who should know. One of the most lauded figures in Baltimore's reproductive-health community, Blumenthal is an associate professor of obstetrics and gynecology at Johns Hopkins, director of contraceptive research and programs at Hopkins' Bayview Medical Center, and director of clinical services at Planned Parenthood of Maryland. "If you were a programmatic provider of abortion services looking for experienced, long-term, capable staff, it would be hard to find them," he says.

While there are obviously some doctors, like Andrew Harris, with moral or religious objections to abortion, Blumenthal says that is not a factor in the shortage. "A lot of physicians and potential physicians are pro-choice, but there are fewer and fewer physicians committed to actually providing abortion services themselves," he says. "A lot of people are committed to things they think it's someone's else's job to do."

Why? The most obvious reason is fear. Baltimore's clinics have been virtually violence-free, but there are always reminders that providing reproductive-health services can be a lethal business. Like the bomb threat at Planned Parenthood's Baltimore clinic this past July. Or the wanted poster taped to the clinic wall, above the latex gloves and urine specimen cups, of Clayton Lee Waagner, a 44-year-old felon who escaped from an Illinois prison in February and who claims that God has ordered him to kill "abortionists."

Clinic staff laugh off the poster. But according to the National Abortion Federation, extremists have murdered seven abortion workers in North America the past eight years and attempted to kill at least 17 others--not just doctors, but secretaries and security guards.

If this isn't enough to make health workers nervous, there is also the Nuremberg Files, a strident, scripture-quoting Web site that posts names, home addresses, spouses' names, and photos of abortion providers, pro-choice judges, and politicians (including, oddly enough, President Bush) across the country. The site, which recently survived a court challenge to its existence, urges visitors to gather data on "baby-butchers" so they may be brought to justice. By chance, the site uses Maryland as an example of how a state's abortion data can be organized.

Kristin Patzkowsky, a second-year medical student at the University of Maryland, knows about the Web site's "blacklist." A Towson native, Patzkowsky says she is pro-choice but hadn't given abortion much thought as part of her medical education until this past summer, when she participated in a reproductive-health program with Planned Parenthood and Bayview Medical Center. From Blumenthal and other doctors she worked with, Patzkowsky learned just how scarce abortion providers are.

"Now I feel like if I do go into ob/gyn, then I almost have to [provide abortions]," she says. "I almost want to." But the thought gives her pause: "I want to have a family someday, and it would be very scary to have my name and face up there on a Web site. It's a scary aspect of the job."

Meanwhile, Patzkowsky is working on the provider shortage from another angle. Galvanized by the summer program, she revitalized the University of Maryland's chapter of Medical Students for Choice (MSFC), a Berkeley, Calif.-based group that aims to put abortion and reproductive-health care back into the curriculums of the nation's med schools.

A key factor in the provider shortage, according MSFC's national office, is that most medical students are simply not exposed to abortion in school. Spurred by a 1992 Alan Guttmacher Institute study that found that only 12 percent of ob/gyn residency programs nationwide required routine training in first-trimester abortion, MSFC formed in 1993 and began lobbying for curriculum reform and providing training programs like the one Patzkowsky took. The group, which has grown to about 7,000 members in 110 chapters, lays claim to effecting curriculum changes at about 50 med schools in the United States and Canada.

At Maryland, Patzkowsky's group decided to address the lack of technical information on abortion in their first- and second-year courses by organizing informal lectures on emergency contraception and the recently approved abortion drug mifepristone, or RU486. Over at Johns Hopkins, members of a very active MSFC chapter organized a monthly lecture series and have managed to get a lecture on abortion care and abortion-related pharmacology added to the second-year student curriculum. (As is always the case with such med-school programs, objectors can opt out.)

"The goal is not necessarily to turn everyone into an abortion provider," says Carolyn Sufrin, a former MSFC coordinator and a fourth-year medical student at Hopkins, "but to educate them, to make them aware of what reproductive-health care is, and how it fits into different areas of medicine, so they can ultimately make an informed choice about what they want to do."

Sufrin is a rarity among even her most actively pro-choice peers. Of five MSFC members in Baltimore interviewed for this article, only she definitely plans to include abortion in her future practice. The others, most of whom are fairly new to med school and still have time left to pick a specialization, aren't quite ready to commit. Their stated reasons have less to do with fear or personal safety than with lingering uncertainty over what kind of medicine they want to practice, and a vague sense that abortion services make for uninteresting medicine. "No one just wants to just do abortions all day," says one third-year student who preferred not to be named, "because you'd miss out on other aspects of medicine."

Sufrin does have other career plans--she is currently taking a yearlong sabbatical from Hopkins to study medical anthropology at Harvard--but "reproductive-health care is my passion," she says. "It's where everything leads me."

Having grown up in the western New York town in which Dr. Barnett Slepian was killed, through his kitchen window, by an anti-abortion gunman in 1998, she acknowledges that there is a risk to the decision. "I'm very lucky in that I've always been in liberal communities and haven't experienced [violence] yet for real myself," she says, sitting in a Mount Vernon coffee bar a few days before embarking for Harvard. "But it's something I think about a lot. I'm sure when I encounter it for the first time, I won't be quite as brave as I feel right now.

"But when you're passionate about something, when you're committed to something, you just have to do it."

It is not just Sufrin's commitment to providing abortions that makes her rare. It is also her willingness to talk matter-of-factly about the issue, to a reporter, in the bright of day. She makes it seem like a normal career choice, the way another medical student might discuss, say, orthopedic surgery.

More common are the feelings of one local ob/gyn resident who declined to be interviewed for this article--not just to protect her own privacy, but that of her employer. "I don't want my institution named," she said. "I don't want people to read it and say, 'Oh, they do abortions.'"

Her institution, like most of the non-Catholic hospitals in and around Baltimore, does perform abortions. But many don't want this fact publicized--not in the press, not even, generally speaking, to patients. Most area hospitals that offer abortions do so on a word-of-mouth basis. They don't list their abortion services in the phone book or, for the most part, on their Web sites.

For any other routinely performed health-care service, this silence would be unthinkable, and unprofitable. But, despite the fact that it is one of the most common surgical procedures in the country--performed about 1.2 million times annually, right up there with corrective eye surgery and neonatal circumcision--abortion is not treated as a routine health-care service, sometimes not even by people who believe it is one.

The reasons are manifold: the stigma associated with abortion, the moral murkiness; the political passion and fanatical wrath it provokes; the need to consider the demands of deep-pocketed donors. Perhaps you can't fully fault the mainstream medical community for wanting to distance itself from the whole mess. But you can lament the repercussions.

Just as abortion has slowly drifted out of medical-school curriculums over the years, it has also drifted out of hospitals. The Alan Guttmacher Institute estimates that, as of 1996, hospitals accounted for only 34 percent of all abortion providers in the country, down from 81 percent in 1973. Of the 1.4 million abortions performed in the United States in 1996, more than 70 percent were done in specialized abortion clinics. About 20 percent were done in other independent facilities, such as surgical centers and Planned Parenthood family-planning clinics; only 7 percent were performed in hospitals.

The state Health Department has no reliable data on how many hospitals perform abortions in Maryland, since reporting is voluntary, but a statewide survey conducted by Maryland NARAL in 2000 found that 12 out of 47 eligible hospitals (meaning non-Catholic, nonchildren's, and nonhospice) in the state provide some form of abortion services. Most are clustered in the Interstate 95 corridor, and many, such as Baltimore's Sinai and Union Memorial, offer abortion only to established patients or to women who live in the immediate ZIP code. Some, like Prince George's Hospital Center in Cheverly and Memorial Hospital in Cumberland, will only provide abortions if the mother's health is in danger.

The shift away from hospital-based services puts more of the burden on independent clinics that are more vulnerable than large medical institutions to anti-abortion violence and the whims of nervous landlords. "We had an electrical fire two years ago," says Liz, a counselor at Hagerstown Reproductive Health Clinic in Washington County (who declined to give her last name), "and I can tell you that no one was too eager to rent a new building to us. We had to rebuild the old one."

These freestanding clinics are also more vulnerable to the economic challenges that buffet any small business. Perhaps recognizing this, abortion opponents across the country are pushing for stringent regulations they say are designed to protect women's health, but which choice advocates contend are aimed at ratcheting up clinics' expenses in order to drive them out of business, or at least drive up the price of abortion.

Twenty-two states have enforced so-called "TRAP laws" (targeted regulation of abortion providers) that require abortion clinics to meet onerous standards for things such as room size, door width, ventilation, and staff size that pro-choice critics say are not applied to other types of medical facilities performing comparable procedures. (One Louisiana measure sought to regulate the angle and jet types of clinic water fountains, according to a recent Mother Jones report.) "TRAP laws do not fill any alleged loophole," the New York-based Center for Reproductive Law and Policy argues. "Instead, they take abortion providers out of mainstream regulatory schemes and subject them to more burdensome requirements." One South Carolina clinic collapsed under the financial weight of trying to meet the standards.

Although Maryland has no TRAP laws--for regulatory purposes, abortion clinics are treated the same as physicians' offices--the sticky licensing debate is familiar to practitioners and lawmakers here. A licensing bill was introduced in the Maryland Senate 10 years ago, after CBS News' 60 Minutes aired a segment about the allegedly shoddy medical practices of a clinic in Suitland, in Prince George's County. Nothing came of that bill, but the renewed national interest in regulating clinics may spark similar measures in Maryland.

"We obviously think regulation would be a good thing," Maryland Right to Life's Lam says. "Abortion is the least regulated industry in America. There have been deaths, and that should be something even people who call themselves pro-choice should care about. But those numbers are buried."

Since statistical abortion reporting is voluntary in Maryland, there are no reliable numbers on abortion-related deaths or complications here. (Maryland is one of only four states in which such reporting is not required; a bill to change that, filed by Baltimore County Sen. Harris, was defeated in the state legislature last year.) Nationally, according to the federal Centers for Disease Control and Prevention (CDC) less than one woman in 100 develops a major complication from induced abortion and less than one in 100,000 dies. (There were three abortion-related deaths in the United States in 1997, the most recent year listed on the CDC Web site.) CDC reports that most complications arise from late-term abortions, which are more surgically complicated; 90 percent of all abortions occur within the first 12 weeks of pregnancy.

Abortion oversight in Maryland focuses not on the sites where the procedure is performed but on the doctors who perform it. Administrators such as Planned Parenthood of Maryland CEO John Nugent and Hopkins' Blumenthal say that adequately addresses safety concerns. "No, abortion shouldn't be regulated," Blumenthal says. "It's a well-described, well-researched procedure that we know in skilled hands is safe and effective."

In Maryland, abortion can only be performed by licensed physicians who can document that they were trained in the procedure. They answer to the state Board of Quality Assurance if any problems arise from an abortion. When abortion-related problems reach the board, they are referred to Blumenthal.

But critics point out, as 60 Minutes did in its report on the Suitland clinic, that grievances brought against individual doctors don't touch the clinic that hired the doctor in the first place. Such accusations could be an Achilles heel in an already vulnerable profession, and at least one doctor in Maryland has taken steps to make sure his work is beyond reproach.

Gynemed, which also provides surgical tubal ligation, is the only abortion clinic in Maryland that has voluntarily initiated the expensive process of reconfiguring to meet the stringent standards of the national Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a nonprofit agency that more commonly deals with facilities such as nursing homes and hospices. Owner O'Connor says his aim is to give Gynemed an unimpeachable reputation and thus a competitive edge over other clinics. But he acknowledges that it would be very difficult for some clinics to pay for the remodeling and restructuring required to meet licensing guidelines, even if they are not as strict as JCAHO's, and still provide affordable abortions.

"Do I wish more clinics were regulated? Yes, I do," he says. "I would like there to be consistent standards, but it's a very difficult issue. How do you ensure standards without affecting accessibility?"

O'Connor says has spent more than $50,000 on improvements at Gynemed, ranging from hiring a registered nurse to purchasing fire-resistant trash cans. The cost has left the clinic with little margin for error if business takes a downturn. "I might have to lay some girls off," frets Gynemed's office manager, Maryann (who asked that her last name not be used). She says the clinic has been hit by a rash of no-shows in recent months and she wonders if right-to-lifers are calling to make fake appointments. "They do that from time to time," she says.

No one knows more about the economic challenges of abortion than officials at Planned Parenthood of Maryland (PPM). With seven clinics (including one on Howard Street just north of downtown) and a $5 million annual budget, PPM is hardly a small operator. While it is not the state's largest provider of abortion services (it does about 200 procedures a month in two clinics), it is, hands down, Maryland's largest provider of family-planning services to young, low-income women.

Sixty percent of the 15,000 women Planned Parenthood of Maryland sees each year for abortions, family-planning assistance, STD checks, and Pap smears are considered "self-pay level one," meaning they have no insurance, no Medicaid, and little or no income. These women--often college students or women between or without jobs--are asked only to make a $20 to $40 donation for contraceptive, prenatal, and ob/gyn services. Some can't even do that. And they certainly don't have the money to pay for a first-trimester abortion, for which PPM charges $350, regardless of income.

They are women like Wilma, a pregnant, 39-year-old mother of three. Without insurance or Medicaid, she and her partner were able to scrounge up only about half the cost of an abortion. She could be eligible for help from Planned Parenthood's June Coleman Fund, which pays part of the cost of abortions for about 10 to 15 women in the Baltimore and Annapolis clinics each month. "But there are so many applicants, I could go over budget each month," Amber Eisenmann, the fund's administrator, says.

Women who can't afford Planned Parenthood might try American Healthcare Services, a cash-only clinic behind Union Memorial Hospital, whose fees are slightly lower than PPM's. But Marty, the office manager at American Healthcare, says no-shows are frequent, probably because her patients simply can't get the money together. For those women, private clinics usually aren't an option; most cater to patients with their own insurance, don't accept Medicaid, and report a self-pay level of only about 10 percent. Hospitals, which charge between $1,100 and $3,000 for an abortion, are out of the question.

That largely leaves one of Greater Baltimore's 10 or so "crisis pregnancy centers," counseling offices funded by the pro-life movement and listed in the phone book under "Abortion Alternatives." These centers, which now outnumber abortion clinics by more than three to one in Maryland, present as facts the dubious link between breast cancer and abortion (recently discredited by a study of 1.5 million women reported in the New England Journal of Medicine) and the prevalence of "post-abortion syndrome," a latent guilt/anger/shame complex that the American Psychological Association does not recognize.

The bleak abortion picture for low-income women isn't likely to improve any time soon. Planned Parenthood is staggering under the weight of its plethora of self-pay patients. PPM ran a deficit of $1 million last year, prompting Nugent to cut staff by 20 percent the day he took office as president/CEO in May. Since then more staff members have left or been let go, and those remaining are struggling to keep up with patient flow. As a result, it is noticeably more difficult to reach the Baltimore clinic's appointment desk to schedule anything, from a checkup to an abortion. Nonetheless, Nugent maintains abortion services have not been affected by the cuts, noting that the number of abortions performed at PPM clinics has risen steadily, from about 1,700 in 1998 to more than 2,000 already this year.

Nugent, a former Jesuit with a master's degree in ethics from San Francisco Theological Seminary, points out that PPM's abortion services are funded through clinic fees and private donations only, and completely distinct from its contraceptive and ob/gyn services, which are partially paid for with state and federal money. "Our abortion services will not be compromised," he says. "And if the family-planning services become a drain, then we'll discontinue them." However, the two services share facilities, as well as support and administrative staff; it seems unlikely that abortion services can be completely insulated from Planned Parenthood's financial woes.

Nugent says PPM is trying to avoid that circumstance by asking the state to increase funding for contraceptive services, which it has not done in five years. "If they believe that contraceptives save money" by pre-empting the cost of state-funded abortions or caring for children on welfare, he says, "they should prove it."

Another strategy is to hire clinic workers is to enroll self-pay clients on Medicaid. This would increase clinic revenue--as long as Medicaid is still in the business of funding family-planning services and/or abortions, a practice that an increasing number of Maryland's lawmakers want to stop.

Although PPM primarily serves low-income women, in a larger sense its financial woes could have an impact on all women who find themselves with an unwanted pregnancy. Planned Parenthood is, to many, the public face of abortion. It is the only institution in Maryland with both the clout and courage to speak up for women who want safe, legal abortions, and to provide that service, no matter the cost.

In Maryland, at least, the realities of economics and changing medical mores may ultimately be more crucial to limiting women's access to abortion than the fierce legal and political battles of the past few decades. The likes of Jerry Falwell may still blame "abortionists" for ills ranging up to the Sept. 11 terrorist attacks, but such tactics are embarrassing and superfluous. (Something even Falwell recognized; he retracted his comments days after making them.) The forces working against choice have spread out, and are quietly succeeding in picking abortion--piecemeal, state by state--out of our lawbooks, out of our medical institutions, out of reach of rural and poor women. And completely out of the thoughts of most people, who would really rather not think about any of it, until an extra blue line should appear on that plastic stick.

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