The United States needs people to stand up for abortionBMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1493 (Published 22 June 2022) Cite this as: BMJ 2022;377:o1493
- Sharon Lau, midwest advocacy director, Whole Woman’s Health Alliance
The unprecedented leak of a draft opinion by the US Supreme Court that would overturn the 1973 Roe v Wade decision legalising abortion in the US sent shockwaves around the world, as activists for women’s and human rights grappled with the potential repercussions.
The content of the draft opinion wasn’t a surprise to those of us who’ve dedicated our lives to preserving and expanding abortion rights, especially those working in states hostile towards abortion.
At Whole Woman’s Health (WWH) and Whole Woman’s Health Alliance (WWHA), we’ve been living in a post-Roe v Wade world since September 2021 when the state of Texas enforced Senate Bill 8, a law that bans abortion after six weeks of pregnancy. We began to see the writing on the wall when the Supreme Court refused to block the law and gave the green light to other states to pass copycat legislation. The court’s inaction sent a strong message: reproductive rights aren’t guaranteed.
For years, WWH and WWHA have had to adapt to an increasing number of restrictions on abortion care in the five states where we operate (particularly in Texas and Indiana). These restrictions range from strict regulations on building standards for abortion clinics,1 pointless licensing conditions for clinicians performing abortions that require they be affiliated with a nearby hospital, mandatory waiting periods before abortion can take place, insurance not covering abortions (like the longstanding Hyde Amendment that bans people from using federal funds, like Medicaid, to cover the cost of abortion), medically unnecessary ultrasounds, and bans on abortion on the basis of gestational age. As part of the informed consent process, we’ve even been forced to recite counselling scripts to patients that include inaccuracies and blatant falsities, such as statements that having an abortion increases the risk of breast cancer or causes fetal pain.2 These policies are designed to make it more difficult to provide and have abortions.
As they work to navigate obstacles like these, people seeking an abortion are pushed into later stages of pregnancy and are forced to travel outside their communities or the states they call home to receive the care they need. All of these steady encroachments on abortion care have culminated in Texas-style bans in other states and the expected overturning of Roe v Wade by the Supreme Court, which will exponentially magnify these barriers and burdens if it comes to pass.
Tens of thousands of patients seeking abortion care will be forced to travel thousands of miles to the estimated 24 states where abortion will remain legal.3 Providers in those “surge” states are doing their best to prepare for an influx of patients—securing additional space and hiring more staff. WWH, WWHA, and other abortion providers and abortion funds are also working within their organisations and together across the country to coordinate referral programmes and financial and logistical support for patients from states where abortion will be illegal—essentially setting up concierge abortion travel agencies. Still, no matter how much support is available, some patients simply will not be able to travel, and they will self-manage an abortion or carry to term against their will.
Unlike in 1973, our fear for those who cannot travel to obtain care is less around unsafe, illegal abortion, thanks to the availability of medical abortion, which is safe even when administered away from a formal healthcare setting.4 Of much greater concern is the dismal maternal mortality rate in the US,5 one of the worst among high income countries.6 Childbirth in the US is many times more dangerous than abortion,7 so if patients are unable to obtain the abortions they seek, they will have to shoulder the worse odds of death from pregnancy or causes related to childbirth. This risk is especially high for black women, who are nearly three times more likely to die of maternal complications than white women.5 We know that unintended pregnancies are more likely to result in obstetric complications,8 and some research has suggested that pregnancy can be a risk factor for intimate partner violence.9 One study found that homicide is a leading cause of death for pregnant and postpartum women (numbers that wouldn’t be included in maternal mortality rates for the US), with the homicide prevalence 16% higher than it is for women of reproductive age who were not pregnant or postpartum.10
Roe v Wade has been the reason why freestanding abortion clinics like WWH and WWHA have been able to serve patients in states hostile towards abortion rights. It protected abortion rights at the federal level, ensuring abortion was legal in all 50 states even if they added restrictions and stipulations. Before the 1973 legislation, abortion was completely banned in Texas and other states. Roe v Wade was far from a perfect legal framework, but its loss will be an economic, social, and human rights tragedy for women and people who can get pregnant. Without it, rebuilding the abortion care landscape, especially in the midwestern and southern states, could take years, maybe even decades.
Abortion providers are not going away. We will provide the care that we can, to as many patients as we can, for as long as we can. But we cannot do it alone. Given the makeup of the Supreme Court and many of the appeals courts, the court system will not be a reliable avenue of relief. Change will only come through congressional or state actions. Poll after poll shows that most US citizens support the right to access abortion11—they need to vote accordingly.
Competing interests: SL is an advocacy director for Whole Woman's Health Alliance.
Provenance and peer review: commissioned, not peer reviewed.