Review of Obstacle Course: The Everyday Struggle to Get an Abortion in America. David S. Cohen and Carole E. Joffe, Berkeley: University of California Press, 2020, 296 pp.

Reviewed Book

Obstacle Course: The Everyday Struggle to Get an Abortion in America. David S. Cohen and Carole E. Joffe, Berkeley: University of California Press, 2020, 296 pp.

Terminating a pregnancy in the United States today is like “playing a game of abortion Tetris,” according to Cindi, a Midwest abortion clinic administrator. Each day in Cindi’s clinic, she sees patients and providers struggling “to lock in all of these little pieces into their exact place” (p. 101) so that pregnant people can access a safe, common, and legal medical procedure. Challenges obtaining an abortion may seem unavoidable within the infamous U.S. health care system known for its difficulty navigating and affording. But, as legal scholar David Cohen and sociologist Carole Joffe show in Obstacle Course: The Everyday Struggle to Get an Abortion in America, seekers and providers of abortion services face exceptional barriers within U.S. medicine. While a basic procedure elected by nearly a million Americans each year, abortion has been uniquely targeted by political opponents striving to foreclose access. Since the 1973 Roe v. Wade Supreme Court decision legalizing abortion, antiabortion lawmakers have succeeded in passing over 1,200 laws making it harder and, consequently, more expensive and riskier, to obtain. Focused on the past decade of intensified antiabortion lawmaking, Cohen and Joffe present a timely, thorough, and troubling account about the everyday consequences of treating abortion unlike any other medical procedure in America.

The authors draw on over 70 interviews with abortion providers and support volunteers, public abortion narratives, legal history, and empirical research to show what it is like inside the obstacle course at each step of the process, from decision to procedure. Nine focused chapters examine how wide-ranging restrictions burden, rather than benefit, people’s lives, and the immense effort required by providers, patients, and volunteers to creatively overcome them. Chapters are organized around key themes, including: how abortion became exceptional in U.S. law; making a decision; finding and getting to a clinic; paying for the procedure; encountering protesters outside the clinic; counseling support; waiting periods; the procedure itself; and better alternatives. Nearly half of Americans live in states with laws described by the Guttmacher Institute as hostile or very hostile to abortion, though barriers make it extremely difficult for pregnant people everywhere to have abortions. Among them, the poor, young, undocumented, and people of color suffer most.

From the start, accurate information can be difficult to find. “Gag” orders disallow health care professionals from providing abortion referrals, even to survivors of rape. Hundreds of fake clinics legally circulate medically inaccurate information about abortion, which some states require providers to read to patients. Finding and getting to an abortion provider is challenging for over 90% of Americans who live in counties without one. Freestanding clinics, where the vast majority (95%) of abortions occur, are targets for extreme protest tactics and laws designed to shutter them. Over a quarter of the nation’s abortion clinics closed in the past decade, making abortion even more burdensome to access and provide. Affording an abortion poses the greatest roadblock for patients, who are predominantly low-income. Insurance restrictions for users of Medicaid, public employees, and military and Peace Corps servicemembers often force patients to delay receiving a very time-sensitive procedure that becomes more expensive as pregnancy progresses. Restrictions on the procedure itself, including bans on particular medical techniques and delivery (e.g., telemedicine), gestational limits, mandatory waiting periods, and physician-only requirements, interfere in providing the highest quality of care that patients want and deserve.

Abortion, like other reproductive experiences, offers a profound window into how power works in society. Systemic brutalities against the poor persist through abortion restrictions that make it even harder for people to get by. Antiabortion policies that target communities of color entrench and extend structural racism. Attempts to force pregnancies of immigrant youth in U.S. custody, like the Jane Doe case in 2017, make clear how anti-immigration and antiabortion politics work in tandem to further marginalize vulnerable people. While this book does not center a reproductive justice analysis, it supports the position advanced by the reproductive justice movement, led by Black and Brown communities, which maintains that freedom to decide whether, when, and how to parent requires basic human rights of secure income, housing, transportation, insurance, and so on. This book illustrates in compelling detail how abortion exceptionalism undermines fundamental rights that would support all people’s free reproductive and sexual decision-making. 

Obstacle Course is a provocation and guide for more a robust engagement within medical anthropology on abortion politics, laws, and care. In this vein, it extends anthropologists Elise Andaya and Joanna Mishtal’s (2017) important call for ethnographers to pay closer attention to abortion in the United States. While this book is not ethnographic, it highlights many areas where anthropological insights could generate valuable “research-based testimony” and “expert evidence” (p. 23) used by U.S. courts to evaluate the impact of abortion-related policies on people’s lives. Abortion storytelling has become vital for stigma reduction and legal advocacy, which anthropologists could support by gathering people’s experiences with pregnancy and navigating obstacles to comprehensive care. Ethnographies about the vast networks of grassroots volunteers who provide practical support to providers and patients—e.g., clinic escorts, abortion funds, overnight hosts, talkline peer counselors, full-spectrum doulas, and self-managed abortion aides—would illuminate how communities respond to constraining conditions. Given close connections between U.S. abortion politics and religion, anthropologists could meaningfully investigate how religious beliefs factor into abortion decisions, provision, and advocacy, for both supporters and opponents. Building on rich ethnographic work about public health care systems, anthropologists could examine related legal strategies for analyses about the consequential intersections of law and medicine. Guided by the tenets of reproductive justice, anthropologists could beneficially contextualize abortion within broader social justice issues, such as police violence, immigrant rights, food and housing security, and child welfare, among others. Opportunities for much-needed ethnographic research on abortion are myriad.

Decades of social, political, and infrastructural momentum sustain abortion exceptionalism, but playing treacherous games of abortion Tetris are not inevitable. Reflecting on this book in the middle of the global COVID-19 pandemic raises questions about what will be reproduced and revolutionized in the pandemic’s wake. Published in early 2020, Obstacle Course does not comment on the ongoing pandemic but will motivate students and scholars of reproduction, health care, law, social movements, poverty, racism, religion, and the United States to consider what futures are possible. As recent headlines attest, battles over the future of abortion rights and the broader vision of reproductive justice are actively underway. Antiabortion politicians seized early opportunities to exploit the public health crisis by deeming abortion non-essential and advancing extremely restrictive agendas, such as the passing of Tennessee’s HB 2263, which prohibits abortion at six weeks gestation.

At the same time, some alternatives are gaining traction. A federal judge temporarily lifted in-person requirements for medication abortion by deeming them a “substantial obstacle” during the current public health emergency. Importantly, leaders in the resurging Movement for Black Lives are advancing racial and reproductive justice as inextricably linked in the fight for freedom. This book is accessibly written for audiences moved by stories about the everyday stakes of health care politics and will be an invaluable resource for use in anthropology, sociology, history, legal studies, gender studies, public health, and ethics courses. 

Reference Cited

Andaya, E., and J. Mishtal. 2017. The Erosion of Rights to Abortion Care in the United States: A Call for a Renewed Anthropological Engagement with the Politics of Abortion. Medical Anthropology Quarterly 31: 40–59.