When Roe v. Wade was overturned, decisions about access to abortion, and other reproductive rights, fell to the states. The change has been significant, and unequal.
Many people thought the issue of bodily autonomy was settled back in 1973 when the court ruled with Roe that state abortion bans were unconstitutional.
But with the court’s new ruling in 2022, known as Dobbs v. Jackson, which stated that the constitution did not confer a right to abortion, the floodgates for anti-abortion legislation across states were opened.
But even way back before 2022 or 1973, the topics of abortion and reproductive health have been front and center for those of us working in public health. Researchers and practitioners have long studied the connections between access to reproductive care and health outcomes–and there are many!
So today I want to talk about what the research shows and how changing laws across states impact us all.
Legally speaking, things have become complicated. Where there once was fairly uniform access to care, we now have a patchwork of policies that vary dramatically across state borders.
Large swaths of the country, especially the South, have banned abortion or severely restricted access to it.
The Northeast and West Coast have largely expanded protections and are now accommodating increasing numbers of out-of-state abortion seekers.
Prior to the fall of Roe vs. Wade, 18 states banned abortion after 20-22 weeks gestation, and Texas banned abortion after six weeks.
Texas’s ban saw immediate consequences.
The law, passed in 2021 before the repeal of Roe, has no exemption for fetuses with congenital abnormalities, which are often detected later in pregnancy and can make the fetus incompatible with life.
In 2022, the rate of infant mortality in the state increased by 13%, and the rate of death in neonates (babies less than 28 days old) due to congenital issues increased by 23% but had decreased in the rest of the country.
People pregnant with babies who could not survive outside the womb were forced to carry the pregnancy to term, only to immediately lose their children after birth.
Many states with some level of access to abortion in the era of Roe v Wade also had trigger laws on the books.
Trigger laws were designed to go into effect quickly if Roe were overturned.
Here’s where we are now: 14 states have a full ban on abortions with few exemptions allowed, and 4 more ban it after 6 weeks, a point in time when many people don’t even know they are pregnant.
Georgia is one of those states with a 6-week ban, the impact of which researchers are estimating could be significant.
One Rollins-led study in early 2023 estimated that the ban would eliminate access to abortion in the state for up to 90% of patients, especially those with lower socioeconomic status, those who are Black, and those who are under 20 years old.
Despite Georgia’s abortion-restrictive policies, and a 23% decrease in clinician-provided abortions since 2020, it remains a hub for abortion care in the Southeast for one important reason: It is less restrictive than the states that surround it.
Alabama and Tennessee both have a full ban on abortion, and Florida requires two in-person trips to a clinic, at least 24 hours apart.
In 2020, Georgia had the 2nd highest number of patients who traveled from out of state to seek care, and in 2023, even with a 6-week abortion ban, Georgia still had the sixth highest number of patients who traveled for care.
Traveling for abortion care is not exclusive to Georgia.
One in five patients seeking an abortion traveled out of state for care in 2023, compared to only one in 10 in 2020.
It’s unsurprising that the states that have seen some of the largest increases include Illinois, New Mexico, and Colorado, all three of which are bordered by states with more restrictive policies.
While it’s true interstate travel for abortion care can put a strain on local clinics, not everyone has the option to travel.
In some of the most restrictive states, patients can be a nearly 12-hour drive from the nearest abortion clinic. People who don’t have transportation, childcare, or paid time off from work may not have any options to get to clinics.
For those people and others, medication abortion is one way to make care more accessible.
Medication abortions make up 66% of abortions that are performed before 9 weeks of gestation, and requests for the medications via telehealth have increased in recent years, particularly in states with total bans.
Recently a Supreme Court case challenged access to one of two drugs commonly used in medication abortions - mifepristone.
The safety of the drug was not in question. Rather, opponents wanted the courts to revert rules about how to prescribe mifepristone to what they were in 2016, before the FDA expanded access.
If the court had upheld rulings by the lower courts, the drug would have to be prescribed in person (rather than via telehealth), by a physician only (instead of a nurse practitioner or physician assistant) and taken in clinic (instead of at home).
All this despite recent studies that have shown medication abortions prescribed by telehealth have the same safety and outcomes as those administered in person.
The Supreme Court struck the case down, allowing for the continued prescribing of mifepristone via telehealth, but some states are already working toward their own limits.
In Louisiana, the governor recently signed a bill classifying both drugs used in medication abortions (mifepristone and misoprostol) as controlled substances, a designation usually reserved for drugs with a high risk of abuse or dependence.
The law makes possessing the drugs without a prescription a crime punishable with up to 5 years in prison and $5,000 in fines.
Though pregnant people are exempt from the punishment, anyone who aids someone in obtaining the drugs is at risk.
As for the candidates’ stances on abortion access:
Former President Donald Trump’s public statements or policy history are limited. He says that abortion should be left up to individual states to decide.
Trump has also previously taken credit for Dobbs, noting he nominated three of the five justices who voted to overturn Roe.
Vice President Kamala Harris has a longer public record. While serving alongside President Joe Biden, she has consistently supportedprotecting access to abortion, including medication abortion, emergency abortion care, and interstate travel for abortion.
Just recently, she has stated she supports ending the filibuster in an effort to restore abortion access at the federal level.
Abortion isn’t the only important aspect of reproductive rights.
Family planning is all about the services that help people have kids on their schedule. This can include contraceptive services like birth control, pregnancy testing, infertility services, and testing for sexually transmitted infections.
In the U.S., 90% of women have used contraception at some point in their lives. But it’s not as accessible as one might think.
Uninsured women and those on Medicaid are more likely than individuals with private insurance to get contraceptive care at a clinic, rather than a doctor’s office.
This would be places like community family planning clinics, walk-in clinics such as urgent care, or Planned Parenthood. These clinics often receive much of their funding through something called Title X(ten), the federal family planning program.
In 2019, the Trump administration passed the “domestic gag rule,”which prohibited clinics that provide abortion care or referrals from receiving Title X funds.
This forced many clinics (up to 100% in some states) to leave the Title X program, severely reducing the accessibility of family planning services for low-income people and the un- and under-insured.
The Biden administration reversed this policy in 2021, and the program has mostly recovered.
Senate Democrats have attempted to prevent possible challenges to birth control by introducing legislation in June 2024 that would have provided nation-wide protection for contraceptive access.
Family planning is not only preventing pregnancy at the wrong time, but also getting pregnant at the right time.
Getting pregnant isn’t always easy for those who want to build a family that way.
4% of women aged 15-49 have an impaired ability to conceive, and 8.5% of married women in this age group are infertile.
Many of these people will turn to in vitro fertilization (IVF) to expand their families.
The process of IVF involves the harvesting of eggs from the ovaries, which can then be frozen for later fertilization and implantation or can be fertilized and turned into embryos before being frozen or implanted.
While a process to help those who are struggling to grow their families might seem like a universally positive thing, not everyone agrees.
In February of 2024, the Alabama Supreme Court ruled that frozen embryos created through IVF have the same rights and legal protections as children.
IVF often involves discarding unused embryos, and if those embryos are treated as children then…obviously that would cause some issues.
Clinics in the state immediately halted IVF related services as a result.
Outrage at the decision was swift and Alabama passed a law granting immunity to IVF clinics and providers so that treatments could be resumed.
A bill introduced in summer of 2024 by senate democrats, aimed at protecting access to IVF treatments, was also blocked by house republicans.
Harris and her VP pick Tim Walz, both support IVF access (Walz has been very open about the role IVF played in the birth of his daughter Hope).
Trump also says he supports access to IVF.
In June of this year, delegates from the Southern Baptist Convention voted to oppose the use of IVF, and advocate for the government to limit its use.
The vote is non-binding and has no legal effect, but the views of the nearly 13 million-member faith are seen as highly influential to conservative political candidates, and could indicate potential future laws if there’s a conservative majority in Washington.
The rate varies greatly between states, but states with restrictive abortion policies have higher maternal and infant mortality rates than those that have abortion access.
States with restrictive abortion policy environments also have higher rates of life-threatening and health-threatening birth outcomes like low birthweight and preterm birth.
And the effects of restrictive abortion environments go beyond the individual.
Over 60 clinics, including clinics that provided reproductive health care besides abortion, closed or limited services in just the first 100 days post-Dobbs.
Some research has shown that many physicians and trainees prefer to practice in areas that do not restrict abortion, which translates to lower medical residency application numbers in states where abortion is banned.
This creates maternity care deserts, or areas with no obstetric providers or facilities offering obstetric care, these care deserts are larger in states with restrictive abortion policies. These states also tend to have higher rates of uninsured women of reproductive age and childhood poverty due to lack of supportive policies.
Women in states with less access to abortion care are also less likely to be able to access other health care services like contraception to prevent pregnancies.
And, if they have a child, they are less likely to have access to the support they need to ensure their family’s health and well-being, which can have long-lasting effects on their children.
