Nursing and Hospital Abortions in the United States, 1967–1973

Nursing and Hospital Abortions in the United States, 1967–1973 Abstract Before elective abortion was legalized nationally in 1973 with the U.S. Supreme Court decision Roe v. Wade, seventeen states and the District of Columbia liberalized their abortion statutes. While scholars have examined the history of physicians who had performed abortions before and after it was legal and of feminists’ work to expand the range of healthcare choices available to women, we know relatively little about nurses’ work with abortion. By focusing on the history of nursing in those states that liberalized their abortion laws before Roe, this article reveals how women who sought greater control over their lives by choosing abortion encountered medical professionals who were only just beginning to question the gendered conventions that framed labor roles in American hospitals. Nurses, whose workloads increased exponentially when abortion laws were liberalized, were rarely given sufficient training to care for abortion patients. Many nurses directed their frustrations to the women patients who sought the procedure. This essay considers how the expansion of women’s right to abortion prompted nurses to question the gendered conventions that had shaped their work experiences. After Hawaii repealed its criminal abortion statute in March 1970, hospital nurses flooded administrators with complaints about their abortion work; some threatened to quit their jobs. Flummoxed administrators turned to University of Hawaii psychiatrists John F. McDermott, Jr. and Walter F. Char for counsel. After visiting nurses from three hospitals, McDermott and Char offered a grim assessment. Although most had supported the decriminalization of abortion, every nurse with whom they visited “showed symptoms of anxiety and depression” the psychiatrists reported. Moreover, “once the nurses became personally, intimately, and constantly involved with abortions,” their support for legal abortion was “replaced by deeply personal emotional reactions so strong that many of them were even questioning the wisdom of the new law.”1 When states began to decriminalize abortion, many hospital nurses claimed a legal right to refrain from participating in abortion care as a matter of conscience. Consequently, many Americans came to understand only the religious dimensions of nurses’ objection to abortion work. However, nurses’ dissatisfaction with abortion work was also informed by a host of secular issues. Nurses’ longstanding grievances with labor conditions in American hospitals, the inadequacy of their abortion training, and their uneven commitments to feminism also came into focus when they were tasked to care for abortion patients. The study of nurses’ secular grievances during the late 1960s and early 1970s clarifies why so many of them opposed abortion and enables us to understand how abortion became marginalized within American medicine. The nursing profession was in turmoil before abortion was decriminalized. It was among the most poorly-paid, female-dominated professions for white women in 1965: while starting secretaries earned $5,000 per year and newly-minted teachers earned almost $6,000, starting general duty nurses earned only $4,500 annually.2 In 1967, registered nurses had a sixty-seven percent turnover rate and hospitals nationwide suffered from a chronic shortage of nursing staff.3 Boston day shift nurses commonly cared for entire wards of twenty or more patients, while nightshift nurses were responsible for up to forty patients each.4 The US Surgeon General’s Office warned that the number of registered nurses nationwide, which stood around 621,000 in 1965, fell woefully short of the 850,000 needed to provide “safe, therapeutically effective, and efficient” care.5 Despite acute shortages, the profession remained inhospitable to women of color and attracted few men. Although African Americans comprised slightly more than eleven percent of the US population in 1965, only about five percent of American nurses were black.6 Nursing schools were even more hostile to black women than employers: by the mid-1960s, ninety-seven percent of nursing graduates were white and ninety-nine percent were women.7 One of the consequences of the profession’s lack of racial diversity was that patients of color were often cared for by white women. In 1970, New York City’s municipal hospitals reported that just over fifty-eight percent of the women who obtained abortions were African American and 10.5 percent were Puerto Rican. At the time, only seven percent of the registered nurses in the United States were African American.8 The decriminalization of abortion occurred against the backdrop of a reinvigorated feminist movement that empowered many nurses to demand reform. Wilma Scott Heide, a nurse who served as the president of the National Organization for Women from 1971-1973, observed that many nurses refrained from being assertive or decisive in the workplace because of cultural pressures for women—and nurses in particular—to be caring.9 Professor of nursing Virginia Cleland, maintained that nursing’s reputation as “women’s work” isolated it from nearly all vestiges of power in the male-controlled systems of medicine, higher education, and hospital administration. Others contested the casual sexism that frequently marked relationships between doctors and nurses, including physicians’ common practice of addressing nurses as “girls.”10 In 1972, several readers recoiled after the Journal of American Nursing published an editorial that chastised women nurses for not doing more to welcome men into the profession.11 “Charges of ‘feminine snobbery’ and prejudice by female nurses against male nurses can be all too easily reversed and applied to the male-dominated medical profession in this country,” explained Karen Schutzenhofer.12 Registered nurse Lydia Kotchek, asked whether anyone would suggest that physicians make women feel more welcome to enter that profession. “No, I believe they would not,” she explained. “For such is the sexual bias of our culture: a woman who becomes a doctor has stepped up; a man who becomes a nurse has stepped down; and women should keep their place—under men.”13 In the 1970s, thousands of nurses joined the larger feminist project of reforming American medicine by clamoring for the elimination of quotas in medical schools and advocating for equitable funding for women’s health research.14 Scholars of abortion history have emphasized the work of clergy, physicians, attorneys, feminist activists, and the women who sought the procedure.15 Scholarship on the history of nursing has examined how nursing education and employment patterns were shaped by a host of external forces, including changes in medical technology and feminism.16 However, we know relatively little about the relationship between the legalization of abortion and the history of nursing: how did the decriminalization of abortion affect nurses’ work? And conversely, how did nurses shape women’s experiences with abortion after the procedure was decriminalized? The Criminalization of Abortion For nearly one hundred years, American women could obtain legal abortions under only very narrow circumstances. Between 1821 and 1880, every state criminalized abortion. Each state permitted abortion in order to save a woman’s life, and a few included exemptions to protect women’s health, for fetal abnormalities, or in cases of rape or incest.17 Until the 1940s, states granted physicians broad authority to perform medically necessary or “therapeutic” abortions.18 Individual physicians’ authority to perform abortions declined in the mid-1940s, when hospitals took charge of interpreting abortion laws. Hoping to reduce the practice of abortion, hospital administrators formed abortion committees to determine whether abortions were medically necessary. These committees, which were usually comprised of three or more senior physicians, required women to submit to intrusive physical and psychiatric examinations.19 The institutionalization of abortion committees moved the legal practice of abortion out of physicians’ private offices and into hospitals.20 Petitioning for an abortion was prohibitively expensive for most women. Historian Leslie Reagan found that the cost of legal abortions more than quadrupled after Chicago’s hospitals implemented abortion committees, increasing from $68 in the early 1940s to $325 by the 1950s.21 In 1968, a California woman paid $1800 for her daughter’s therapeutic abortion after navigating “a great deal of red tape.”22 Referring to the experience as “disgusting,” she described how she and her daughter encountered doctors and nurses whom they found “unbending—we got the definite feeling they don’t like to handle such cases,” she explained. The advent of abortion committees moved the practice of abortion in the United States underground. By the mid-1960s, abortion committees approved only 8,000 abortions each year, while up to 1.2 million women received illegal abortions annually.23 Although illegal abortions were fraught with risk, sociologist Carole Joffe maintains that most underground abortion providers were committed to protecting women’s health. Thousands of physicians, nurses, and midwives risked their careers and criminal prosecution by continuing to perform abortions.24 Although most women found competent abortionists, the underground marketplace left them vulnerable to exploitation. Some nefarious physicians exploited the power of their recommendations for therapeutic abortions by overcharging patients.25 Quacks sold fake abortifacients and a range of providers, including some physicians, offered illegal abortions in exchange for sex.26 The unpredictability of the illicit market prompted many women to take matters into their own hands. In California, one-third of the women who died from abortion between 1958 and 1961 had attempted to self-abort in their homes.27 Most chillingly, during an era when the overall maternal mortality rate fell and abortion became one of the safest medical procedures, the proportion of maternal deaths caused by abortion increased. After abortion committees seized control of New York’s legal abortion market in 1951, the abortion-related maternal mortality rate nearly doubled. By 1962—when blood transfusions and antibiotics had become readily available—abortion-related mortality accounted for twenty-five percent of pregnant white women’s deaths and fifty percent of the deaths of pregnant women of color.28 Hospitals nationwide opened septic wards to treat mortally ill women who had turned to unsafe abortionists or had tried to self-induce.29 By the mid-1960s, up to 5,000 women died annually because they could not count on receiving care from licensed practitioners.30 Between 1967 and 1972, seventeen states and the District of Columbia responded to the unfolding illegal abortion crisis by reforming or repealing their criminal abortion statutes. Attorneys drafted model legislation to expand physicians’ authority to perform abortions, culminating with the American Law Institute’s (ALI) 1962 Model Penal Code.31 Most states drew upon the ALI’s guidelines to enlarge the range of legal abortions to include cases of rape, incest, or fetal deformity, and to expand the range of therapeutic abortions to include mental health. In many of these states, reform legalized practices that were already commonplace, but shielded physicians from the specter of prosecution.32 Invigorated by a resurgent feminist movement, coalitions of progressive women’s organizations and professional women called for even greater change. Feminists found allies among physicians who treated women with unwanted pregnancies and ministers from the Clergy Consultation Service, an underground abortion referral system that had helped women to find reputable providers since 1967.33 Inspired by the movement to legalize birth control, those who advocated for the repeal of criminal abortion statutes maintained that women and physicians ought to control decisions about reproduction privately.34 They observed that even under the ALI’s Model Penal Code, most women were ineligible for legal abortions because pregnancy rarely imperiled their health. Four states, beginning with Hawaii in 1970, repealed their abortion laws to permit women to request abortions without committee approval, a type of abortion that came to be regarded as elective.35 While the repeal of criminal abortion statutes signaled a watershed for women’s ability to control their reproduction, the more limited—and more commonplace—reformed abortion laws had comparatively little effect on women’s ability to obtain legal abortions. Abortion in Reform States, 1967-1973 In 1967, California, which had previously authorized abortions only to save a woman’s life, revised its abortion law to align with the ALI’s Model Penal Code to permit therapeutic abortions and abortions in cases of rape or incest.36 Within two years, ninety-two percent of abortions were approved for psychiatric reasons.37 Physician C. Lee Buxton, admitted that he and his colleagues interpreted “psychological harm” broadly in order to improve the odds that an abortion committee would approve a therapeutic abortion request. Unlike physical claims, which had to be supplemented with diagnostic proof, mental health petitions relied primarily upon psychiatrists’ recommendations.38 The capacious interpretation of mental health exemptions made nearly everyone uncomfortable. Buxton explained, “Such are the various interpretations of the law that ‘saving the life of the mother’ has become a matter of possibly protecting this ‘life’ from socioeconomic or psychiatric stress. Certainly those cases in which the patient might ‘die’ because of her psychiatric status…are few and far between.”39 Robert F. Drinan, a pro-choice Roman Catholic priest and dean of the Boston College Law School, was even more pointed, calling the health exemptions “as phony as a three dollar bill.”40 Therapeutic abortions were usually the culmination of elaborate charades: women pretended that they would commit suicide if they continued with a pregnancy, physicians pretended to agree, and abortion committees pretended that the petitions brought before them were legitimate. Many nurses were frustrated by the abortion petitioning process. Some believed that women duped physicians while others wondered whether abortions were appropriate for women with psychological problems.41 Other nurses worried that physicians participated in the farce to make money and not because they cared about women.42 Despite widespread skepticism, hospitals’ use of cumbersome, if dubious, abortion committees proved to be an effective means for keeping hospital abortion rates low. Most women who sought abortions did not benefit from reformed abortion laws. After California revised its abortion law, the legal abortion rate rose only modestly compared to the volume of women who would seek the procedure after repeal. Before 1967, an average of 700 hospital abortions were performed annually in a state with a population approaching nineteen million.43 In 1968, the year after the reformed law went into effect, 5,030 women received hospital abortions.44 The modest uptick was primarily due to the expansion of the criteria for therapeutic abortions to also include mental health. Race, class, and geography continued to shape women’s access to legal abortion, even for those who now qualified for a therapeutic abortion. Ninety percent of the women who obtained legal abortions the year the reformed law went into effect were white.45 Lower-middle class, young, nonwhite, and rural women remained disenfranchised because the petitioning process continued to be too expensive, too humiliating, or too far away. In 1968, as many as 120,000 California women sought illegal abortions because the circumstances of their lives did not square with the reformed law.46 After the state repealed its abortion law in 1969, 100,000 women, the majority of whom would have turned to the illegal marketplace or continued with unwanted pregnancies only the year before—obtained legal abortions in California.47 Abortion in Repeal States, 1970-1973 Before the Roe v. Wade decision decriminalized abortion nationwide in 1973, Hawaii, New York, Alaska, and Washington repealed their abortion laws to permit women to obtain abortions without having to justify a medical need for the procedure. The decriminalization of abortion created new, unanticipated challenges for medical professionals. In repeal states, nurses’ dissatisfaction with abortion work stemmed from the new ethical dimensions of abortion care, their increased workload, and the new types of patients whom they encountered. Most pro-choice physicians had not taken into consideration the importance of nurses’ work with abortion patients when they called for the decriminalization of abortion. When hospital administrators in Hawaii turned to McDermott and Char for guidance with the post-repeal nursing crisis, perhaps no one was as surprised by the request than the psychiatrists themselves. McDermott and Char had supported decriminalization, sharing their colleagues’ “urgent wish” to get out of the “unsavory business” of signing dubious therapeutic abortion petitions.48 They explained that many psychiatrists had been “so swept up with the social and psychological importance” of legalizing abortion that they had given “little thought toward the new clinical problems that might be created” for nurses.49 McDermott and Char lamented that administrators and physicians had also generally failed to include hospital nurses in the policy-making and program-planning process to prepare for legalization. Many nurses in repeal states objected to the dissolution of abortion committees, whose physician-members served as gatekeepers and moral arbiters. Char and McDermott explained that even though they had regarded the process as farcical, many nurses nevertheless preferred committee-sanctioned abortions “because they were certified as being legal, therapeutic, and hence, proper.”50 A 1968 survey of nurses at two large hospitals in Washington revealed that an overwhelming majority preferred physician committees to manage abortion requests to the elective model.51 Medical professionals were caught off-guard by the volume of women who sought elective abortions. Although Hawaii was the first state to decriminalize abortion, New York was the first to permit non-residents to obtain them. Before New York legalized abortion in 1970, approximately 1,000 hospital abortions were performed in New York City each year. However, during the first year that elective abortion was legal, 55,347 New York residents and 83,975 nonresidents received abortions in hospitals and clinics New York City. These figures do not offer a full account because the city did not require physicians to report abortions performed in private offices and clinics.52 So many women from across the country flocked to New York City between 1970 and 1973 that observers commonly referred to it as the nation’s “abortion capital.”53 Nevertheless, the state’s hospitals and clinics were generally prepared to handle the volume of women who sought abortions.54 Some nurses objected to the speed with which first trimester abortions were performed. When nurses at Mount Sinai Hospital began tendering their resignations, administrators sought psychiatrist Marcel Heiman’s counsel. Heiman reported that nurses objected to the assembly-line system for first-trimester abortions. “The women were in and out of the hospital so quickly, most of them the same day, that the nurses couldn’t have any personal relationship with them and they resented it,” he explained.55 A nurse who accompanied a friend for an abortion in 1970 compared the private New York City hospital they visited to the notorious British psychiatric hospital, reporting that “It was like Bedlam.” She recalled that women “were herded like cattle, given no counseling, no support at the time of such crisis in their young lives.”56 Another registered nurse wrote to the American Journal of Nursing to describe how poorly nurses and doctors treated her when she had a saline abortion in the early 1970s. She recounted the cacophony of the obstetric clinic, explaining that “Doctors and nurses ran about, examining, yelling, commanding, laughing together.” From her perspective, “Two worlds seemed to exist. In one there were busy, active hospital personnel, in the other, frightened, quiet, withdrawn patients. There was no interaction.”57 Because many physicians were paid by the patient, unscrupulous clinic owners and doctors rushed patients through procedures, taxing medical staff and compromising patient care—sometimes by forgoing counseling altogether—in order to perform as many abortions as possible during a single shift.58 Hospital Nurses’ Abortion Work Abortion Patients Nurses’ experiences with abortion between 1967 and 1973 were also transformed by technological innovations. Most abortions were—and continue to be—performed during the first trimester of pregnancy.59 Prior to the late 1960s, the handful of women approved to receive legal abortions before the twelfth week of pregnancy typically received dilation and curettage (D&C) abortions. After dilating the cervix, a surgeon removed the fetus with a small, scoop-shaped curette.60 A new technology—vacuum aspiration—unfolded in tandem with the liberalization of abortion laws in the late 1960s. Medical professionals and women welcomed the new procedure, which was cheaper, safer, and resulted in less blood loss than the D&C method.61 Nurses’ work with first trimester abortions focused primarily on patient counseling and monitoring. During preliminary visits, nurses obtained patients’ medical histories, explained the D&C or vacuum aspiration procedure, and, discussed contraceptive methods before physicians performed physical examinations.62 Although states required at least one registered nurse assist with the abortion procedure itself, nursing care was generally limited to monitoring and supporting patients.63 To perform vacuum aspiration abortions, physicians inserted a speculum into the vagina, administered a local anesthetic, dilated the cervix, then inserted a dilator or a suction curette into the uterine cavity. Finally, physicians inserted a vacuum tip to aspirate the fetus out of the uterus. The entire procedure took between thirty seconds and three minutes to complete. After removing the vacuum tip, physicians sometimes scraped the uterine wall with a metal curette to ensure that they did not miss any fragments. Abortions that include this step were commonly referred to as suction curettage. After vacuum aspiration or suction curettage abortions, nurses observed the patients for about an hour and offered advice about the side-effects they might experience and instructions for post-operative care.64 Vacuum aspiration abortions, which are technically simple and safe, could have been performed in nonhospital clinics.65 However, with the exception of New York, every state that reformed or repealed its abortion laws before 1973 required that all abortions be performed in hospitals.66 Although they were in the hospital for only a few hours, women in these states often had to navigate a cumbersome infrastructure that had not been designed to serve elective abortion patients. First trimester abortion patients in Hawaii were often admitted to emergency rooms, then transferred to operating rooms for the procedure, then moved to the recovery room, then transferred back to the emergency room before they were discharged. This labyrinth not only taxed hospital staff, nurses in particular, but also contributed to the cost of abortions.67 Although they were less common, mid-trimester abortions dominated discussions about abortion and nursing care in the late 1960s and early 1970s. Bureaucratic and legal hurdles prevented some women from obtaining first-trimester abortions. By the time abortion committees approved therapeutic abortion requests, women’s pregnancies had sometimes advanced beyond the first trimester. Women who had to secure the money to travel to repeal states for elective abortions were also more likely to have to delay abortion until after the twelfth week of pregnancy.68 Before the late 1970s, women who were twelve-to-sixteen weeks pregnant were in limbo: they missed the window for receiving a suction abortions, yet were not far enough along for saline abortions.69 Legal abortions at any stage of pregnancy were very safe by the late 1960s, posing fewer health risks than childbirth. However, abortions after the first trimester posed greater health risks and were more expensive.70 The mechanics of saline abortions sometimes overwhelmed unprepared nurses. When a saline abortion patient was admitted to the hospital, nurses asked them to urinate then change into a gown. Nurses commonly injected patients with Benadtryl and Valium to sedate patients before wheeling them to the operating room. To administer saline abortions, surgeons inserted a needle into the uterine cavity to withdraw amniotic fluid and to replace it with saline, which led to miscarriage, usually within twenty-four to thirty-six hours. During the procedure, which took between ten and fifteen minutes to complete, nurses offered patients emotional support, monitored vital signs, timed contractions, and watched for vaginal discharge.71 Although some hospitals permitted women to go home after the saline induction and to return to the hospital once they began to miscarry, most required them to be admitted for the duration of the abortion.72 It was during this time—between the administration of the saline solution and the expulsion of the fetus—that physicians left patients’ bedsides and nurses took primary responsibility for patient care.73 Unless complications arose, nurses commonly supervised saline-induced labor and delivery. Between induction and delivery, patients commonly experienced side-effects—including nausea, diarrhea, and thirst—that demanded nursing care. Nurses who worked night shifts found saline deliveries to be especially burdensome because wards were often understaffed at night.74 Nurses’ primary source of dissatisfaction with saline abortions stemmed from their delivery of fetuses that resembled premature babies that were often recognizable as boys or girls. Many nurses lamented that they lacked even basic training, with some having to figure out on their own how to discard the fetuses. One nurse complained, “Doctors don’t understand our problems. A patient aborting in bed in the middle of the night…is most distasteful. It upsets the other patients to see [a nurse] running out of the room with a fetus in a bottle.”75 An operating nurse who had assisted comfortably with first trimester abortions explained why she struggled to care for saline abortion patients: “There it is, a recognizable boy or girl, and you know that you have been part of the operation that caused its life to be terminated,” she confided. “I can’t say that I feel I am an accessory to a murder. I wouldn’t go that far,” she reported. “But I say that it shakes me up—and I cannot help asking myself whether this is right, just for any trivial reason that a woman might cook up,” she explained.76 Exceptions: Trained Nurses Nurses in New York were better prepared than most to care for abortion patients. In 1971, professor of nursing Dolores Malo-Juvera, designed one of the first elective courses on abortion care at Hunter College in New York City. Abortion posed a special challenge for nurse educators: historically, they had encouraged students to suppress their feelings and to concentrate on patients’ needs.77 Nurses who provided abortion care, however, needed to be acutely attuned to their own emotions in order to avoid stigmatizing patients with verbal and nonverbal cues. During orientation, Malo-Juvera encouraged students to speak frankly about the prospect of caring for abortion patients. Some Catholic students worried about participating in a procedure that their religion condemned.78 Other students maintained that they lacked the technical expertise to assist with abortions, which Malo-Juvera believed was an “avoidance technique” to sidestep their ambivalence about the procedure.79 Over the course of the term, Malo-Juvera’s students learned how to regard abortion as professionals. Students who volunteered to participate in abortions related their experiences to their classmates. They described uneventful first-trimester abortions and more complicated saline inductions that could last over two days. Some students related that they felt unusually weepy and others admitted that they found themselves laughing at inappropriate times after assisting with abortions. Malo-Juvera assured students that these were normal responses to new, stressful experiences and should not be sources of embarrassment. The sharing process taught students how to manage their personal feelings and offered opportunities to discuss abortion work in a supportive, yet professional setting. Students also came to appreciate how abortion work offered them opportunities to deploy their technical skills and to provide important reassurances to anxious patients. Malo-Juvera reported that many students who had initially been reluctant to participate in abortions came to regard the procedure as one of a range of maternal health services that they might offer, albeit one that had unique challenges.80 In order to prioritize their patients’ needs, nursing students needed to learn to identify and manage their own feelings about abortion. Many students concluded that they needed to separate their personal beliefs about abortion from their professional obligations to provide care, not by sublimating their emotions, but by finding new ways to think about their work. Subsequent research confirmed the value of abortion training for nurses. In the mid-1970s, researchers found that nursing students who received abortion training retained their support for abortion rights. This was significant because previous studies had emphasized that nurses, even those who had supported the legalization of abortion, withdrew their support for abortion rights after assisting with abortions.81 The nurses in those studies, however, had not received abortion training. Of eighty-one nursing students who worked with abortion patients as part of their maternity coursework in a 1976 study, sixty-four percent continued to favor unrestricted abortion rights at the conclusion of the semester.82 Despite its value, abortion training became less commonplace for medical residents during the late twentieth century. While twenty-six percent of residency programs required training in first-trimester pregnancies in 1978, only twelve percent required the training by 1995.83 A 2003 survey of California clinicians revealed that nearly sixty-eight percent of nurse practitioners and 62.5 percent of nurse midwives were willing to administer Mifepristone pills to induce a medical abortion identified their own lack of training as a barrier to offering even simple abortion care.84 In 2017, professor of nursing Pat Mahaffee Gingrich, lamented that “few guidelines” existed for nurses who cared for women with unwanted pregnancies and that the topic of abortion remained “overlooked or optional” in most health care education programs.85 Officials in New York did more than clinicians in most states to prepare personnel and the public for the liberalization of the state’s abortion law. Between March 1970, when the New York State Assembly repealed the state’s abortion statute and July 1970, when women could begin receiving elective abortions, public and private medical facilities mobilized to coordinate abortion care.86 New York City public health officials organized an advertising campaign to ensure that women were made aware of the changed abortion statute, replete with an information and referral hotline. In addition to specialized outpatient abortion clinics, women could turn to Columbia Presbyterian Medical Center, Kings County Hospital, and the New York Hospital, which had created special outpatient units staffed with specially-trained physicians, nurse-midwives, and nurses who had volunteered to work with abortion patients.87 Pro-choice nurses were instrumental in the creation of nonhospital abortion clinics. These nurses often understood abortion as a component of the emerging women’s health movement, which sought to empower women by destigmatizing their sexuality and by encouraging them to take more control over medical decision making. In 1972, registered nurse Margot J. Fromer, asserted that “The patient having an abortion has the right to quality nursing; she has the right not to be discriminated against by the nurse who finds the procedure morally offensive.”88 Indeed, many of the first standalone abortion clinics adopted feminist models of care. At the Women’s Abortion Clinic in Greenwich Village, women received suction abortions in a “casual, cheerful, and intentionally un-hospital like” setting, staffed with physicians, nurses, and medical assistants who supported abortion rights.89 Some nurses sought to empower women patients by embedding abortion care into comprehensive sexual health programs. At New York’s Bellevue Hospital, nurses Christa Keller and Pamela Copeland counseled abortion patients about their anatomy and the biology of reproduction. “As we teach and identify with diagrams the various body parts,” the nurses reflected, “we’re continually reminded how little many women really know about themselves.”90 They found that many abortion patients had refused to use contraception because of the controversy over excessive estrogen levels in birth control pills during the 1960s. Others had been too self-conscious to ask their physicians about contraception.91 Consequences of Unprepared Nurses Nurses who had started their careers before the decriminalization of abortion had few guides to understand the mechanics of their new work with abortion patients. Few administrators altered their hospitals’ infrastructure to create separate abortion units or offered nurses specialized training in response to legal and medical developments that affected abortion care.92 Similarly, most nursing programs and professional journals paid scant attention to abortion training after states decriminalized abortion. Hospital nurses’ lack of preparedness to offer abortion care in the immediate pre-Roe period elevated their ambivalence about women who had the procedure and contributed to the stigmatization of abortion. In September 1971, nursing instructor Linda R. Cronenwett and Janice M. Choyce, the head nurse of Stanford University Hospital’s delivery suite, offered nurses one of the first tutorials about saline abortion work in the profession’s flagship journal, the American Journal of Nursing.93 While nurses could readily find articles that examined nurses’ opinions about abortion, they struggled to find information about the actual mechanics of abortion work. Writing in a dispassionate tone, Cronenwett and Choyce explained how nurses should prepare women for saline abortions, the chemistry of the procedure, and the medical complications that could arise. Cronenwett and Choyce’s only reference to the psychosocial dynamics of abortion care was oblique and brief: “We believe that providing emotional support during this crisis period represents one of the most important aspects of nursing care,” the pair wrote. “One of the nurse’s primary goals should be to help mobilize the coping mechanisms of the patient and her family so that abortion may become a growth experience.” What it meant for nurses to “mobilize” a patient’s “coping mechanisms” was, according to the nurses, “beyond the scope of this paper.”94 Cronenwett and Choyce did not advocate for abortion training requirements, nor did they broach the ethics of abortion. Readers’ responses to the impartial article offer insight about the early mobilization of antiabortion nurses. Nurses who opposed abortion condemned the Journal’s editors for publishing the saline abortion article. Edythe Thompson, a registered nurse from Minnesota complained, “It seems we as a nation have more compassion for baby seals than we have for prenatal human babies. Those who kill baby seals at least are merciful enough to give them an instantaneous death by a whack on the head.”95 New Jersey registered nurse Joan Higgins maintained that it was inappropriate to teach nurses about abortion, explaining “This is not nursing and has no business in a nurses’ professional magazine.”96 Ella Richter, a registered nurse from Missouri asked, “How inconsistent can we get? We as members of the healing professions are pledged to preserve life. But without any qualms of conscience we can condone and participate in the intrauterine killing of 394 babies within a twelve-month period in one hospital.” She maintained that it was hypocritical to spend money and time researching how to increase people’s life expectancy and to also invest resources “destroying unborn babies.”97 Pro-choice nurses didn’t weigh in until after they read antiabortion nurses’ angry letters to the editor. Many suggested that they were caught off-guard by antiabortion nurses’ politicization of the saline abortion article. Jane Mendez-Pico, a registered nurse from Virginia who worked with saline abortion patients explained, “I was amazed and shocked at some of the letters responding to the article ‘Saline Abortion.’”98 She continued, “This article was only trying to convey some nursing measures which will best help the patient who is undergoing this particular procedure.” Registered nurses Martha Calder from Ontario, Canada and Mary Jo Roberts from Alabama described feeling “shocked and disappointed” and “saddened” by the antiabortion nurses’ angry responses to the saline abortion article.99 Other nurses worried how patients would fare if nurses did not learn the mechanics of abortion or if administrators’ prioritized nurses’ personal beliefs over patients’ needs. Loyal Allen, a registered nurse from New York, worried that her antiabortion colleagues had lost sight of their professional responsibilities: “As professionals we are obligated to respect [a patient’s] decision apart from our own value system.”100 Gloria Dittmar, a registered nurse from New York, asked why abortion patients had been singled out for scrutiny. “Are the alcoholic, the drug abuser, the homosexual, the suicidal—patients many nurses find difficult to care for because of the underlying psychological components and social stigma—also to be denied good nursing care?” she wondered. “Are we now discarding our non-judgmental approach and deciding which patients deserve good nursing care and which do not?”101 Glenice Anderson, a registered nurse from Ohio, reported feeling relieved by the saline abortion tutorial: “If I were to have an abortion, I would hope that the nurses attending me would be able to deliver expert nursing care.” She continued, “If it weren’t for these articles, the ‘head in the sand’ approach would prevail.”102 The lack of curricular and scholarly attention—or, as Glenice Anderson phrased it, the “head in the sand approach,” to nurses’ abortion work was hardly surprising, given that in 1970, most nursing education curricula still lacked very basic information about sex education.103 In 1974, British researchers observed the continued paucity of scholarship about nurses’ work with surgical abortions in English language nursing journals.104 One year later, the newsletter Nursing Update featured a cover story warning that many nurses still lacked basic knowledge about abortion care.105 Two years after that, in 1977, American researchers found that only four of eleven major studies of the psychological effects of abortion work on health care professionals included nurses.106 Indeed, nurses complained about their lack of training. A 1973 survey of 457 Michigan nurses revealed how unprepared most of them felt.107 Nurses evaluated how much abortion training they had received on a seven-point scale, with one labeled “little” and seven labeled “much.” Fifty-four percent of the respondents indicated that they had received one (little) training. Forty-one-percent indicated that they should have received much (seven) training and fifty-three percent circled seven (much) when asked “How important is this?”108 Almost all of the respondents had heard of D&C abortions, but nearly twenty-five percent were unfamiliar with the other three major abortion procedures, including vacuum aspiration, hypertonic saline injection, and hysterotomy. With the exception of New York’s specialized abortion units, most hospitals that provided abortions prior to 1973 admitted patients to combined obstetrical/gynecological units instead of designated abortion units. Sociologist Patricia G. Steinhoff and physician Milton Diamond explained that hospitals initially treated abortion patients alongside other obstetrical and gynecological patients in an effort not stigmatize them. “While the policy had good intentions,” they lamented, “in practice it caused some problems.”109 Before decriminalization, most gynecological nurses had cared for women who had suffered from septic abortions or women who required D&Cs after experiencing miscarriages.110 While many had not objected to assisting with abortions that were medically necessary, some found it challenging to care for women who did not require abortions for health reasons. Obstetrical nurses, many of whom had no previous experience with abortion care, were even less prepared when their units were “virtually flooded” with abortion patients.111 Obstetrical nurses confronted special challenges after the decriminalization of abortion: not only did their patient volume expand, but they also had to reconfigure the type of care they provided.112 Some obstetrical nurses, citing a lack of training, reported that they did not know whether to approach elective abortion patients with a smile or what they should say.113 A nurse who worked in the labor and delivery unit of a Washington, D.C. hospital explained how pained she felt the first time she saw an abortion patient on a stretcher next to a woman about to give birth. “Seeing the two women so close together physically but so far apart in attitude struck me hard,” she explained. “One came in for a live delivery and the other for a dead one. I’m a nurse, concerned about preserving life. What am I supposed to do—turn away and say life isn’t that important?”114 Many obstetrical nurses came to regard abortion patients as burdens who took care away from more deserving patients.115 When states began to decriminalize the procedure, most nurses opposed a woman’s right to elective abortions, but supported the right to abortion in case of rape or incest. A 1970 survey of 548 registered nurses revealed that seventy-seven percent opposed unrestricted abortion rights, but only seven-percent opposed abortion under all circumstances. Nurses who had experience caring for women who had suffered botched abortions or had endured the humiliating abortion petitioning process were the most supportive of decriminalization. Emergency room and psychiatric nurses were the most supportive of repeal, with thirty-six percent of ER nurses and thirty-one percent of psychiatric nurses supporting a woman’s right to elective abortion. In contrast, operating room and obstetrical nurses—two specialties who would be tapped to assist with hospital abortions as states decriminalized the procedure—were most likely to oppose elective abortion rights. As states began to decriminalize the procedure, only thirteen percent of operating room nurses and fifteen percent of obstetrical nurses supported a woman’s right to elective abortion.116 Nurses were less supportive of abortion rights than physicians, social workers, or Americans generally. In 1971, researchers surveyed 137 public health nurses and 373 social workers who attended a family planning training program sponsored by the Planned Parenthood Association of Nashville. While two-thirds of the social workers supported a woman’s right to choose abortion, only two-fifths of the nurses agreed.117 In 1975, Gallup, a nonpartisan public opinion research firm, conducted its first poll of Americans’ attitudes about abortion. They found that slightly more than half of Americans supported legal abortion under certain circumstances, and similar numbers favored legal abortion under all circumstances (twenty-one percent) and opposed abortion under all circumstances (twenty-two percent).118 Researchers speculated that nurses were more likely to be ambivalent about abortion rights than social workers because nurses’ exposure to abortion patients was usually limited to the day of the procedure. Nurses generally knew very little about women’s circumstances or the long-term effects of continuing with unwanted pregnancies. On the other hand, social workers had longer-term relationships with the clients they served and were more likely to be sympathetic to a woman’s social, psychological, and economic circumstances.119 A separate 1971 study revealed that nursing students were less likely to support abortion rights than social work or medical school students. While seventy-six percent of social work students and nearly seventy percent of medical students supported a woman’s right to elective abortion, only forty-two percent of nursing students agreed.120 Other researchers observed nurses were more likely to be Catholic than other health professionals and more likely than physicians or social workers to have been raised by parents who had not attended college; college attendance correlated to support for abortion rights.121 The decriminalization of abortion afforded women opportunities to defy gendered stereotypes at a time when stereotypes about women and work still pervaded the nursing profession. Although some nurses had begun to challenge the hierarchical relationships that framed relationships between nurses and physicians, many more remained attached to distinctly gendered ways of thinking about their work. At a time when many nurses still believed that good nurses exhibited the maternal qualities of caring and deference, they were asked to care for women who sought to delay or forgo motherhood in order to focus on educational, career, or other familial pursuits. Nurses’ ambivalence about abortion reflected the tensions between postwar sexual and gender conservatism and emerging expectations about women’s reproductive choices. Whereas most women who sought abortions simply did not want to have more children, the public supported abortion reform only under narrow circumstances. A 1965 National Opinion Research Center poll revealed that the overwhelming majority (seventy-one percent) of Americans supported legal abortion when a pregnancy threatened a woman’s health. A slight majority (fifty-six percent) favored the right to legal abortion when the pregnancy resulted from a rape or if the fetus was likely to have a “defect” (fifty-five percent.) But only twenty-one percent supported a woman’s right to choose abortion for economic reasons and just fifteen percent supported a married woman’s right to abortion if she did not want another child.122 In 1966, sociologist Alice S. Rossi reflected on the inverse relationship between public support for abortion and the circumstances that most often spurred women to seek the procedure. “Americans disapprove of any legitimate institutionalization of a widespread practice if the practice runs counter to the traditional social and religious norms surrounding sex and maternity,” she observed.123 Indeed, the more a woman was judged to have transgressed gender and sexual norms, the more likely nurses—and most Americans—opposed her right to abortion.124 Nurses themselves were not immune to the tensions between popular mores about women’s sexuality and the new possibilities offered by legal abortion. An unmarried registered nurse recounted how conflicted she felt about her abortion at a New York City Planned Parenthood in the early 1970s. Although she felt reassured by her nurses, describing them as “tolerant, even glorious,” she nevertheless felt tremendous guilt for having become pregnant out of wedlock.125 “Feelings of persecution surrounded me, and I wondered, ‘Why, of all girls, me? I don’t deserve this. I’ve always striven so hard to be ‘pure.’” She asked herself, “Am I still a pure virgin, merely tainted, who can return to her pink cloud demure and ignorant? Or am I the decided vamp who must play the manipulated though educated role or a just-in-case female who faithfully pops her pill?”126 The nurse’s anxiety about being exposed as the sort of woman who engaged in premarital sex reveals how women’s reputations took on heightened significance when most women lacked the economic means to live independently. Nurses’ lack of preparedness to care for abortion patients and their ambivalence about the decriminalization of abortion contributed to the stigmatization of the procedure. Because most nurses had not been trained to understand the psychosocial dynamics of elective abortions, they often formed opinions about their patients without much context. The first women who sought decriminalized, elective abortions were commonly anxious about a procedure that had been illegal in the recent past. Psychiatrists observed that these women often exuded a special degree of “bravado, brazenness, and indifference” to cope with their fears and anxieties.127 Untrained nurses were vulnerable to misinterpreting women’s expressions of relief as evidence of their callous disregard for human life. Some nurses reported to McDermott and Char that they were “shocked” to see so many women whom they believed were eager to get rid of “the thing” so that they could “get off the hook” for having engaged in premarital sex.128 For nurses who worked with elective abortion patients, the legalization of the procedure brought into focus the ubiquity of premarital sex and women’s strong desire to postpone motherhood. Hostile nurses amplified abortion patients’ feelings of anxiety and even pain. In the late 1970s, researchers determined that medical professionals’ verbal and nonverbal cues influenced the way women regarded their decisions to have abortions.129 They found that patients were particularly responsive to nurses’ cues about whether they should feel guilty or depressed about having had the procedure.130 Other researchers concluded that abortion patients reported experiencing more pain when they received care from nurses whom they believed opposed abortion.131 Nurses sometimes treated abortion patients punitively. Some placed abortion patients in rooms with women who’d just given birth or near the nursery. Others admitted that they told patients that it was against hospital policy for their boyfriends to sit on their beds if they believed the couple had been “making out” before the procedure.132 Nurses in Colorado admitted that they ignored abortion patients’ requests for cigarettes, pain medication, and water, while nurses in Hawaii encouraged physicians to warn women that abortions could rupture their uteruses.133 Nurses’ “Conscientious Objection” to Abortion Work Scholars have examined how abortion opponents blunted women’s right to abortion by developing legal protections for medical providers’ religious liberties, parental and spousal interests, and restrictions on public funding for abortion after Roe v. Wade.134 However, medical personnel had already begun deploying these strategies before abortion was legalized nationally. Nurses drew upon the strategies of civil disobedience to assert that they had the right to refuse to participate in abortion care. By the late 1960s, Americans were familiar with pacifists and civil rights activists who had cited their conscientious objection to fighting in wars they believed to be immoral or unjust.135 When states began to decriminalize abortion, clergy extended the concept of “conscience” to medical personnel, encouraging them to regard abortion work as a moral wrong rather than a professional duty. In New York, Cardinal Terence Cooke warned Catholic medical personnel that they risked excommunication if they participated in abortions.136 Indeed, many Catholic nurses cited their faith to explain why they would not offer abortion care. “I’m a Catholic, and I know I would feel guilty if I had anything to do with it,” explained a nurse who worked at Chicago’s Weiss Memorial Hospital.137 Antiabortion nurses who were not Catholic also sometimes framed their opposition in moral or ethical terms. A nurse who worked at Chicago’s Bethesda Hospital explained that she would not be comfortable assisting with abortions because “I don’t approve of abortions. It’s just my own philosophy—I’m not Catholic.”138 Section 79-i of the 1971 New York State Civil Rights Law offered medical professionals the right to “refuse to perform or assist” with abortions if they were “contrary to the conscience or religious beliefs” of the workers.139 Shortly after states and individual hospitals began implementing conscience clauses to protect medical providers from having to participate in abortion work, nurses invoked them for reasons unrelated to religious belief. Some antiabortion nurses invoked feminist language and ideas to justify their refusal to participate in abortions. Registered nurse Irene Matousek, asserted that conscience clauses afforded nurses choices that they had been denied historically. “Peoples’ image of nurses and our image of ourselves is that we never complain,” she explained. “We’re always cheerful, always smiling, always supporting whatever the doctor does.”140 She maintained that abortion care revealed a sexist-double standard: while physicians’ engagement with patients was relatively brief, nurses bore the brunt of the procedure’s emotional and physical labor demands. “The physician does his thing, then leaves,” Matousek explained. “It’s the nurse who is left to clean up, to be the recipient of such questions as ‘did I do the right thing?’ The doctor comes and goes; the nurse is left with the consequences.”141 Many nurses resented that physicians chose whether to offer abortions while nurses were expected to care for the patients they were assigned to cover each day, regardless of their feelings about abortion.142 Antiabortion nurses generally ignored how their refusal to participate in abortions might affect patients’ abilities to exercise their rights. Nurses’ refusal to provide abortion as a matter of “conscience” had profound consequences for women who sought abortions. In 1971, so many nurses refused to assist with abortions at Los Angeles’s County-USC Medical Center that the hospital briefly reduced by one-third the number of therapeutic abortions performed each month.143 Hospital administrators maintained that they had money to hire nurses, but could not find enough who were willing to assist with abortions. At Cleveland’s Metropolitan General Hospital, so many nurses and anesthesiologists refused to assist with abortions that obstetrician-gynecologists had to perform the procedure alone. As a result, the hospital could only accept four of the more than fifty women who requested abortions each week.144 Medical professionals’ right to refuse to participate in abortions became enshrined into federal policy in 1973, when President Nixon signed into law a bill that included a conscience clause permitting federally-funded hospitals and medical professionals to refuse to participate in abortions or sterilizations on the basis of moral belief or moral conviction.145 One year later, the Legal Services Corporation Act permitted similar protections to federally-funded attorneys or institutions tasked with supporting abortion rights.146 In 1976, abortion was singled out once more with the Hyde Amendment, which prohibited the use of federal funds for most abortions. Hospitals, buoyed by their legal right not to perform abortions, never became reliable sources for abortion services in the United States. Poor and rural women were disproportionately affected by the lack of hospital provision because they were less likely to be able to afford private care and often lived in regions that did not have standalone abortion clinics.147 In the mid-1970s, one-third of poor Americans lived in states with public hospitals that performed one or no abortions. More than half of all abortions occurred in nonhospital clinics located in metropolitan areas. By the mid-1990s, only about seven percent of all abortions were performed in hospitals.148 The women’s liberation movement transformed American women’s expectations of medical care. But the legalization of abortion preceded many feminist reforms within American medicine. The first generation of women who sought legal, elective abortions depended upon an overworked, underprepared, overwhelmingly white, female nursing corps. Although nurses would perform important emotional—and in the case of mid-trimester abortions, technical—work, most hospital administrators did not prepare them to assist with abortions. Similarly, most nursing schools and professional journals did not educate nurses about the technical or psychosocial dynamics of elective abortion care. As a consequence, many nurses who had initially supported decriminalization became hostile to the procedure after participating in abortion care. Nurses drew upon the burgeoning women’s liberation movement to articulate their grievances with their workloads and the sexism that often marked their relationships with physicians. Conscience clauses, which were intended to protect medical professionals’ religious beliefs, instead enabled nurses to refuse to participate in the procedure for a host of secular reasons. Ironically, nurses often deployed distinctly feminist arguments to justify their refusal to help other women to exercise their right to abortion. In the process, they created boundaries between themselves and patients, physicians, and hospital administrators and helped to ensure that abortion would remain at the margins of mainstream medicine long after decriminalization. Indeed, legal protections that prioritized medical professionals’ personal religious liberties proved to be one of the most salient strategies for curbing abortion access well into the twenty-first century. In January 2018, the Trump administration announced the creation of the Conscience and Religious Freedom Division within the Department of Health and Human Services. The new unit was established to ensure that medical providers could refuse to engage procedures or patients whose demands, identities, or lifestyles violated their religious beliefs. With echoes of debates about nurses’ right to refuse to participate in abortions in the late 1960s, Hal C. Lawrence III, the chief executive of the American College of Obstetricians and Gynecologists lambasted the new federal enforcement unit, explaining, “No individual, employer, politician, or entity should be given legal cover to deny a patient needed medical care.” Eric D. Hargan, the acting secretary of health and human services, countered that the office would ensure that religious medical professionals would no longer be “bullied by the federal government because of their religious beliefs.”149 Since the late 1960s, debates about medical professionals’ responsibilities to abortion patients have emphasized providers’ religious beliefs. By reflecting on the period immediately before Roe, we see how nurses’ invocation of conscience clauses ultimately obscured many of the problems that the legalization of abortion had exposed. When they invoked their right to refuse to fulfill their professional obligations on the basis of personal conscience, nurses declared that they would not defer to physicians’, administrators’, or patients’ demands. However, by taking cover under the umbrella of conscience clauses, a legal protection shrouded with religious meaning, the other issues that had come into focus when abortion was decriminalized—including nurses’ long-standing labor grievances, some nurses’ discomfort with changing sexual mores, and most nurses’ lack of preparedness to care for abortion patients—faded from view. Footnotes I presented a version of this article at the triennial meeting of the Berkshire Conference of Women’s Historians in June 2017. Thanks to Benjamin Benus, Christopher Crenner, Sara Dubow, Cory Ellen Gatrall, Linda K. Kerber, Johanna Schoen, Charissa Threat, and the two anonymous reviewers for helping me to identify sentences to keep, words to toss, and ideas that I needed to rethink. 1 Walter F. Char and John F. McDermott, Jr., “Abortions and Acute Identity Crisis in Nursing,” Am. J. Psychiatry 128 (1972): 953. 2 “Nurse Shortage Worsens, Desperate in Some Areas,” Chicago Tribune, September 11, 1966, B2. 3 Joan E. Lynaugh and Barbara L. Brush, American Nursing: From Hospitals to Health Systems (Malden, Mass.: Blackwell Publishers Ltd., 1996), 29–30. 4 Carl M. Cobb, “Severe Shortage of Nurses Creates City Hospital Crisis,” Boston Globe, July 17, 1966, A38. 5 “Nurse Shortage Worsens,” B1. 6 Campbell Gibson and Kay Jung, “Historical Census Statistics on Population Totals by Race, 1790 to 1990” (Washington, D.C.: U.S. Census Bureau, 2002), 26, https://www.census.gov/population/www/documentation/twps0076/twps0076.pdf, accessed September 2017; “Nurse Shortage Worsens,” B2. 7 Susan Gelfand Malka, Daring to Care: American Nursing and Second-Wave Feminism (Urbana: University of Illinois Press, 2007), 25. 8 Although they were not as stark, the city’s voluntary ward and private hospitals also had pronounced race-based disparities between patients and nurses. Jean Pakter, David Harris, and Frieda Nelson, “Surveillance of the Abortion Program in New York City: Preliminary Report,” in Clinical Obstetrics and Gynecology, ed. George Schaefer, vol. 14 (New York: Harper & Row, 1971), 280; Angela Byars-Winston, Nadya Fouad, and Yao Wen, “Race/Ethnicity and Sex in US Occupations, 1970–2010,” J. Vocational Behavior, 87 (2015): 67. 9 Wilma Scott Heide, “Nursing and Women’s Liberation: A Parallel,” Am. J. Nursing, 73 (1973): 824. 10 Pat Yoder, letter to the editor, Am. J. Nursing, 71 (1971): 2308. 11 Henry K. Silver and Patricia A. McAtee, “Opinion: Health Care Practice: An Expanded Profession of Nursing for Men and Women,” Am. J. Nursing, 72 (1972): 78–80. 12 Karen Schutzenhofer, letter to the editor, Am. J. Nursing, 72 (1972): 443. 13 Virginia Cleland, “Sex Discrimination: Nursing’s Most Pervasive Problem,” Am. J. Nursing, 71 (1971): 1543. 14 William Ray Arney, Power and the Profession of Obstetrics (Chicago: University of Chicago Press, 1982), 208–42; Wendy Kline, Bodies of Knowledge: Sexuality, Reproduction, and Women’s Health in the Second Wave (Chicago: University of Chicago Press, 2010). 15 Carole E. Joffe, Doctors of Conscience: The Struggle to Provide Abortion Before and After “Roe v. Wade” (Boston: Beacon Press, 1995), 53–142; Rickie Solinger, “‘A Complete Disaster’: Abortion and the Politics of Hospital Abortion Committees, 1950-1970,” Feminist Studies 19 (1993): 241–68. On lay feminist abortion provision, see Laura Kaplan, The Story of Jane: The Legendary Underground Feminist Abortion Service (Chicago: University of Chicago Press, 1997). On feminist and clerical work to refer women to safe abortion providers, see Arlene Carmen, Abortion Counseling and Social Change From Illegal Act to Medical Practice: The Story of the Clergy Consultation Service on Abortion (Valley Forge, Penn.: Judson Press, 1973); Leslie J. Reagan, “Crossing the Border for Abortions: California Activists, Mexican Clinics, and the Creation of a Feminist Health Agency in the 1960s,” in Women, Health, and Nation: Canada and the United States since 1945, ed. Georgina Feldberg et al. (Quebec: McGill-Queen’s University Press, 2003), 355–78; Jennifer Nelson, More Than Medicine: A History of the Feminist Women’s Health Movement (New York: New York University Press, 2015), 57–89. On the relationship between medical technology, feminism, and abortion law, see Johanna Schoen, Abortion after Roe: Abortion after Legalization (Chapel Hill: The University of North Carolina Press, 2015). On discourses that framed the abortion debate before and after decriminalization, see Sara Dubow, Ourselves Unborn: A History of the Fetus in Modern America (New York: Oxford University Press, 2010); Carol Sanger, About Abortion: Terminating Pregnancy in Twenty-First Century America (Cambridge: Harvard University Press, 2017). 16 Darlene Clark Hine, Black Women in White: Racial Conflict and Cooperation in the Nursing Profession, 1890-1950 (Bloomington: Indiana University Press, 1989); Susan Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 (New York: Cambridge University Press, 1987); Malka, Daring to Care: American Nursing and Second-Wave Feminism; Kara Dixon Vuic, Officer, Nurse, Woman: The Army Nurse Corps in the Vietnam War (Baltimore: Johns Hopkins University Press, 2009); Patricia D’Antonio, American Nursing: A History of Knowledge, Authority, and the Meaning of Work (Baltimore: Johns Hopkins University Press, 2010); Charissa J. Threat, Nursing Civil Rights: Gender and Race in the Army Nurse Corps (Urbana: University of Illinois Press, 2015). 17 Mary C. Segers and Timothy A. Byrnes, eds., Abortion Politics in American States (Armonk, New York: M.E. Sharpe, 1995), 2; Leslie J. Reagan, When Abortion Was a Crime: Women, Medicine, and Law in the United States, 1867-1973 (Berkeley: University of California Press, 1997), 12–13. 18 A 1931-32 study of nearly 1,000 women who lived in the Bronx revealed that 35 percent had obtained at least one illegal abortion; three-quarters turned to a person they referred to as a “doctor.” Regine K. Stix, “A Study of Pregnancy Wastage,” Milbank Memorial Fund Quarterly, 13 (1935): 352, 359–60. Johanna Schoen has demonstrated that until the 1930s, state authorities were more invested in punishing women’s sexual partners for failing to be supportive and enthusiastic fathers than rooting out physicians who performed abortions illegally. Johanna Schoen, Choice & Coercion: Birth Control, Sterilization, and Abortion in Public Health and Welfare (Chapel Hill: University of North Carolina Press, 2005), 148–52. 19 Reagan, When Abortion Was a Crime, 179; Rose Leroux et al., “Abortion,” Am. J. Nursing, 70 (1970): 1921. 20 Stix, “A Study of Pregnancy Wastage,” 352, 359–60. See also Schoen, Choice & Coercion, 139–79. 21 Reagan, When Abortion Was a Crime, 197. See also Morton Sontheimer et al., “A Report on Abortion from Nine American Cities,” Woman’s Home Companion, 82 (1955): 45 and 96. 22 Ralph Dighton, “Legal Abortions: Running Far Fewer than Estimated,” Washington Post, September 20, 1968, C6. 23 Nathan Hershey, “The Law and the Nurse: As Society’s Views Change, Law Changes,” Am. J. Nursing, 67 (1967): 2312; Jeanne D. Fonseca, “Induced Abortion: Nursing Attitudes and Action,” Am. J. Nursing, 68 (1968): 1022. 24 Joffe, Doctors of Conscience. Nathan Hershey, “The Law and the Nurse: The Legal Side of Medical-Moral Issues,” Am. J. Nursing, 62 (1962): 103–4. On nurses arrested for performing abortions outside of hospitals, see “Medic, Nurse Held Again for Abortion,” New York Amsterdam News, March 13, 1965, 1; “Nurse, 70, Found Guilty of Abortion on Girl, 18,” Chicago Tribune, December 7, 1966, A10; “Nurse Jailed In Abortion of Woman,” Los Angeles Sentinel, August 31, 1967, A7; “Male Nurse Arrested in Teenager Abortion,” Los Angeles Sentinel, 30 January 1969, B2. 25 Reagan, When Abortion Was a Crime, 201. 26 Janet Allured, Remapping Second-Wave Feminism: The Long Women’s Rights Movement in Louisiana, 1950-1997 (Athens: University of Georgia Press, 2016), 150, 153–57; Schoen, Choice & Coercion, 140. 27 California Health & Welfare Agency Department of Public Health, “Report to the Legislature,” in Information on California Therapeutic Abortion Act of 1967 (Lansing, MI: Michigan State Senate Committee on Abortion Law Reform SR 185, 1968), 44, http://hdl.handle.net/2027/mdp.39015071227360, accessed August 2017. 28 Reagan, When Abortion Was a Crime, 205, 213–14. 29 Ibid., 210. 30 Schoen, Choice & Coercion, 176. 31 Roy G. Smith, Beverly Manner, and George Goto, “Physicians’ Attitudes on the Abortion Law: Report of Survey, 1969,” Hawaii Med. J., 29 (1970): 209–11. 32 Kaplan, The Story of Jane; Joffe, Doctors of Conscience; Linda Greenhouse and Reva Siegel, Before Roe v. Wade: Voices That Shaped the Abortion Debate Before the Supreme Court’s Ruling (New York: Kaplan Publishing, 2010), 3–34. 33 “The Story of California’s Abortion Law,” Information on California’s Therapeutic Abortion Act of 1967 (Michigan State Senate Committee on Abortion Law Reform SR185, 1968), 61, https://babel.hathitrust.org/cgi/pt?id=mdp.39015071227360;view=1up;seq=7; Durlin Hickok and Colin Campbell, “Attitudes Toward Abortion Law Reform at the University of Michigan Medical Center,” Michigan Medicine, 71 (1972): 327–29, accessed August 2017. Nurses also pointed to their work with women suffering from botched abortion to explain their support for abortion rights. Christine Winter, “Abortion from the Nurse’s Point of View–Will She Be a Participant?” Chicago Tribune, March 11, 1973, D3. 34 Mary L. Dudziak, “Just Say No: Birth Control in the Connecticut Supreme Court before Griswold v. Connecticut,” Iowa Law Review 75 (1990): 915–39. 35 Roy G. Smith et al., “Abortion in Hawaii: The First 124 Days,” Am. J. Public Health, 61 (1971): 530. Many states, including Hawaii and California, liberalized their laws incrementally, through both legislation and the courts. Segers and Byrnes, Abortion Politics in American States, 3–4. 36 “California Therapeutic Abortion Act of 1967,” California Health & Safety Code §§25950-54 (June 1967). 37 Dorothy Townsend, “Doctor Gives Data on Legal Abortions: Only 3% Performed for Mother’s Physical Health,” L. A. Times, September 24, 1970, A3. 38 Rothlyn Zahourek, “Liberalized Abortion: Devastation–Preservation,” AORN Journal, 15 (1972): 94–96. On women’s difficulty obtaining legal abortions after having been raped, see Leroux et al., “Abortion,” 1919–20. 39 C. Lee Buxton, “One Doctor’s Opinion of Abortion Laws,” Am. J. Nursing, 68 (1968): 1027. 40 Ibid., 1028. 41 Rothlyn Zahourek, “Therapeutic Abortion and Cultural Shock,” Nursing Forum 10 (1971): 13. 42 Char and McDermott, “Abortions and Acute Identity,” 954. 43 “Estimates of the Population of States, By Age, 1965 to 1967” (Washington, D.C.: US Department of Commerce and Bureau of the Census, April 17, 1969), 6, https://www.census.gov/content/dam/Census/library/publications/1969/demo/p25-420.pdf, accessed October 2017. 44 Gwen Gibson, “Liberalized Abortion Law: Four Years Later,” Los Angeles Times, November 21, 1971, E1. 45 Bureau of Maternal & Child Health California Department of Public Health, “Therapeutic Abortions Report,” in Information on California Therapeutic Act of 1967 (Lansing, MI: Michigan State Senate Committee on Abortion Law Reform SR 185, 1968), 12–13, http://hdl.handle.net/2027/mdp.39015071227360, accessed August 2017. 46 California Department of Public Health, 14. 47 Michael S. Goldstein, “Abortion as a Medical Career Choice: Entrepreneurs, Community Physicians, and Others,” J. Health and Social Behavior, 25 (1984) 223. 48 McDermott, Jr. and Char, “Abortion Repeal in Hawaii,” 620. 49 Ibid., 620. 50 Zahourek, “Therapeutic Abortion,” 13. 51 Norman K. Brown et al., “How Do Nurses Feel about Euthanasia and Abortion?” Am. J. Nursing, 71 (1971): 1416. 52 New York City’s Center for Reproductive and Sexual Health clinic served 60,000 during its first two years of operation in the early 1970s. Schoen, Abortion after Roe, 33. 53 Carl M. Cobb, “New York City: Abortion Capital of U.S.,” Boston Globe, July 26, 1970, A3; Richard Knox, “Residency Curb Debated For New York Abortions,” Boston Globe, January 31, 1971, 1; Gary S. Berger et al., “Maternal Mortality Associated with Legal Abortion in New York State,” J. Obstetrics and Gynecology 43, (1974): 315. 54 Hollis S. Ingraham and Robert J. Longood, “Abortions in New York State since July 1970,” in Clinical Obstetrics and Gynecology, ed. George Schaefer, vol. 14 (New York: Harper & Row, 1971), 17. 55 Enid Nemy, “Even Now, Helping with Abortions Is Traumatic Shock for Some Nurses,” New York Times, February 1, 1972, A32. 56 Quoted in Thelma M. Schorr, “Editorial: Issues of Conscience,” Am. J. Nursing, 72 (1972): 61. 57 “Does Anybody Care?,” Am. J. Nursing, 73 (1973): 1564. 58 Schoen, Abortion after Roe, 36. 59 Between 1970 and 2009, between eighty-five and ninety-two percent of abortions in the United States were performed at or before thirteen weeks’ gestation. Smith et al., “Abortion in Hawaii,” 532; Karen Pazol et al., “Abortion Surveillance–United States, 2009,” Morbidity and Mortality Weekly Report, 61 (2012): 2. 60 Robert Drinan, “The Desperate Dilemma of Abortion,” Time, 13 October 1967, 42. 61 Leroux et al., “Abortion,” 1921–22; Christa Keller and Pamela Copeland, “Counseling the Abortion Patient Is More than Talk,” Am. J. Nursing, 82 (1972): 104; Schoen, Abortion after Roe, 27. 62 Catherine H. Siener and Elizabeth Mahoney, “Coordination of Outpatient Services for Patients Seeking Elective Abortions,” in Clinical Obstetrics and Gynecology, ed. George Schaefer, vol. 14 (New York: Harper & Row, 1971), 53. 63 Mary C. McLaughlin, “Abortion Standards, New York City Board of Health,” in ibid., 32–33. 64 Janet D’Archangelo, “Abortion: Nursing Expertise Needed,” Nursing Update 6 (1975): 10. 65 A Planned Parenthood in Syracuse charged women up to $250 for a first-trimester abortion in 1971. Ellen Fairchild and A. Jefferson Penfield, “Should Family Planning Clinics Perform Abortions?” Family Planning Perspectives, 3 (1971): 16. 66 Christopher Tietze et al., Provisional Estimates of Abortion Need & Services in the Year Following the 1973 Supreme Court Decisions (New York: Alan Guttmacher Institute, 1975), 30. 67 Most women (64 percent) paid out-of-pocket for the $350-400 cost of hospital-based abortions. Smith et al., “Abortion in Hawaii,” 534–35. 68 Jean Dietz, “Upstate: Conservatism, Staff Reluctance Greets Patients,” Boston Globe, July 26, 1970, A3. 69 Schoen, Abortion after Roe, 30–31. 70 On the health risks associated with later-term abortions, see Berger et al., “Maternal Mortality,” 315; R. R. Macdonald, “Complications of Abortion,” Nursing Times, 63 (1967): 305–7. In the early 1970s, saline abortions were $420, compared to $140 for vacuum aspiration abortions. Gibson, “Liberalized Abortion Law,” E20. 71 Deborah Farber Kallop, “Preoperative Instruction for the Patient Undergoing Elective Abortion,” in Obstetrics and Gynecology, ed. George Schaefer, vol. 14 (New York: Harper & Row, 1971), 60–66; David T.Y. Liu and Pamela M. Thwaites, “Induced Mid-Trimester Abortion,” Nursing Times, 70 (1974): 1543. 72 Nemy, “Even Now.” 73 Yaloff, Wade, and Burlingame, “Nursing Care in an Abortion Unit,” 78. 74 Nancy B. Kaltreider, Sadja Goldsmith, and Alan J. Margolis, “The Impact of Midtrimester Abortion Techniques on Patients and Staff,” Am. J. Obstetrics and Gynecology, 135 (1979): 236. 75 Unnamed nurse qtd. in Phyllis Langton Stewart, “Normative Views of Doctors & Nurses on Abortion,” Sociological Symposium, 8 (1972): 93. 76 Helen Branson, “Nurses Talk about Abortion,” Am. J. Nursing, 72 (1972): 106. 77 Historian Susan Reverby has observed that nursing students and nurses often resisted pressures to conform or to defer to authority. Ordered to Care, 34, 57, and 160. 78 McDermott and Char observed that Catholic nurses had an advantage over their non-Catholic colleagues. While most nurses appeared to have felt overwhelmed or undertrained, the Catholic Church’s strict opposition to abortion offered Catholic nurses a framework for articulating their discomfort. “Abortion Repeal in Hawaii,” 622. 79 Dolores Malo-Juvera, “Preparing Students for Nursing Care,” Nursing Outlook 19 (1971): 348. 80 Ibid., 349; Goldstein, “Abortion as a Medical Career Choice,” 224. 81 See Char and McDermott, Jr., “Abortions and Acute Identity”; Arlene Hurwitz and R. Frank Eadie, “Psychologic Impact on Nursing Students of Participation in Abortion,” Nursing Research 26 (1977): 112–20. 82 Patricia Jenaway Estok, “Abortion Attitude of Nurses: A Cognitive Dissonance Perspective,” Image 10 (1978): 74. See also Sarp Askel et al., “Unintended Consequences: Abortion Training in the Years after ‘Roe v. Wade,’” Am. J. Public Health, 103 (2013): 404–7; Monica R. McLemore, Amy Levi, and E. Angel James, “Recruitment and Retention Strategies for Expert Nurses in Abortion Care Provision,” Contraception, 91 (2016): 474–79. 83 Katherine L. Eastwood et al., “Abortion Training in United States Obstetrics and Gynecology Residency Programs,” Obstetrics & Gynecology, 108 (2006): 303–7. 84 Ann C. Hwang et al., “Advanced Practice Clinicians’ Interest in Providing Medical Abortions: Results of a California Survey,” Perspectives on Sexual and Reproductive Health, 37 (2005): 96. 85 Pat Mahaffee Gingrich, “Improving Student Receptivity to Abortion Care Education,” Nursing Education Perspectives 38 (2017): 350. 86 Jean Pakter, Frieda Nelson, and Martin Svigir, “Legal Abortion: A Half-Decade of Experience,” Family Planning Perspectives 7 (1975): 248. 87 Yaloff, Wade, and Burlingame, “Nursing Care in an Abortion Unit,” 68; Mildred I. Abbott, Andrea J. Renovitch, and Doris Barker, “The Role of the Nurse-Midwife in an Abortion Evaluation Clinic,” J. Nurse-Midwifery, 18 (1973): 17; Tietze et al., Provisional Estimates of Abortion Need, 16. Nurse-midwives at Brooklyn’s Kings County Hospital taught Lamaze to saline abortion patients. Nancy Whitley, “Second Trimester Abortion,” JOGNN, 2 (1973): 15–21. 88 Margot J. Fromer, “Abortion,” JOGNN, 1 (1972): 72. 89 Elizabeth Shelton, “A Quick, Painless and Uncostly Abortion Procedure,” Washington Post, September 26, 1970, C1. 90 Keller and Copeland, “Counseling the Abortion Patient,” 104. 91 Ibid., 105. 92 Beverly Yaloff, Margot Wade, and Mildred Burlingame, “Nursing Care in an Abortion Unit,” in Clinical Obstetrics and Gynecology, ed. George Schaefer, vol. 14 (New York: Harper & Row, 1971), 67. 93 Linda R. Cronenwett and Janice M. Choyce, “Saline Abortion,” Am. J. Nursing, 71 (1971): 1754. 94 Ibid., 1755–56. 95 Edythe Thompson, letter to the editor, Am. J. Nursing, 71 (1971): 2312. 96 Ibid., Joan Higgins, letter to the editor. 97 Ibid., Ella Richter, letter to the editor. 98 Jane Mendez-Pico, letter to the editor, Am. J. Nursing, 72 (1972): 237-238. 99 Ibid., Martha Calder and Mary Jo Roberts, letters to the editor, 240. 100 Ibid., Loyal Allen, letter to the editor., 238. 101 Ibid., Gloria J. Dittmar, letter to the editor, 240. 102 Ibid., Glenice Anderson, letter to the editor. 103 Keller and Copeland cite “Educators Seek Sex Education in Nursing Curriculum,” SIECUS Newsletter, (1970): 6 in “Counseling the Abortion Patient Is More than Talk,” 106. 104 Liu and Thwaites, “Induced Mid-Trimester Abortion,” 1543. Most nursing journals published articles explaining the technical or legal aspects of abortion but did not address nursing care. See J. S. Scott, “Implications of Abortion Law Reform,” Nursing Times, 62 (1966): 1478–80; Minna H. Marshall, “Septic Abortion: Crisis Care,” Am. J. Nursing, 66 (1966) 1042–44; James C. Caillouette, “Septic Abortion: Pathology and Treatment,” in ibid. 1045–48; Macdonald, “Complications of Abortion,” 306–7; Hershey, “The Law and the Nurse: As Society’s Views Change, Law Changes,” 2310–12; Diane Brett, Jennifer Jackson, and Anne Wright, “Nursing Care Study: Abortion–With Complications,” Nursing Times, 67 (1971): 67, 1209–10. However, there were exceptions. In 1968, Am. J. Nursing published an article that examined the technical and emotional dimensions of nurses work with abortion: Jeanne Fonseca, “Nursing Attitudes and Action,” Am. J. Nursing, 68 (1968): 1022–27. In 1971, Clinical Obstetrics and Gynecology published an article that considered both the technical and emotional dynamics of nursing care for abortion patients. Yaloff, Wade, and Burlingame, “Nursing Care in an Abortion Unit,” 67–80. In January 1972, Am. J. Nursing published a special issue about abortion care that included articles about nurse training, offered advice to administrators, and featured first-person accounts by nurses who worked with abortion patients. In their survey of American and British nursing journal articles about abortion care published between 1971 and 2011, Monica McLemore and Amy Levi observed that only 15 percent pertained to the physiology of abortions. “Nurses and Care of Women Seeking Abortions, 1971 to 2011,” JOGNN 50 (2011): 675. 105 D’Archangelo, “Abortion: Nursing Expertise Needed,” 1–10. 106 Hurwitz and Eadie, “Psychologic Impact on Nursing Students,” 113. 107 Doris V. Allen et al., “Factors to Consider in Staffing an Abortion Facility,” J. Nursing Administration, 4 (1974): 24. 108 Ibid. 109 Patricia G. Steinhoff and Milton Diamond, Abortion Politics: The Hawaii Experience (Honolulu: University of Hawaii Press, 1977), 179. 110 Zahourek, “Therapeutic Abortion,” 11. 111 Ibid., 11. 112 Char and McDermott, Jr., “Abortions and Acute Identity,” 68. 113 Ibid., 954. 114 Colman McCarthy, “Abortion–No Escaping Psychic Trauma,” Los Angeles Times, February 28, 1971, F3. 115 Zahourek, “Therapeutic Abortion and Cultural Shock”; McDermott, Jr. and Char, “Abortion Repeal in Hawaii.” 116 “The RN Panel of 500 Tells What Nurses Think about Abortion,” RN, 33 (1970): 40. 117 G E Hendershot and J W Grimm, “Abortion Attitudes among Nurses and Social Workers,” Am. J. Public Health, 64 (1974): 438–41. 118 Frank Newport, David W. Moore, and Lydia Saad, “Long-Term Gallup Poll Trends: A Portrait of American Public Opinion through the Century” (Washington, D.C.: Gallup News Service, December 20, 1999), http://news.gallup.com/poll/3400/longterm-gallup-poll-trends-portrait-american-public-opinion.aspx. 119 Lynaugh and Brush, American Nursing, 29. 120 R. A. Hudson Rosen et al., “Health Professionals’ Attitudes toward Abortion,” Public Opinion Quarterly, 38 (1974): 166. 121 Allen et al., “Factors to Consider,” 26. Catholic nurses were less likely to support the right to elective abortion than Catholic Americans generally. R. A. Hudson Rosen et al., “Health Professionals’ Attitudes,” 164–71. Registered nurses’ opposition to participating in abortion care increased over time: in 1988, 48 percent of registered nurses indicated that they would refuse to participate in a unit where abortions were performed. Ten years later, 61 percent said that they would refuse. Nurses in the Midwest and South were most likely to oppose abortion rights and nurses on the West Coast were most supportive. Allyson Lipp, “A Review of Termination of Pregnancy: Prevalent Health Care Professional Attitudes and Ways of Influencing Them,” J. of Clinical Nursing 17 (2008): 1684–85. 122 Arthur Peck, “Therapeutic Abortion: Patients, Doctors, and Society,” Am. J. Psychiatry, 125 (1968): 800; Alice S. Rossi, “Abortion Laws and Their Victims,” Trans-Action, 3 (1966): 7. 123 Rossi, “Abortion Laws,” 9. 124 Edward H. Fischer, “Student Nurses View an Abortion Client: Attitude and Context Effects,” J. Population, 1979, 2, 33–46. On Americans’ attitudes about abortion and gender norms, see Ann Fessler, The Girls Who Went Away: The Hidden History of Women Who Surrendered Children for Adoption in the Decades before ‘Roe v. Wade,’ Reprint (New York: Penguin Books, 2007). 125 “Personal Experience at a Legal Abortion Center,” Am. J. Nursing, 72 (1972): 112. 126 Ibid., 111. 127 Char and McDermott, Jr., “Abortions and Acute Identity,” 954. 128 Ibid., 953. Catherine Haney found that Canadian women who sought illegal abortions also sometimes exhibited aggressive or defensive behaviors in their interactions with doctors and nurses because they feared medical professionals’ judgements. Catherine Haney, “Towards Legitimate Nursing Work? Historical Discursive Constructions of Abortion in The Canadian Nurse, 1950-1965,” Canadian Bulletin of Nursing History, 31 (2014): 100. 129 Ellen W. Freeman, “Abortion: Subjective Attitudes and Feelings,” Family Planning Perspectives, 10 (1978): 150–55. 130 Janie Spelton Weinberg, “Issues in Sexuality: Abortion,” in Sexuality: Human Needs and Nursing Practice (Philadelphia: W.B. Saunders Company, 1982), 191. 131 Mary W. Harper, Betty R. Marcom, and Victor D. Wall, “Do Attitudes of Nursing Personnel Affect the Patient’s Perception of Care?” Nursing Research, 21 (1972): 327–31; Sara L. Marshall, Dinah Gould, and Julia Roberts, “Nurses’ Attitudes towards Termination of Pregnancy,” J. Advanced Nursing, 20 (1994): 567. 132 Char and McDermott, Jr., “Abortions and Acute Identity,” 954. 133 Rothlyn Zahourek and Margene Tower, “Therapeutic Abortion: The Psychiatric Nurse as Therapist, Liaison, and Consultant,” Perspectives in Psychiatric Care, 9 (1971): 69; McDermott, Jr. and Char, “Abortion Repeal in Hawaii,” 623. Physicians also sometimes punished women, often by sterilizing therapeutic abortion patients. They justified the practice by drawing on the eugenic belief that they were preventing mentally unfit women from reproducing. Reagan, When Abortion Was a Crime, 207–8; Zahourek, “Therapeutic Abortion and Cultural Shock,” 14–15. 134 Scholars have emphasized the significance of post-Roe federal legislation, including the 1973 Church Amendment to the Health Care Extension Act and the 1976 Hyde Amendment, as well as Supreme Court decisions, including Planned Parenthood v. Casey 505 US 833 and Burwell v. Hobby Lobby, 573 US (2014). Reva B. Siegel, “Dignity and the Politics of Protection: Abortion Restrictions under Casey/Carhart,” Yale Law Journal, 117 (2008): 1694–1801; Sara Dubow, “‘A Constitutional Right Rendered Utterly Meaningless’: Religious Exemptions and Reproductive Politics, 1973–2014,” Journal of Policy History, 27 (2015): 1–35; Alisa Von Hagel and Daniela Mansbach, Reproductive Rights in the Age of Human Rights (New York: Palgrave Macmillan, 2016). Historian Rebecca M. Kluchin examines the 1972 Hathaway v. Worcester City Hospital decision, in which the US District Court of Massachusetts ruled that hospitals were not obligated to offer sterilizations or abortions, in Fit to Be Tied: Sterilization and Reproductive Rights in America, 1950-1980 (New Brunswick, N.J: Rutgers University Press, 2009), 134–36. 135 Cynthia Eller, Conscientious Objectors and the Second World War: Moral and Religious Arguments in Support of Pacifism (New York: Praeger, 1991); Simon Hall, Peace and Freedom: The Civil Rights and Antiwar Movements of the 1960s (Philadelphia: University of Pennsylvania Press, 2005). 136 Cobb, “New York City.” 137 Winter, “Abortion from the Nurse’s Point of View,” D3. 138 Ibid. 139 Quoted in Tom Callahan, “Backing the Right of Nurses Not to Assist in Abortions,” New York Times, January 4, 1998, E1. 140 Tia Gindick, “Conscience vs. Duty: Nurse and Abortion: Feelings of Helplessness, Pity, and Anger,” Los Angeles Times, June 30, 1974, CS4. 141 Ibid. 142 Char and McDermott, Jr., “Abortions and Acute Identity”; Gindick, “Conscience vs. Duty.” 143 Harry Nelson, “County Hospital to Reduce Therapeutic Abortions One-Third,” Los Angeles Times, August 7, 1971, A1. 144 Roy Meyers, “Some Metro Hospital Aides Won’t Assist in Abortions,” Cleveland Press April 24, 1973, A1. 145 Dubow, “‘A Constitutional Right,’” 1. 146 Ibid., 18–19. 147 Tietze et al., Provisional Estimates of Abortion Need, 38. 148 Ibid., 38; Joffe, Doctors of Conscience, 161; Johanna Schoen, “Living Through Some Giant Change: The Establishment of Abortion Services,” Am. J. Public Health, 103 (2013): 418. 149 Quoted in Robert Pear and Jeremy W. Peters, “New Protections for Health Workers Who Oppose Abortion,” New York Times, January 19, 2018, A14. Civil rights and gay activists joined abortion rights activists to warn that the federal enforcement of conscience clause protections would give medical providers license to discriminate against lesbian, gay, and transgendered patients, as well as women who seek abortions. © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the History of Medicine and Allied Sciences Oxford University Press

Nursing and Hospital Abortions in the United States, 1967–1973

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com
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0022-5045
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1468-4373
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10.1093/jhmas/jry014
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Abstract

Abstract Before elective abortion was legalized nationally in 1973 with the U.S. Supreme Court decision Roe v. Wade, seventeen states and the District of Columbia liberalized their abortion statutes. While scholars have examined the history of physicians who had performed abortions before and after it was legal and of feminists’ work to expand the range of healthcare choices available to women, we know relatively little about nurses’ work with abortion. By focusing on the history of nursing in those states that liberalized their abortion laws before Roe, this article reveals how women who sought greater control over their lives by choosing abortion encountered medical professionals who were only just beginning to question the gendered conventions that framed labor roles in American hospitals. Nurses, whose workloads increased exponentially when abortion laws were liberalized, were rarely given sufficient training to care for abortion patients. Many nurses directed their frustrations to the women patients who sought the procedure. This essay considers how the expansion of women’s right to abortion prompted nurses to question the gendered conventions that had shaped their work experiences. After Hawaii repealed its criminal abortion statute in March 1970, hospital nurses flooded administrators with complaints about their abortion work; some threatened to quit their jobs. Flummoxed administrators turned to University of Hawaii psychiatrists John F. McDermott, Jr. and Walter F. Char for counsel. After visiting nurses from three hospitals, McDermott and Char offered a grim assessment. Although most had supported the decriminalization of abortion, every nurse with whom they visited “showed symptoms of anxiety and depression” the psychiatrists reported. Moreover, “once the nurses became personally, intimately, and constantly involved with abortions,” their support for legal abortion was “replaced by deeply personal emotional reactions so strong that many of them were even questioning the wisdom of the new law.”1 When states began to decriminalize abortion, many hospital nurses claimed a legal right to refrain from participating in abortion care as a matter of conscience. Consequently, many Americans came to understand only the religious dimensions of nurses’ objection to abortion work. However, nurses’ dissatisfaction with abortion work was also informed by a host of secular issues. Nurses’ longstanding grievances with labor conditions in American hospitals, the inadequacy of their abortion training, and their uneven commitments to feminism also came into focus when they were tasked to care for abortion patients. The study of nurses’ secular grievances during the late 1960s and early 1970s clarifies why so many of them opposed abortion and enables us to understand how abortion became marginalized within American medicine. The nursing profession was in turmoil before abortion was decriminalized. It was among the most poorly-paid, female-dominated professions for white women in 1965: while starting secretaries earned $5,000 per year and newly-minted teachers earned almost $6,000, starting general duty nurses earned only $4,500 annually.2 In 1967, registered nurses had a sixty-seven percent turnover rate and hospitals nationwide suffered from a chronic shortage of nursing staff.3 Boston day shift nurses commonly cared for entire wards of twenty or more patients, while nightshift nurses were responsible for up to forty patients each.4 The US Surgeon General’s Office warned that the number of registered nurses nationwide, which stood around 621,000 in 1965, fell woefully short of the 850,000 needed to provide “safe, therapeutically effective, and efficient” care.5 Despite acute shortages, the profession remained inhospitable to women of color and attracted few men. Although African Americans comprised slightly more than eleven percent of the US population in 1965, only about five percent of American nurses were black.6 Nursing schools were even more hostile to black women than employers: by the mid-1960s, ninety-seven percent of nursing graduates were white and ninety-nine percent were women.7 One of the consequences of the profession’s lack of racial diversity was that patients of color were often cared for by white women. In 1970, New York City’s municipal hospitals reported that just over fifty-eight percent of the women who obtained abortions were African American and 10.5 percent were Puerto Rican. At the time, only seven percent of the registered nurses in the United States were African American.8 The decriminalization of abortion occurred against the backdrop of a reinvigorated feminist movement that empowered many nurses to demand reform. Wilma Scott Heide, a nurse who served as the president of the National Organization for Women from 1971-1973, observed that many nurses refrained from being assertive or decisive in the workplace because of cultural pressures for women—and nurses in particular—to be caring.9 Professor of nursing Virginia Cleland, maintained that nursing’s reputation as “women’s work” isolated it from nearly all vestiges of power in the male-controlled systems of medicine, higher education, and hospital administration. Others contested the casual sexism that frequently marked relationships between doctors and nurses, including physicians’ common practice of addressing nurses as “girls.”10 In 1972, several readers recoiled after the Journal of American Nursing published an editorial that chastised women nurses for not doing more to welcome men into the profession.11 “Charges of ‘feminine snobbery’ and prejudice by female nurses against male nurses can be all too easily reversed and applied to the male-dominated medical profession in this country,” explained Karen Schutzenhofer.12 Registered nurse Lydia Kotchek, asked whether anyone would suggest that physicians make women feel more welcome to enter that profession. “No, I believe they would not,” she explained. “For such is the sexual bias of our culture: a woman who becomes a doctor has stepped up; a man who becomes a nurse has stepped down; and women should keep their place—under men.”13 In the 1970s, thousands of nurses joined the larger feminist project of reforming American medicine by clamoring for the elimination of quotas in medical schools and advocating for equitable funding for women’s health research.14 Scholars of abortion history have emphasized the work of clergy, physicians, attorneys, feminist activists, and the women who sought the procedure.15 Scholarship on the history of nursing has examined how nursing education and employment patterns were shaped by a host of external forces, including changes in medical technology and feminism.16 However, we know relatively little about the relationship between the legalization of abortion and the history of nursing: how did the decriminalization of abortion affect nurses’ work? And conversely, how did nurses shape women’s experiences with abortion after the procedure was decriminalized? The Criminalization of Abortion For nearly one hundred years, American women could obtain legal abortions under only very narrow circumstances. Between 1821 and 1880, every state criminalized abortion. Each state permitted abortion in order to save a woman’s life, and a few included exemptions to protect women’s health, for fetal abnormalities, or in cases of rape or incest.17 Until the 1940s, states granted physicians broad authority to perform medically necessary or “therapeutic” abortions.18 Individual physicians’ authority to perform abortions declined in the mid-1940s, when hospitals took charge of interpreting abortion laws. Hoping to reduce the practice of abortion, hospital administrators formed abortion committees to determine whether abortions were medically necessary. These committees, which were usually comprised of three or more senior physicians, required women to submit to intrusive physical and psychiatric examinations.19 The institutionalization of abortion committees moved the legal practice of abortion out of physicians’ private offices and into hospitals.20 Petitioning for an abortion was prohibitively expensive for most women. Historian Leslie Reagan found that the cost of legal abortions more than quadrupled after Chicago’s hospitals implemented abortion committees, increasing from $68 in the early 1940s to $325 by the 1950s.21 In 1968, a California woman paid $1800 for her daughter’s therapeutic abortion after navigating “a great deal of red tape.”22 Referring to the experience as “disgusting,” she described how she and her daughter encountered doctors and nurses whom they found “unbending—we got the definite feeling they don’t like to handle such cases,” she explained. The advent of abortion committees moved the practice of abortion in the United States underground. By the mid-1960s, abortion committees approved only 8,000 abortions each year, while up to 1.2 million women received illegal abortions annually.23 Although illegal abortions were fraught with risk, sociologist Carole Joffe maintains that most underground abortion providers were committed to protecting women’s health. Thousands of physicians, nurses, and midwives risked their careers and criminal prosecution by continuing to perform abortions.24 Although most women found competent abortionists, the underground marketplace left them vulnerable to exploitation. Some nefarious physicians exploited the power of their recommendations for therapeutic abortions by overcharging patients.25 Quacks sold fake abortifacients and a range of providers, including some physicians, offered illegal abortions in exchange for sex.26 The unpredictability of the illicit market prompted many women to take matters into their own hands. In California, one-third of the women who died from abortion between 1958 and 1961 had attempted to self-abort in their homes.27 Most chillingly, during an era when the overall maternal mortality rate fell and abortion became one of the safest medical procedures, the proportion of maternal deaths caused by abortion increased. After abortion committees seized control of New York’s legal abortion market in 1951, the abortion-related maternal mortality rate nearly doubled. By 1962—when blood transfusions and antibiotics had become readily available—abortion-related mortality accounted for twenty-five percent of pregnant white women’s deaths and fifty percent of the deaths of pregnant women of color.28 Hospitals nationwide opened septic wards to treat mortally ill women who had turned to unsafe abortionists or had tried to self-induce.29 By the mid-1960s, up to 5,000 women died annually because they could not count on receiving care from licensed practitioners.30 Between 1967 and 1972, seventeen states and the District of Columbia responded to the unfolding illegal abortion crisis by reforming or repealing their criminal abortion statutes. Attorneys drafted model legislation to expand physicians’ authority to perform abortions, culminating with the American Law Institute’s (ALI) 1962 Model Penal Code.31 Most states drew upon the ALI’s guidelines to enlarge the range of legal abortions to include cases of rape, incest, or fetal deformity, and to expand the range of therapeutic abortions to include mental health. In many of these states, reform legalized practices that were already commonplace, but shielded physicians from the specter of prosecution.32 Invigorated by a resurgent feminist movement, coalitions of progressive women’s organizations and professional women called for even greater change. Feminists found allies among physicians who treated women with unwanted pregnancies and ministers from the Clergy Consultation Service, an underground abortion referral system that had helped women to find reputable providers since 1967.33 Inspired by the movement to legalize birth control, those who advocated for the repeal of criminal abortion statutes maintained that women and physicians ought to control decisions about reproduction privately.34 They observed that even under the ALI’s Model Penal Code, most women were ineligible for legal abortions because pregnancy rarely imperiled their health. Four states, beginning with Hawaii in 1970, repealed their abortion laws to permit women to request abortions without committee approval, a type of abortion that came to be regarded as elective.35 While the repeal of criminal abortion statutes signaled a watershed for women’s ability to control their reproduction, the more limited—and more commonplace—reformed abortion laws had comparatively little effect on women’s ability to obtain legal abortions. Abortion in Reform States, 1967-1973 In 1967, California, which had previously authorized abortions only to save a woman’s life, revised its abortion law to align with the ALI’s Model Penal Code to permit therapeutic abortions and abortions in cases of rape or incest.36 Within two years, ninety-two percent of abortions were approved for psychiatric reasons.37 Physician C. Lee Buxton, admitted that he and his colleagues interpreted “psychological harm” broadly in order to improve the odds that an abortion committee would approve a therapeutic abortion request. Unlike physical claims, which had to be supplemented with diagnostic proof, mental health petitions relied primarily upon psychiatrists’ recommendations.38 The capacious interpretation of mental health exemptions made nearly everyone uncomfortable. Buxton explained, “Such are the various interpretations of the law that ‘saving the life of the mother’ has become a matter of possibly protecting this ‘life’ from socioeconomic or psychiatric stress. Certainly those cases in which the patient might ‘die’ because of her psychiatric status…are few and far between.”39 Robert F. Drinan, a pro-choice Roman Catholic priest and dean of the Boston College Law School, was even more pointed, calling the health exemptions “as phony as a three dollar bill.”40 Therapeutic abortions were usually the culmination of elaborate charades: women pretended that they would commit suicide if they continued with a pregnancy, physicians pretended to agree, and abortion committees pretended that the petitions brought before them were legitimate. Many nurses were frustrated by the abortion petitioning process. Some believed that women duped physicians while others wondered whether abortions were appropriate for women with psychological problems.41 Other nurses worried that physicians participated in the farce to make money and not because they cared about women.42 Despite widespread skepticism, hospitals’ use of cumbersome, if dubious, abortion committees proved to be an effective means for keeping hospital abortion rates low. Most women who sought abortions did not benefit from reformed abortion laws. After California revised its abortion law, the legal abortion rate rose only modestly compared to the volume of women who would seek the procedure after repeal. Before 1967, an average of 700 hospital abortions were performed annually in a state with a population approaching nineteen million.43 In 1968, the year after the reformed law went into effect, 5,030 women received hospital abortions.44 The modest uptick was primarily due to the expansion of the criteria for therapeutic abortions to also include mental health. Race, class, and geography continued to shape women’s access to legal abortion, even for those who now qualified for a therapeutic abortion. Ninety percent of the women who obtained legal abortions the year the reformed law went into effect were white.45 Lower-middle class, young, nonwhite, and rural women remained disenfranchised because the petitioning process continued to be too expensive, too humiliating, or too far away. In 1968, as many as 120,000 California women sought illegal abortions because the circumstances of their lives did not square with the reformed law.46 After the state repealed its abortion law in 1969, 100,000 women, the majority of whom would have turned to the illegal marketplace or continued with unwanted pregnancies only the year before—obtained legal abortions in California.47 Abortion in Repeal States, 1970-1973 Before the Roe v. Wade decision decriminalized abortion nationwide in 1973, Hawaii, New York, Alaska, and Washington repealed their abortion laws to permit women to obtain abortions without having to justify a medical need for the procedure. The decriminalization of abortion created new, unanticipated challenges for medical professionals. In repeal states, nurses’ dissatisfaction with abortion work stemmed from the new ethical dimensions of abortion care, their increased workload, and the new types of patients whom they encountered. Most pro-choice physicians had not taken into consideration the importance of nurses’ work with abortion patients when they called for the decriminalization of abortion. When hospital administrators in Hawaii turned to McDermott and Char for guidance with the post-repeal nursing crisis, perhaps no one was as surprised by the request than the psychiatrists themselves. McDermott and Char had supported decriminalization, sharing their colleagues’ “urgent wish” to get out of the “unsavory business” of signing dubious therapeutic abortion petitions.48 They explained that many psychiatrists had been “so swept up with the social and psychological importance” of legalizing abortion that they had given “little thought toward the new clinical problems that might be created” for nurses.49 McDermott and Char lamented that administrators and physicians had also generally failed to include hospital nurses in the policy-making and program-planning process to prepare for legalization. Many nurses in repeal states objected to the dissolution of abortion committees, whose physician-members served as gatekeepers and moral arbiters. Char and McDermott explained that even though they had regarded the process as farcical, many nurses nevertheless preferred committee-sanctioned abortions “because they were certified as being legal, therapeutic, and hence, proper.”50 A 1968 survey of nurses at two large hospitals in Washington revealed that an overwhelming majority preferred physician committees to manage abortion requests to the elective model.51 Medical professionals were caught off-guard by the volume of women who sought elective abortions. Although Hawaii was the first state to decriminalize abortion, New York was the first to permit non-residents to obtain them. Before New York legalized abortion in 1970, approximately 1,000 hospital abortions were performed in New York City each year. However, during the first year that elective abortion was legal, 55,347 New York residents and 83,975 nonresidents received abortions in hospitals and clinics New York City. These figures do not offer a full account because the city did not require physicians to report abortions performed in private offices and clinics.52 So many women from across the country flocked to New York City between 1970 and 1973 that observers commonly referred to it as the nation’s “abortion capital.”53 Nevertheless, the state’s hospitals and clinics were generally prepared to handle the volume of women who sought abortions.54 Some nurses objected to the speed with which first trimester abortions were performed. When nurses at Mount Sinai Hospital began tendering their resignations, administrators sought psychiatrist Marcel Heiman’s counsel. Heiman reported that nurses objected to the assembly-line system for first-trimester abortions. “The women were in and out of the hospital so quickly, most of them the same day, that the nurses couldn’t have any personal relationship with them and they resented it,” he explained.55 A nurse who accompanied a friend for an abortion in 1970 compared the private New York City hospital they visited to the notorious British psychiatric hospital, reporting that “It was like Bedlam.” She recalled that women “were herded like cattle, given no counseling, no support at the time of such crisis in their young lives.”56 Another registered nurse wrote to the American Journal of Nursing to describe how poorly nurses and doctors treated her when she had a saline abortion in the early 1970s. She recounted the cacophony of the obstetric clinic, explaining that “Doctors and nurses ran about, examining, yelling, commanding, laughing together.” From her perspective, “Two worlds seemed to exist. In one there were busy, active hospital personnel, in the other, frightened, quiet, withdrawn patients. There was no interaction.”57 Because many physicians were paid by the patient, unscrupulous clinic owners and doctors rushed patients through procedures, taxing medical staff and compromising patient care—sometimes by forgoing counseling altogether—in order to perform as many abortions as possible during a single shift.58 Hospital Nurses’ Abortion Work Abortion Patients Nurses’ experiences with abortion between 1967 and 1973 were also transformed by technological innovations. Most abortions were—and continue to be—performed during the first trimester of pregnancy.59 Prior to the late 1960s, the handful of women approved to receive legal abortions before the twelfth week of pregnancy typically received dilation and curettage (D&C) abortions. After dilating the cervix, a surgeon removed the fetus with a small, scoop-shaped curette.60 A new technology—vacuum aspiration—unfolded in tandem with the liberalization of abortion laws in the late 1960s. Medical professionals and women welcomed the new procedure, which was cheaper, safer, and resulted in less blood loss than the D&C method.61 Nurses’ work with first trimester abortions focused primarily on patient counseling and monitoring. During preliminary visits, nurses obtained patients’ medical histories, explained the D&C or vacuum aspiration procedure, and, discussed contraceptive methods before physicians performed physical examinations.62 Although states required at least one registered nurse assist with the abortion procedure itself, nursing care was generally limited to monitoring and supporting patients.63 To perform vacuum aspiration abortions, physicians inserted a speculum into the vagina, administered a local anesthetic, dilated the cervix, then inserted a dilator or a suction curette into the uterine cavity. Finally, physicians inserted a vacuum tip to aspirate the fetus out of the uterus. The entire procedure took between thirty seconds and three minutes to complete. After removing the vacuum tip, physicians sometimes scraped the uterine wall with a metal curette to ensure that they did not miss any fragments. Abortions that include this step were commonly referred to as suction curettage. After vacuum aspiration or suction curettage abortions, nurses observed the patients for about an hour and offered advice about the side-effects they might experience and instructions for post-operative care.64 Vacuum aspiration abortions, which are technically simple and safe, could have been performed in nonhospital clinics.65 However, with the exception of New York, every state that reformed or repealed its abortion laws before 1973 required that all abortions be performed in hospitals.66 Although they were in the hospital for only a few hours, women in these states often had to navigate a cumbersome infrastructure that had not been designed to serve elective abortion patients. First trimester abortion patients in Hawaii were often admitted to emergency rooms, then transferred to operating rooms for the procedure, then moved to the recovery room, then transferred back to the emergency room before they were discharged. This labyrinth not only taxed hospital staff, nurses in particular, but also contributed to the cost of abortions.67 Although they were less common, mid-trimester abortions dominated discussions about abortion and nursing care in the late 1960s and early 1970s. Bureaucratic and legal hurdles prevented some women from obtaining first-trimester abortions. By the time abortion committees approved therapeutic abortion requests, women’s pregnancies had sometimes advanced beyond the first trimester. Women who had to secure the money to travel to repeal states for elective abortions were also more likely to have to delay abortion until after the twelfth week of pregnancy.68 Before the late 1970s, women who were twelve-to-sixteen weeks pregnant were in limbo: they missed the window for receiving a suction abortions, yet were not far enough along for saline abortions.69 Legal abortions at any stage of pregnancy were very safe by the late 1960s, posing fewer health risks than childbirth. However, abortions after the first trimester posed greater health risks and were more expensive.70 The mechanics of saline abortions sometimes overwhelmed unprepared nurses. When a saline abortion patient was admitted to the hospital, nurses asked them to urinate then change into a gown. Nurses commonly injected patients with Benadtryl and Valium to sedate patients before wheeling them to the operating room. To administer saline abortions, surgeons inserted a needle into the uterine cavity to withdraw amniotic fluid and to replace it with saline, which led to miscarriage, usually within twenty-four to thirty-six hours. During the procedure, which took between ten and fifteen minutes to complete, nurses offered patients emotional support, monitored vital signs, timed contractions, and watched for vaginal discharge.71 Although some hospitals permitted women to go home after the saline induction and to return to the hospital once they began to miscarry, most required them to be admitted for the duration of the abortion.72 It was during this time—between the administration of the saline solution and the expulsion of the fetus—that physicians left patients’ bedsides and nurses took primary responsibility for patient care.73 Unless complications arose, nurses commonly supervised saline-induced labor and delivery. Between induction and delivery, patients commonly experienced side-effects—including nausea, diarrhea, and thirst—that demanded nursing care. Nurses who worked night shifts found saline deliveries to be especially burdensome because wards were often understaffed at night.74 Nurses’ primary source of dissatisfaction with saline abortions stemmed from their delivery of fetuses that resembled premature babies that were often recognizable as boys or girls. Many nurses lamented that they lacked even basic training, with some having to figure out on their own how to discard the fetuses. One nurse complained, “Doctors don’t understand our problems. A patient aborting in bed in the middle of the night…is most distasteful. It upsets the other patients to see [a nurse] running out of the room with a fetus in a bottle.”75 An operating nurse who had assisted comfortably with first trimester abortions explained why she struggled to care for saline abortion patients: “There it is, a recognizable boy or girl, and you know that you have been part of the operation that caused its life to be terminated,” she confided. “I can’t say that I feel I am an accessory to a murder. I wouldn’t go that far,” she reported. “But I say that it shakes me up—and I cannot help asking myself whether this is right, just for any trivial reason that a woman might cook up,” she explained.76 Exceptions: Trained Nurses Nurses in New York were better prepared than most to care for abortion patients. In 1971, professor of nursing Dolores Malo-Juvera, designed one of the first elective courses on abortion care at Hunter College in New York City. Abortion posed a special challenge for nurse educators: historically, they had encouraged students to suppress their feelings and to concentrate on patients’ needs.77 Nurses who provided abortion care, however, needed to be acutely attuned to their own emotions in order to avoid stigmatizing patients with verbal and nonverbal cues. During orientation, Malo-Juvera encouraged students to speak frankly about the prospect of caring for abortion patients. Some Catholic students worried about participating in a procedure that their religion condemned.78 Other students maintained that they lacked the technical expertise to assist with abortions, which Malo-Juvera believed was an “avoidance technique” to sidestep their ambivalence about the procedure.79 Over the course of the term, Malo-Juvera’s students learned how to regard abortion as professionals. Students who volunteered to participate in abortions related their experiences to their classmates. They described uneventful first-trimester abortions and more complicated saline inductions that could last over two days. Some students related that they felt unusually weepy and others admitted that they found themselves laughing at inappropriate times after assisting with abortions. Malo-Juvera assured students that these were normal responses to new, stressful experiences and should not be sources of embarrassment. The sharing process taught students how to manage their personal feelings and offered opportunities to discuss abortion work in a supportive, yet professional setting. Students also came to appreciate how abortion work offered them opportunities to deploy their technical skills and to provide important reassurances to anxious patients. Malo-Juvera reported that many students who had initially been reluctant to participate in abortions came to regard the procedure as one of a range of maternal health services that they might offer, albeit one that had unique challenges.80 In order to prioritize their patients’ needs, nursing students needed to learn to identify and manage their own feelings about abortion. Many students concluded that they needed to separate their personal beliefs about abortion from their professional obligations to provide care, not by sublimating their emotions, but by finding new ways to think about their work. Subsequent research confirmed the value of abortion training for nurses. In the mid-1970s, researchers found that nursing students who received abortion training retained their support for abortion rights. This was significant because previous studies had emphasized that nurses, even those who had supported the legalization of abortion, withdrew their support for abortion rights after assisting with abortions.81 The nurses in those studies, however, had not received abortion training. Of eighty-one nursing students who worked with abortion patients as part of their maternity coursework in a 1976 study, sixty-four percent continued to favor unrestricted abortion rights at the conclusion of the semester.82 Despite its value, abortion training became less commonplace for medical residents during the late twentieth century. While twenty-six percent of residency programs required training in first-trimester pregnancies in 1978, only twelve percent required the training by 1995.83 A 2003 survey of California clinicians revealed that nearly sixty-eight percent of nurse practitioners and 62.5 percent of nurse midwives were willing to administer Mifepristone pills to induce a medical abortion identified their own lack of training as a barrier to offering even simple abortion care.84 In 2017, professor of nursing Pat Mahaffee Gingrich, lamented that “few guidelines” existed for nurses who cared for women with unwanted pregnancies and that the topic of abortion remained “overlooked or optional” in most health care education programs.85 Officials in New York did more than clinicians in most states to prepare personnel and the public for the liberalization of the state’s abortion law. Between March 1970, when the New York State Assembly repealed the state’s abortion statute and July 1970, when women could begin receiving elective abortions, public and private medical facilities mobilized to coordinate abortion care.86 New York City public health officials organized an advertising campaign to ensure that women were made aware of the changed abortion statute, replete with an information and referral hotline. In addition to specialized outpatient abortion clinics, women could turn to Columbia Presbyterian Medical Center, Kings County Hospital, and the New York Hospital, which had created special outpatient units staffed with specially-trained physicians, nurse-midwives, and nurses who had volunteered to work with abortion patients.87 Pro-choice nurses were instrumental in the creation of nonhospital abortion clinics. These nurses often understood abortion as a component of the emerging women’s health movement, which sought to empower women by destigmatizing their sexuality and by encouraging them to take more control over medical decision making. In 1972, registered nurse Margot J. Fromer, asserted that “The patient having an abortion has the right to quality nursing; she has the right not to be discriminated against by the nurse who finds the procedure morally offensive.”88 Indeed, many of the first standalone abortion clinics adopted feminist models of care. At the Women’s Abortion Clinic in Greenwich Village, women received suction abortions in a “casual, cheerful, and intentionally un-hospital like” setting, staffed with physicians, nurses, and medical assistants who supported abortion rights.89 Some nurses sought to empower women patients by embedding abortion care into comprehensive sexual health programs. At New York’s Bellevue Hospital, nurses Christa Keller and Pamela Copeland counseled abortion patients about their anatomy and the biology of reproduction. “As we teach and identify with diagrams the various body parts,” the nurses reflected, “we’re continually reminded how little many women really know about themselves.”90 They found that many abortion patients had refused to use contraception because of the controversy over excessive estrogen levels in birth control pills during the 1960s. Others had been too self-conscious to ask their physicians about contraception.91 Consequences of Unprepared Nurses Nurses who had started their careers before the decriminalization of abortion had few guides to understand the mechanics of their new work with abortion patients. Few administrators altered their hospitals’ infrastructure to create separate abortion units or offered nurses specialized training in response to legal and medical developments that affected abortion care.92 Similarly, most nursing programs and professional journals paid scant attention to abortion training after states decriminalized abortion. Hospital nurses’ lack of preparedness to offer abortion care in the immediate pre-Roe period elevated their ambivalence about women who had the procedure and contributed to the stigmatization of abortion. In September 1971, nursing instructor Linda R. Cronenwett and Janice M. Choyce, the head nurse of Stanford University Hospital’s delivery suite, offered nurses one of the first tutorials about saline abortion work in the profession’s flagship journal, the American Journal of Nursing.93 While nurses could readily find articles that examined nurses’ opinions about abortion, they struggled to find information about the actual mechanics of abortion work. Writing in a dispassionate tone, Cronenwett and Choyce explained how nurses should prepare women for saline abortions, the chemistry of the procedure, and the medical complications that could arise. Cronenwett and Choyce’s only reference to the psychosocial dynamics of abortion care was oblique and brief: “We believe that providing emotional support during this crisis period represents one of the most important aspects of nursing care,” the pair wrote. “One of the nurse’s primary goals should be to help mobilize the coping mechanisms of the patient and her family so that abortion may become a growth experience.” What it meant for nurses to “mobilize” a patient’s “coping mechanisms” was, according to the nurses, “beyond the scope of this paper.”94 Cronenwett and Choyce did not advocate for abortion training requirements, nor did they broach the ethics of abortion. Readers’ responses to the impartial article offer insight about the early mobilization of antiabortion nurses. Nurses who opposed abortion condemned the Journal’s editors for publishing the saline abortion article. Edythe Thompson, a registered nurse from Minnesota complained, “It seems we as a nation have more compassion for baby seals than we have for prenatal human babies. Those who kill baby seals at least are merciful enough to give them an instantaneous death by a whack on the head.”95 New Jersey registered nurse Joan Higgins maintained that it was inappropriate to teach nurses about abortion, explaining “This is not nursing and has no business in a nurses’ professional magazine.”96 Ella Richter, a registered nurse from Missouri asked, “How inconsistent can we get? We as members of the healing professions are pledged to preserve life. But without any qualms of conscience we can condone and participate in the intrauterine killing of 394 babies within a twelve-month period in one hospital.” She maintained that it was hypocritical to spend money and time researching how to increase people’s life expectancy and to also invest resources “destroying unborn babies.”97 Pro-choice nurses didn’t weigh in until after they read antiabortion nurses’ angry letters to the editor. Many suggested that they were caught off-guard by antiabortion nurses’ politicization of the saline abortion article. Jane Mendez-Pico, a registered nurse from Virginia who worked with saline abortion patients explained, “I was amazed and shocked at some of the letters responding to the article ‘Saline Abortion.’”98 She continued, “This article was only trying to convey some nursing measures which will best help the patient who is undergoing this particular procedure.” Registered nurses Martha Calder from Ontario, Canada and Mary Jo Roberts from Alabama described feeling “shocked and disappointed” and “saddened” by the antiabortion nurses’ angry responses to the saline abortion article.99 Other nurses worried how patients would fare if nurses did not learn the mechanics of abortion or if administrators’ prioritized nurses’ personal beliefs over patients’ needs. Loyal Allen, a registered nurse from New York, worried that her antiabortion colleagues had lost sight of their professional responsibilities: “As professionals we are obligated to respect [a patient’s] decision apart from our own value system.”100 Gloria Dittmar, a registered nurse from New York, asked why abortion patients had been singled out for scrutiny. “Are the alcoholic, the drug abuser, the homosexual, the suicidal—patients many nurses find difficult to care for because of the underlying psychological components and social stigma—also to be denied good nursing care?” she wondered. “Are we now discarding our non-judgmental approach and deciding which patients deserve good nursing care and which do not?”101 Glenice Anderson, a registered nurse from Ohio, reported feeling relieved by the saline abortion tutorial: “If I were to have an abortion, I would hope that the nurses attending me would be able to deliver expert nursing care.” She continued, “If it weren’t for these articles, the ‘head in the sand’ approach would prevail.”102 The lack of curricular and scholarly attention—or, as Glenice Anderson phrased it, the “head in the sand approach,” to nurses’ abortion work was hardly surprising, given that in 1970, most nursing education curricula still lacked very basic information about sex education.103 In 1974, British researchers observed the continued paucity of scholarship about nurses’ work with surgical abortions in English language nursing journals.104 One year later, the newsletter Nursing Update featured a cover story warning that many nurses still lacked basic knowledge about abortion care.105 Two years after that, in 1977, American researchers found that only four of eleven major studies of the psychological effects of abortion work on health care professionals included nurses.106 Indeed, nurses complained about their lack of training. A 1973 survey of 457 Michigan nurses revealed how unprepared most of them felt.107 Nurses evaluated how much abortion training they had received on a seven-point scale, with one labeled “little” and seven labeled “much.” Fifty-four percent of the respondents indicated that they had received one (little) training. Forty-one-percent indicated that they should have received much (seven) training and fifty-three percent circled seven (much) when asked “How important is this?”108 Almost all of the respondents had heard of D&C abortions, but nearly twenty-five percent were unfamiliar with the other three major abortion procedures, including vacuum aspiration, hypertonic saline injection, and hysterotomy. With the exception of New York’s specialized abortion units, most hospitals that provided abortions prior to 1973 admitted patients to combined obstetrical/gynecological units instead of designated abortion units. Sociologist Patricia G. Steinhoff and physician Milton Diamond explained that hospitals initially treated abortion patients alongside other obstetrical and gynecological patients in an effort not stigmatize them. “While the policy had good intentions,” they lamented, “in practice it caused some problems.”109 Before decriminalization, most gynecological nurses had cared for women who had suffered from septic abortions or women who required D&Cs after experiencing miscarriages.110 While many had not objected to assisting with abortions that were medically necessary, some found it challenging to care for women who did not require abortions for health reasons. Obstetrical nurses, many of whom had no previous experience with abortion care, were even less prepared when their units were “virtually flooded” with abortion patients.111 Obstetrical nurses confronted special challenges after the decriminalization of abortion: not only did their patient volume expand, but they also had to reconfigure the type of care they provided.112 Some obstetrical nurses, citing a lack of training, reported that they did not know whether to approach elective abortion patients with a smile or what they should say.113 A nurse who worked in the labor and delivery unit of a Washington, D.C. hospital explained how pained she felt the first time she saw an abortion patient on a stretcher next to a woman about to give birth. “Seeing the two women so close together physically but so far apart in attitude struck me hard,” she explained. “One came in for a live delivery and the other for a dead one. I’m a nurse, concerned about preserving life. What am I supposed to do—turn away and say life isn’t that important?”114 Many obstetrical nurses came to regard abortion patients as burdens who took care away from more deserving patients.115 When states began to decriminalize the procedure, most nurses opposed a woman’s right to elective abortions, but supported the right to abortion in case of rape or incest. A 1970 survey of 548 registered nurses revealed that seventy-seven percent opposed unrestricted abortion rights, but only seven-percent opposed abortion under all circumstances. Nurses who had experience caring for women who had suffered botched abortions or had endured the humiliating abortion petitioning process were the most supportive of decriminalization. Emergency room and psychiatric nurses were the most supportive of repeal, with thirty-six percent of ER nurses and thirty-one percent of psychiatric nurses supporting a woman’s right to elective abortion. In contrast, operating room and obstetrical nurses—two specialties who would be tapped to assist with hospital abortions as states decriminalized the procedure—were most likely to oppose elective abortion rights. As states began to decriminalize the procedure, only thirteen percent of operating room nurses and fifteen percent of obstetrical nurses supported a woman’s right to elective abortion.116 Nurses were less supportive of abortion rights than physicians, social workers, or Americans generally. In 1971, researchers surveyed 137 public health nurses and 373 social workers who attended a family planning training program sponsored by the Planned Parenthood Association of Nashville. While two-thirds of the social workers supported a woman’s right to choose abortion, only two-fifths of the nurses agreed.117 In 1975, Gallup, a nonpartisan public opinion research firm, conducted its first poll of Americans’ attitudes about abortion. They found that slightly more than half of Americans supported legal abortion under certain circumstances, and similar numbers favored legal abortion under all circumstances (twenty-one percent) and opposed abortion under all circumstances (twenty-two percent).118 Researchers speculated that nurses were more likely to be ambivalent about abortion rights than social workers because nurses’ exposure to abortion patients was usually limited to the day of the procedure. Nurses generally knew very little about women’s circumstances or the long-term effects of continuing with unwanted pregnancies. On the other hand, social workers had longer-term relationships with the clients they served and were more likely to be sympathetic to a woman’s social, psychological, and economic circumstances.119 A separate 1971 study revealed that nursing students were less likely to support abortion rights than social work or medical school students. While seventy-six percent of social work students and nearly seventy percent of medical students supported a woman’s right to elective abortion, only forty-two percent of nursing students agreed.120 Other researchers observed nurses were more likely to be Catholic than other health professionals and more likely than physicians or social workers to have been raised by parents who had not attended college; college attendance correlated to support for abortion rights.121 The decriminalization of abortion afforded women opportunities to defy gendered stereotypes at a time when stereotypes about women and work still pervaded the nursing profession. Although some nurses had begun to challenge the hierarchical relationships that framed relationships between nurses and physicians, many more remained attached to distinctly gendered ways of thinking about their work. At a time when many nurses still believed that good nurses exhibited the maternal qualities of caring and deference, they were asked to care for women who sought to delay or forgo motherhood in order to focus on educational, career, or other familial pursuits. Nurses’ ambivalence about abortion reflected the tensions between postwar sexual and gender conservatism and emerging expectations about women’s reproductive choices. Whereas most women who sought abortions simply did not want to have more children, the public supported abortion reform only under narrow circumstances. A 1965 National Opinion Research Center poll revealed that the overwhelming majority (seventy-one percent) of Americans supported legal abortion when a pregnancy threatened a woman’s health. A slight majority (fifty-six percent) favored the right to legal abortion when the pregnancy resulted from a rape or if the fetus was likely to have a “defect” (fifty-five percent.) But only twenty-one percent supported a woman’s right to choose abortion for economic reasons and just fifteen percent supported a married woman’s right to abortion if she did not want another child.122 In 1966, sociologist Alice S. Rossi reflected on the inverse relationship between public support for abortion and the circumstances that most often spurred women to seek the procedure. “Americans disapprove of any legitimate institutionalization of a widespread practice if the practice runs counter to the traditional social and religious norms surrounding sex and maternity,” she observed.123 Indeed, the more a woman was judged to have transgressed gender and sexual norms, the more likely nurses—and most Americans—opposed her right to abortion.124 Nurses themselves were not immune to the tensions between popular mores about women’s sexuality and the new possibilities offered by legal abortion. An unmarried registered nurse recounted how conflicted she felt about her abortion at a New York City Planned Parenthood in the early 1970s. Although she felt reassured by her nurses, describing them as “tolerant, even glorious,” she nevertheless felt tremendous guilt for having become pregnant out of wedlock.125 “Feelings of persecution surrounded me, and I wondered, ‘Why, of all girls, me? I don’t deserve this. I’ve always striven so hard to be ‘pure.’” She asked herself, “Am I still a pure virgin, merely tainted, who can return to her pink cloud demure and ignorant? Or am I the decided vamp who must play the manipulated though educated role or a just-in-case female who faithfully pops her pill?”126 The nurse’s anxiety about being exposed as the sort of woman who engaged in premarital sex reveals how women’s reputations took on heightened significance when most women lacked the economic means to live independently. Nurses’ lack of preparedness to care for abortion patients and their ambivalence about the decriminalization of abortion contributed to the stigmatization of the procedure. Because most nurses had not been trained to understand the psychosocial dynamics of elective abortions, they often formed opinions about their patients without much context. The first women who sought decriminalized, elective abortions were commonly anxious about a procedure that had been illegal in the recent past. Psychiatrists observed that these women often exuded a special degree of “bravado, brazenness, and indifference” to cope with their fears and anxieties.127 Untrained nurses were vulnerable to misinterpreting women’s expressions of relief as evidence of their callous disregard for human life. Some nurses reported to McDermott and Char that they were “shocked” to see so many women whom they believed were eager to get rid of “the thing” so that they could “get off the hook” for having engaged in premarital sex.128 For nurses who worked with elective abortion patients, the legalization of the procedure brought into focus the ubiquity of premarital sex and women’s strong desire to postpone motherhood. Hostile nurses amplified abortion patients’ feelings of anxiety and even pain. In the late 1970s, researchers determined that medical professionals’ verbal and nonverbal cues influenced the way women regarded their decisions to have abortions.129 They found that patients were particularly responsive to nurses’ cues about whether they should feel guilty or depressed about having had the procedure.130 Other researchers concluded that abortion patients reported experiencing more pain when they received care from nurses whom they believed opposed abortion.131 Nurses sometimes treated abortion patients punitively. Some placed abortion patients in rooms with women who’d just given birth or near the nursery. Others admitted that they told patients that it was against hospital policy for their boyfriends to sit on their beds if they believed the couple had been “making out” before the procedure.132 Nurses in Colorado admitted that they ignored abortion patients’ requests for cigarettes, pain medication, and water, while nurses in Hawaii encouraged physicians to warn women that abortions could rupture their uteruses.133 Nurses’ “Conscientious Objection” to Abortion Work Scholars have examined how abortion opponents blunted women’s right to abortion by developing legal protections for medical providers’ religious liberties, parental and spousal interests, and restrictions on public funding for abortion after Roe v. Wade.134 However, medical personnel had already begun deploying these strategies before abortion was legalized nationally. Nurses drew upon the strategies of civil disobedience to assert that they had the right to refuse to participate in abortion care. By the late 1960s, Americans were familiar with pacifists and civil rights activists who had cited their conscientious objection to fighting in wars they believed to be immoral or unjust.135 When states began to decriminalize abortion, clergy extended the concept of “conscience” to medical personnel, encouraging them to regard abortion work as a moral wrong rather than a professional duty. In New York, Cardinal Terence Cooke warned Catholic medical personnel that they risked excommunication if they participated in abortions.136 Indeed, many Catholic nurses cited their faith to explain why they would not offer abortion care. “I’m a Catholic, and I know I would feel guilty if I had anything to do with it,” explained a nurse who worked at Chicago’s Weiss Memorial Hospital.137 Antiabortion nurses who were not Catholic also sometimes framed their opposition in moral or ethical terms. A nurse who worked at Chicago’s Bethesda Hospital explained that she would not be comfortable assisting with abortions because “I don’t approve of abortions. It’s just my own philosophy—I’m not Catholic.”138 Section 79-i of the 1971 New York State Civil Rights Law offered medical professionals the right to “refuse to perform or assist” with abortions if they were “contrary to the conscience or religious beliefs” of the workers.139 Shortly after states and individual hospitals began implementing conscience clauses to protect medical providers from having to participate in abortion work, nurses invoked them for reasons unrelated to religious belief. Some antiabortion nurses invoked feminist language and ideas to justify their refusal to participate in abortions. Registered nurse Irene Matousek, asserted that conscience clauses afforded nurses choices that they had been denied historically. “Peoples’ image of nurses and our image of ourselves is that we never complain,” she explained. “We’re always cheerful, always smiling, always supporting whatever the doctor does.”140 She maintained that abortion care revealed a sexist-double standard: while physicians’ engagement with patients was relatively brief, nurses bore the brunt of the procedure’s emotional and physical labor demands. “The physician does his thing, then leaves,” Matousek explained. “It’s the nurse who is left to clean up, to be the recipient of such questions as ‘did I do the right thing?’ The doctor comes and goes; the nurse is left with the consequences.”141 Many nurses resented that physicians chose whether to offer abortions while nurses were expected to care for the patients they were assigned to cover each day, regardless of their feelings about abortion.142 Antiabortion nurses generally ignored how their refusal to participate in abortions might affect patients’ abilities to exercise their rights. Nurses’ refusal to provide abortion as a matter of “conscience” had profound consequences for women who sought abortions. In 1971, so many nurses refused to assist with abortions at Los Angeles’s County-USC Medical Center that the hospital briefly reduced by one-third the number of therapeutic abortions performed each month.143 Hospital administrators maintained that they had money to hire nurses, but could not find enough who were willing to assist with abortions. At Cleveland’s Metropolitan General Hospital, so many nurses and anesthesiologists refused to assist with abortions that obstetrician-gynecologists had to perform the procedure alone. As a result, the hospital could only accept four of the more than fifty women who requested abortions each week.144 Medical professionals’ right to refuse to participate in abortions became enshrined into federal policy in 1973, when President Nixon signed into law a bill that included a conscience clause permitting federally-funded hospitals and medical professionals to refuse to participate in abortions or sterilizations on the basis of moral belief or moral conviction.145 One year later, the Legal Services Corporation Act permitted similar protections to federally-funded attorneys or institutions tasked with supporting abortion rights.146 In 1976, abortion was singled out once more with the Hyde Amendment, which prohibited the use of federal funds for most abortions. Hospitals, buoyed by their legal right not to perform abortions, never became reliable sources for abortion services in the United States. Poor and rural women were disproportionately affected by the lack of hospital provision because they were less likely to be able to afford private care and often lived in regions that did not have standalone abortion clinics.147 In the mid-1970s, one-third of poor Americans lived in states with public hospitals that performed one or no abortions. More than half of all abortions occurred in nonhospital clinics located in metropolitan areas. By the mid-1990s, only about seven percent of all abortions were performed in hospitals.148 The women’s liberation movement transformed American women’s expectations of medical care. But the legalization of abortion preceded many feminist reforms within American medicine. The first generation of women who sought legal, elective abortions depended upon an overworked, underprepared, overwhelmingly white, female nursing corps. Although nurses would perform important emotional—and in the case of mid-trimester abortions, technical—work, most hospital administrators did not prepare them to assist with abortions. Similarly, most nursing schools and professional journals did not educate nurses about the technical or psychosocial dynamics of elective abortion care. As a consequence, many nurses who had initially supported decriminalization became hostile to the procedure after participating in abortion care. Nurses drew upon the burgeoning women’s liberation movement to articulate their grievances with their workloads and the sexism that often marked their relationships with physicians. Conscience clauses, which were intended to protect medical professionals’ religious beliefs, instead enabled nurses to refuse to participate in the procedure for a host of secular reasons. Ironically, nurses often deployed distinctly feminist arguments to justify their refusal to help other women to exercise their right to abortion. In the process, they created boundaries between themselves and patients, physicians, and hospital administrators and helped to ensure that abortion would remain at the margins of mainstream medicine long after decriminalization. Indeed, legal protections that prioritized medical professionals’ personal religious liberties proved to be one of the most salient strategies for curbing abortion access well into the twenty-first century. In January 2018, the Trump administration announced the creation of the Conscience and Religious Freedom Division within the Department of Health and Human Services. The new unit was established to ensure that medical providers could refuse to engage procedures or patients whose demands, identities, or lifestyles violated their religious beliefs. With echoes of debates about nurses’ right to refuse to participate in abortions in the late 1960s, Hal C. Lawrence III, the chief executive of the American College of Obstetricians and Gynecologists lambasted the new federal enforcement unit, explaining, “No individual, employer, politician, or entity should be given legal cover to deny a patient needed medical care.” Eric D. Hargan, the acting secretary of health and human services, countered that the office would ensure that religious medical professionals would no longer be “bullied by the federal government because of their religious beliefs.”149 Since the late 1960s, debates about medical professionals’ responsibilities to abortion patients have emphasized providers’ religious beliefs. By reflecting on the period immediately before Roe, we see how nurses’ invocation of conscience clauses ultimately obscured many of the problems that the legalization of abortion had exposed. When they invoked their right to refuse to fulfill their professional obligations on the basis of personal conscience, nurses declared that they would not defer to physicians’, administrators’, or patients’ demands. However, by taking cover under the umbrella of conscience clauses, a legal protection shrouded with religious meaning, the other issues that had come into focus when abortion was decriminalized—including nurses’ long-standing labor grievances, some nurses’ discomfort with changing sexual mores, and most nurses’ lack of preparedness to care for abortion patients—faded from view. Footnotes I presented a version of this article at the triennial meeting of the Berkshire Conference of Women’s Historians in June 2017. Thanks to Benjamin Benus, Christopher Crenner, Sara Dubow, Cory Ellen Gatrall, Linda K. Kerber, Johanna Schoen, Charissa Threat, and the two anonymous reviewers for helping me to identify sentences to keep, words to toss, and ideas that I needed to rethink. 1 Walter F. Char and John F. McDermott, Jr., “Abortions and Acute Identity Crisis in Nursing,” Am. J. Psychiatry 128 (1972): 953. 2 “Nurse Shortage Worsens, Desperate in Some Areas,” Chicago Tribune, September 11, 1966, B2. 3 Joan E. Lynaugh and Barbara L. Brush, American Nursing: From Hospitals to Health Systems (Malden, Mass.: Blackwell Publishers Ltd., 1996), 29–30. 4 Carl M. Cobb, “Severe Shortage of Nurses Creates City Hospital Crisis,” Boston Globe, July 17, 1966, A38. 5 “Nurse Shortage Worsens,” B1. 6 Campbell Gibson and Kay Jung, “Historical Census Statistics on Population Totals by Race, 1790 to 1990” (Washington, D.C.: U.S. Census Bureau, 2002), 26, https://www.census.gov/population/www/documentation/twps0076/twps0076.pdf, accessed September 2017; “Nurse Shortage Worsens,” B2. 7 Susan Gelfand Malka, Daring to Care: American Nursing and Second-Wave Feminism (Urbana: University of Illinois Press, 2007), 25. 8 Although they were not as stark, the city’s voluntary ward and private hospitals also had pronounced race-based disparities between patients and nurses. Jean Pakter, David Harris, and Frieda Nelson, “Surveillance of the Abortion Program in New York City: Preliminary Report,” in Clinical Obstetrics and Gynecology, ed. George Schaefer, vol. 14 (New York: Harper & Row, 1971), 280; Angela Byars-Winston, Nadya Fouad, and Yao Wen, “Race/Ethnicity and Sex in US Occupations, 1970–2010,” J. Vocational Behavior, 87 (2015): 67. 9 Wilma Scott Heide, “Nursing and Women’s Liberation: A Parallel,” Am. J. Nursing, 73 (1973): 824. 10 Pat Yoder, letter to the editor, Am. J. Nursing, 71 (1971): 2308. 11 Henry K. Silver and Patricia A. McAtee, “Opinion: Health Care Practice: An Expanded Profession of Nursing for Men and Women,” Am. J. Nursing, 72 (1972): 78–80. 12 Karen Schutzenhofer, letter to the editor, Am. J. Nursing, 72 (1972): 443. 13 Virginia Cleland, “Sex Discrimination: Nursing’s Most Pervasive Problem,” Am. J. Nursing, 71 (1971): 1543. 14 William Ray Arney, Power and the Profession of Obstetrics (Chicago: University of Chicago Press, 1982), 208–42; Wendy Kline, Bodies of Knowledge: Sexuality, Reproduction, and Women’s Health in the Second Wave (Chicago: University of Chicago Press, 2010). 15 Carole E. Joffe, Doctors of Conscience: The Struggle to Provide Abortion Before and After “Roe v. Wade” (Boston: Beacon Press, 1995), 53–142; Rickie Solinger, “‘A Complete Disaster’: Abortion and the Politics of Hospital Abortion Committees, 1950-1970,” Feminist Studies 19 (1993): 241–68. On lay feminist abortion provision, see Laura Kaplan, The Story of Jane: The Legendary Underground Feminist Abortion Service (Chicago: University of Chicago Press, 1997). On feminist and clerical work to refer women to safe abortion providers, see Arlene Carmen, Abortion Counseling and Social Change From Illegal Act to Medical Practice: The Story of the Clergy Consultation Service on Abortion (Valley Forge, Penn.: Judson Press, 1973); Leslie J. Reagan, “Crossing the Border for Abortions: California Activists, Mexican Clinics, and the Creation of a Feminist Health Agency in the 1960s,” in Women, Health, and Nation: Canada and the United States since 1945, ed. Georgina Feldberg et al. (Quebec: McGill-Queen’s University Press, 2003), 355–78; Jennifer Nelson, More Than Medicine: A History of the Feminist Women’s Health Movement (New York: New York University Press, 2015), 57–89. On the relationship between medical technology, feminism, and abortion law, see Johanna Schoen, Abortion after Roe: Abortion after Legalization (Chapel Hill: The University of North Carolina Press, 2015). On discourses that framed the abortion debate before and after decriminalization, see Sara Dubow, Ourselves Unborn: A History of the Fetus in Modern America (New York: Oxford University Press, 2010); Carol Sanger, About Abortion: Terminating Pregnancy in Twenty-First Century America (Cambridge: Harvard University Press, 2017). 16 Darlene Clark Hine, Black Women in White: Racial Conflict and Cooperation in the Nursing Profession, 1890-1950 (Bloomington: Indiana University Press, 1989); Susan Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 (New York: Cambridge University Press, 1987); Malka, Daring to Care: American Nursing and Second-Wave Feminism; Kara Dixon Vuic, Officer, Nurse, Woman: The Army Nurse Corps in the Vietnam War (Baltimore: Johns Hopkins University Press, 2009); Patricia D’Antonio, American Nursing: A History of Knowledge, Authority, and the Meaning of Work (Baltimore: Johns Hopkins University Press, 2010); Charissa J. Threat, Nursing Civil Rights: Gender and Race in the Army Nurse Corps (Urbana: University of Illinois Press, 2015). 17 Mary C. Segers and Timothy A. Byrnes, eds., Abortion Politics in American States (Armonk, New York: M.E. Sharpe, 1995), 2; Leslie J. Reagan, When Abortion Was a Crime: Women, Medicine, and Law in the United States, 1867-1973 (Berkeley: University of California Press, 1997), 12–13. 18 A 1931-32 study of nearly 1,000 women who lived in the Bronx revealed that 35 percent had obtained at least one illegal abortion; three-quarters turned to a person they referred to as a “doctor.” Regine K. Stix, “A Study of Pregnancy Wastage,” Milbank Memorial Fund Quarterly, 13 (1935): 352, 359–60. Johanna Schoen has demonstrated that until the 1930s, state authorities were more invested in punishing women’s sexual partners for failing to be supportive and enthusiastic fathers than rooting out physicians who performed abortions illegally. Johanna Schoen, Choice & Coercion: Birth Control, Sterilization, and Abortion in Public Health and Welfare (Chapel Hill: University of North Carolina Press, 2005), 148–52. 19 Reagan, When Abortion Was a Crime, 179; Rose Leroux et al., “Abortion,” Am. J. Nursing, 70 (1970): 1921. 20 Stix, “A Study of Pregnancy Wastage,” 352, 359–60. See also Schoen, Choice & Coercion, 139–79. 21 Reagan, When Abortion Was a Crime, 197. See also Morton Sontheimer et al., “A Report on Abortion from Nine American Cities,” Woman’s Home Companion, 82 (1955): 45 and 96. 22 Ralph Dighton, “Legal Abortions: Running Far Fewer than Estimated,” Washington Post, September 20, 1968, C6. 23 Nathan Hershey, “The Law and the Nurse: As Society’s Views Change, Law Changes,” Am. J. Nursing, 67 (1967): 2312; Jeanne D. Fonseca, “Induced Abortion: Nursing Attitudes and Action,” Am. J. Nursing, 68 (1968): 1022. 24 Joffe, Doctors of Conscience. Nathan Hershey, “The Law and the Nurse: The Legal Side of Medical-Moral Issues,” Am. J. Nursing, 62 (1962): 103–4. On nurses arrested for performing abortions outside of hospitals, see “Medic, Nurse Held Again for Abortion,” New York Amsterdam News, March 13, 1965, 1; “Nurse, 70, Found Guilty of Abortion on Girl, 18,” Chicago Tribune, December 7, 1966, A10; “Nurse Jailed In Abortion of Woman,” Los Angeles Sentinel, August 31, 1967, A7; “Male Nurse Arrested in Teenager Abortion,” Los Angeles Sentinel, 30 January 1969, B2. 25 Reagan, When Abortion Was a Crime, 201. 26 Janet Allured, Remapping Second-Wave Feminism: The Long Women’s Rights Movement in Louisiana, 1950-1997 (Athens: University of Georgia Press, 2016), 150, 153–57; Schoen, Choice & Coercion, 140. 27 California Health & Welfare Agency Department of Public Health, “Report to the Legislature,” in Information on California Therapeutic Abortion Act of 1967 (Lansing, MI: Michigan State Senate Committee on Abortion Law Reform SR 185, 1968), 44, http://hdl.handle.net/2027/mdp.39015071227360, accessed August 2017. 28 Reagan, When Abortion Was a Crime, 205, 213–14. 29 Ibid., 210. 30 Schoen, Choice & Coercion, 176. 31 Roy G. Smith, Beverly Manner, and George Goto, “Physicians’ Attitudes on the Abortion Law: Report of Survey, 1969,” Hawaii Med. J., 29 (1970): 209–11. 32 Kaplan, The Story of Jane; Joffe, Doctors of Conscience; Linda Greenhouse and Reva Siegel, Before Roe v. Wade: Voices That Shaped the Abortion Debate Before the Supreme Court’s Ruling (New York: Kaplan Publishing, 2010), 3–34. 33 “The Story of California’s Abortion Law,” Information on California’s Therapeutic Abortion Act of 1967 (Michigan State Senate Committee on Abortion Law Reform SR185, 1968), 61, https://babel.hathitrust.org/cgi/pt?id=mdp.39015071227360;view=1up;seq=7; Durlin Hickok and Colin Campbell, “Attitudes Toward Abortion Law Reform at the University of Michigan Medical Center,” Michigan Medicine, 71 (1972): 327–29, accessed August 2017. Nurses also pointed to their work with women suffering from botched abortion to explain their support for abortion rights. Christine Winter, “Abortion from the Nurse’s Point of View–Will She Be a Participant?” Chicago Tribune, March 11, 1973, D3. 34 Mary L. Dudziak, “Just Say No: Birth Control in the Connecticut Supreme Court before Griswold v. Connecticut,” Iowa Law Review 75 (1990): 915–39. 35 Roy G. Smith et al., “Abortion in Hawaii: The First 124 Days,” Am. J. Public Health, 61 (1971): 530. Many states, including Hawaii and California, liberalized their laws incrementally, through both legislation and the courts. Segers and Byrnes, Abortion Politics in American States, 3–4. 36 “California Therapeutic Abortion Act of 1967,” California Health & Safety Code §§25950-54 (June 1967). 37 Dorothy Townsend, “Doctor Gives Data on Legal Abortions: Only 3% Performed for Mother’s Physical Health,” L. A. Times, September 24, 1970, A3. 38 Rothlyn Zahourek, “Liberalized Abortion: Devastation–Preservation,” AORN Journal, 15 (1972): 94–96. On women’s difficulty obtaining legal abortions after having been raped, see Leroux et al., “Abortion,” 1919–20. 39 C. Lee Buxton, “One Doctor’s Opinion of Abortion Laws,” Am. J. Nursing, 68 (1968): 1027. 40 Ibid., 1028. 41 Rothlyn Zahourek, “Therapeutic Abortion and Cultural Shock,” Nursing Forum 10 (1971): 13. 42 Char and McDermott, “Abortions and Acute Identity,” 954. 43 “Estimates of the Population of States, By Age, 1965 to 1967” (Washington, D.C.: US Department of Commerce and Bureau of the Census, April 17, 1969), 6, https://www.census.gov/content/dam/Census/library/publications/1969/demo/p25-420.pdf, accessed October 2017. 44 Gwen Gibson, “Liberalized Abortion Law: Four Years Later,” Los Angeles Times, November 21, 1971, E1. 45 Bureau of Maternal & Child Health California Department of Public Health, “Therapeutic Abortions Report,” in Information on California Therapeutic Act of 1967 (Lansing, MI: Michigan State Senate Committee on Abortion Law Reform SR 185, 1968), 12–13, http://hdl.handle.net/2027/mdp.39015071227360, accessed August 2017. 46 California Department of Public Health, 14. 47 Michael S. Goldstein, “Abortion as a Medical Career Choice: Entrepreneurs, Community Physicians, and Others,” J. Health and Social Behavior, 25 (1984) 223. 48 McDermott, Jr. and Char, “Abortion Repeal in Hawaii,” 620. 49 Ibid., 620. 50 Zahourek, “Therapeutic Abortion,” 13. 51 Norman K. Brown et al., “How Do Nurses Feel about Euthanasia and Abortion?” Am. J. Nursing, 71 (1971): 1416. 52 New York City’s Center for Reproductive and Sexual Health clinic served 60,000 during its first two years of operation in the early 1970s. Schoen, Abortion after Roe, 33. 53 Carl M. Cobb, “New York City: Abortion Capital of U.S.,” Boston Globe, July 26, 1970, A3; Richard Knox, “Residency Curb Debated For New York Abortions,” Boston Globe, January 31, 1971, 1; Gary S. Berger et al., “Maternal Mortality Associated with Legal Abortion in New York State,” J. Obstetrics and Gynecology 43, (1974): 315. 54 Hollis S. Ingraham and Robert J. Longood, “Abortions in New York State since July 1970,” in Clinical Obstetrics and Gynecology, ed. George Schaefer, vol. 14 (New York: Harper & Row, 1971), 17. 55 Enid Nemy, “Even Now, Helping with Abortions Is Traumatic Shock for Some Nurses,” New York Times, February 1, 1972, A32. 56 Quoted in Thelma M. Schorr, “Editorial: Issues of Conscience,” Am. J. Nursing, 72 (1972): 61. 57 “Does Anybody Care?,” Am. J. Nursing, 73 (1973): 1564. 58 Schoen, Abortion after Roe, 36. 59 Between 1970 and 2009, between eighty-five and ninety-two percent of abortions in the United States were performed at or before thirteen weeks’ gestation. Smith et al., “Abortion in Hawaii,” 532; Karen Pazol et al., “Abortion Surveillance–United States, 2009,” Morbidity and Mortality Weekly Report, 61 (2012): 2. 60 Robert Drinan, “The Desperate Dilemma of Abortion,” Time, 13 October 1967, 42. 61 Leroux et al., “Abortion,” 1921–22; Christa Keller and Pamela Copeland, “Counseling the Abortion Patient Is More than Talk,” Am. J. Nursing, 82 (1972): 104; Schoen, Abortion after Roe, 27. 62 Catherine H. Siener and Elizabeth Mahoney, “Coordination of Outpatient Services for Patients Seeking Elective Abortions,” in Clinical Obstetrics and Gynecology, ed. George Schaefer, vol. 14 (New York: Harper & Row, 1971), 53. 63 Mary C. McLaughlin, “Abortion Standards, New York City Board of Health,” in ibid., 32–33. 64 Janet D’Archangelo, “Abortion: Nursing Expertise Needed,” Nursing Update 6 (1975): 10. 65 A Planned Parenthood in Syracuse charged women up to $250 for a first-trimester abortion in 1971. Ellen Fairchild and A. Jefferson Penfield, “Should Family Planning Clinics Perform Abortions?” Family Planning Perspectives, 3 (1971): 16. 66 Christopher Tietze et al., Provisional Estimates of Abortion Need & Services in the Year Following the 1973 Supreme Court Decisions (New York: Alan Guttmacher Institute, 1975), 30. 67 Most women (64 percent) paid out-of-pocket for the $350-400 cost of hospital-based abortions. Smith et al., “Abortion in Hawaii,” 534–35. 68 Jean Dietz, “Upstate: Conservatism, Staff Reluctance Greets Patients,” Boston Globe, July 26, 1970, A3. 69 Schoen, Abortion after Roe, 30–31. 70 On the health risks associated with later-term abortions, see Berger et al., “Maternal Mortality,” 315; R. R. Macdonald, “Complications of Abortion,” Nursing Times, 63 (1967): 305–7. In the early 1970s, saline abortions were $420, compared to $140 for vacuum aspiration abortions. Gibson, “Liberalized Abortion Law,” E20. 71 Deborah Farber Kallop, “Preoperative Instruction for the Patient Undergoing Elective Abortion,” in Obstetrics and Gynecology, ed. George Schaefer, vol. 14 (New York: Harper & Row, 1971), 60–66; David T.Y. Liu and Pamela M. Thwaites, “Induced Mid-Trimester Abortion,” Nursing Times, 70 (1974): 1543. 72 Nemy, “Even Now.” 73 Yaloff, Wade, and Burlingame, “Nursing Care in an Abortion Unit,” 78. 74 Nancy B. Kaltreider, Sadja Goldsmith, and Alan J. Margolis, “The Impact of Midtrimester Abortion Techniques on Patients and Staff,” Am. J. Obstetrics and Gynecology, 135 (1979): 236. 75 Unnamed nurse qtd. in Phyllis Langton Stewart, “Normative Views of Doctors & Nurses on Abortion,” Sociological Symposium, 8 (1972): 93. 76 Helen Branson, “Nurses Talk about Abortion,” Am. J. Nursing, 72 (1972): 106. 77 Historian Susan Reverby has observed that nursing students and nurses often resisted pressures to conform or to defer to authority. Ordered to Care, 34, 57, and 160. 78 McDermott and Char observed that Catholic nurses had an advantage over their non-Catholic colleagues. While most nurses appeared to have felt overwhelmed or undertrained, the Catholic Church’s strict opposition to abortion offered Catholic nurses a framework for articulating their discomfort. “Abortion Repeal in Hawaii,” 622. 79 Dolores Malo-Juvera, “Preparing Students for Nursing Care,” Nursing Outlook 19 (1971): 348. 80 Ibid., 349; Goldstein, “Abortion as a Medical Career Choice,” 224. 81 See Char and McDermott, Jr., “Abortions and Acute Identity”; Arlene Hurwitz and R. Frank Eadie, “Psychologic Impact on Nursing Students of Participation in Abortion,” Nursing Research 26 (1977): 112–20. 82 Patricia Jenaway Estok, “Abortion Attitude of Nurses: A Cognitive Dissonance Perspective,” Image 10 (1978): 74. See also Sarp Askel et al., “Unintended Consequences: Abortion Training in the Years after ‘Roe v. Wade,’” Am. J. Public Health, 103 (2013): 404–7; Monica R. McLemore, Amy Levi, and E. Angel James, “Recruitment and Retention Strategies for Expert Nurses in Abortion Care Provision,” Contraception, 91 (2016): 474–79. 83 Katherine L. Eastwood et al., “Abortion Training in United States Obstetrics and Gynecology Residency Programs,” Obstetrics & Gynecology, 108 (2006): 303–7. 84 Ann C. Hwang et al., “Advanced Practice Clinicians’ Interest in Providing Medical Abortions: Results of a California Survey,” Perspectives on Sexual and Reproductive Health, 37 (2005): 96. 85 Pat Mahaffee Gingrich, “Improving Student Receptivity to Abortion Care Education,” Nursing Education Perspectives 38 (2017): 350. 86 Jean Pakter, Frieda Nelson, and Martin Svigir, “Legal Abortion: A Half-Decade of Experience,” Family Planning Perspectives 7 (1975): 248. 87 Yaloff, Wade, and Burlingame, “Nursing Care in an Abortion Unit,” 68; Mildred I. Abbott, Andrea J. Renovitch, and Doris Barker, “The Role of the Nurse-Midwife in an Abortion Evaluation Clinic,” J. Nurse-Midwifery, 18 (1973): 17; Tietze et al., Provisional Estimates of Abortion Need, 16. Nurse-midwives at Brooklyn’s Kings County Hospital taught Lamaze to saline abortion patients. Nancy Whitley, “Second Trimester Abortion,” JOGNN, 2 (1973): 15–21. 88 Margot J. Fromer, “Abortion,” JOGNN, 1 (1972): 72. 89 Elizabeth Shelton, “A Quick, Painless and Uncostly Abortion Procedure,” Washington Post, September 26, 1970, C1. 90 Keller and Copeland, “Counseling the Abortion Patient,” 104. 91 Ibid., 105. 92 Beverly Yaloff, Margot Wade, and Mildred Burlingame, “Nursing Care in an Abortion Unit,” in Clinical Obstetrics and Gynecology, ed. George Schaefer, vol. 14 (New York: Harper & Row, 1971), 67. 93 Linda R. Cronenwett and Janice M. Choyce, “Saline Abortion,” Am. J. Nursing, 71 (1971): 1754. 94 Ibid., 1755–56. 95 Edythe Thompson, letter to the editor, Am. J. Nursing, 71 (1971): 2312. 96 Ibid., Joan Higgins, letter to the editor. 97 Ibid., Ella Richter, letter to the editor. 98 Jane Mendez-Pico, letter to the editor, Am. J. Nursing, 72 (1972): 237-238. 99 Ibid., Martha Calder and Mary Jo Roberts, letters to the editor, 240. 100 Ibid., Loyal Allen, letter to the editor., 238. 101 Ibid., Gloria J. Dittmar, letter to the editor, 240. 102 Ibid., Glenice Anderson, letter to the editor. 103 Keller and Copeland cite “Educators Seek Sex Education in Nursing Curriculum,” SIECUS Newsletter, (1970): 6 in “Counseling the Abortion Patient Is More than Talk,” 106. 104 Liu and Thwaites, “Induced Mid-Trimester Abortion,” 1543. Most nursing journals published articles explaining the technical or legal aspects of abortion but did not address nursing care. See J. S. Scott, “Implications of Abortion Law Reform,” Nursing Times, 62 (1966): 1478–80; Minna H. Marshall, “Septic Abortion: Crisis Care,” Am. J. Nursing, 66 (1966) 1042–44; James C. Caillouette, “Septic Abortion: Pathology and Treatment,” in ibid. 1045–48; Macdonald, “Complications of Abortion,” 306–7; Hershey, “The Law and the Nurse: As Society’s Views Change, Law Changes,” 2310–12; Diane Brett, Jennifer Jackson, and Anne Wright, “Nursing Care Study: Abortion–With Complications,” Nursing Times, 67 (1971): 67, 1209–10. However, there were exceptions. In 1968, Am. J. Nursing published an article that examined the technical and emotional dimensions of nurses work with abortion: Jeanne Fonseca, “Nursing Attitudes and Action,” Am. J. Nursing, 68 (1968): 1022–27. In 1971, Clinical Obstetrics and Gynecology published an article that considered both the technical and emotional dynamics of nursing care for abortion patients. Yaloff, Wade, and Burlingame, “Nursing Care in an Abortion Unit,” 67–80. In January 1972, Am. J. Nursing published a special issue about abortion care that included articles about nurse training, offered advice to administrators, and featured first-person accounts by nurses who worked with abortion patients. In their survey of American and British nursing journal articles about abortion care published between 1971 and 2011, Monica McLemore and Amy Levi observed that only 15 percent pertained to the physiology of abortions. “Nurses and Care of Women Seeking Abortions, 1971 to 2011,” JOGNN 50 (2011): 675. 105 D’Archangelo, “Abortion: Nursing Expertise Needed,” 1–10. 106 Hurwitz and Eadie, “Psychologic Impact on Nursing Students,” 113. 107 Doris V. Allen et al., “Factors to Consider in Staffing an Abortion Facility,” J. Nursing Administration, 4 (1974): 24. 108 Ibid. 109 Patricia G. Steinhoff and Milton Diamond, Abortion Politics: The Hawaii Experience (Honolulu: University of Hawaii Press, 1977), 179. 110 Zahourek, “Therapeutic Abortion,” 11. 111 Ibid., 11. 112 Char and McDermott, Jr., “Abortions and Acute Identity,” 68. 113 Ibid., 954. 114 Colman McCarthy, “Abortion–No Escaping Psychic Trauma,” Los Angeles Times, February 28, 1971, F3. 115 Zahourek, “Therapeutic Abortion and Cultural Shock”; McDermott, Jr. and Char, “Abortion Repeal in Hawaii.” 116 “The RN Panel of 500 Tells What Nurses Think about Abortion,” RN, 33 (1970): 40. 117 G E Hendershot and J W Grimm, “Abortion Attitudes among Nurses and Social Workers,” Am. J. Public Health, 64 (1974): 438–41. 118 Frank Newport, David W. Moore, and Lydia Saad, “Long-Term Gallup Poll Trends: A Portrait of American Public Opinion through the Century” (Washington, D.C.: Gallup News Service, December 20, 1999), http://news.gallup.com/poll/3400/longterm-gallup-poll-trends-portrait-american-public-opinion.aspx. 119 Lynaugh and Brush, American Nursing, 29. 120 R. A. Hudson Rosen et al., “Health Professionals’ Attitudes toward Abortion,” Public Opinion Quarterly, 38 (1974): 166. 121 Allen et al., “Factors to Consider,” 26. Catholic nurses were less likely to support the right to elective abortion than Catholic Americans generally. R. A. Hudson Rosen et al., “Health Professionals’ Attitudes,” 164–71. Registered nurses’ opposition to participating in abortion care increased over time: in 1988, 48 percent of registered nurses indicated that they would refuse to participate in a unit where abortions were performed. Ten years later, 61 percent said that they would refuse. Nurses in the Midwest and South were most likely to oppose abortion rights and nurses on the West Coast were most supportive. Allyson Lipp, “A Review of Termination of Pregnancy: Prevalent Health Care Professional Attitudes and Ways of Influencing Them,” J. of Clinical Nursing 17 (2008): 1684–85. 122 Arthur Peck, “Therapeutic Abortion: Patients, Doctors, and Society,” Am. J. Psychiatry, 125 (1968): 800; Alice S. Rossi, “Abortion Laws and Their Victims,” Trans-Action, 3 (1966): 7. 123 Rossi, “Abortion Laws,” 9. 124 Edward H. Fischer, “Student Nurses View an Abortion Client: Attitude and Context Effects,” J. Population, 1979, 2, 33–46. On Americans’ attitudes about abortion and gender norms, see Ann Fessler, The Girls Who Went Away: The Hidden History of Women Who Surrendered Children for Adoption in the Decades before ‘Roe v. Wade,’ Reprint (New York: Penguin Books, 2007). 125 “Personal Experience at a Legal Abortion Center,” Am. J. Nursing, 72 (1972): 112. 126 Ibid., 111. 127 Char and McDermott, Jr., “Abortions and Acute Identity,” 954. 128 Ibid., 953. Catherine Haney found that Canadian women who sought illegal abortions also sometimes exhibited aggressive or defensive behaviors in their interactions with doctors and nurses because they feared medical professionals’ judgements. Catherine Haney, “Towards Legitimate Nursing Work? Historical Discursive Constructions of Abortion in The Canadian Nurse, 1950-1965,” Canadian Bulletin of Nursing History, 31 (2014): 100. 129 Ellen W. Freeman, “Abortion: Subjective Attitudes and Feelings,” Family Planning Perspectives, 10 (1978): 150–55. 130 Janie Spelton Weinberg, “Issues in Sexuality: Abortion,” in Sexuality: Human Needs and Nursing Practice (Philadelphia: W.B. Saunders Company, 1982), 191. 131 Mary W. Harper, Betty R. Marcom, and Victor D. Wall, “Do Attitudes of Nursing Personnel Affect the Patient’s Perception of Care?” Nursing Research, 21 (1972): 327–31; Sara L. Marshall, Dinah Gould, and Julia Roberts, “Nurses’ Attitudes towards Termination of Pregnancy,” J. Advanced Nursing, 20 (1994): 567. 132 Char and McDermott, Jr., “Abortions and Acute Identity,” 954. 133 Rothlyn Zahourek and Margene Tower, “Therapeutic Abortion: The Psychiatric Nurse as Therapist, Liaison, and Consultant,” Perspectives in Psychiatric Care, 9 (1971): 69; McDermott, Jr. and Char, “Abortion Repeal in Hawaii,” 623. Physicians also sometimes punished women, often by sterilizing therapeutic abortion patients. They justified the practice by drawing on the eugenic belief that they were preventing mentally unfit women from reproducing. Reagan, When Abortion Was a Crime, 207–8; Zahourek, “Therapeutic Abortion and Cultural Shock,” 14–15. 134 Scholars have emphasized the significance of post-Roe federal legislation, including the 1973 Church Amendment to the Health Care Extension Act and the 1976 Hyde Amendment, as well as Supreme Court decisions, including Planned Parenthood v. Casey 505 US 833 and Burwell v. Hobby Lobby, 573 US (2014). Reva B. Siegel, “Dignity and the Politics of Protection: Abortion Restrictions under Casey/Carhart,” Yale Law Journal, 117 (2008): 1694–1801; Sara Dubow, “‘A Constitutional Right Rendered Utterly Meaningless’: Religious Exemptions and Reproductive Politics, 1973–2014,” Journal of Policy History, 27 (2015): 1–35; Alisa Von Hagel and Daniela Mansbach, Reproductive Rights in the Age of Human Rights (New York: Palgrave Macmillan, 2016). Historian Rebecca M. Kluchin examines the 1972 Hathaway v. Worcester City Hospital decision, in which the US District Court of Massachusetts ruled that hospitals were not obligated to offer sterilizations or abortions, in Fit to Be Tied: Sterilization and Reproductive Rights in America, 1950-1980 (New Brunswick, N.J: Rutgers University Press, 2009), 134–36. 135 Cynthia Eller, Conscientious Objectors and the Second World War: Moral and Religious Arguments in Support of Pacifism (New York: Praeger, 1991); Simon Hall, Peace and Freedom: The Civil Rights and Antiwar Movements of the 1960s (Philadelphia: University of Pennsylvania Press, 2005). 136 Cobb, “New York City.” 137 Winter, “Abortion from the Nurse’s Point of View,” D3. 138 Ibid. 139 Quoted in Tom Callahan, “Backing the Right of Nurses Not to Assist in Abortions,” New York Times, January 4, 1998, E1. 140 Tia Gindick, “Conscience vs. Duty: Nurse and Abortion: Feelings of Helplessness, Pity, and Anger,” Los Angeles Times, June 30, 1974, CS4. 141 Ibid. 142 Char and McDermott, Jr., “Abortions and Acute Identity”; Gindick, “Conscience vs. Duty.” 143 Harry Nelson, “County Hospital to Reduce Therapeutic Abortions One-Third,” Los Angeles Times, August 7, 1971, A1. 144 Roy Meyers, “Some Metro Hospital Aides Won’t Assist in Abortions,” Cleveland Press April 24, 1973, A1. 145 Dubow, “‘A Constitutional Right,’” 1. 146 Ibid., 18–19. 147 Tietze et al., Provisional Estimates of Abortion Need, 38. 148 Ibid., 38; Joffe, Doctors of Conscience, 161; Johanna Schoen, “Living Through Some Giant Change: The Establishment of Abortion Services,” Am. J. Public Health, 103 (2013): 418. 149 Quoted in Robert Pear and Jeremy W. Peters, “New Protections for Health Workers Who Oppose Abortion,” New York Times, January 19, 2018, A14. Civil rights and gay activists joined abortion rights activists to warn that the federal enforcement of conscience clause protections would give medical providers license to discriminate against lesbian, gay, and transgendered patients, as well as women who seek abortions. © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

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