Abortion Is Healthcare: Lessons From a Public Hospital

Abortion Is Healthcare: Lessons From a Public Hospital

Even in the Roe era, access to abortion was limited, hard-fought, and dependent on local conditions.

Pro- and anti-abortion protesters gather outside an abortion clinic in Chicago on April 27, 1992. (Stacia Timonere/Getty Images)

Since the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision, many have invoked the coat hanger and the public hospital septic abortion ward as portents of life after the fall of Roe. Illinois Governor J. B. Pritzker was one of many pro-choice advocates who made direct reference to Ward 41 at Chicago’s public hospital, Cook County Hospital. But by only paying attention to the horror stories of botched abortions in the pre-Roe era, we miss the other lessons that public hospitals like Cook County can teach us: even during Roe, access to abortion was limited, hard-fought, and dependent on local conditions. 

Public hospitals are key to understanding the brutal consequences of policies that limit people’s access to healthcare, as well as the role that local governments often play in a country with no national healthcare system. In providing care to everyone who came through its doors, the public hospital approximated the right to healthcare. When county, state, and federal lawmakers undermined the right to reproductive care, Chicagoans demanded its reinstatement at Cook County Hospital. 

These struggles and the hospital’s history shed light on the importance of tethering demands for reproductive rights to a more expansive welfare state and healthcare system. They also help us understand the crucial importance of federal action.

Cook County Hospital Before Roe

The State of Illinois passed its first anti-abortion law in 1827. But making abortion illegal never prevented women from having abortions. In the twentieth century, even before Roe, “abortion was not extraordinary, but ordinary,” according to historian Leslie Reagan. Women with means were often able to access safe abortions in doctors’ or midwives’ offices. Low-income women were more likely to self-induce abortion and, as a result, more likely to suffer complications and end up in the hospital. 

In Chicago, more often than not, that hospital was Cook County. Opened in 1866 to fulfill the county’s legal obligation to finance medical care for the indigent, County (as it was called by many Chicagoans) provided a full spectrum of healthcare to the city’s marginalized people. Communities of color, especially Black Chicagoans, relied disproportionately on County, the city’s only public hospital until the 1990s. Historically barred from the industrial jobs most likely to provide insurance, Black Chicagoans were uninsured at higher rates. Private hospitals also routinely discriminated against Black Chicagoans. Medicaid, created in 1965, left out many people because the program was means-tested and because many private providers did not care for publicly insured patients. Before and after Roe, County provided care, reproductive and otherwise, to Chicagoans who needed it. Public hospitals all over the country played similar roles.

In 1934, County admitted 1,159 patients suffering complications related to abortion; in 1949, the number reached 1,683 patients—about thirty-two per week in a city of approximately 3.6 million. By the early 1960s, hospital personnel cared for around 5,000 patients suffering complications from abortions annually. In 1965, one abortion patient was admitted to County for every 4.1 deliveries, compared to 1 in 10.8 at other Chicago hospitals.

A twenty-one-year-old woman who underwent an illegal abortion in September 1970 was one such patient. An ambulance first brought her to a private hospital less than two miles from her South Side home. But hospital personnel sent her to County, about five miles to the northwest, claiming they had no obstetric beds available and that she had not previously seen a doctor on staff. (Private hospitals routinely sent uninsured or otherwise “undesirable” patients to County, a practice advocates decried as “patient dumping.”) When she arrived at County, she was hemorrhaging and, according to the Chicago Daily Defender, “reacting adversely to poisoning from the dead fetus” left in her uterus. She died soon after.

Cook County Hospital After Roe

Roe v. Wade made abortion legal in 1973. But it did not guarantee the right to abortion: the absence of a comprehensive healthcare system put the onus on pregnant people to find providers and pay for abortions, as scholars including Dorothy Roberts and Johanna Schoen have argued. Still, fewer patients sick from abortion complications showed up on County’s doorstep. Shortly after the decision, the hospital closed its septic abortion ward and opened an abortion clinic. 

In subsequent years, the anti-abortion movement succeeded in targeting the welfare state to diminish abortion access for poor women. In 1976, the Hyde Amendment—named for Henry Hyde, the freshman Illinois congressman who proposed it—banned the use of federal funds to pay for abortions. Then, in 1977, the State of Illinois passed a law prohibiting state-funded abortions. Many opposed the legislation through protest and litigation, but as legal challenges played out over the next several years, a number of Chicago clinics stopped providing Medicaid-funded abortions. County continued to do so, but its leadership said it could not increase its clinic capacity.

In 1980, the Supreme Court upheld the constitutionality of the Hyde Amendment, protecting federal and state restrictions on funding for abortions. In Illinois and other states that passed similar legislation, state funds could no longer cover the costs of the procedure except in cases when the pregnant person’s life was endangered. The Illinois state law was even more restrictive than the federal legislation: it did not list rape as an exception.

Low-income women’s access to abortion plummeted. The Chicago Reporter estimated that “had funding been readily available,” 20,114 Medicaid recipients in Illinois would have obtained publicly funded abortions in 1978. Instead, the number was 8,972. Meanwhile, 8,435 found other means (including county hospital services) to access abortions, and 2,707 carried unwanted pregnancies to term. In Chicago, County became an even more crucial safety net. Without federal or state funding, the county footed the bill for procedures performed at the public hospital—between 3,000 and 4,000 per year, which was not nearly enough to meet the need. Many women who called up to make appointments got a busy signal hour after hour, week after week.

Things got worse when local policymakers implemented anti-abortion rules of their own. On October 9, 1980, the president of the Cook County Board of Commissioners, George Dunne, ordered Cook County Hospital to stop providing abortions, except when necessary “to save the mother’s life.” In a memo to the board, Dunne claimed that the ban was necessary for the hospital to comply with state legislation. 

The day after Dunne issued the edict, an eighteen-year-old South Side resident went to County to get an abortion. The public aid recipient was given a slip of paper with the names of three private clinics the hospital thought “safe and reasonably priced for abortions,” according to the Chicago Tribune. With County’s clinic closed, it’s unclear if she was able to access the procedure.

Winning the Right to Abortion Under Roe 

Chicago’s reproductive rights movement enthusiastically protested the ban. County employees and other healthcare workers, feminist groups, anti-poverty activists, and more mobilized to send the message that the right to healthcare—abortion included—must extend to people who couldn’t afford to pay for it. If the federal and state governments would not protect that right, they insisted, then the local government must.

At least 200 people showed up to an October County Board meeting to protest the ban. A member of the Illinois Welfare Rights Coalition successfully demanded a public hearing where poor people and persons of color most likely to be affected by the ban could offer their input. Dozens testified at that hearing. One woman talked about her experience as a victim of rape. A medical student recounted the history of County’s septic abortion ward and expressed her “fear that [Dunne’s] action may result in the reopening of Ward 41, thereby giving students and housestaff the unfortunate experience of learning how to deal with septic abortion through firsthand experience.” Other reproductive rights advocates denounced Dunne’s ban as a violation of poor women’s legal right to abortion and County’s mandate to provide care.

The spike in septic abortion cases many feared never materialized—likely the impact of the legal right, if not always access, to abortion. Still, the ban’s impact was made manifest in other ways. Hundreds who wanted but could not afford abortions called pro-choice organizations for advice. Some women traveled to cities in neighboring states.

Over the course of the next decade, reproductive rights activists on County’s staff and members of Women Organized for Reproductive Choice, the Illinois Pro-Choice Alliance, the Chicago Abortion Fund, and other reproductive right groups showed up at public hearings, wrote op-eds, and otherwise organized for abortion reinstatement at County. They presented example after example of Chicago women unable to afford abortions without sacrificing the resources they required for basic needs. The ban on funding affected girls as young as fifteen; welfare recipients who didn’t have enough money to feed their families; women with known genetic risks; and poor pregnant women with HIV/AIDS, whose medications put their fetuses at risk.

After Richard Phelan, whose platform was pro-reinstatement and pro-choice, was elected president of the Cook County Board in 1990, activists saw an opportunity to push even harder to realize their shared goal. In a press conference called by the Illinois Pro-Choice Alliance a month after the election, representatives of reproductive rights groups, sitting in front of a banner that read “Keep Abortion Legal,” again spoke of the stakes of delaying reinstatement. They also deployed more disruptive tactics. One day after the press conference, activists interrupted a Cook County Board meeting by unfurling a banner and chanting, “Restore abortion now!”

Advocates’ sustained attention to securing abortion care at the local level worked. Twelve years after Dunne’s ban, Phelan issued an executive order to restore abortion services at County on June 18, 1992. Within ten days of reinstatement in September, 4,100 women called to make appointments, far exceeding the hospital’s capacity.

Abortion and the Welfare State

In recent years, the State of Illinois has taken steps to protect abortion rights more fully. In 2017, Governor Bruce Rauner signed House Bill 40, which reversed the 1977 ban on state-funded abortion. The state now covers legal abortions for Illinois Medicaid recipients, providing publicly insured people more care options. Governor Pritzker went further in 2019, signing into law the Reproductive Health Act, which repealed the state’s 1975 trigger law and promised “fundamental reproductive health rights.”

Together, these laws are likely to have reduced barriers to care for publicly insured Illinoisians and relieved the burden on safety-net institutions. This not only shields Illinoisians from Dobbs’ most harmful effects but goes further than Roe in ensuring abortion access by supporting legal rights with public funds. But it does little for publicly insured people outside of Illinois or for the uninsured out of the public hospital’s reach. 

 The people who rely on safety-net healthcare institutions in the United States—the poor, the uninsured, the publicly insured, the undocumented, and others the private sector discriminates against—are the most affected by restrictions on abortion care and other forms of healthcare access. This was true in the pre-Roe period, in the era of Roe, and today. And public safety nets do not exist everywhere; the care they are able to offer is decided at the local, state, and federal levels.

Ward 41 exposed the dire consequences of outlawing abortion and provided critical care. And the sustained, successful, and immensely important struggles for the provision of abortion care at Cook County Hospital show the meaningful, life-saving role that local institutions have long played in the absence of a more robust healthcare system. This history also invites us to think about the limits of the legal rights and the welfare state institutions that exist only at the local or state level, especially post-Roe.

As reproductive rights and reproductive justice activists have long argued, framing the right to abortion as a narrow, negative right excludes people for whom costs and local circumstances present obstacles to access. Prioritizing the needs of the most vulnerable requires we demand the government play a role.

If we are to provide dignified care to everyone in the United States, including those living outside reproductive healthcare sanctuaries, we desperately require changes to federal legislation on abortion—and healthcare more broadly. According to the Guttmacher Institute, the Hyde Amendment “leaves 7.8 million women aged 15–49 with Medicaid coverage but without abortion coverage.” Over 26 million people in the United States are uninsured. Congress can enshrine the right to abortion as law. But to ensure the most vulnerable can access the full spectrum of reproductive care—fewer Ward 41s, busy public hospital phone lines, and trips out of state—access to accountable, quality healthcare in the United States must be comprehensive and universal.

Amy Zanoni is a historian of social policy and social movements. She is working on a book tentatively titled Poor Health: The Public Hospital in the Twentieth Century.