Reproductive Reality

In the lead up to the 2024 presidential election, reproductive health and bodily autonomy weigh heavily on the minds of millions. After the Supreme Court, in June 2022, ruled in Dobbs v. Jackson Women’s Health Organization to overturn Roe v. Wade and eliminate the fundamental right to an abortion, the reproductive health policy landscape has been in a state of upheaval.

“There's no one clear national or state policy on reproductive rights, and it’s very much cherry picking the issue,” says Sarah Blake, PhD, associate professor of health policy and management.

With control of abortion’s legality returned to the states, the country has become a patchwork of policies. 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 have seen increasing numbers of out-of-state abortion seekers. And the ever-changing landscape has caused confusion for people seeking abortions, as well as fears about the security of access to other reproductive health services.

“The reproductive health landscape is one where we have multiple levels at which our access to health services is regulated, and there is quite a lot of variation by state in what reproductive health access looks like,” says Whitney Rice, DrPH, director of the Center for Reproductive Health Research in the Southeast (RISE). “That can have a direct impact on our ability to access services, and it can also affect how we interact with health care systems. That is an important piece to think about when we consider the importance of elections for reproductive health.”

The abortion landscape has shifted dramatically in the U.S. since the fall of Roe v. Wade. In early 2022, 19 states were enacting abortion bans: 18 of those banned abortion after 20-22 weeks gestation, and Texas banned abortion after six weeks. Many of those states, however, also had abortion trigger laws on the books, designed to go into effect quickly if Roe were overturned.

Today, only nine states and Washington, D.C., do not restrict abortions based on gestation. Twenty-eight states have enacted what Guttmacher Institute describes as restrictive, very restrictive, or most restrictive policies, with 14 states banning abortion with only very limited exceptions. Six more, including Georgia, ban abortion after approximately six weeks gestation.

Georgia’s ban is expected to have far-reaching consequences for people who could become pregnant in the state. 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. In the first 18 months post-Dobbs, Georgia and other states with six-week and total abortion bans saw marked decreases in the number of in-person abortions provided as care became less accessible within state lines.

Despite Georgia’s abortion-restrictive policies, and a nearly 20% 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.

“In 2020, Georgia had the second highest number of patients who traveled from out of state to get abortion care,” says Sara Redd, PhD, director of research translation at RISE. “In 2023, with the six-week ban in effect, Georgia still had the sixth highest number of patients who traveled from out of state to receive abortion care. In 2020, 17% of abortions in Georgia were provided to people from out of state, and in 2023, it was 24%. This shows that Georgia is still a hub for early abortion care specifically.”

This trend of more patients traveling out of state for abortion care extends beyond Georgia and the Southeast. One in five patients seeking an abortion traveled out of state for care in 2023, compared to only one in 10 in 2020, pre-Dobbs. 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.

Interstate abortion travel has caused strains and increased wait times at abortion clinics in less-restrictive states. However, it is important to note that traveling out of state for abortion care is not accessible to many in the U.S.

In some of the most restrictive states, patients can be a nearly 12-hour drive from the nearest abortion clinic. For those who lack transportation, childcare, or paid time off from work, this can prove an insurmountable barrier.

“We have to not only ask who has the financial and logistical means to travel, but who is safe traveling out of state for care?” says Redd. “For people who are undocumented, or for people who are on probation or on parole, it may not be safe to cross state lines, or there may be legal barriers.”

Medication abortion is one way to ease some of the burdens on abortion clinics and make abortion care more accessible.

Most abortions performed in the U.S. are medication abortions, including about 66% of abortions before nine weeks gestation. Cases of patients using telemedicine to request abortion medication and self-manage their abortions have gone up since Dobbs, especially in states with total bans.

The Supreme Court recently struck down a case that challenged the guidelines for prescription and use of mifepristone, a drug widely used in medication abortion. This case would have eliminated the ability to prescribe it via telemedicine.

“Nationally, there have been tests to the legality of abortion after the fall of Roe,” says Blake. “We saw one of those tests in the mifepristone case. The rejection of any further restrictions on mifepristone means that there’s now a stop gap where the federal government will let this be decided by the states.”

Some states have already begun efforts to restrict access to mifepristone and misoprostol, another drug used in medication abortion. This includes Louisiana, whose governor recently signed a bill classifying both as controlled substances.

Former President Donald Trump’s stance is that abortion should be left up to individual states to decide. Trump also previously took credit for the Dobbs decision, as he nominated three of the five justices who voted to overturn Roe.

Vice President Kamala Harris, while serving alongside President Joe Biden, has consistently supported protecting access to abortion, including medication abortion, emergency abortion care, and interstate travel for abortion. As a senator in 2017, she co-sponsored a bill that aimed to ban states from restricting abortion, and in 2018, she voted against a bill that sought to ban abortions after 20 weeks of gestation. Harris has promised to protect and expand abortion access if elected president.

States across the country (including Florida, Maryland, and New York) will have abortion on the ballot come November, giving constituents the opportunity to vote for increased abortion protections.

Family planning encompasses a range of services and supplies that help people plan for and have their desired number of children in the timeframe that they want to have them. This can include contraceptive (birth control) services, pregnancy testing, infertility services, and testing for sexually transmitted infections.

Access to contraception and other family planning services has been shown globally to improve maternal health, family well-being, and economic opportunities. But, since the fall of Roe, the future of access to some of these services has been uncertain. This also means an uncertain future for some people who may become pregnant.

“People's inability to fully self-determine the timing of when they have children can impose challenges to their pursuit of life, career, and financial goals,” says Rice.

In the U.S., 90% of women have used contraception at some point in their lives. Despite its widespread use, it remains hard to access for many. Almost a quarter of women who use Medicaid, do not have health insurance, or are low income do not use contraception, often because of problems with affordability or access to clinics or doctors’ offices.

“In public health, there's an assumption that everybody who wants contraception can access contraception. But the reality is that any kind of social or structural determinant of health that influences people's ability to access abortion care is also going to affect their access to contraception,” says Redd. “The demand for contraceptive care in the U.S. has always surpassed the supply. Those gaps shrank with the Affordable Care Act, but there are still people in the U.S. today who cannot access contraception or may not be able to access the method that they want.”

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 could include community family planning clinics, walk-in clinics such as urgent care, or Planned Parenthood. These clinics often receive much of their funding through Title X, the federal family planning program.

In 2019, the Trump administration passed the “domestic gag rule,” which prohibited clinics that provided 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. However, state-level restrictive reproductive health policies continue to pose a challenge to Title X funding and contraceptive access in parts of the country. This includes some states that have proposed bills that would restrict contraceptive access based on false claims—based on ideas of “fetal personhood”—that some birth control methods cause abortions. Although not yet widespread, this legislation could be a preview of more to come.

“What we see in the abortion state policy landscape is that, first, one state might write a specific law, one that restricts abortion access in a novel way,” says Redd. “As soon as that one state introduces their novel restrictive policy, that policy idea quickly proliferates in other state legislatures that are also seeking to restrict access to abortion. This is relevant to state policy regulating contraception as well, so we’re trying to stay ahead of the game.”

As part of the Biden Administration, Harris has supported access to comprehensive family planning and contraception, and she has voiced support for national legal protections for contraception. While Trump said in an interview in May 2024 that he would support regulations on contraception, he quickly walked back that statement, saying that it should be left up to states.

Meanwhile, Senate Democrats brought legislation forward in June 2024 that would have provided nation-wide protection for contraceptive access. The bill was blocked by Senate Republicans, as was a similar bill that would have made access to in vitro fertilization (IVF) and fertility treatments a right.

The latter came in response to a ruling in the Alabama Supreme Court in February 2024 that frozen embryos created through IVF have the same rights and legal protections as children. Given the process of IVF, which involves discarding nonviable embryos, this ruling makes providing IVF services legally murky.

“The Alabama legislature passed a bill in response [to the IVF ruling] that protects both clinics and providers from civil and criminal liability, but Alabama still has a fetal personhood law, as do other states like Georgia,” says Redd. “This is a good example of a type of restrictive policy that could proliferate in other states.”

Although the bill protecting IVF access failed to pass in the Senate, both Harris and her vice presidential pick, Tim Walz, support IVF access, as does Trump.

Restrictions on access to reproductive health care have far-reaching negative consequences. These consequences affect people who can become or are trying to become pregnant, as well as their families and the U.S. health care system at large.

The U.S. has the highest maternal mortality rate of any high-income country. 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.

Both abortion care and contraceptives are incredibly important to health care outside of just preventing or terminating pregnancies.

 “People use contraceptives to manage chronic health conditions. Abortion care, particularly medication abortion, is very important in the context of pregnancy complications and miscarriage management,” says Redd.

The effects of restrictive abortion environments go beyond just the individual. The country’s reproductive health infrastructure is threatened when abortion is restricted. Over 60 clinics, including clinics that provided reproductive health care besides abortion, closed or limited services in just the first 100 days post-Dobbs.

“Restrictions on reproductive health services can impact things like the availability of providers,” says Rice. “There’s been quite a drastic shift in the number of clinics available in certain states and regions over the past few years. Those closures not only affect people who are directly seeking care there, but it can affect things like whether there's availability of a certain type of provider in a county, or in a city, or in a ZIP code. It can affect things like what the influx of patients or potential patients is at the other remaining clinics.”

Some research has revealed that many physicians and trainees prefer to practice in areas that do not restrict abortion. Medical residency application numbers are also lower in states where abortion is banned. This contributes to more people living in maternity care deserts, or areas with no obstetric providers or facilities offering obstetric care, 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.

This means that in states where women are less likely to be able to access an abortion if they want or need one, they 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.

“We must be vigilant about not only advocating for individuals’ rights to reproductive health, but also making sure that reproductive health care is affordable and available," says Blake. "Even when there's access on paper, we know that there's not access for all. We need to work toward making sure that we're reducing disparities and increasing access to services.”

Story by Shelby Crosier
Designed by Linda Dobson
Illustration by John Jay Cabuay