It started with a phone call.

You didn’t know who would answer. The woman who answered didn’t know you. You and she were a pair of links in an elaborate chain, and what you discussed was illegal.

But she said she could help.

Before 1973, the year when a U.S. Supreme Court decision made abortion legal in all 50 states, there was an underground network of known, safe abortion providers in Wisconsin, said Sarah, who agreed to be interviewed on the condition that her real name not be used.

She was a student at the University of Wisconsin-La Crosse in 1971, where she learned of a secret phone tree that connected women seeking abortions with sympathetic nurses on the eastern side of the state. Risking loss of career and jail time if caught, the nurses provided illegal abortions in secret, ever-changing locations.

“Abortions were not frequent to my knowledge,” she said. “But when you live in an all-female dorm, you learned about it fast.”

Others traveled as far as New York, Sarah said. A student in Baird Hall knew where to go, and others helped raise money to cover the cost of round-trip plane tickets and the cost of the procedure.

“Self abortion attempts were awful — usually they ended up with sepsis,” Sarah said. “I knew of one suicide of a pregnant girl. No one knew she was pregnant when she died.”

While the landmark Roe v. Wade ruling made abortion legal nationwide, the decision did not settle the question. Americans remain polarized, and many state legislatures, including Wisconsin’s, have gradually tightened regulations, testing the limits of that high court ruling.

Opponents of legal abortion have applauded such regulation and pushed for further restrictions, while supporters of legal abortion have decried the diminishment of women’s reproductive freedom.

Then and now, for women who choose abortion, the stigma remains. Like Sarah, the women who shared their abortion experiences for this story all did so anonymously – not because they felt shame or remorse, but because they feared the repercussions for their families. Each wished she could speak openly.

“No matter what a pregnant girl did in response to her pregnancy, it wasn’t right because of the fact that she was pregnant,” Sarah said. “It was on her and her alone.”

A struggle for access

More than 40 years have passed since Roe v. Wade, but access to abortion is still a challenge for Wisconsin women.

With just four abortion clinics in the state — one in Madison, two in Milwaukee and one in Appleton — 93 percent of Wisconsin counties do not have a provider. Those counties house 67 percent of Wisconsin women.

“Access to abortion services in Wisconsin is very, very limited,” said Nicole Safar, public policy director for Planned Parenthood Wisconsin.

The closest abortion clinics for La Crosse-area women are in Madison and Minneapolis. Wisconsin’s mandatory 24-hour waiting period, which requires that a woman receive in-person counseling at the clinic before an abortion, means either two trips or an overnight stay.

“That is really, really troubling, especially for rural women and those in lower income brackets,” Safar said.

The decision to end a pregnancy is already difficult enough, said Amy, who was a 17-year-old high school senior living in rural Jackson County when she became pregnant with twins 10 years ago.

The child of a teenage mother, Amy saw firsthand the impact of an unwanted pregnancy. Her mother had her at 16, dropped out of high school and kept her for the welfare money, Amy said. Eventually, Amy moved in with her grandparents.

“I know what it’s like to be so small and have no one care and not be able to do something about your situation,” she said “My mom loved me, but she didn’t want me. I was an inconvenience.”

Amy said abortion was the right choice for her. She was preparing for college in Eau Claire in the fall. She saw the opportunity to get an education as a chance to break the cycle. But with parental consent laws in Wisconsin and Minnesota, she had to wait nearly three months until she turned 18 -- putting her within two days of her second trimester. She secretly withdrew $700 from the bank and had a friend drive her to Minneapolis.

“I couldn’t tell my grandparents, because I knew how disappointed they would be,” she said. “I didn’t want them to think that history was repeating itself.”

Can a woman get an abortion in La Crosse?

The city is home to two major hospitals, each with a full complement of surgical services. It might seem a plausible assumption that abortion is available in La Crosse.

Not so fast.

Gundersen Health System routinely releases the following statement when asked about abortion: “Gundersen Lutheran believes that pregnancy and fertility are confidential concerns between patient and physician and it is the Medical Center’s policy not to interfere.”

The media department hasn’t updated the statement to reflect the recent name change to Gundersen Health System: It’s the same line officials have given for years. Beyond that, hospital officials have no further comment. And abortion opponents regularly picket Gundersen.

With its Catholic affiliation, Franciscan Healthcare, an affiliate of Mayo Clinic Health System, does not offer abortion services, spokesman Rick Theisse said. None of its pharmacies stock Plan B emergency contraceptives. The hospital does, however, provide birth control.

On Friday, Mayo opened a sterilization clinic in Onalaska, but that clinic is under the Mayo banner alone. Franciscan Healthcare is not a clinic sponsor.

As an institution, the Rochester-based Mayo Clinic Health System “has a long-held policy that the matter of abortion is a private decision to be made by a patient and her physician,” spokesman Brian Anderson wrote in an email.

“We believe that little would be gained from sustaining a debate on this issue,” he said.

La Crosse's only reproductive health clinic is Options Clinic on the North Side, a federally funded affiliate of Gundersen Health System. As a provision of its Title X funding, Options Clinic does not perform abortions, nor does it provide referrals, its executive director, Beth Hartung, said.

There are 18 Title X clinics in Wisconsin that provide contraceptives, pregnancy testing and counseling, sexually transmitted disease testing and cancer screenings to their patients with the goal of reducing poverty and improving quality of life by helping women manage their reproductive health and plan their pregnancies.

“Options (Clinic) tries to prevent unintended pregnancies with a reproductive life plan,” Hartung said.

Despite the fact that Options Clinic neither performs abortions nor refers women to abortion providers, members of the Life League of La Crosse demonstrate outside the clinic on Wednesdays, displaying signs, reciting prayers and offering literature to clinic patrons. To them, contraceptives and abortion are the same thing, said Sister Rosalia Bauer, a member of the Franciscan Sisters of Perpetual Adoration who regularly attends the protest.

“The problem with contraceptives is that they fail,” Bauer said. “When they fail, people have abortions.”

Social pressure drives policy

Both the Wisconsin Medical Society and the Wisconsin Hospital Association declined to comment on the scope of abortion access in the state or the process by which medical institutions determine the procedures they provide.

But the reasons are “so complex, it’s simple,” said Doug Laube, a professor and former chairman of the University of Wisconsin department of obstetrics and gynecology and former president of the American College of Obstetricians and Gynecologists.

“It’s a confluence of the influence from the Catholic bishops, frightened hospital administrators and a divided public that prevents these things from happening,” he said. “It’s an issue of not wanting to be tainted and not wanting to be stained by the controversy.”

Laube was a resident at the University of Iowa when abortion became legal in 1973. He remembers the shift clearly. The university hospital system set up a clinic for the procedure on an elective basis. It was part of the residents’ training. There were no questions asked. 

But over the decades, pressure from abortion opponents mounted and began to influence policy, Laube said. The procedure shifted out of hospitals and into clinics, many run by Planned Parenthood.

“It was a very convenient way for (doctors) to avoid the whole issue,” he said. “They didn’t have to get their hands dirty."

Declining providers

In 2008, clinics performed 94 percent of abortions despite only accounting for 47 percent of abortion facilities, according to the Guttmacher Institute. In contrast, hospitals performed 4 percent of procedures and accounted for 34 percent of facilities.

Now, the number of abortion providers is in decline. Wisconsin lost 11 percent of its providers between 2008 and 2011; an abortion clinic in Green Bay closed in 2013.

Nationwide, about 50 abortion clinics closed between 2010 and 2013, many a result of targeted restrictions on abortion providers -- laws such as mandatory ultrasounds and requirements for clinic physicians to have admitting privileges at nearby hospitals.

For anti-abortion groups, the decline is welcome news. But for those who argue for access, it’s a troubling trend that puts women’s health and safety in the political crosshairs.

“(Abortion) will always be necessary and it will always be done,” Laube said. “If it becomes something that is so limited that you can’t do it legally, people will do it illegally.”

Safe, legal and rare?

Access to abortion in western Wisconsin was of little concern to Mia until she became pregnant just weeks after the birth of her second child.

“The doctor said, ‘congratulations,’ and I just started crying,” she said. “This was not good news.”

The newborn had colic. The older daughter was still a toddler. Mia and her husband ran a business from their small, two-bedroom home. They talked about trying to make it work.

They decided it wouldn’t.

“It wasn’t that we didn’t want another child,” she said. “This just wasn’t the right time.”

She called her doctor at Mayo and was shocked to learn she couldn’t get an abortion in La Crosse. She and her husband drove to Iowa City.

“I was devastated,” she said.

Two years later the economy tanked, and the family lost their business and their home. With their income cut in half, it was difficult enough, surviving with the two children they planned for, Mia said.

“Sometimes, having another child affects more than just the man and woman that made it,” she said. “I think we made the right decision.”

An estimated one in three women in the U.S. will have an abortion by age 45. And with an average of 1.4 million legal abortions performed annually in the U.S. since 1973, it is one of the most common medical procedures.

First trimester abortions are relatively simple surgical procedures done under local anesthesia, sometimes accompanied by a light sedative. They can be completed in less than 10 minutes and account for 90 percent of all abortions performed.

The procedure is safe. A 2013 study published in the Journal of Public Health showed that 1.3 percent of 11,500 abortions resulted in complications, only six of which — 0.05 percent — were major: two uterine perforations, three infections and one hemorrhage.

The same study found that newly trained nurse practitioners, certified nurse midwives and physician assistants can perform the procedure with success equal to that of physicians.

Medical abortion uses a series of pills to end a pregnancy within the first nine weeks. It requires no hospitalization –- only a prescription. The second half of the regimen is taken at home.

“I have often wished that Gundersen and even now Mayo would step up and say ‘we’re going to do this, it’s a necessary service,’” said Kate, a social worker in La Crosse who had an abortion in Madison 30 years ago. “Health care should be health care -- it shouldn’t be based on religion or politics.” 

A declining rate

The national abortion rate in 2011 in fell to 16.9 per 1,000 women — a 13 percent drop since 2008 and the lowest rate since Roe v. Wade.

The numbers come from a study released in January by the Guttmacher Institute, a New York-based think tank known for both support of abortion rights and meticulous data collection and analysis. Wisconsin saw a decline as well, with the number of abortions falling from 8,229 in 2008 to 7,249 in 2011.

Abortion rights supporters see the decline as proof that their efforts to increase access to birth control are working. Anti-abortion groups point to increasingly stringent legislation restricting access to the procedure at the state level.

“Having 1.1 million abortions is far too many annually, but it’s certainly gratifying that it’s down from the high of 1.6 million in 1990,” said Barbara Lyons, executive director of Wisconsin Right to Life. “We think that’s a very good outcome for mothers, babies, families and society.”

Lyons cited the closure of 87 abortion clinics nationwide in 2013 and 205 pieces of antiabortion legislation passed between 2011 and 2013 as major factors in the decline.

But the Guttmacher report studied the period before those laws went into effect.

Researchers Rachel Jones and Jenna Jerman pointed to increased use of contraceptives -- particularly long-acting reversible contraceptive methods -- as one likely driver of the change. The U.S. birthrate declined with the abortion rate, suggesting fewer unplanned pregnancies.

Planned Parenthood agrees.

“This report really shows what those of us who work in women’s health have been saying for a long time,” Safar said. “When women have access to birth control and tools they need to prevent unintended pregnancies, the abortion rate will drop.”

A shifting landscape

Always controversial, abortion policy took a dramatic shift in the past three years, with states enacting more abortion restrictions between 2011 and 2013 than in the entire previous decade. The Guttmacher Institute listed 13 states as “hostile to abortion” in 2000; by 2013, that number jumped to 27. Wisconsin is among them. 

Few states saw as big a shift in policy as Wisconsin, which in 2012 changed leadership from Democratic Gov. Jim Doyle, who vetoed bills restricting access to birth control and signed a law requiring hospitals to provide emergency contraceptives to rape victims, to Republican Gov. Scott Walker -- who in his first term signed an unprecedented number of laws restricting abortion.

In July of 2013, Walker signed a controversial bill that requires women seeking abortions to first undergo a transvaginal ultrasound and bans doctors without admitting privileges at nearby hospitals from performing the procedure.

The second provision of the law is being challenged in federal court. If the lawsuit fails, two of Wisconsin’s four abortion clinics will close.

The legislation earned praise from anti-abortion groups and caused concern among those who favor abortion rights. NARAL Pro-Choice America gave Wisconsin a D+ on its 2014 report card on women’s reproductive rights.

Abortion opponents have proved a powerful lobbying force in recent years. But 2014 could be the year the abortion rights movement goes on the offensive.

Earlier this month, the Vermont Senate voted to repeal a series of anti-abortion laws. California expanded abortion access in 2013 by allowing nurse practitioners to perform abortions. In Oregon, lawmakers are considering a bill that would prevent unregulated, anti-abortion crisis pregnancy centers from disseminating false information about abortion. Washington's House passed a bill requiring insurers who cover maternity care to also pay for abortions.

In Wisconsin, the tide could turn in 2014 as well. Democratic challenger Mary Burke said she would work to repeal the Republican anti-abortion measures, specifically the transvaginal ultrasound requirement. If Walker wins reelection in November, the trend of restriction could continue.

“I think we’re in a dangerous position,” Safar said. “We were able to do a lot of work up until 2010, but with Walker, we’re fighting to sustain the gains.”

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