By Kate Michelman

and Carol E. Tracy

With Kermit Gosnell's criminal trial under way in Philadelphia, public outrage at the physician accused of murdering one woman and seven infants increases with each grisly revelation. In a state that has led the nation in imposing restrictions on abortion, how could such atrocities go undetected?

The answer goes back to the 1970s and '80s, when abortion policy was established. In the wake of Roe v. Wade, Pennsylvania moved to impose as many barriers as possible to abortion access. By and large, our policymakers have never treated abortion as a medical procedure, and they therefore have not nurtured a system of abortion care that is focused on women, readily accessible, and responsive to medical needs.

If the charges against Gosnell prove true, he was an outlaw whose practice should have been shut down years earlier. So why did women go to him instead of a more reputable provider?

One former patient at the clinic told a state Senate committee that women in her neighborhood knew Gosnell offered the cheapest abortions available. Another Gosnell patient told the Associated Press that she had intended to go to a Planned Parenthood clinic but was scared away by antiabortion protesters. An acquaintance suggested Gosnell's clinic, where protesters - ironically - were not an issue.

The evidence suggests a number of factors led women to Gosnell: Medicaid's refusal to cover most abortions; the scarcity of providers in Pennsylvania; fear of violent protesters; and a right-wing culture that has stigmatized abortion.

It's important that the women of Pennsylvania know that abortion is a legal, safe medical procedure. As set forth in the Gosnell indictment, legitimate providers like Planned Parenthood and members of the National Abortion Federation follow standard medical procedures and the law.

Unfortunately, politicians continue to make it harder for women to get safe abortions. Every year since 1976, Congress has reauthorized the Hyde Amendment, which bans federal Medicaid coverage of abortion except in cases of rape, incest, or danger to the pregnant woman's life. Pennsylvania likewise restricts state Medicaid money from funding the procedure except in those rare circumstances. So low-income Pennsylvania women are as a rule responsible for the entire cost. That typically equals or exceeds an entire month of Temporary Assistance for Needy Families benefits.

Bills in the state legislature would also ban coverage of abortion by policies sold on the health-care exchange to be established under the Patient Protection and Affordable Care Act.

Moreover, reputable providers of abortion care are under attack. As a result of an orchestrated campaign of harassment, intimidation, and violence, the number of abortion providers in the United States declined 38 percent between 1982 and 2005. In Pennsylvania, there is not a single free-standing abortion provider between Pittsburgh and Harrisburg.

Compounding this shortage, the Pennsylvania legislature passed a law in 2011 mandating that the remaining handful of abortion providers comply with volumes of costly regulations designed for ambulatory surgical facilities, where much more complex surgeries take place. Today, there are just 13 free-standing providers of surgical abortion care in Pennsylvania, down from 22 two years ago.

Pennsylvania lawmakers are not alone in developing strategies to regulate abortion care right out of existence. In fact, state legislatures have enacted 135 abortion restrictions in just the last two years, according to the Guttmacher Institute.

History tells us that whether abortion is legal or illegal, women will have abortions - the only difference being whether more women will die. Today, as in the pre-Roe days, women with ample resources can usually find high-quality care. But those without resources will often seek out the cheapest possible care. The long-term impact of burdening and stigmatizing abortion care could be that the most vulnerable women will once again have to risk their health and lives to get what should be a completely safe and common medical procedure.