Abstract
Restrictions on the use of federal funds to provide abortions have limited the access to abortion services for Native American women receiving care at Indian Health Service facilities. Current data suggest that the vast majority of Indian Health Service facilities are unequipped to provide abortions under any circumstances. Native American women experience disproportionately high rates of sexual assault and unintended pregnancy. Hyde Amendment restrictions systematically infringe on the reproductive rights of Native American women and present a pressing public health policy concern.
Unlike many cultures in which access to abortion is limited, gender norms in Native American cultures traditionally support and respect women’s autonomy with regard to reproductive health decisions. In more recent times, federal regulation and deepening social problems have largely usurped Native American women’s control over their reproductive health.
Active colonization of Native American communities and lands has not only marginalized traditional healing practices and resulted in devastating poverty but also disrupted traditional family structures and matriarchal gender norms, leading to high rates of sexual assault, intimate partner violence, and unintended pregnancy.1
For many Native American women living in the United States, Indian Health Service (IHS) facilities are the primary source of reproductive health care.2 Made possible by the 1921 Snyder Act,2 federal funds are used to provide free health services for 1.9 million American Indians and Alaska Natives (AI/ANs) belonging to 564 federally recognized tribes in 35 states.3 Because it receives federal dollars, however, the IHS is subject to congressional regulation of the provision of abortion services, as stipulated under the Hyde Amendment.2,4,5
Passed in 1976 and amended in 1993, the Hyde Amendment bans the use of federal funds for abortion services, except in cases of pregnancies resulting from rape or incest or those that pose a threat to the mother’s life.4,6 IHS regulations codified Hyde Amendment restrictions in 1982 and were then updated in 1996 to match the current amendment.7 Because the IHS is often the sole provider of reproductive health services for Native populations, Hyde Amendment restrictions effectively deny Native American women access to full-scope women’s health care that includes access to abortion.
METHODS
I performed a literature search to obtain relevant data on abortion practices within the IHS. I searched PubMed, CINHAL, EMBASE, and Web of Science databases using search terms “indian health service,” “abortion,” and “hyde amendment.” I did not place any date restrictions on the search. I used a variety of databases, broad search terms, and no date restrictions because my goal was to capture as much as possible of the limited literature that exists on IHS abortion practices.
RESULTS
In 20 years of recordkeeping (1981–2001), the IHS performed 25 abortions.8 A 2002 study published by the Native American Women’s Health Education Resource Center (NAWHERC) reported that 85% of IHS facilities were not in compliance with IHS and Hyde Amendment regulations; in other words, they did not have abortion services available or did not refer to abortion providers even for women in the permitted circumstances.2 Only 5% of IHS facilities actually provided abortion services onsite, and no facility-based IHS pharmacies kept Mifeprex (RU-486), a medication used for nonsurgical abortion, in stock.2
Except for the NAWHERC study, limited data exist on abortion practices within the IHS, and according to the study, a request for data on the number of abortions Native American women sought over the past 30 years could not be honored because of lack of data collection.2
The low provision of permitted services may be owing in part to misconceptions among IHS employees about the official policy on the provision of abortion services.2 In the NAWHERC study, 62% of IHS personnel interviewed reported that IHS funds could not be used for abortion even in the case of a threat to the mother’s life.2 Furthermore, the study found that how abortion cases and abortion-seeking women are handled is often left up to the discretion of the IHS employee, with no standing protocols for procedure, counseling, or referral to external services.2
DISCUSSION
Native American women are disproportionately at risk for sexual assault and adolescent pregnancy. Nearly half (46%) of Native American women are younger than 20 years when they give birth to their first child.2 The 1994 South Dakota Native American Youth Behavior Survey found that 87% of female high school seniors reported having sexual intercourse, and 92% of those respondents reported they had been forced to have intercourse.2
One in 3 Native American women will be assaulted in her lifetime, a risk 3.5 times higher than that of other ethnic groups in the United States.8 The majority of perpetrators are nonnative and, thus, cannot be prosecuted under tribal law, leaving Native American women vulnerable to continued attacks from these individuals.8 It is critical that public health and legislative interventions to reduce sexual assault and intimate partner violence target nonnative perpetrators of sexual violence.
Native American women living in tribal territories are US citizens and, thus, are entitled to abortion rights guaranteed by the 1973 Supreme Court decision Roe v. Wade. Restrictions on the use of federal funds for abortion through the IHS amount to a systematic infringement on reproductive choice for AI/AN women.
The Hyde Amendment discriminates against women who often need abortion services the most: women who are poor, have reduced access to family planning, and experience higher rates of sexual victimization. Hyde restrictions affect not only Native American women but female military service members, Medicaid enrollees, and prison inmates as well.4,8 In effect, the Hyde Amendment violates the constitutional rights of women, with negative consequences for public health, and therefore should be repealed.
Human Participant Protection
Institutional review board approval was not needed because this study did not involve human participants.
References
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- 7.Trujillo MH. Special general memorandum 96–1: current restrictions on use of Indian Health Service funds for abortions. 1996. Available at: http://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_sgm_main&sgm=ihm_sgm_9601. Accessed February 18, 2012.
- 8. Law Students for Reproductive Justice. Women of color and the struggle for reproductive justice. 2011. Available at: http://lsrj.org/documents/factsheets/08-09_Women_of_Color.pdf. Accessed February 12, 2012.