abortion rights case study

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Killed by abortion laws: five women whose stories we must never forget

As the US supreme court threatens to undo 49 years of access to safe and legal terminations, five women who died because of bans on abortion stand as warnings of what is at stake globally

Savita Halappanavar , Ireland

Savita Halappanavar was 31 years old when she died of blood poisoning nearly a week after she arrived at University Hospital Galway (UHG) in Ireland complaining of intense back pain.

Halappanavar, a dentist from Karnataka, in south-west India, was 17 weeks pregnant with her first child and went to hospital with her husband, Praveen, on Sunday 21 October 2012. Within hours, doctors said a miscarriage was inevitable, even though a foetal heartbeat could be heard. By this point, Halappanavar was in “unbearable” pain and “very upset”, according to healthcare staff. The plan was, she was told, to “wait and see” if she would miscarry naturally.

At the time, Irish law stated that abortions were permitted only if there was a “real and substantive” threat to a woman’s life. By Tuesday, there had been no miscarriage. The couple asked whether one could be induced but were told by the doctor: “Under Irish law, if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a foetal heart[beat].”

Halappanavar developed a high fever. On the Wednesday morning, the medical team diagnosed infection and, later, septic shock. Her condition was deteriorating rapidly.

A plan was made, but not enacted, to give Halappanavar a drug to induce abortion. According to the Health Service Executive inquiry , by this point, the death of the foetus was certain and the appropriate treatment was to terminate the pregnancy because of the risk to Halappanavar’s life.

Halappanavar spontaneously miscarried mid-afternoon on Wednesday and was admitted to intensive care. She was now critically ill with severe sepsis and multiple organ failure. She suffered a cardiac arrest and died in the early hours of Sunday 28 October, almost a week after being admitted.

The case sparked outrage in Ireland and highlighted how the law put women with life-threatening medical conditions at risk in Irish hospitals. In media interviews, Halappanavar’s husband revealed that he and his wife had repeatedly asked for the pregnancy to be terminated but had been refused and told: “This is a Catholic country.”

Protesters took to the streets , calling for accountability and change, accusing the Irish state of failing to protect its citizens. An Amnesty International report in 2015 said her “entirely preventable death was a consequence of Ireland’s restrictive abortion law”.

Anti-abortion campaigners said the case was being exploited by those with an agenda to liberalise Ireland’s laws, and the Catholic church declared that a woman had no more right to life than the foetus .

The government, under intense public scrutiny, carried out multiple inquiries into Halappanavar’s death. In the HSE’s final report , the investigation team stated that a termination of pregnancy was medically indicated and would have been performed in “other jurisdictions”.

In May 2018, Ireland voted by a landslide to repeal its near-total ban on abortion . The referendum – in which 66.4% voted Yes, a majority of 706,349 – drew the highest turnout for a ballot on social issues.

Olga Reyes , Nicaragua

Olga Reyes, 22, waited in pain for hours at the hospital ward in 2006. She had already been turned away from one hospital but arrived at the next one with the proof that she needed urgent care: an ultrasound scan from a private clinic that showed an ectopic pregnancy was rupturing her fallopian tube.

The fertilised egg had implanted itself outside her womb and the embryo, at about six weeks old, could not survive but was threatening her life: Reyes was bleeding to death. Doctors delayed treatment, fearful of the repercussions of the ban on therapeutic abortions that had been introduced only months earlier, in November 2006. By the time they took Reyes for surgery it was too late.

The 22-year-old law student, who had celebrated her wedding only two months earlier, suffered repeated heart attacks during the operation and died from cerebral arrest due to haemorrhaging.

In a report published the same year on the banning of therapeutic abortions in Nicaragua, the rights organisation Human Rights Watch said she should have been treated immediately under government rules on ectopic pregnancies, but the contradictory new ban on therapeutic abortions meant doctors feared intervening.

Only days after the law was changed, another young woman, the same age as Reyes, spent days asking for treatment from a local hospital without success. When she was transferred to another hospital it was, again, too late. She died of a cardiac arrest.

The penal code Nicaragua introduced to enforce its ban included prison sentences for anyone performing abortions, as well as the women seeking them, regardless of whether their lives were in danger. It was because of this, her husband told the media, that Reyes was left bent double in agony in the hospital ward.

The young women’s deaths did not alter the course of Nicaraguan law. After the ban on therapeutic abortions in 2006, more amendments brought a blanket ban by 2008, with no exceptions for saving the woman’s life.

‘Izabela’ , Poland

The morning before her death, Izabela* texted her mother from the hospital. “The child weighs 485g. For now, because of the abortion law, I have to stay in bed and they can’t do anything,” she wrote. “They will wait for the baby to die or for something to start happening. If it doesn’t then great, I can expect sepsis.”

Izabela, 30, owned a hair salon in Pszczyna, a small town in Silesia. On her Instagram account Pani Iza, as she was known to customers, would regularly post photos of her influencer-worthy wedding coiffures and hair transformation. Her clients did not spare compliments. “The best hairdresser in the world, you can see that she loves her job,” reads one of the last online reviews dated June 2021, a month before Izabela died. “Thanks to her, I went from black to blonde and my hair survived!”

When her waters broke at 22 weeks, Izabela thought it was stress. She had spent the day at hospital with her nine-year-old daughter, who had fallen from her scooter. Izabela was taken to hospital the next day, though no treatment was undertaken until the next morning.

“They can’t do anything, because then it’ll look like they did it on purpose,” she texted her mother, to explain why doctors were not inducing the birth hours after the waters broke.

“They have to wait for it to happen on its own. And if it doesn’t, then we’re waiting for the heart to stop beating,” she wrote. “The woman is like an incubator. And the baby is suffering too – it has nothing to breathe with.”

According to a Polish law introduced in 2021, abortion is legal to save the health or life of the mother and in cases where the pregnancy is a result of rape. Previously, the procedure could also be legally carried out in cases of severe foetal abnormalities.

Although the doctors could have legally aborted, they chose not to until it was too late. The law that would have allowed them to do this was “difficult to apply in practice”, says Jolanta Budzowska, the lawyer representing Izabela’s family in a court case against the hospital. “If they carry out an abortion too early and the prosecutors then decide that there was no danger to the mother [at that point] they can face up to three years in prison. Consequently, doctors are more cautious in their decisions.”

As doctors waited for the foetal heartbeat to stop, women on Izabela’s ward recall her pleading with the staff. “She felt that something was not right. But they kept telling her that the heart is beating, and that as long as the heart is beating this is the way it must be,” one woman told Polish media.

“I can still hear her words to this day: that she wants to live, she doesn’t want to die, that she has people to live for,” the woman said.

After nationwide protests, the hospital where Izabela died was fined 650,000złoty (£120,000) by the Polish health service. The court case against the doctor responsible for Izabela during her stay at the hospital is ongoing. The hospital’s director resigned in March.

‘Manuela’ , El Salvador

Manuela*, a mother of two from El Salvador , did what most people would do when she fell ill while pregnant in 2008: she went to hospital. Tragically, she miscarried, but instead of medical and social support, she was handcuffed to her hospital bed and interrogated by police.

Manuela, 33, whose full name has never been made public, was charged with aggravated homicide under El Salvador’s draconian anti-abortion laws, and sentenced to 30 years in prison. She died of cancer two years later – a disease that activists say was ignored and left untreated during her incarceration.

“The stories of women in El Salvador who have been unjustly criminalised for experiencing obstetric emergencies, as happened to Manuela, should also serve as a global example of the terrible consequences of criminal restrictions on access to a service such as abortion,” says Carmen Martínez, an associate director in Latin America for the Center For Reproductive Rights, a US-based human rights organisation.

Last November, the Inter-American Court of Human Rights (IACHR) ruled that the state was responsible for Manuela’s death , having violated her rights to life, health, judicial protections and guarantees, freedom from discrimination and gender violence. The court ordered El Salvador to pay reparations to the young woman’s family and to reform its strict abortion laws and healthcare policies.

“There is no doubt that Manuela suffered an obstetric emergency,” stated the landmark ruling. “Such situations, as they are medical conditions, cannot lead to a criminal sanction.”

El Salvador has some of the world’s most restrictive abortion laws. Since 1998, the procedure has been banned without exception, including in cases of rape and incest. Over the past 20 years, more than 180 women have been jailed for murder for having an abortion after suffering obstetric emergencies, according to rights groups.

“I remember my mum, she gave us advice and never left us alone. It is painful to grow up without a mother because that love is incomparable,” Santos de Jesús, Manuela’s eldest son, said in a statement before the hearing in March last year. “I ask the state not to do these things because they left us abandoned without a mother.”

At the time of the ruling, many women’s rights activists believed that the Americas could be on the path to further liberalisation of abortion laws – and decriminalisation gains in Colombia and Argentina fuelled those hopes.

However, the leak of the US supreme court’s draft opinion to overturn Roe v Wade has many rights groups worried that progressive policies may remain out of reach.

“The threats to abortion rights in the US matter to all of us because it is a terrible precedent at the international level,” Martinez, one of the lawyers who argued Manuela’s case before the IACHR, says. “This does not mean that what happens in a court like the one in that country can affect the achievements we have made in El Salvador and throughout Latin America, and for which we will continue to work with more enthusiasm.

“Roe v Wade must be protected as well as all laws that have advanced in the decriminalisation of abortion in the world. The fight for our rights has no borders.”

‘Mildred’ , Kenya

Mildred* was a 15-year-old girl from Manyani estate in the Kenyan city of Nakuru. She was admitted at the Nakuru Level 5 hospital last summer with acute abdominal pains and uncontrollable vomiting. She died writhing in pain, 20 weeks into a pregnancy she had tried and failed to end using herbs and salt.

Her anguished father, David, explained that the family did not know about her pregnancy. Mildred had travelled to the family’s rural home in Bungoma, where, her family believe, she tried to end the pregnancy with the help of an older woman she knew there.

“I did not know that my daughter attempted to terminate her pregnancy using a mixture of herbs, concentrated drinks and salt, a secret she kept close to her heart,” her father says.

“I wish my daughter had accessed a safer abortion … terminating the pregnancy was a better option to her happiness than trading her life with herbs that caused her infection and painful death,” he says.

At the same hospital, two years ago, Betty* died after trying to use detergent to end her pregnancy. The pain of the loss is still raw for her mother, from Racecourse estate, in Nakuru. “I thought my daughter was suffering from malaria. She was vomiting and complained of a severe headache,” she says.

Betty died on 19 May 2020 in agony. “It is sad that my daughter suffered in silence. I would have supported and walked with her in her pregnancy journey, and guaranteed her a safe delivery,” says her mother. “It pains me that she died such a painful death, yet I could have helped raise the baby as she continued with her studies.”

Her mother claims Betty was encouraged to take the detergent by her peers for fear of being forced to drop out of school and the stigma that comes with a teenage pregnancy. Kenyan society views teenage mothers as failures, with a number being denied education and forced into early marriages, often with abusive men.

“I wish there was a way of stopping my daughter from dying,” says her mother. “I trusted she would save me from poverty.”

In Kenya, abortion is outlawed under the constitution, with the exception of pregnancy from rape, pushing women and girls into crude methods of abortions, risking their health and their lives. According to the most recent Demographic Health Survey, 35% of maternal deaths in 2014 were as a result of unsafe abortions.

Dr Susan Gitau, chair of the Department of Counselling Psychology at Africa Nazarene University , says many of those who survive such unsafe procedures suffer lasting trauma. “Psychological counselling is key, counselling that should be done within 48 hours,” she says, “because abortion is illegal, girls do not access this.”

* Names have been changed to protect identities.

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Roe v. Wade and Supreme Court Abortion Cases

Reproductive rights in the United States, explained.

Is abortion a constitutional right?

Roe v. wade, what was the impact of the roe v. wade decision.

• The law after  Roe v. Wade

Supreme Court justices’ abortion views

Not under the U.S. Constitution, according to the current Supreme Court. In  Dobbs v. Jackson Women’s Health Organization  (2022), the Supreme Court overturned  Roe v. Wade  (1973), which guaranteed a constitutional right to abortion. Some state constitutions, however, independently protect abortion rights.

In  Roe v. Wade , the Supreme Court decided that the right to privacy implied in the 14th Amendment protected abortion as a fundamental right. However, the government retained the power to regulate or restrict abortion access depending on the stage of pregnancy. And after fetal viability, outright bans on abortion were permitted if they contained exceptions to preserve life and health. 

For the following 49 years, states, health care providers, and citizens fought over what limits the government could place on abortion access, particularly during the second and third trimesters. But abortion was fundamentally legal in all 50 states during that period.

Writing for the majority in  Dobbs , Justice Samuel Alito said that the only legitimate unenumerated rights — that is, rights not explicitly stated in the Constitution — are those “deeply rooted in the Nation’s history and tradition” and “implicit in the concept of ordered liberty.” Abortion, the majority held, is not such a right. 

Following  Dobbs , reproductive rights are being decided state by state.  Constitutions in 10 states  — Alaska, Arizona, California, Florida, Kansas, Massachusetts, Minnesota, Montana, New Jersey, and New Mexico — have been interpreted by state high courts to guarantee the right to abortion or protect access more strongly than the federal constitution. Other state legislatures have passed laws protecting abortion rights. Many states, however, have  made abortion illegal .

The road to  Roe

Abortion was illegal in most states in the 1960s, often with no exceptions for cases of rape or threat to life. A pair of high-profile crises, however, shined a spotlight on the impact of these restrictions.

Beginning in the late 1950s, thousands of babies were born with severe birth defects after their mothers took the morning sickness drug thalidomide while pregnant. The most well-known case was that of Sherri Finkbine, a host of the children’s television program  Romper Room , who was forced to travel to Sweden to obtain an abortion. A Gallup poll showed, perhaps surprisingly given the legal backdrop, that a majority of Americans  supported  Finkbine’s decision.

Shortly after the thalidomide scandal, an epidemic of rubella, or German measles, swept across the country. Babies that survived rubella in utero were often born with a  wide range of disabilities  such as deafness, heart defects, and liver damage. (A  rubella vaccine  didn’t become available until 1971.)

It was in this environment of maternal risk that high-profile doctors like  Alan Guttmacher  began to argue publicly that abortion should be treated like other medical procedures — as a decision to be made between physician and patient.

Griswold v. Connecticut  (1965)

While thalidomide and rubella impacted public perspectives on abortion, a series of cases built the foundation for the coming revolution in abortion law. The first involved the right to contraception, and the story begins in the 19th century.

In 1879, Connecticut senator P.T. Barnum (yes,  that  P.T. Barnum)  introduced a bill  barring not only contraceptives but also the distribution of information relating to them. The Barnum Act was still on the books in Connecticut in 1960, when the Food and Drug Administration approved the first oral contraceptive. Estelle Griswold, executive director of the Planned Parenthood League of Connecticut, was fined $100 for violating the law. Her appeal went all the way to the Supreme Court.

In  Griswold v. Connecticut , a seven-justice majority struck down the Barnum Act. Justice William O. Douglas explained that the Bill of Rights implies a right to privacy because when viewed as a coherent whole, it focuses on limiting government intrusions. The  Griswold  majority held that the government cannot prevent married couples from accessing contraception. (At the time, the justices did not extend the right to unmarried people.)  Griswold ’s contention that the Constitution creates a zone of privacy into which the government cannot enter paved the way for  Roe , among other landmark decisions.

Eisenstadt v. Baird  (1972)

The road from  Griswold  to  Roe  was not perfectly straight. Two years after  Griswold , reproductive rights activist  William Baird  offered contraceptives to an unmarried woman after a lecture on contraception to students at Boston University. He was sentenced to three months in prison.

Like Estelle Griswold, Baird appealed his conviction to the Supreme Court. In  Eisenstadt v. Baird , the Justices extended  Griswold . Justice William Brennan, writing for the six-justice majority, explained that the 14th Amendment guarantees equal protection under the law. There was no reason to treat married and unmarried people differently with regard to contraception.

United States v. Vuitch  (1971) 

Over the course of nine years, Washington, DC,–based physician Milan Vuitch was  arrested 16 times  for performing abortions, which had been illegal in the district since 1901 except “as necessary for the preservation of the mother’s life or health.”

Vuitch appealed his eventual conviction, arguing in part that the exception for “health” was unconstitutionally vague. The Supreme Court disagreed in  United States v. Vuitch . Taking a broad view of the word “health,” the justices ruled that abortion was legal in the district whenever necessary to protect mental or physical health.

The significance of  Vuitch , however, was to be short-lived.  Roe v. Wade  was already wending its way through the courts by the time of the decision. The day after they decided  Vuitch , the justices voted to hear  Roe . 

The parties to  Roe

Texan Norma McCorvey became pregnant for the third time in 1969. Struggling with drug and alcohol use, she previously relinquished responsibility for her first two children. She decided that she did not want to continue the pregnancy. 

Texas law, however, allowed abortion only to save the patient’s life. With McCorvey six months pregnant, Texas lawyers Linda Coffee and Sarah Weddington filed a suit on her behalf in federal court under the pseudonym Jane Roe.

Henry Wade was a legendary and  controversial  district attorney with an impressive conviction rate, most famous for prosecuting  Jack Ruby , who killed JFK’s assassin, Lee Harvey Oswald. Wade was, however, an odd foil for pro-choice activists. He did not aggressively prosecute illegal abortions and said little about them.

The lower court

A three-judge panel of the U.S. District Court for the Northern District of Texas  struck down  Texas’s abortion ban, finding it overbroad and locating the right to reproductive choice in the 9th and 14th Amendments. Citing  Griswold , the court noted that the Constitution guarantees “the right of choice over events which, by their character and consequences, bear in a fundamental manner on the privacy of individuals.” While the federal court declared the Texas law unconstitutional, it declined to immediately block its enforcement, putting  Roe v. Wade  on a fast track to the Supreme Court.

Norma McCorvey gave birth to a girl, Shelley Lynn, on June 2, 1970, fifteen days before the federal district court issued its ruling. The baby was adopted when she was three days old. Her identity was not known to the public until 2021. 

The  Roe v. Wade  oral argument

Sarah Weddington, who was just 26 years old when she stood before the justices of the Supreme Court on December 13, 1971, built her case for the constitutional right to abortion around the 9th and 14th Amendments, arguing that “meaningful” liberty must include the right to terminate an unwanted pregnancy.

Although the justices were largely receptive to Weddington’s points, Justice Byron White demanded to know whether the right to abortion extended right up to the moment of birth. After some hesitation, Weddington answered yes. Legal personhood began at birth, Weddington claimed. Until that moment, there should be an unfettered constitutional right to abortion.

After Weddington sat down, Texas Assistant Attorney General Jay Floyd stood to defend the state law. He began, inexplicably, with a sexist joke: “It’s an old joke, but when a man argues against two beautiful ladies like this, they are going to have the last word.” The bafflingly inappropriate comment was followed by three seconds of dead silence.

There was, however, one moment of wit in the argument. When Floyd argued that a woman who becomes pregnant has already made her choice, Justice Potter Stewart shot back, “Maybe she makes a choice when she decides to live in Texas!” The retort brought roars of laughter from the gallery.

Of particular note is how little the oral argument focused on the history of abortion laws during the founding or the post–Civil War era when the 14th Amendment was ratified. The justices focused instead on the biological realities of abortion and the text of the Constitution itself.

Also interesting: Justice Harry Blackmun, who would write the majority opinion in  Roe v. Wade , spoke only twice during the oral argument. By contrast, Justice Thurgood Marshall spoke more than 10 times, Justices White and William Brennan more than 20 times, and Justice Stewart more than 30. (Perhaps this was because Blackmun was initially inclined to  write a much more restrained opinion  than he ultimately did.)

The  Roe v. Wade  opinion

The Supreme Court handed down its decision on January 22, 1973. Seven of the nine justices agreed that the Due Process Clause of the 14th Amendment — which says that no state shall “deprive any person of life, liberty, or property, without due process of law” — implies a right to privacy. The majority seized upon Weddington’s definition of liberty, citing a series of prior cases indicating that the term “liberty” must be interpreted broadly in a free society.

The justices did, however, recognize that the state could place some limits on abortion if necessary to further a compelling state interest. The state’s ability to regulate increased as a pregnancy progressed. And after a fetus reached viability, the state could prohibit abortion, except when necessary to protect health or life.

Justices William Rehnquist and White dissented. Rehnquist argued that privacy, in the constitutional sense of illegal search and seizure, has nothing to do with abortion. In his view, since abortion bans implicate no fundamental rights, they must only have some rational basis, such as protecting a fetus. Foreshadowing the  Dobbs  decision in 2022, Rehnquist also declared that the only recognizable rights not explicitly listed in the Constitution are those with deep roots in the American legal tradition.

Doe v. Bolton  (1973)

On the same day the Supreme Court decided  Roe , it decided  Doe v. Bolton , which challenged Georgia’s abortion ban. The Georgia law limited abortion to cases of documented rape, a severely disabled fetus, or a threat to life. Before the procedure, it was necessary to obtain the approval of a doctor, two additional consulting physicians, and a hospital committee. The law also permitted relatives to challenge the abortion decision. It was, in short, a burdensome process.

In another 7–2 vote, with Blackmun again writing for the majority, the Court ruled that although the rights identified in  Roe  are not absolute, Georgia’s restrictions violated the constitutional right to abortion. He noted that the law established hurdles that were far higher than those that had to be overcome for other surgical procedures.

White and Rehnquist again dissented.

Roe  significantly reduced maternal mortality. A total of 39 women are known to have  died from unsafe abortions  in 1972, and this was almost certainly a drastic undercount. In 1975, there were only three such deaths. In 1965, eight years before  Roe  was decided, illegal abortion  caused 17 percent of pregnancy-related deaths . In modern times, just 0.2 percent of people who undergo abortions even require hospitalization for complications.

It’s not entirely clear what effect  Roe  had on public attitudes toward abortion because public opinion was already in flux before the case was decided. In 1965, just  5 percent  of Americans thought abortion should be legal for married people who simply didn’t want any more children. That number had risen to 36 percent by 1972, the year before  Roe  was decided. After  Roe  came down, pollsters began asking about abortion “for any reason,” and the polls show  relative stability  in the responses to that question since the mid-1970s.

The law after Roe v. Wade

Lingering resistance to abortion, particularly strong in certain parts of the country, led legislatures to test the decision’s boundaries. The Supreme Court issued many major abortion rulings up to the overturning of  Roe v. Wade  in the 2022 case  Dobbs v. Jackson Women’s Health Organization .

• In  Planned Parenthood v. Danforth   (1976), the justices blocked a law requiring spousal consent for abortion.
• Maher v. Roe   (1979) permitted states to exclude abortion services from Medicaid coverage.
• Colautti v. Franklin   (1979) struck down an unconstitutionally vague Pennsylvania law that required physicians to try to save the life of a fetus that might have been viable.
• In  Harris v. McRae   (1980), the Court upheld the  Hyde Amendment , a federal law that proscribed federal funding for abortions except when necessary to preserve life or as a result of rape or incest.
• In  L. v. Matheson   (1981), the Court upheld a law requiring parental notification when the patient is a minor living with parents.
• In  City of Akron v. Akron Center for Reproductive Health   (1983), the justices invalidated a wide range of limitations on abortion, such as a waiting period, parental consent without judicial bypass, and a ban on abortions outside of hospitals after the first trimester.
• Thornburgh v. American College of Obstetricians and Gynecologists   (1986) struck down a law that required informed consent to include information about fetal development and alternatives to abortion.
• In  Webster v. Reproductive Health Services   (1989), Justice Rehnquist upheld rules requiring doctors to test for viability after 20 weeks and blocking state funding and state employee participation in abortion services.
• Rust v. Sullivan   (1991) upheld a ban on certain federal funds being used for abortion referrals or counseling.
• Hill v. Colorado   (2000) upheld a law limiting protest and leafletting close to an abortion clinic.
• Stenberg v. Carhart   (2000) struck down Nebraska’s ban on the  dilation and extraction  abortion procedure.
• In  Gonzales v. Carhart   (2007), a slightly changed Court upheld a federal ban on the dilation and extraction procedure.

Planned Parenthood of Southeastern Pennsylvania v. Casey  (1992)

One case in the period between  Roe  and  Dobbs  deserves special attention. Through the 1980s, abortion opponents demanded the appointment of Supreme Court justices who would overturn  Roe . With the confirmation of Justices Anthony Kennedy, Sandra Day O’Connor, and David Souter, anti-abortion activists were confident they had the votes.

In 1988 and 1989, the Pennsylvania legislature adopted new abortion restrictions, including parental consent requirements, spousal notification, a waiting period, and an expanded informed consent process. Planned Parenthood of Southeastern Pennsylvania challenged the law, and many viewed the case as  Roe ’s last stand — an opportunity for the Court to do away with the constitutional right to abortion.

In  Planned Parenthood of Southeastern Pennsylvania v. Casey , however, the new members of the Court disappointed anti-abortion advocates. While the Court replaced  Roe ’s trimester-by-trimester doctrine with a weaker level of protection and upheld elements of the Pennsylvania law that did not unduly burden the right to abortion, the justices declined to overrule  Roe . A plurality opinion authored by O’Connor, Kennedy, and Souter explained that, while Supreme Court precedents are not eternal, there must be a compelling reason to abandon  stare decisis  — the notion that precedents should be upheld. The Court decided there was no adequate justification for overturning  Roe , especially since Americans had arranged their lives around an expectation of control over their reproductive health, including having access to abortion.  Casey  also acknowledged the strong equality concerns that justify abortion rights, arguing that women cannot participate fully in the social and economic life of the nation if they are forced to continue unwanted pregnancies. 

Dobbs v. Jackson Women’s Health Organization  (2022)

In 2018, the Mississippi legislature  banned abortions  after 15 weeks of gestation, except in cases of narrowly defined medical emergency or severe fetal abnormality. The law was a challenge to both  Roe  and  Casey . Jackson Woman’s Health Organization, the sole abortion provider in the state, contested the ban.

Long before  Dobbs  was decided, signs pointed to the Supreme Court’s intention to rescind the constitutional right to abortion. First, in a separate case that first appeared on the Court’s  shadow docket , the justices  allowed a Texas abortion ban  that contravened  Roe  and  Casey  to remain in force. Then, in the weeks before  Dobbs  came down, a draft decision overturning  Roe  and  Casey  leaked out of the Court in an unprecedented breach of Court protocol. 

The final  decision  was little changed from the leaked draft. Writing for the five-justice majority (with Chief Justice Roberts concurring only in the judgment), Justice Samuel Alito argued that the right to privacy is not specifically guaranteed anywhere in the Constitution. When unenumerated liberty rights exist — the right to raise your child as you see fit, for example — those rights must be “deeply rooted in the Nation’s history and tradition.” Reviewing the history of abortion restrictions in the early United States, Alito concluded that the right to abortion is not.

The opinion ignited a firestorm of controversy. Predictably so:  Dobbs  is arguably the first case to formally rescind a fundamental constitutional right. The opinion also  failed to explain  how its logic would not also result in the overturning of  Griswold ’s right to contraception or a series of other cases that rely on the same logic as  Roe . These include  Lawrence v. Texas  (2003), which invalidated laws criminalizing same-sex intimate sexual conduct, and  Obergefell v. Hodges  (2015), which recognized the right to marriage for same-sex couples. 

Also, for many Americans, Alito’s insistence that rights be “deeply rooted” in U.S. history revealed a broad discounting of historically marginalized communities, including women, people of color, and gay Americans. The only rights “deeply rooted” in our history are the ones that served the white, heterosexual men who dominated government at the time of the founding. While  Casey  had begun to address the equality dimensions of abortion rights,  Dobbs  moved in precisely the opposite direction, suggesting that non-majority groups must overcome special hurdles to have their rights recognized.

Abortion rights will now be defined on a state-by-state basis. Several state courts have ruled that their constitutions  guarantee the right to abortion , whether because of explicit references to “privacy” or by relying on language that broadly protects personal autonomy. The  Kansas Supreme Court , for example, has ruled that the constitution’s guarantee of “equal and inalienable natural rights” protects personal decision-making, self-determination, and bodily integrity. Other states have adopted an approach consistent with  Roe , in which the right to privacy, including reproductive freedom, has been recognized as implied in the state constitution.

Following the  Dobbs  case, anti-abortion activists have proposed state constitutional amendments stating that nothing in the constitution protects abortion rights. In some cases, these measures seek to overrule their state courts’ interpretations of the constitution. In others, there has been no court decision regarding the constitutional right to abortion. Other states have, in contrast, moved to expand or cement abortion rights, including through constitutional amendments.

Dobbs  also leaves a long list of unanswered practical questions. Can states ban women from traveling to obtain an abortion? How will they police the importation and use of abortion drugs? How will state courts handle the slew of “trigger laws” — state anti-abortion statutes designed to come into effect upon the overturning of  Roe ? Just as  Roe  set off years of legal uncertainty over the precise boundaries of abortion rights,  Dobbs  has launched a long period of uncertainty over states’ power to restrict abortion in the absence of those rights.

The current Court

• Chief Justice John   Roberts , during his time as a lawyer for the George W. Bush administration, wrote that  Roe  has “ no support  in the text, structure, or history of the Constitution.” In his  Dobbs  concurrence, however, Roberts favored preserving a more limited constitutional right to abortion, without specifying how far it would extend. “Surely we should adhere closely to principles of judicial restraint here, where the broader path the Court chooses entails repudiating a constitutional right we have not only previously recognized, but also expressly reaffirmed applying the doctrine of  stare decisis .”
• Justice Clarence Thomas , who was in the  Dobbs  majority, has written that  Roe  was “grievously wrong for many reasons, but the most fundamental is that its core holding — that the Constitution protects a woman’s right to abort her unborn child —  finds no support  in the text of the Fourteenth Amendment.”
• Justice Samuel Alito  complained as a young lawyer in the Reagan administration about “the courts’ refusal to  allow breathing room  for reasonable state regulation” of abortion. In a job application, he wrote, “I personally believe very strongly that the Constitution  does not protect  a right to an abortion.” As the authority of the majority opinion in  Dobbs , he wrote that “ Roe  was . . . egregiously wrong and on a collision course with the Constitution from the day it was decided.”
• Justice Neil Gorsuch , who was in the  Dobbs  majority, has said and written less on abortion than many other justices, but during his confirmation hearing, he noted that  Roe  was “a precedent of the U.S. Supreme Court” and added, “once a case is settled, that  adds to the determinacy  of the law.”
• Justice Amy Coney Barrett  added her name to a 2006 ad  calling for  Roe  to be overturned  and suggested that the possibility of adoption might  obviate the need for abortion rights .
• Justice Brett Kavanaugh , in 2017, proclaimed his admiration of former justice Rehnquist’s  Roe  dissent, noting that his views about unenumerated rights were “successful in  stemming the general tide  of freewheeling judicial creation of unenumerated rights that were not rooted in the nation’s history and tradition.”
• Justice Ketanji Brown Jackson  repeatedly described  Roe  as “settled law” in her confirmation hearings. In the same hearings, when asked when human life begins, she replied simply, “ I don’t know .”
• Justice Sonia Sotomayor  has focused much of her writing about abortion on the cost that bans impose on those who are economically disadvantaged. Objecting to the Court’s decision to allow a Texas abortion ban to stand, Sotomayor wrote, “Those without the ability to make this journey [to a state allowing abortion], whether due to lack of money or childcare or employment flexibility or the myriad other constraints that shape people’s day-to-day lives, may be forced to carry to term against their wishes or  resort to dangerous methods of self-help .” The  Dobbs  dissent, authored by Justice Breyer and joined by Justices Sotomayor and Kagan, continued that theme of disempowerment, lamenting the end of an era in which “respecting a woman as an autonomous being, and granting her full equality, meant giving her substantial choice over this most personal and most consequential of all life decisions.”
• Justice Elena Kagan  has a significant and slightly complicated record on abortion. As a lawyer in the Clinton administration, she wrote a  memo recommending  that the president sign a ban on “partial birth abortion” if it contained an exception in cases of serious risk to health. As a justice, however, Kagan has voted consistently against restrictions on abortion. She called a recent Texas abortion ban “patently unconstitutional” and dissented forcefully in  Dobbs . 

Notable past justices

• Justice Stephen Breyer : “Millions of Americans  believe that life begins at conception  and consequently that an abortion is akin to causing the death of an innocent child . . . Other millions fear that a law that forbids abortion would condemn many American women to lives that lack dignity, depriving them of equal liberty and leading those with least resources to undergo illegal abortions with the attendant risks of death and suffering.”
• Chief Justice Warren Burger : “The Constitution  does not compel a state to fine-tune its statutes  so as to encourage or facilitate abortions. To the contrary, state action ‘encouraging childbirth except in the most urgent circumstances’ is ‘rationally related to the legitimate governmental objective of protecting potential life.’”
• Justice Ruth Bader Ginsburg : “ Roe v. Wade  sparked public opposition and academic criticism, in part, I believe, because the Court  ventured too far in the change it ordered  and presented an incomplete justification for its action.”
• Justice Sandra Day O’Connor : “The  Roe  framework . . . is  clearly on a collision course  with itself.”
• Chief Justice William Rehnquist : “We do not see why the state’s interest in protecting human life should  come into existence only at the point of viability .”
• Justice Antonin Scalia : “We should get out of this area [abortion law], where we have no right to be, and where we  do neither ourselves nor the country  any good by remaining.”
• Justice Byron White : “The Court apparently  values the convenience of the pregnant mother  more than the continued existence of the life or potential life that she carries.”
• Justice William J. Brennan Jr. : “If the right to privacy means anything, it is the right of the individual, married or single, to be  free from unwanted government intrusion  into matters so fundamentally affecting a person as the decision to bear or beget a child.”
• Justice Anthony Kennedy : “Where it has a rational basis to act, and it does not impose an undue burden, the State may  use its regulatory power  to bar certain procedures and substitute others, all in furtherance of its legitimate interests in regulating the medical profession in order to promote respect for life, including life of the unborn.”
• Justice David Souter : “I have not got any agenda on  what should be done with  Roe v. Wade , if that case is brought before me.”

Government Classification and the Mar-a-Lago Documents

Understanding how the classification system works is critical to understanding Trump’s culpability — legal and otherwise.

What Gifts Must Supreme Court Justices Disclose?

There are significant loopholes in the rules that apply to the high court.

Myths and Realities: Understanding Recent Trends in Violent Crime

The recent rise in crime is extraordinarily complex. Policymakers and the public should not jump to conclusions or expect easy answers.

Informed citizens are democracy’s best defense

• Case report
• Open access
• Published: 14 June 2019

“Regardless, you are not the first woman”: an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua

• Samantha M. Luffy 1 ,
• Dabney P. Evans   ORCID: orcid.org/0000-0002-2201-5655 1 &
• Roger W. Rochat 1  

BMC Women's Health volume  19 , Article number:  76 ( 2019 ) Cite this article

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Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, public health practicioners and human rights advocates have made great strides to advance our understanding of sexual and reproductive rights and how they should be protected. The overall aim of the study was to understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua, from June to July 2014.

Case presentation

This case study focuses on the story of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her case, detailed under the pseudonym Ana Maria, presents unique challenges related to the fulfillment of sexual and reproductive rights due to the restrictive social norms related to sexual health, ubiquitous violence against women (VAW) and the total ban on abortion in Nicaragua. The case also provides a useful lens through which to examine individual sexual and reproductive health (SRH) experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; this in-depth analysis identifies the contextual risk factors that contributed to Ana Maria’s experience.

Conclusions

Far too many women experience their sexuality in the context of individual and structural violence. Ana Maria’s case provides several important lessons for the realization of sexual and reproductive health and rights in countries with restrictive legal policies and conservative cultural norms around sexuality. Ana Maria’s experience demonstrates that an individual’s health decisions are not made in isolation, free from the influence of social norms and national laws. We present an overview of the key risk and contextual factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion.

Peer Review reports

Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, however, the international community, States, and advocates have made great strides to advance our understanding of sexual and reproductive rights and how they can be protected at the national and international levels. The 1994 Cairo Declaration began this process by including sexual health under the umbrella of reproductive health and recognized the impact of violence on an individual’s sexual and reproductive health (SRH) decision-making. [ 1 ] One year later, the 1995 Beijing Platform for Action specifically addressed the issues of unintended pregnancy and abortion by emphasizing that improved family planning services should be the main method by which unintended pregnancies and unsafe abortions are prevented. [ 2 ]

A recent World Health Organization (WHO) report on the relationships between sexual health, human rights, and State’s laws sets the foundation for our contemporary understanding of these issues. The 2015 report describes sexual health as, “a state of physical, emotional, mental and social well-being in relation to sexuality.” [ 3 ] That state includes control over one’s fertility via access to health services such as abortion; it also includes the right to enjoy sexual experiences free from coercion, discrimination, and violence. [ 3 ] Whether experienced alone or in combination, rape, unintended pregnancy, and abortion are important SRH issues on which public health can and should intervene.

In the public health field, case studies provide a useful lens through which to examine individual women’s sexual and reproductive health experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; an in-depth analysis of these personal experiences can identify contextual risk factors and missed opportunities for public health rights-based  intervention. This type of analysis is especially cogent when legal policies and social factors, such as gender inequality, may influence one’s SRH decision-making process. On an individual level, bearing witness to women’s stories through in-depth interviews helps document their lived experience; surveying these experiences within the context of laws related to SRH provides important evidence for the impact of such policies on women’s well-being.

We present the case of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her complex experience of violence, unintended pregnancy, and unsafe abortion represent a series of contextual factors and missed opportunities for public health and human rights intervention. Ana Maria’s story, told through the use of a pseudonym, takes place in a city located in North Central Nicaragua – a country that presents unique challenges related to its citizens’ fulfillment of their sexual and reproductive health and rights.

Violence against women in Nicaragua

Along with 189 States, Nicaragua is a party to the United Nations (UN) Convention on the Elimination of All Forms of Discrimination against Women, which includes State obligations to protect and promote the health and well-being of Nicaraguan women. [ 4 ] As defined by human rights documents, the right to health includes access to health care services, as well as provisions for the underlying social determinants of health, such as personal experiences of structural violence. [ 5 ]

In the Nicaraguan context, political and sociocultural institutions support unequal power relations between genders. [ 6 ] Machismo is one such form of structural violence that perpetuates gender inequality and has been identified as a barrier to SRH promotion in Nicaragua. [ 7 , 8 ] The term ‘ machismo ’ is most commonly used to describe male behaviors that are sexist, hyper masculine, chauvinistic, or violent towards women. [ 9 ] These behaviors often legitimize the patriarchy, reinforce traditional gender roles, and are used to limit or control the actions of women, who are often perceived as inferior. [ 10 ]

The vast majority (89.7%) of Nicaraguan women have experienced some form of gender-based violence  during their lifetime, which poses a serious public health problem. The latest population-based Demographic and Health Survey showed that at least 50% of Nicaraguan women surveyed had experienced either verbal/psychological, physical, or sexual violenceduring their lifetime. An additional 29.3% of women reported having experienced both physical and sexual violence at least once, while another 10.4% reported having experienced all three types of violence. [ 11 ]

In 2012, Nicaragua joined a host of other Central and South American countries that have implemented laws to eliminate all forms of violence against women VAW, including rape and femicide. [ 12 ] Nicaragua’s federal law against VAW, Law 779, intends to eradicate such violence in both public and private spheres. [ 13 ] On paper, Law 779 guarantees women freedom from violence and discrimination, but it is unclear if the law is being adequately enforced; it has been reported that some women believe VAW has increased since the law’s implementation. [ 14 ]

Before Law 779, violent acts like rape, particularly of young women ages 15–24, were endemic in Nicaragua. Approximately two-thirds of rapes reported in Nicaragua between 1998 and 2008 were committed against girls under 17 years of age; most of these acts were committed by a known acquaintance. [ 15 ] Due to a lack of reporting and to culturally propagated stigma regarding rape, no reliable data suggest that Law 779 has been effective in reducing the incidence of rape in Nicaragua. For women who wish to terminate a pregnancy that resulted from rape, access to abortion services is vital, yet completely illegal. [ 16 ] In contrast, technical guidance from the WHO recommends that health systems include access to safe abortion services for women who experience unintended pregnancy or become pregnant as a result of rape. [ 17 ]

Family planning and unintended pregnancy in Nicaragua

Like violence, unintended pregnancies -- not only those that result from rape -- pose a widespread public health problem in Nicaragua. National data suggest that 65% of pregnancies among women ages 15–29 were unintended. [ 11 ] Oftentimes, unintended pregnancy results from a complex combination of social determinants of health including: low socioeconomic status (SES), low education level, lack of access to adequate reproductive health care, and restrictive reproductive rights laws. [ 18 , 19 , 20 ] Nicaraguan women of low SES with limited access to family planning services are at an increased risk of depression, violence, and unemployment due to an unintended pregnancy. [ 19 , 20 ]

The UN Committee on the Elimination of all forms of Discrimination Against Women (CEDAW) has expressed concern regarding the lack of comprehensive sexual education programs, as well as inadequate family planning services, and high rates of unintended pregnancy throughout Nicaragua. [ 21 ] Due to a lack of sexual education, Nicaraguan adolescents, if they use contraceptives like male condoms or oral contraceptive pills, often do so inconsistently or incorrectly. [ 22 ]

Deeply rooted cultural stigma surrounding unmarried women’s sexual behavior contributes to the harsh criticism of young women in Nicaragua that use a method of family planning or engage in sexual relationships outside of a committed union. [ 18 , 22 ] Also, young women who are not in a formal union may experience unplanned sex (consensual or nonconsensual) and are unlikely to be using contraception, which further increases the risk of unintended pregnancy. [ 22 ] These social and cultural factors, in conjunction with restrictive reproductive rights laws, may contribute to a high incidence of unintended pregnancy among young Nicaraguan women.

The total ban on abortion in Nicaragua

Compounding the economic, social, and emotional burden of unintended pregnancy on women’s lives is the current prohibition of abortion in Nicaragua. In 2006, the National Assembly unanimously passed a law to criminalize abortion, which had been legal in Nicaragua since the late 1800s. [ 20 ] Researchers often refer to this law as the “total ban” on abortion. [ 20 , 23 ] The total ban prohibits the termination of a pregnancy in all cases, including incest, rape, fetal anomaly, and danger to the life of the woman. Laws that prohibit medical procedures are, by definition, barriers to access; equitable access to safe medical services is a critical element of the right to health. [ 3 , 5 ] The UN Committee on Civil and Political Rights (CCPR) has also recognized the discriminatory and harmful nature of criminalizing medical procedures that only women undergo. [ 24 ]

Nicaragua is one of the few countries in the world to completely ban abortion in all circumstances. In States where illegal, abortion does not stop. Instead, women are forced to obtain abortions from unskilled providers in conditions that are often unsafe and unhygienic. [ 25 ] Unsafe abortions are among the main preventable causes of maternal morbidity and mortality worldwide and can be avoided through decriminalization of such services. [ 26 ]

The Nicaraguan ban includes serious legal penalties for women who obtain illegal abortions, as well as for the medical professionals who perform them, which can have profound negative effects on women’s health. [ 20 , 23 ] Women who need or want an abortion face not only the health risks that accompany an unsafe procedure, but additional criminal penalties. The total ban on abortion violates the human rights of both health care providers and women nationwide, as well as the confidentiality inherent in the patient-provider relationship. [ 20 ] It also results in a ‘chilling effect’ where health care providers are unwilling to provide both abortion and postabortion care (PAC) services for fear of prosecution. [ 20 ]

In response to the negative impacts of the total ban on maternal morbidity and mortality in Nicaragua, as well as detrimental effects on women’s physical, mental, and emotional health, CEDAW has recommended that the Nicaraguan government review the total ban and remove the punitive measures imposed on women who have abortions. [ 21 ] While the Nicaraguan government may not view abortion as a human right per se, women should not face morbidity or mortality as a result of illegal or unsafe abortion. [ 27 ]

Criminalizing abortion also increases stigma around this issue and significantly reduces people’s willingness to speak openly about abortion and related SRH services. Qualitative research conducted in Nicaragua suggests that women who have had unsafe abortions rarely discuss their experiences openly due to the illegal and highly stigmatized nature of such procedures. [ 18 ] Therefore, the overall aim of the study was to better understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua from June to July 2014. This private method of data collection allowed for the detailed exploration of each young woman’s personal experience with an unintended pregnancy, including the decision-making process she went through regarding how to respond to the pregnancy. Given the personal nature of this experience – including the criminalization and stigmatization of women who obtain abortions – IDIs allowed the participants to share intimate details and information that would be inappropriate or dangerous to share in a group setting. One case, presented here, emerged as salient for understanding the intersections of violence, unintended pregnancy, and abortion – and the missed opportunities for rights-based public health intervention.

Emory University’s Institutional Review Board ruled the study exempt from review because it did not meet the definition of “research” with human subjects as set forth in Emory policies and procedures and federal rules. Nevertheless, procedural steps were taken to protect the rights of participants and ensure confidentiality throughout data collection, management, and analysis. The first author reviewed the informed consent form in Spanish with each participant and then acquired each participant’s signature and verbal informed consent before the IDIs were conducted. The investigators developed a semi-structured interview guide with open-ended questions and piloted the guide twice to improve the cultural appropriateness of the script (Additional file 1 ). The investigators also collaborated with local partners to design and implement the research according to local cultural and social norms. Due to the contentious topics discussed in this study, these collaborators prefer to not be mentioned by name. Interviews were conducted in Spanish in a private location and audio taped to protect the participants’ privacy. Recordings were transcribed verbatim and transcripts were coded and analyzed using MAXQDA11 software (VERBI GmbH, Berlin, Germany).

Initially, participants were recruited for interviews through purposive sampling of individuals who had disclosed a personal experience with unintended pregnancy during focus group discussions (FGDs) conducted in a larger parent study. At the end of each interview, participants were asked to refer other young women they knew who may have experienced an unintended pregnancy to participate in an interview. This form of respondent-driven sampling created a network of participants with a wide variety of experiences with unintended pregnancy. Of the ten interviewees, two had experienced unintended pregnancy as a result of rape, though both used the phrase “ sexo no consensual ” or “nonconsensual sex” in lieu of “ violación, ” the Spanish word for rape. One of these women shared her personal experience receiving an unsafe abortion to terminate an unintended pregnancy that had resulted from rape. Her story, shared under the use of the pseudonym Ana Maria, is presented here in order to:

Illustrate the harmful impact of restrictive abortion laws on the health and well-being of women – especially those who do not have access to abortion in the case of rape; and

Exemplify the nexus of contextual risk factors that impact women’s SRH decision-making, such as conservative social norms and restrictive legal policies.

Through thorough analysis, we examine the impact of these contextual factors that impacted Ana Maria’s experience.

When she was 19, Ana Maria was raped by her godfather, a close friend of her family.

In an in-depth interview, Ana Maria described enduring incessant verbal harassment from her godfather – her elder brother’s best friend – in the months before the assault. He constantly called and texted her cell phone in order to interrogate her about platonic relationships with other men in town and to convince her to spend time alone with him. Even though he was married with children and she repeatedly dismissed his advances, he continued to engage in this form of psychological violence with his goddaughter. Ana Maria described eventually “giving in” and meeting him – not knowing that this encounter would result in her forcible rape.

The disclosure of Ana Maria’s rape during her interview was spontaneous and unexpected. Ana Maria was unwilling to disclose explicit details of the sexual assault. Instead, she stated multiple times that the sexual contact was nonconsensual and she did not want to have sex with him. When asked if she told anyone about this experience, she said no because she did not want others to judge her for what had happened.

Approximately a month of scared silence after she was raped, Ana Maria noticed that her period had not come. Nervous, she bought a pregnancy test from a local pharmacy. To her dismay, the test was positive. In order to confirm the pregnancy, she traveled alone to the nearby health center in her town to obtain a blood test. Again, the test was positive. She had never been pregnant before and she was terrified. In the midst of her fear, she shared the results with her rapist, her godfather.

His response: get an abortion. He did not want to lose his wife and children if they found out about the pregnancy.

Other than their illegal nature, Ana Maria knew nothing about abortions – where to get one, how it was done, what it felt like. She asked her neighbors to explain it to her. They said “it was worse than having a baby and [experiencing] childbirth.”

Though Ana Maria did not want to get the abortion, her godfather continued to pressure her to get the procedure saying, “Regardless, you must get the abortion… you are not the first woman to have ever had one.” Similar to the emotional violence before he raped her, he called and texted Ana Maria every day telling her to, “do it as fast as you can.” He forbade her from telling anyone about the pregnancy and Ana Maria didn’t feel like she had anyone to confide in about the situation. She worried about people judging her for getting pregnant outside of a committed relationship – even though she was raped. Ana Maria described this difficult time:

“When he started to pressure me [to get the abortion], I felt alone. I did not have enough trust in anyone to tell them [what had happened] because… if I had had enough trust in someone, I know that they would not have let me do it. If I had been given advice, they would have said, ‘No, do not do it,’ but I did not have anyone and I felt so depressed. What made it worse, I couldn’t sleep; I could not sleep [because I was] thinking of everything he had told me. At night, I would remember how it all started and I do not know what he did to find that money, but he gave me the money to get the abortion.”

Her godfather gave her 3000 Córdobas (approximately USD112 at the time) and put her on a public bus, alone. He had arranged for her to receive the abortion from an older woman that practiced “natural medicine” in a nearby city. When Ana Maria arrived at the woman’s home, she was instructed to remove her pants and underwear and lie on a bed. Ana Maria did not receive any medication before the woman inserted a “device like the one used for a Papanicolau… and then another device like an iron rod” into her vagina.

After describing these devices, Ana Maria made a jerking motion back and forth with her arm to imitate the movement the woman used to perform the abortion.

Once it was over, the woman gave Ana Maria an injection of an unknown substance and told her that she would pass a few blood clots over the next few days. That night, however, Ana Maria’s condition worsened; she became feverish, felt disoriented, and began to pass dark, fetid clots of blood. She described the pain she experienced throughout the ordeal:

“I felt so much pain when they took her out of me. I felt pain when the blood was leaving my body and when I had the fever. I felt a terrible pain that only I suffered. I am [a] different [person] now because of those pains.”

Ana Maria was too afraid to tell her family about the assault or the abortion because she was uncertain how they would react. She was even more terrified of the potential legal repercussions that she could face for violating the total ban on abortion. Within a few days of the abortion, though, Ana Maria’s brother heard rumors of his sister’s situation from neighbors “in the street” and confronted her about what had happened. At first, Ana Maria denied that she had had an abortion, but her brother continued to ask for the truth. Though she was nervous, Ana Maria eventually told her brother everything that had happened – from her godfather’s incessant verbal harassment, to the rape, to the unsafe abortion she was forced to get.

Afraid for his sister’s life, Ana Maria’s brother contacted a local nurse who discreetly provides postabortion care (PAC) to women experiencing complications from unsafe abortion and other obstetric emergencies. This nurse is locally known to be one of the few health care providers who provide PAC despite many other providers’ fear of prosecution under the total ban. The nurse recommended that Ana Maria come to the hospital immediately.

Ana Maria spent almost two weeks as an inpatient at the only hospital in the region. She had become septic as a result of what she described as a “perforated uterus,” a common complication from unsafe abortion. [ 28 ] Upon her initial examination, the nurse was afraid that her uterus could not be repaired because the infection was so severe. Fortunately, the medical team administered an ultrasound, removed infected blood clots, and completed uterine surgery to repair the damage from the unsafe abortion. At the request of the gynecologist taking care of her, Ana Maria received the one-month contraceptive hormonal injection before being discharged. At the time of the interview, Ana Maria had not received the next month’s injection because she “didn’t have any use for a man.”

As a result of this experience, Ana Maria reported feelings of depression, isolation, and recurring dreams about a little girl, which she described in this way:

“After I was discharged, I always dreamt of a little girl and that she was mine, standing in my doorway and when I awoke, I couldn’t find her. I looked for her in my bed but she wasn’t there. And this has tormented me because, it’s true: I am the girl that committed this error, but the little girl was not at fault. He pressured me so strongly to get the abortion, so I did.”

Ana Maria had the same recurring dream every night for more than two weeks and she continued to feel depressed weeks after leaving the hospital. One of the sources of her depression was the isolation she felt because there was no one with whom she could share this experience.

According to Ana Maria, she longs to have other people to talk to about her experience – particularly those who may have had similar experiences. She also expressed a desire to pursue a law degree so that she can have a career in local government.

Discussion and conclusions

Ana Maria’s case provides insight into the contextual factors effecting her ability to realize her sexual and reproductive health and rights in Nicaragua where restrictive legal policies and conservative cultural norms around sexuality abound. These contextual risk factors include social norms related to sexual health, laws targeting VAW, and the criminalization of abortion.

Social norms related to sexual health

The fundamental relationship between structural inequality and sexual and reproductive rights has been duly noted; gender inequality, in particular, must be addressed in order to fulfill sexual rights for women. [ 29 ] As in many cases in Nicaragua, the fact that Ana Maria’s first sexual experience was nonconsensual and was initiated by an older male and trusted family friend highlights the uneven power relations between men and women in Nicaraguan culture, which propagate high instances of VAW and sexual assault. In a patriarchal society where machismo and gender inequality run rampant, women’s sexuality is further constrained by the stigmatization of sexual health and a culture of violence that limits women’s autonomy. The compound stigma surrounding sexual health in general, and rape in particular, negatively impacted Ana Maria’s knowledge and ability to access mental health and SRH services, including emergency contraception and post-rape care, which may have assisted her immediately following her assault. Before her brother intervened, Ana Maria’s fear of judgment and legal repercussions also prevented her from seeking PAC, which was necessary to save her life.

Comprehensive sexual education is a primary way to challenge these social norms and widespread stigma surrounding sexuality and SRH services, such as contraception and PAC, at the population level. Such education might have mitigated Ana Maria’s experience of unintended pregnancy through the provision of advance knowledge of emergency contraception and medical options in the event of pregnancy. CEDAW has recognized this missed opportunity for public health intervention in Nicaragua, and recommends sexual education as a means of addressing stigma related to sexuality, decreasing unintended pregnancy, and increasing the acceptability and use of family planning services throughout the country. [ 21 ] Furthermore, the lack of adolescent-friendly sexual education and SRH services symbolizes a social reluctance to acknowledge the reality that young people have sex. [ 30 ] Such ignorance results in a lack of information on healthy relationships and human reproduction, as well as experiences of unintended pregnancy, early motherhood, and unsafe abortion. Exposure to this type of information may have improved Ana Maria’s ability to protect herself, mitigated the impact of Nicaragua’s pervasive misogyny on her decision making, and lessened the influence of her godfather’s coercion before her experiences of rape and unsafe abortion.

Individual and structural violence against women

Though we do not know explicit details of Ana Maria’s rape, the act of rape is inherently violent. The assault violated her right to enjoy sexual experiences free from coercion and violence. [ 3 ] To further constrain her sexual and reproductive rights, Ana Maria’s experience of rape resulted in an unintended pregnancy and an unsafe abortion that she was pressured into undergoing. Along with physical sequelae as a result of the procedure, she also expressed feelings of depression and isolation, which are common symptoms of post-traumatic stress disorder (PTSD). [ 31 ] These mental health consequences are forms of emotional violence that Ana Maria continued to experience long after the initial insult of physical violence. We can’t distinguish whether her mental health symptoms were a pre-existing condition or a result of the traumatic experience presented here. It is likely, however, that all parts of this experience impacted her mental and physical health. As reported elsewhere, perceived social criticism and a lack of social support are barriers to the fulfillment of sexual and reproductive health among young Nicaraguan women. [ 18 ] These contextual risk factors undoubtedly played a role in Ana Maria’s ability to navigate the circumstances surrounding her assault and its aftermath.

What legal recourse was feasibly available to Ana Maria for the crime of her sexual assault? To our knowledge, Ana Maria did not report the rape to authorities nor did her godfather ever face criminal charges for his actions. Yet Ana Maria’s own fear of prosecution for undergoing the unsafe abortion, as well as shame and fear of being stigmatized by others in her community, strongly influenced her decision not to report the rape -- even though Law 779 contains sanctions specific to those who commit rape.

In the event she had reported the crime, however, it is unclear if Law 779 would have provided justice. There are no data to suggest that Law 779 has led to an increase in the reporting or prosecution of rape at the national level. To the contrary, qualitative work in Nicaragua found a perceived increase in VAW following the passage of the law. [ 14 ] In Nicaragua, the inconsistent or ineffective enforcement of Law 779 is another factor worthy of consideration in cases like Ana Maria’s where individuals do not report such crimes. Documents like the UN Women Model Protocol have recently been released to improve the enforcement of laws like Law 779 in Latin American countries, presenting an opportunity for the effective operationalization of the law in Nicaragua. [ 32 ] If Law 779 is not adequately enforced, women like Ana Maria face the potential for re-victimization through the structural violence of impuity and continued exposure to VAW. To our knowledge, Ana Maria’s perpetrator faced no consequences for his perpetration of harassment, coercion and rape of Ana Maria. Moreover, in countries where abortion is criminalized, such as El Salvador, it is most often women who face criminal sanctions. [ 33 ] Indeed, it was Ana Maria herself who bore the physical and mental burden that resulted from her assault, unintended pregnancy, and unsafe abortion.

The criminalization of abortion

The criminalization of health services is a strategy that governments use to regulate people’s sexuality and sexual activity. [ 34 ] The criminalization of services such as abortion limits women’s ability to make autonomous decisions about their SRH. By definition, laws that restrict access to health services exclude people from receiving the information and services necessary to realize the highest level of SRH possible. [ 5 ] The criminalization of abortion puts the health and well-being of individuals and communities at risk. Beyond the individual level, complications from unsafe abortion often put unnecessary and immeasurable financial burdens on health systems that are already stretched [ 28 ].

Ana Maria did not have a choice when it came to her abortion; the man who raped her coerced her to undergo an unsafe and illegal procedure. The criminalization of abortion in Nicaragua put Ana Maria’s health at risk in two ways: first, it prevented her from obtaining a safe abortion and second, it limited her access to comprehensive sexual health information that could have helped her address her unintended pregnancy, through emergency contraception. After the unsafe abortion procedure, her access to PAC was likely constrained by her own fear of the possible legal repercussions of undergoing an abortion, and was compounded by her inability to trust that a health care provider would maintain patient confidentiality and provide adequate PAC.

In Nicaragua, the total ban on abortion directly contradicts strategic objectives outlined in the Beijing Declaration, which guarantees women’s rights to comprehensive SRH care, including family planning and PAC services. Though providing PAC is not considered illegal under the total ban, many Nicaraguan health care providers refuse to treat women who have had unsafe abortions, which results in a ‘chilling effect’; providers do not want to be accused of being complicit in providing abortions so they refuse to provide PAC services. The ‘chilling effect’ put Ana Maria at risk of morbidity or mortality as a result of the complications that resulted from her unsafe abortion.

Equally troubling is the use of criminal law against individuals like Ana Maria as well as health care professionals that provide PAC. By requiring health care providers to report to the police women who have had abortions, the total ban violates the privacy inherent in the patient-provider relationship. Health care providers are faced with a dual loyalty to both the State’s laws and the confidentiality of their patients, which makes it difficult for providers to fulfill their professional obligations. It also makes health care professionals complicit in a discriminatory practice, one where women face legal sanctions in ways that men do not. The criminalization of abortion in Nicaragua therefore resulted in the fear, stigma, discrimination, and negative health outcomes observed in Ana Maria’s case.

The contextual risk factors that contributed to Ana Maria’s experience of rape, unintended pregnancy, and unsafe abortion are as follows: sexual assault, impunity for violence, gender inequality, restrictive social norms around SRH, stigma resulting from unintended pregnancy and abortion, harmful health impacts from an unsafe abortion, and fear of prosecution due to the total ban. Her first sexual experience was forced and nonconsensual and preceded by months of harassment. Social norms made taboo any discussion of the harassment and sexual violence she experienced at the hands of her godfather; without social support, she was coerced into undergoing an unsafe abortion that resulted in serious mental and physical health sequelae. The illegal nature of abortion in Nicaragua placed Ana Maria at risk for social stigma as well as criminal prosecution. Her subsequent underutilization of family planning services at the time of the interview also placed Ana Maria at risk for an unintended pregnancy in the future; other long-term physical and mental health effects of her experience remain unknown.

The realization of one’s sexual and reproductive rights guarantees autonomous decision-making over one’s fertility and sexual experiences. However, Ana Maria’s story demonstrates that an individual’s SRH decisions are not made in isolation, free from the influence of social norms and national laws. Far too many women experience their sexuality in the context of individual and structural violence, such as VAW and gender inequality. This case highlights the contextual risk factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion; we must continue to critically investigate these factors to ensure that experiences like Ana Maria’s do not become further normalized in Nicaragua. Due to restrictive social norms around SRH, Ana Maria grew up experiencing stigma and taboo associated with sex, sexuality, contraceptive use and abortion. She also lacked access to information regarding SRH, healthy relationships, and how to respond to VAW before she was assaulted. After her assault, she did not have access to post-rape care, emergency contraception, safe abortion services, or mental health services to help her process this trauma. Shame and fear of stigma also prevented Ana Maria from reaching out for social support from family, friends, or the health or legal system. From the legal perspective, inadequate enforcement of VAW laws and the criminalization of abortion further exacerbated the trauma Ana Maria experienced.

It would require active engagement from the Nicaraguan government to address the contextual risk factors identified herein to protect their citizens’ right to health and prevent future experiences like Ana Maria’s. These efforts are particularly relevant given recent political unrest throughout Nicaragua including anti-government protests demanding the president’s resignation. [ 35 ] Nicaraguans’ right to health is at risk not only due to the widespread violence, but also because health care workers are being dismissed and persecuted nationwide. [ 36 ] Sexual and reproductive health researchers, advocates, and the public will continue to monitor Nicaragua’s response to the immediate demands and needs of its citizens -- including the demand that Nicaraguan women like Ana Maria are able to fully exercise their sexual and reproductive rights in times of both conflict and peace.

Availability of data and materials

Deidentified data are available upon reasonable request.

Abbreviations

Committee on Civil and Political Rights

Committee on the Elimination of all forms of Discrimination Against Women

In-Depth Interviews

Postabortion Care

Post-Traumatic Stress Disorder

Socioeconomic Status

Sexual and Reproductive Health

United Nations

Violence Against Women

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Acknowledgements

The authors thank the research team and in-country collaborators from Proyecto Paz y Amistad, as well as the Emory University Global Field Experience (GFE) Fund and the Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund for financially supporting this project. We are also grateful to Ellen Chiang for her editorial support.

This study was funded with support from the Emory University Global Field Experience (GFE) Fund and the Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund. The funders did not play any direct role in the design of the study; the collection, analysis, and interpretation of data; or the writing of the manuscript.

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All authors contributed extensively to the work presented in this manuscript. SML, DPE, and RWR jointly designed the study. SML performed data collection and data analysis. SML and DPE wrote the manuscript with significant input from RWR. DPE and RWR also provided support and supervision throughout the study. All authors read and approved the final manuscript.

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Emory University’s Institutional Review Board found the study exempt from review because it did not meet the definition of “research” with human subjects as set forth in Emory policies and procedures and federal rules. The authors partnered with Proyecto Paz y Amistad, a local organization to design and implement this study. Proyecto Paz y Amistad deferred to the Emory University IRB’s determination. Nicaragua is notably absent from the US Department of Health and Human Services, International Compilation of Human Research Standards ( https://www.hhs.gov/ohrp/sites/default/files/2018-International-Compilation-of-Human-Research-Standards.pdf ). To our knowledge, there were no existing national level human subjects requirements or exemptions at the time of data collection.

Though the project was exempt from full review by Emory University’s Institutional Review Board, procedural steps were taken to protect the rights of participants and ensure confidentiality throughout data collection, management, and analysis. Verbal informed consent was acquired from all participants before the IDIs were conducted and each participant signed a waiver to participate.

Due to the sensitive nature of this work, individual partners at Proyeto Paz y Amistad have asked not be named publicly as authors on this work, although their partnership was instrumental in the implementation of this study.

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Luffy, S.M., Evans, D.P. & Rochat, R.W. “Regardless, you are not the first woman”: an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua. BMC Women's Health 19 , 76 (2019). https://doi.org/10.1186/s12905-019-0771-9

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Public Health in the Field: The Public Health Case for Abortion Rights

Annalies Winny

Lindsay Smith Rogers

This article is adapted from a special episode of the Public Health On Call Podcast called Public Health in the Field. You can hear the full episode here .

Please note: Throughout this article, the gendered terms “woman” and “women” are used as that’s how the CDC and other sources record related data. 

More coverage:

• Overturning Roe v. Wade and Public Health
• What We Know—and Don't Yet Know—About The Leaked Supreme Court Draft Opinion That Could Overturn Roe v. Wade

A single case before the Supreme Court will likely decide the future of Roe v. Wade.

In 2018, the Mississippi legislature passed and the governor signed House Bill 1510, known as the  Gestational Age Act , which bans abortions after 15 weeks. There are exceptions if the life of the fetus or parent is at risk—but not in cases of rape or incest. The law violated Roe v. Wade, a Supreme Court decision that protects the right to abortion prior to “viability” of the fetus, which is at around 24 weeks. The bill was quickly blocked by lower federal courts but now the law’s fate is up to the Supreme Court.

The outcome of this case— Dobbs v. Jackson Women’s Health Organization —has implications for abortion rights far beyond Mississippi: A decision that previability bans are not unconstitutional could upend longstanding protections established by Roe v. Wade, the 1973 landmark case that legalized abortion nationwide. 

The conversation about abortion rights in the U.S. is a noisy one involving politics, precedents, and personal beliefs. What often gets short shrift, however, is the public health reality that restricting access to abortion results in erosion of the health of women, especially low-income and women of color. This is why abortion is so much more than a legal battle. 

The Public Health Case for Abortion Rights

Many women who were denied wanted abortions had higher levels of household poverty, debt, evictions, and other economic hardships and instabilities, according to Joanne Rosen , JD , associate director of the  Johns Hopkins Center for Law and the Public’s Health .

The findings come from a 10-year study,  The Turnaway Study , which followed nearly 1,000 women who either had or were denied abortions and tracked their mental and physical health and financial impacts. 

“The study also found that women who were seeking but unable to obtain abortions endured higher levels of physical violence from the men who had fathered these children,” Rosen says. “And people who were turned away when seeking abortions endured more health problems than women who were able to obtain [them], as well as more serious health problems.

“That gives you a sense of the ways in which being unable to obtain abortions had really long lasting impacts on these peoples’ lives.”

A 2020 study in the  American Journal of Preventive Medicine found that women living in states with less restrictive reproductive health policies were less likely to give birth to low-weight babies. Other research  published in The Lancet found that restrictive abortion laws actually mean a higher rate of abortion-related maternal deaths.

Restrictive abortion laws affect more than just the health of individuals and families—they affect the economy, too. Research from The Lancet found that “ensuring women’s access to safe abortion services does lower medical costs for health systems.”  

The  Institute for Women’s Policy Research has a host of data around how reproductive health restrictions impact women’s earning potential, including an interactive map tool, Total Economic Losses Due to State-level Abortion Restrictions. In Mississippi , for example, the data indicate that an absence of abortion restrictions would translate to a 1.8% increase of Black women in the labor force, over 2% for Hispanic women, and a leap of more than 2.6% for women who identify as Asian-Pacific Islander. This same tool calculates that removing abortion restrictions would translate to an estimated $13.4 million in increased earnings at the state level for Black women alone. 

Abortion restrictions disproportionately affect people of color and those with low-incomes. According to  data from the CDC , Black women are five times more likely to have an abortion than white women, and Latinx women are two times as likely as whites. Seventy-five percent of people who have abortions are low-income or poor. 

Mississippi, Texas, and The Supreme Court   

On December 1, the Supreme Court will hear Dobbs v. Jackson Women’s Health Organization and Joanne Rosen thinks it’s unlikely the Court would agree to hear the case if they were just going to affirm the status quo. 

The case isn’t the only one on the docket, however. Texas’ Senate Bill 8, which bans abortion after six weeks of pregnancy, made headlines earlier this month and may impact SCOTUS’ ultimate decision on the Mississippi case. The high-profile law came before the Supreme Court in November 2021 and Rosen said the important thing to note is that the Court didn’t actually address whether the six-week ban is constitutional. Rather, they examined the unusual enforcement scheme of the law—where, when, and by whom the Texas law could be challenged.

Rosen says that the justices may compare the Texas law with the Mississippi law and, when considering a six-week abortion ban, a 15-week ban may seem less extreme. In this way, the Texas case could give the Court some cover to uphold Mississippi’s 15-week ban.

It’s likely to be months before an opinion is released; Rosen says the Court typically releases its decisions on high-stakes or controversial cases in June. And high stakes this is: for the future of abortion, for reproductive health rights, and for public health. 

Annalies Winny is an associate editor for  Global Health NOW . 

Alissa Zhu is a journalist and current  MSPH student at the Bloomberg School.

Lindsay Smith Rogers, MA, is the producer of the  Public Health On Call podcast and the associate director of content strategy for the Johns Hopkins Bloomberg School of Public Health.

RELATED CONTENT:

• Public Health Law Experts Discuss the Supreme Court Vacancy and Barrett Nomination

Public Health On Call

This article is adapted from a special episode of the  Public Health On Call Podcast  called Public Health in the Field.

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The public health case for abortion rights

Joanne rosen from the johns hopkins center for law and the public's health discusses dobbs v. jackson women's health organization, which heads to the supreme court dec. 1.

By Annalies Winny, Alissa Zhu, and Lindsay Smith Rogers

This article is adapted from a special episode of the Public Health On Call podcast called Public Health in the Field. Hear the full episode online .

Editor's note: The terms "woman" and "women" are used throughout this article because that is how the CDC and other sources record related data.

A potentially landmark battle is in play over abortion rights, and it's headed to the U.S. Supreme Court on Dec. 1.

In 2018, the Mississippi legislature passed and the governor signed House Bill 1510, known as the Gestational Age Act, which bans abortions after 15 weeks. There are exceptions if the life of the fetus or parent is at risk—but not in cases of rape or incest. The law violated Roe v. Wade, the 1973 Supreme Court decision that legalized abortion nationwide and protects the right to abortion prior to "viability" of the fetus, which is at around 24 weeks. House Bill 1510 was quickly blocked by lower federal courts but now the law's fate is up to the Supreme Court.

The outcome of this case—Dobbs v. Jackson Women's Health Organization—has implications for abortion rights far beyond Mississippi: A decision that previability bans are not unconstitutional could upend longstanding protections established by Roe v. Wade.

The conversation about abortion rights in the U.S. is a noisy one involving politics, precedents, and personal beliefs. What often gets short shrift, however, is the public health reality that restricting access to abortion frequently results in erosion of the health of women, especially low-income women and women of color. This is why abortion is so much more than a legal battle.

According to The Turnaway Study , a 10-year study that followed nearly 1,000 women who either had or were denied abortions, any women who were denied wanted abortions had higher levels of household poverty, debt, evictions, and other economic hardships and instabilities, says Joanne Rosen , associate director of the Johns Hopkins Center for Law and the Public's Health.

"The study also found that women who were seeking but unable to obtain abortions endured higher levels of physical violence from the men who had fathered these children," Rosen says. "And people who were turned away when seeking abortions endured more health problems than women who were able to obtain [them], as well as more serious health problems. That gives you a sense of the ways in which being unable to obtain abortions had really long lasting impacts on these peoples' lives."

A 2020 study in the American Journal of Preventive Medicine found that women living in states with less restrictive reproductive health policies were less likely to give birth to low-weight babies. Other research published in The Lancet found that restrictive abortion laws actually mean a higher rate of abortion-related maternal deaths.

Restrictive abortion laws affect more than just the health of individuals and families—they affect the economy, too. Research from The Lancet found that "ensuring women's access to safe abortion services does lower medical costs for health systems."

The Institute for Women's Policy Research has a host of data around how reproductive health restrictions impact women's earning potential, including an interactive map tool, Total Economic Losses Due to State-level Abortion Restrictions. In Mississippi, for example, the data indicate that removing restrictions to abortion would translate to a 1.8% increase of Black women in the labor force, over 2% for Hispanic women, and a leap of more than 2.6% for women who identify as Asian-Pacific Islander. This same tool calculates that removing restrictions on abortion access would translate to an estimated $13.4 million in increased earnings at the state level for Black women alone.

Abortion restrictions disproportionately affect people of color and those with low-incomes. According to data from the CDC, Black women are five times more likely to have an abortion than white women, and Latinx women are two times as likely as whites. Seventy-five percent of people who have abortions are low-income or poor.

Mississippi, Texas, and the Supreme Court

On Dec. 1, the Supreme Court will hear Dobbs v. Jackson Women's Health Organization and Rosen thinks it's unlikely the court would agree to hear the case if they were just going to affirm the status quo.

The case isn't the only one on the docket, however. Texas' Senate Bill 8, which bans abortion after six weeks of pregnancy, made headlines earlier this month and may impact the court's ultimate decision on the Mississippi case. The high-profile law came before the Supreme Court in November 2021 and Rosen said the important thing to note is that the justices didn't actually address whether the six-week ban is constitutional. Rather, they examined the unusual enforcement scheme of the law—where, when, and by whom the Texas law could be challenged.

Rosen says that the justices may compare the Texas law with the Mississippi law and, when considering a six-week abortion ban, a 15-week ban may seem less extreme. In this way, the Texas case could give the court some cover to uphold Mississippi's 15-week ban.

It's likely to be months before an opinion is released; Rosen says the court typically releases its decisions on high-stakes or controversial cases in June. And high stakes this is: for the future of abortion, for reproductive health rights, and for public health.

Posted in Health , Politics+Society

Tagged supreme court , reproductive health , abortion

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The Most Important Study in the Abortion Debate

Researchers rigorously tested the persistent notion that abortion wounds the women who seek it.

The demographer Diana Greene Foster was in Orlando last month, preparing for the end of Roe v. Wade , when Politico published a leaked draft of a majority Supreme Court opinion striking down the landmark ruling. The opinion, written by Justice Samuel Alito, would revoke the constitutional right to abortion and thus give states the ability to ban the medical procedure.

Foster, the director of the Bixby Population Sciences Research Unit at UC San Francisco, was at a meeting of abortion providers, seeking their help recruiting people for a new study . And she was racing against time. She wanted to look, she told me, “at the last person served in, say, Nebraska, compared to the first person turned away in Nebraska.” Nearly two dozen red and purple states are expected to enact stringent limits or even bans on abortion as soon as the Supreme Court strikes down Roe v. Wade , as it is poised to do. Foster intends to study women with unwanted pregnancies just before and just after the right to an abortion vanishes.

Read: When a right becomes a privilege

When Alito’s draft surfaced, Foster told me, “I was struck by how little it considered the people who would be affected. The experience of someone who’s pregnant when they do not want to be and what happens to their life is absolutely not considered in that document.” Foster’s earlier work provides detailed insight into what does happen. The landmark Turnaway Study , which she led, is a crystal ball into our post- Roe future and, I would argue, the single most important piece of academic research in American life at this moment.

The legal and political debate about abortion in recent decades has tended to focus more on the rights and experience of embryos and fetuses than the people who gestate them. And some commentators—including ones seated on the Supreme Court—have speculated that termination is not just a cruel convenience, but one that harms women too . Foster and her colleagues rigorously tested that notion. Their research demonstrates that, in general, abortion does not wound women physically, psychologically, or financially. Carrying an unwanted pregnancy to term does.

In a 2007 decision , Gonzales v. Carhart , the Supreme Court upheld a ban on one specific, uncommon abortion procedure. In his majority opinion , Justice Anthony Kennedy ventured a guess about abortion’s effect on women’s lives: “While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort the infant life they once created and sustained,” he wrote. “Severe depression and loss of esteem can follow.”

Was that really true? Activists insisted so, but social scientists were not sure . Indeed, they were not sure about a lot of things when it came to the effect of the termination of a pregnancy on a person’s life. Many papers compared individuals who had an abortion with people who carried a pregnancy to term. The problem is that those are two different groups of people; to state the obvious, most people seeking an abortion are experiencing an unplanned pregnancy, while a majority of people carrying to term intended to get pregnant.

Foster and her co-authors figured out a way to isolate the impact of abortion itself. Nearly all states bar the procedure after a certain gestational age or after the point that a fetus is considered viable outside the womb . The researchers could compare people who were “turned away” by a provider because they were too far along with people who had an abortion at the same clinics. (They did not include people who ended a pregnancy for medical reasons.) The women who got an abortion would be similar, in terms of demographics and socioeconomics, to those who were turned away; what would separate the two groups was only that some women got to the clinic on time, and some didn’t.

In time, 30 abortion providers—ones that had the latest gestational limit of any clinic within 150 miles, meaning that a person could not easily access an abortion if they were turned away—agreed to work with the researchers. They recruited nearly 1,000 women to be interviewed every six months for five years. The findings were voluminous, resulting in 50 publications and counting. They were also clear. Kennedy’s speculation was wrong: Women, as a general point, do not regret having an abortion at all.

Researchers found, among other things, that women who were denied abortions were more likely to end up living in poverty. They had worse credit scores and, even years later, were more likely to not have enough money for the basics, such as food and gas. They were more likely to be unemployed. They were more likely to go through bankruptcy or eviction. “The two groups were economically the same when they sought an abortion,” Foster told me. “One became poorer.”

Read: The calamity of unwanted motherhood

In addition, those denied a termination were more likely to be with a partner who abused them. They were more likely to end up as a single parent. They had more trouble bonding with their infants, were less likely to agree with the statement “I feel happy when my child laughs or smiles,” and were more likely to say they “feel trapped as a mother.” They experienced more anxiety and had lower self-esteem, though those effects faded in time. They were half as likely to be in a “very good” romantic relationship at two years. They were less likely to have “aspirational” life plans.

Their bodies were different too. The ones denied an abortion were in worse health, experiencing more hypertension and chronic pain. None of the women who had an abortion died from it. This is unsurprising; other research shows that the procedure has extremely low complication rates , as well as no known negative health or fertility effects . Yet in the Turnaway sample, pregnancy ended up killing two of the women who wanted a termination and did not get one.

The Turnaway Study also showed that abortion is a choice that women often make in order to take care of their family. Most of the women seeking an abortion were already mothers. In the years after they terminated a pregnancy, their kids were better off; they were more likely to hit their developmental milestones and less likely to live in poverty. Moreover, many women who had an abortion went on to have more children. Those pregnancies were much more likely to be planned, and those kids had better outcomes too.

The interviews made clear that women, far from taking a casual view of abortion, took the decision seriously. Most reported using contraception when they got pregnant, and most of the people who sought an abortion after their state’s limit simply did not realize they were pregnant until it was too late. (Many women have irregular periods, do not experience morning sickness, and do not feel fetal movement until late in the second trimester.) The women gave nuanced, compelling reasons for wanting to end their pregnancies.

Afterward, nearly all said that termination had been the right decision. At five years, only 14 percent felt any sadness about having an abortion; two in three ended up having no or very few emotions about it at all. “Relief” was the most common feeling, and an abiding one.

From the May 2022 issue: The future of abortion in a post- Roe America

The policy impact of the Turnaway research has been significant, even though it was published during a period when states have been restricting abortion access. In 2018, the Iowa Supreme Court struck down a law requiring a 72-hour waiting period between when a person seeks and has an abortion, noting that “the vast majority of abortion patients do not regret the procedure, even years later, and instead feel relief and acceptance”—a Turnaway finding. That same finding was cited by members of Chile’s constitutional court  as they allowed for the decriminalization of abortion in certain circumstances.

Yet the research has not swayed many people who advocate for abortion bans, believing that life begins at conception and that the law must prioritize the needs of the fetus. Other activists have argued that Turnaway is methodologically flawed; some women approached in the clinic waiting room declined to participate, and not all participating women completed all interviews . “The women who anticipate and experience the most negative reactions to abortion are the least likely to want to participate in interviews,” the activist David Reardon argued in a 2018 article in a Catholic Medical Association journal.

Still, four dozen papers analyzing the Turnaway Study’s findings have been published in peer-reviewed journals; the research is “the gold standard,” Emily M. Johnston, an Urban Institute health-policy expert who wasn’t involved with the project, told me. In the trajectories of women who received an abortion and those who were denied one, “we can understand the impact of abortion on women’s lives,” Foster told me. “They don’t have to represent all women seeking abortion for the findings to be valid.” And her work has been buttressed by other surveys, showing that women fear the repercussions of unplanned pregnancies for good reason and do not tend to regret having a termination. “Among the women we spoke with, they did not regret either choice,” whether that was having an abortion or carrying to term, Johnston told me. “These women were thinking about their desires for themselves, but also were thinking very thoughtfully about what kind of life they could provide for a child.”

The Turnaway study , for Foster, underscored that nobody needs the government to decide whether they need an abortion. If and when America’s highest court overturns Roe , though, an estimated 34 million women of reproductive age will lose some or all access to the procedure in the state where they live. Some people will travel to an out-of-state clinic to terminate a pregnancy; some will get pills by mail to manage their abortions at home; some will “try and do things that are less safe,” as Foster put it. Many will carry to term: The Guttmacher Institute has estimated that there will be roughly 100,000 fewer legal abortions per year post- Roe . “The question now is who is able to circumvent the law, what that costs, and who suffers from these bans,” Foster told me. “The burden of this will be disproportionately put on people who are least able to support a pregnancy and to support a child.”

Ellen Gruber Garvey: I helped women get abortions in pre- Roe America

Foster said that there is a lot we still do not know about how the end of Roe might alter the course of people’s lives—the topic of her new research. “In the Turnaway Study, people were too late to get an abortion, but they didn’t have to feel like the police were going to knock on their door,” she told me. “Now, if you’re able to find an abortion somewhere and you have a complication, do you get health care? Do you seek health care out if you’re having a miscarriage, or are you too scared? If you’re going to travel across state lines, can you tell your mother or your boss what you’re doing?”

In addition, she said that she was uncertain about the role that abortion funds —local, on-the-ground organizations that help people find, travel to, and pay for terminations—might play. “We really don’t know who is calling these hotlines,” she said. “When people call, what support do they need? What is enough, and who falls through the cracks?” She added that many people are unaware that such services exist, and might have trouble accessing them.

People are resourceful when seeking a termination and resilient when denied an abortion, Foster told me. But looking into the post- Roe future, she predicted, “There’s going to be some widespread and scary consequences just from the fact that we’ve made this common health-care practice against the law.” Foster, to her dismay, is about to have a lot more research to do.

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Ross Douthat

The Case Against Abortion

By Ross Douthat

Opinion Columnist

A striking thing about the American abortion debate is how little abortion itself is actually debated. The sensitivity and intimacy of the issue, the mixed feelings of so many Americans, mean that most politicians and even many pundits really don’t like to talk about it.

The mental habits of polarization, the assumption that the other side is always acting with hidden motives or in bad faith, mean that accusations of hypocrisy or simple evil are more commonplace than direct engagement with the pro-choice or pro-life argument.

And the Supreme Court’s outsize role in abortion policy means that the most politically important arguments are carried on by lawyers arguing constitutional theory, at one remove from the real heart of the debate.

But with the court set this week to hear Dobbs v. Jackson Women’s Health Organization, a direct challenge to Roe v. Wade, it seems worth letting the lawyers handle the meta-arguments and writing about the thing itself. So this essay will offer no political or constitutional analysis. It will simply try to state the pro-life case.

At the core of our legal system, you will find a promise that human beings should be protected from lethal violence. That promise is made in different ways by the Constitution and the Declaration of Independence; it’s there in English common law, the Ten Commandments and the Universal Declaration of Human Rights. We dispute how the promise should be enforced, what penalties should be involved if it is broken and what crimes might deprive someone of the right to life. But the existence of the basic right, and a fundamental duty not to kill, is pretty close to bedrock.

There is no way to seriously deny that abortion is a form of killing. At a less advanced stage of scientific understanding, it was possible to believe that the embryo or fetus was somehow inert or vegetative until so-called quickening, months into pregnancy. But we now know the embryo is not merely a cell with potential, like a sperm or ovum, or a constituent part of human tissue, like a skin cell. Rather, a distinct human organism comes into existence at conception, and every stage of your biological life, from infancy and childhood to middle age and beyond, is part of a single continuous process that began when you were just a zygote.

We know from embryology, in other words, not Scripture or philosophy, that abortion kills a unique member of the species Homo sapiens, an act that in almost every other context is forbidden by the law.

This means that the affirmative case for abortion rights is inherently exceptionalist, demanding a suspension of a principle that prevails in practically every other case. This does not automatically tell against it; exceptions as well as rules are part of law. But it means that there is a burden of proof on the pro-choice side to explain why in this case taking another human life is acceptable, indeed a protected right itself.

One way to clear this threshold would be to identify some quality that makes the unborn different in kind from other forms of human life — adult, infant, geriatric. You need an argument that acknowledges that the embryo is a distinct human organism but draws a credible distinction between human organisms and human persons , between the unborn lives you’ve excluded from the law’s protection and the rest of the human race.

In this kind of pro-choice argument and theory, personhood is often associated with some property that’s acquired well after conception: cognition, reason, self-awareness, the capacity to survive outside the womb. And a version of this idea, that human life is there in utero but human personhood develops later, fits intuitively with how many people react to a photo of an extremely early embryo ( It doesn’t look human, does it? ) — though less so to a second-trimester fetus, where the physical resemblance to a newborn is more palpable.

But the problem with this position is that it’s hard to identify exactly what property is supposed to do the work of excluding the unborn from the ranks of humans whom it is wrong to kill. If full personhood is somehow rooted in reasoning capacity or self-consciousness, then all manner of adult human beings lack it or lose it at some point or another in their lives. If the capacity for survival and self-direction is essential, then every infant would lack personhood — to say nothing of the premature babies who are unviable without extreme medical interventions but regarded, rightly, as no less human for all that.

At its most rigorous, the organism-but-not-person argument seeks to identify some stage of neurological development that supposedly marks personhood’s arrival — a transition equivalent in reverse to brain death at the end of life. But even setting aside the practical difficulties involved in identifying this point, we draw a legal line at brain death because it’s understood to be irreversible, the moment at which the human organism’s healthy function can never be restored. This is obviously not the case for an embryo on the cusp of higher brain functioning — and if you knew that a brain-dead but otherwise physically healthy person would spontaneously regain consciousness in two weeks, everyone would understand that the caregivers had an obligation to let those processes play out.

Or almost everyone, I should say. There are true rigorists who follow the logic of fetal nonpersonhood toward repugnant conclusions — for instance, that we ought to permit the euthanizing of severely disabled newborns, as the philosopher Peter Singer has argued. This is why abortion opponents have warned of a slippery slope from abortion to infanticide and involuntary euthanasia; as pure logic, the position that unborn human beings aren’t human persons can really tend that way.

But to their credit, only a small minority of abortion-rights supporters are willing to be so ruthlessly consistent. Instead, most people on the pro-choice side are content to leave their rules of personhood a little hazy, and combine them with the second potent argument for abortion rights: namely, that regardless of the precise moral status of unborn human organisms, they cannot enjoy a legal right to life because that would strip away too many rights from women.

A world without legal abortion, in this view, effectively consigns women to second-class citizenship — their ambitions limited, their privacy compromised, their bodies conscripted, their claims to full equality a lie. These kind of arguments often imply that birth is the most relevant milestone for defining legal personhood — not because of anything that happens to the child but because it’s the moment when its life ceases to impinge so dramatically on its mother.

There is a powerful case for some kind of feminism embedded in these claims. The question is whether that case requires abortion itself.

Certain goods that should be common to men and women cannot be achieved, it’s true, if the law simply declares the sexes equal without giving weight to the disproportionate burdens that pregnancy imposes on women. Justice requires redistributing those burdens, through means both traditional and modern — holding men legally and financially responsible for all the children that they father and providing stronger financial and social support for motherhood at every stage.

But does this kind of justice for women require legal indifference to the claims of the unborn? Is it really necessary to found equality for one group of human beings on legal violence toward another, entirely voiceless group?

We have a certain amount of practical evidence that suggests the answer is no. Consider, for instance, that between the early 1980s and the later 2010s the abortion rate in the United States fell by more than half . The reasons for this decline are disputed, but it seems reasonable to assume that it reflects a mix of cultural change, increased contraception use and the effects of anti-abortion legal strategies, which have made abortion somewhat less available in many states, as pro-choice advocates often lament.

If there were an integral and unavoidable relationship between abortion and female equality, you would expect these declines — fewer abortions, diminished abortion access — to track with a general female retreat from education and the workplace. But no such thing has happened: Whether measured by educational attainment, managerial and professional positions, breadwinner status or even political office holding, the status of women has risen in the same America where the pro-life movement has (modestly) gained ground.

Of course, it’s always possible that female advancement would have been even more rapid, the equality of the sexes more fully and perfectly established, if the pro-life movement did not exist. Certainly in the individual female life trajectory, having an abortion rather than a baby can offer economic and educational advantages.

On a collective level, though, it’s also possible that the default to abortion as the solution to an unplanned pregnancy actually discourages other adaptations that would make American life friendlier to women. As Erika Bachiochi wrote recently in National Review , if our society assumes that “abortion is what enables women to participate in the workplace,” then corporations may prefer the abortion default to more substantial accommodations like flexible work schedules and better pay for part-time jobs — relying on the logic of abortion rights, in other words, as a reason not to adapt to the realities of childbearing and motherhood.

At the very least, I think an honest look at the patterns of the past four decades reveals a multitude of different ways to offer women greater opportunities, a multitude of paths to equality and dignity — a multitude of ways to be a feminist, in other words, that do not require yoking its idealistic vision to hundreds of thousands of acts of violence every year.

It’s also true, though, that nothing in all that multitude of policies will lift the irreducible burden of childbearing, the biological realities that simply cannot be redistributed to fathers, governments or adoptive parents. And here, too, a portion of the pro-choice argument is correct: The unique nature of pregnancy means that there has to be some limit on what state or society asks of women and some zone of privacy where the legal system fears to tread.

This is one reason the wisest anti-abortion legislation — and yes, pro-life legislation is not always wise — criminalizes the provision of abortion by third parties, rather than prosecuting the women who seek one. It’s why anti-abortion laws are rightly deemed invasive and abusive when they lead to the investigation of suspicious-seeming miscarriages. It’s why the general principle of legal protection for human life in utero may or must understandably give way in extreme cases, extreme burdens: the conception by rape, the life-threatening pregnancy.

At the same time, though, the pro-choice stress on the burden of the ordinary pregnancy can become detached from the way that actual human beings experience the world. In a famous thought experiment, the philosopher Judith Jarvis Thomson once analogized an unplanned pregnancy to waking up with a famous violinist hooked up to your body, who will die if he’s disconnected before nine months have passed. It’s a vivid science-fiction image but one that only distantly resembles the actual thing that it describes — a new life that usually exists because of a freely chosen sexual encounter, a reproductive experience that if material circumstances were changed might be desired and celebrated, a “disconnection” of the new life that cannot happen without lethal violence and a victim who is not some adult stranger but the woman’s child.

One can accept pro-choice logic, then, insofar as it demands a sphere of female privacy and warns constantly against the potential for abuse, without following that logic all the way to a general right to abort an unborn human life. Indeed, this is how most people approach similar arguments in other contexts. In the name of privacy and civil liberties we impose limits on how the justice system polices and imprisons, and we may celebrate activists who try to curb that system’s manifest abuses. But we don’t (with, yes, some anarchist exceptions) believe that we should remove all legal protections for people’s property or lives.

That removal of protection would be unjust no matter what its consequences, but in reality we know that those consequences would include more crime, more violence and more death. And the anti-abortion side can give the same answer when it’s asked why we can’t be content with doing all the other things that may reduce abortion rates and leaving legal protection out of it: Because while legal restrictions aren’t sufficient to end abortion, there really are a lot of unborn human lives they might protect.

Consider that when the State of Texas put into effect this year a ban on most abortions after about six weeks, the state’s abortions immediately fell by half. I think the Texas law, which tries to evade the requirements of Roe v. Wade and Planned Parenthood v. Casey by using private lawsuits for enforcement, is vulnerable to obvious critiques and liable to be abused. It’s not a model I would ever cite for pro-life legislation.

But that immediate effect, that sharp drop in abortions, is why the pro-life movement makes legal protection its paramount goal.

According to researchers at the University of Texas at Austin, who surveyed the facilities that provide about 93 percent of all abortions in the state, there were 2,149 fewer legal abortions in Texas in the month the law went into effect than in the same month in 2020.

About half that number may end up still taking place, some estimates suggest, many of them in other states. But that still means that in a matter of months, more than a thousand human beings will exist as legal persons, rights-bearing Texans — despite still being helpless, unreasoning and utterly dependent — who would not have existed had this law not given them protection.

But, in fact, they exist already. They existed, at our mercy, all along.

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Ross Douthat has been an Opinion columnist for The Times since 2009. He is the author of several books, most recently, “The Deep Places: A Memoir of Illness and Discovery.” @ DouthatNYT • Facebook

What can economic research tell us about the effect of abortion access on women’s lives?

Subscribe to the center for economic security and opportunity newsletter, caitlin knowles myers and caitlin knowles myers john g. mccullough professor of economics; co-director, middlebury initiative for data and digital methods - middlebury college @caitlin_k_myers morgan welch morgan welch senior research assistant & project coordinator - center on children and families, economic studies, brookings institution.

November 30, 2021

• 21 min read

On September 20, 2021, a group of 154 distinguished economists and researchers filed an amicus brief to the Supreme Court of the United States in advance of the Mississippi case, Dobbs v. Jackson Women’s Health Organization . For a full review of the evidence that shows how causal inference tools have been used to measure the effects of abortion access in the U.S., read the brief here .

Introduction

Dobbs v. Jackson Women’s Health Organization considers the constitutionality of a 2018 Mississippi law that prohibits women from accessing abortions after 15 weeks of pregnancy. This case is widely expected to determine the fate of Roe v. Wade as Mississippi is directly challenging the precedent set by the Supreme Court’s decisions in Roe , which protects abortion access before fetal viability (typically between 24 and 28 weeks of pregnancy). On December 1, 2021, the Supreme Court will hear oral arguments in Dobbs v. Jackson . In asking the Court to overturn Roe , the state of Mississippi offers reassurances that “there is simply no causal link between the availability of abortion and the capacity of women to act in society” 1 and hence no reason to believe that abortion access has shaped “the ability of women to participate equally in the economic and social life of the Nation” 2 as the Court had previously held.

While the debate over abortion often centers on largely intractable subjective questions of ethics and morality, in this instance the Court is being asked to consider an objective question about the causal effects of abortion access on the lives of women and their families. The field of economics affords insights into these objective questions through the application of sophisticated methodological approaches that can be used to isolate and measure the causal effects of abortion access on reproductive, social, and economic outcomes for women and their families.

Separating Correlation from Causation: The “Credibility Revolution” in Economics

To measure the causal effect of abortion on women’s lives, one must differentiate its effects from those of other forces, such as economic opportunity, social mores, the availability of contraception. Powerful statistical methodologies in the causal inference toolbox have made it possible for economists to do just that, moving beyond the maxim “correlation isn’t necessarily causation” and applying the scientific method to figure out when it is.

This year’s decision by the Economic Sciences Prize Committee recognized the contributions 3 of economists David Card, Joshua Angrist, and Guido Imbens, awarding them the Nobel Prize for their pathbreaking work developing and applying the tools of causal inference in a movement dubbed “the credibility revolution” (Angrist and Pischke, 2010). The gold standard for establishing such credibility is a well-executed randomized controlled trial – an experiment conducted in the lab or field in which treatment is randomly assigned. When economists can feasibly and ethically implement such experiments, they do. However, in the social world, this opportunity is often not available. For instance, one cannot feasibly or ethically randomly assign abortion access to some individuals but not others. Faced with this obstacle, economists turn to “natural” or “quasi” experimental methods, ones in which they are able to credibly argue that treatment is as good as randomly assigned.

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Pioneering applications of this approach include work by Angrist and Krueger (1991) leveraging variation in compulsory school attendance laws to measure the effects of schooling on earnings and work by Card and Krueger (1994) leveraging minimum wage variation across state borders to measure the effects of the minimum wages on employment outcomes. The use of these methods is now widespread, not just in economics, but in other social sciences as well. Fueled by advances in computing technology and the availability of data, quasi-experimental methodologies have become as ubiquitous as they are powerful, applied to answer questions ranging from the effects of economic shocks on civil conflict (Miguel, Sayanath, and Sergenti, 2004), to the effects of the Clean Water Act on water pollution levels (Keiser and Shapiro, 2019), and effects of access to food stamps in childhood on later life outcomes (Hoynes, Schanzenbach, Almond 2016; Bailey et al., 2020).

Research demonstrates that abortion access does, in fact, profoundly affect women’s lives by determining whether, when, and under what circumstances they become mothers.

Economists also have applied these tools to study the causal effects of abortion access. Research drawing on methods from the “credibility revolution” disentangles the effects of abortion policy from other societal and economic forces. This research demonstrates that abortion access does, in fact, profoundly affect women’s lives by determining whether, when, and under what circumstances they become mothers, outcomes which then reverberate through their lives, affecting marriage patterns, educational attainment, labor force participation, and earnings.

The Effects of Abortion Access on Women’s Reproductive, Economic, and Social Lives

Evidence of the effects of abortion legalization.

The history of abortion legalization in the United States affords both a canonical and salient example of a natural experiment. While Roe v. Wade legalized abortion in most of the country in 1973, five states—Alaska, California, Hawaii, New York, and Washington—and the District of Columbia repealed their abortion bans several years in advance of Roe . Using a methodology known as “difference-in-difference estimation,” researchers compared changes in outcomes in these “repeal states” when they lifted abortion bans to changes in outcomes in the rest of the country. They also compared changes in outcomes in the rest of the country in 1973 when Roe legalized abortion to changes in outcomes in the repeal states where abortion already was legal. This difference-in-differences methodology allows the states where abortion access is not changing to serve as a counterfactual or “control” group that accounts for other forces that were impacting fertility and women’s lives in the Roe era.

Among the first to employ this approach was a team of economists (Levine, Staiger, Kane, and Zimmerman, 1999) who estimated that the legalization of abortion in repeal states led to a 4% to 11% decline in births in those states relative to the rest of the country. Levine and his co-authors found that these fertility effects were particularly large for teens and women of color, who experienced birth rate reductions that were nearly three times greater than the overall population as a result of abortion legalization. Multiple research teams have replicated the essential finding that abortion legalization substantially impacted American fertility while extending the analysis to consider other outcomes. 4 For example, Myers (2017) found that abortion legalization reduced the number of women who became teen mothers by 34% and the number who became teen brides by 20%, and again observed effects that were even larger for Black teens. Farin, Hoehn-Velasco, and Pesko (2021) found that abortion legalization reduced maternal mortality among Black women by 30-40%, with little impact on white women, offering the explanation that where abortion was illegal, Black women were less likely to be able to access safe abortions by traveling to other states or countries or by obtaining a clandestine abortion from a trusted health care provider.

The ripple effects of abortion access on the lives of women and their families

This research, which clearly demonstrates the causal relationship between abortion access and first-order demographic and health outcomes, laid the foundation for researchers ­to measure further ripple effects through the lives of women and their families. Multiple teams of authors have extended the difference-in-differences research designs to study educational and labor market outcomes, finding that abortion legalization increased women’s education, labor force participation, occupational prestige, and earnings and that all these effects were particularly large for Black women (Angrist and Evans, 1996; Kalist, 2004; Lindo, Pineda-Torres, Pritchard, and Tajali, 2020; Jones, 2021).

Additionally, research shows that abortion access has not only had profound effects on women’s economic and social lives but has also impacted the circumstances into which children are born. Researchers using difference-in-differences research designs have found that abortion legalization reduced the number of children who were unwanted (Bitler and Zavodny, 2002a, reduced cases of child neglect and abuse (Bitler and Zavodny, 2002b; 2004), reduced the number of children who lived in poverty (Gruber, Levine, and Staiger, 1999), and improved long-run outcomes of an entire generation of children by increasing the likelihood of attending college and reducing the likelihood of living in poverty and receiving public assistance (Ananat, Gruber, Levine, and Staiger, 2009).

Access to abortion continues to be important to women’s lives

The research cited above relies on variation in abortion access from the 1970s, and much has changed in terms of both reproductive technologies and women’s lives. Recent research shows, however, that even with the social, economic, and legal shifts that have occurred over the last few decades and even with expanded access to contraception, abortion access remains relevant to women’s reproductive lives. Today, nearly half of pregnancies are unintended (Finer and Zolna, 2016). About 6% of young women (ages 15-34) experience an unintended pregnancy each year (Finer, Lindberg, and Desai, 2018), and about 1.4% of women of childbearing age obtain an abortion each year (Jones, Witwer, and Jerman, 2019). At these rates, approximately one in four women will receive an abortion in their reproductive lifetimes. The fact is clear: women continue to rely on abortion access to determine their reproductive lives.

But what about their economic and social lives? While women have made great progress in terms of their educational attainment, career trajectories, and role in society, mothers face a variety of challenges and penalties that are not adequately addressed by public policy. Following the birth of a child, it’s well documented that working mothers face a “motherhood wage penalty,” which entails lower wages than women who did not have a child (Waldfogel, 1998; Anderson, Binder, and Krause, 2002; Kelven et al., 2019). Maternity leave may combat this penalty as it allows women to return to their jobs following the birth of a child – encouraging them to remain attached to the labor force (Rossin-Slater, 2017). However, as of this writing, the U.S. only offers up to 12 weeks of unpaid leave through the FMLA, which extends coverage to less than 60% of all workers. 5 And even if a mother is able to return to work, childcare in the U.S. is costly and often inaccessible for many. Families with infants can be expected to pay around $11,000 a year for childcare and subsidies are only available for 1 in 6 children that are eligible under the federal program. 6 Without a federal paid leave policy and access to affordable childcare, the U.S. lacks the infrastructure to adequately support mothers, and especially working mothers – making the prospect of motherhood financially unworkable for some.

This is relevant when considering that the women who seek abortions tend to be low-income mothers experiencing disruptive life events. In the most recent survey of abortion patients conducted by the Guttmacher Institute, 97% are adults, 49% are living below the poverty line, 59% already have children, and 55% are experiencing a disruptive life event such as losing a job, breaking up with a partner, or falling behind on rent (Jones and Jerman, 2017a and 2017b). It is not a stretch to imagine that access to abortion could be pivotal to these women’s financial lives, and recent evidence from “The Turnaway Study” 7 provides empirical support for this supposition. In this study, an interdisciplinary team of researchers follows two groups of women who were typically seeking abortions in the second trimester: one group that arrived at abortion clinics and learned they were just over the gestational age threshold for abortions and were “turned away” and a second that was just under the threshold and were provided an abortion. Miller, Wherry, and Foster (2020) match individuals in both groups to their Experian credit reports and observe that in the months leading up to the moment they sought an abortion, financial outcomes for both groups were trending similarly. At the moment one group is turned away from a wanted abortion, however, they began to experience substantial financial distress, exhibiting a 78% increase in past-due debt and an 81% increase in public records related to bankruptcies, evictions, and court judgments.

If Roe were overturned, the number of women experiencing substantial obstacles to obtaining an abortion would dramatically increase.

If Roe were overturned, the number of women experiencing substantial obstacles to obtaining an abortion would dramatically increase. Twelve states have enacted “trigger bans” designed to outlaw abortion in the immediate aftermath of a Roe reversal, while an additional 10 are considered highly likely to quickly enact new bans. 8 These bans would shutter abortion facilities across a wide swath of the American south and midwest, dramatically increasing travel distances and the logistical costs of obtaining an abortion. Economics research predicts what is likely to happen next. Multiple teams of economists have exploited natural experiments arising from mandatory waiting periods (Joyce and Kaestner, 2001; Lindo and Pineda-Torres, 2021; Myers, 2021) and provider closures (Quast, Gonzalez, and Ziemba, 2017; Fischer, Royer, and White, 2018; Lindo, Myers, Schlosser, and Cunningham, 2020; Venator and Fletcher, 2021; Myers, 2021). All have found that increases in travel distances prevent large numbers of women seeking abortions from reaching a provider and that most of these women give birth as a result. For instance, Lindo and co-authors (2020) exploit a natural experiment arising from the sudden closure of half of Texas’s abortion clinics in 2013 and find that an increase in travel distance from 0 to 100 miles results in a 25.8% decrease in abortions. Myers, Jones, and Upadhyay (2019) use these results to envision a post- Roe United States, forecasting that if Roe is overturned and the expected states begin to ban abortions, approximately 1/3 of women living in affected regions would be unable to reach an abortion provider, amounting to roughly 100,000 women in the first year alone.

Restricting, or outright eliminating, abortion access by overturning Roe v. Wade  would diminish women’s personal and economic lives, as well as the lives of their families.

Whether one’s stance on abortion access is driven by deeply held views on women’s bodily autonomy or when life begins, the decades of research using rigorous methods is clear: there is a causal link between access to abortion and whether, when, and under what circumstances women become mothers, with ripple effects throughout their lives. Access affects their education, earnings, careers, and the subsequent life outcomes for their children. In the state’s argument, Mississippi rejects the causal link between access to abortion and societal outcomes established by economists and states that the availability of abortion isn’t relevant to women’s full participation in society. Economists provide clear evidence that overturning Roe would prevent large numbers of women experiencing unintended pregnancies—many of whom are low-income and financially vulnerable mothers—from obtaining desired abortions. Restricting, or outright eliminating, that access by overturning Roe v. Wade would diminish women’s personal and economic lives, as well as the lives of their families.

Caitlin Knowles Myers did not receive financial support from any firm or person for this article. She has received financial compensation from Planned Parenthood Federation of America and the Center for Reproductive Rights for serving as an expert witness in litigation involving abortion regulations. She has not and will not receive financial compensation for her role in the amicus brief described here. Other than the aforementioned, she has not received financial support from any firm or person with a financial or political interest in this article. Caitlin Knowles Myers is not currently an officer, director, or board member of any organization with a financial or political interest in this article.

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Jones, Kelly, 2021. “At a Crossroads: The Impact of Abortion Access on Future Economic Outcomes.” American University Working Paper . Retrieved from https://doi.org/10.17606/0Q51-0R11 .

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Jones Rachel K., and Janna Jerman, 2017a. ”Population group abortion rates and lifetime incidence of abortion: United States, 2008–2014.”  American Journal of Public Health 107 (12). Retrieved from https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2017.304042

Jones, Rachel K. and Jenna Jerman, 2017b. “Characteristics and Circumstances of U.S. Women Who Obtain Very Early and Second-Trimester Abortions.” PLoS One . Retrieved from https://pubmed.ncbi.nlm.nih.gov/28121999/

Joyce, Ted, and Robert Kaestner, 2001. “The Impact of Mandatory Waiting Periods and Parental Consent Laws on the Timing of Abortion and State of Occurrence among Adolescents in Mississippi and South Carolina.” Journal of Policy Analysis and Management 20(2) . Retrieved from https://www.jstor.org/stable/3325799 .

Kalist, David E., 2004. “Abortion and Female Labor Force Participation: Evidence Prior to Roe v. Wade.” Journal of Labor Research 25 (3) .

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Levine, Phillip, Staiger, Douglas, Kane, Thomas, and David Zimmerman, 1999. “Roe v. Wade and American Fertility.” American Journal Of Public Health 89(2) . Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1508542/

Lindo, Jason M., Myers, Caitlin Knowles, Schlosser, Andrea, and Scott Cunningham, 2020. “How Far Is Too Far? New Evidence on Abortion Clinic Closures, Access, and Abortions” Journal of Human Resources 55. Retrieved from http://jhr.uwpress.org/content/55/4/1137.refs

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• Thomas E. Dobbs v. Jackson Women’s Health Organization. On Writ of Certiorari to the United States Court of Appeals for the Fifth Circuit, Brief for Petitioners, No. 19-139, Retrieved from https://www.supremecourt.gov/DocketPDF/19/19-1392/184703/20210722161332385_19-1392BriefForPetitioners.pdf
• The Nobel Prize. 2021. “Press release: The Prize in Economic Sciences 202.” Retrieved from https://www.nobelprize.org/prizes/economic-sciences/2021/press-release/
• See Angrist and Evans (1996), Gruber et al. (1999), Ananat et al. (2009), Guldi (2008), Myers (2017), Abboud (2019), Jones (2021).
• Brown, Scott, Herr, Jane, Roy, Radha , and Jacob Alex Klerman, July 2020. “Employee and Worksite Perspectives of the FMLA Who Is Eligible?” U.S. Department of Labor. Retrieved from https://www.dol.gov/sites/dolgov/files/OASP/evaluation/pdf/WHD_FMLA2018PB1WhoIsEligible_StudyBrief_Aug2020.pdf
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• 26 October 2021

Why hundreds of scientists are weighing in on a high-stakes US abortion case

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An upcoming case in the US Supreme Court might hasten the end of abortion across roughly half of the United States — a right that the country has defended for nearly 50 years. More than 800 scientists and several scientific organizations have provided evidence to the court showing that abortion access is an important component of reproductive health care.

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Editor’s note: Nature recognizes that transgender men and non-binary people might become pregnant and seek abortion care. We use ‘women’ in this story to reflect how participants are reported in the studies we cite, and how people are referred to in court briefs.

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Reproductive rights in America

Research at the heart of a federal case against the abortion pill has been retracted.

Selena Simmons-Duffin

The Supreme Court will hear the case against the abortion pill mifepristone on March 26. It's part of a two-drug regimen with misoprostol for abortions in the first 10 weeks of pregnancy. Anna Moneymaker/Getty Images hide caption

The Supreme Court will hear the case against the abortion pill mifepristone on March 26. It's part of a two-drug regimen with misoprostol for abortions in the first 10 weeks of pregnancy.

A scientific paper that raised concerns about the safety of the abortion pill mifepristone was retracted by its publisher this week. The study was cited three times by a federal judge who ruled against mifepristone last spring. That case, which could limit access to mifepristone throughout the country, will soon be heard in the Supreme Court.

The now retracted study used Medicaid claims data to track E.R. visits by patients in the month after having an abortion. The study found a much higher rate of complications than similar studies that have examined abortion safety.

Sage, the publisher of the journal, retracted the study on Monday along with two other papers, explaining in a statement that "expert reviewers found that the studies demonstrate a lack of scientific rigor that invalidates or renders unreliable the authors' conclusions."

It also noted that most of the authors on the paper worked for the Charlotte Lozier Institute, the research arm of anti-abortion lobbying group Susan B. Anthony Pro-Life America, and that one of the original peer reviewers had also worked for the Lozier Institute.

The Sage journal, Health Services Research and Managerial Epidemiology , published all three research articles, which are still available online along with the retraction notice. In an email to NPR, a spokesperson for Sage wrote that the process leading to the retractions "was thorough, fair, and careful."

The lead author on the paper, James Studnicki, fiercely defends his work. "Sage is targeting us because we have been successful for a long period of time," he says on a video posted online this week . He asserts that the retraction has "nothing to do with real science and has everything to do with a political assassination of science."

He says that because the study's findings have been cited in legal cases like the one challenging the abortion pill, "we have become visible – people are quoting us. And for that reason, we are dangerous, and for that reason, they want to cancel our work," Studnicki says in the video.

In an email to NPR, a spokesperson for the Charlotte Lozier Institute said that they "will be taking appropriate legal action."

Role in abortion pill legal case

Anti-abortion rights groups, including a group of doctors, sued the federal Food and Drug Administration in 2022 over the approval of mifepristone, which is part of a two-drug regimen used in most medication abortions. The pill has been on the market for over 20 years, and is used in more than half abortions nationally. The FDA stands by its research that finds adverse events from mifepristone are extremely rare.

Judge Matthew Kacsmaryk, the district court judge who initially ruled on the case, pointed to the now-retracted study to support the idea that the anti-abortion rights physicians suing the FDA had the right to do so. "The associations' members have standing because they allege adverse events from chemical abortion drugs can overwhelm the medical system and place 'enormous pressure and stress' on doctors during emergencies and complications," he wrote in his decision, citing Studnicki. He ruled that mifepristone should be pulled from the market nationwide, although his decision never took effect.

Matthew Kacsmaryk at his confirmation hearing for the federal bench in 2017. AP hide caption

Matthew Kacsmaryk at his confirmation hearing for the federal bench in 2017.

Kacsmaryk is a Trump appointee who was a vocal abortion opponent before becoming a federal judge.

"I don't think he would view the retraction as delegitimizing the research," says Mary Ziegler , a law professor and expert on the legal history of abortion at U.C. Davis. "There's been so much polarization about what the reality of abortion is on the right that I'm not sure how much a retraction would affect his reasoning."

Ziegler also doubts the retractions will alter much in the Supreme Court case, given its conservative majority. "We've already seen, when it comes to abortion, that the court has a propensity to look at the views of experts that support the results it wants," she says. The decision that overturned Roe v. Wade is an example, she says. "The majority [opinion] relied pretty much exclusively on scholars with some ties to pro-life activism and didn't really cite anybody else even or really even acknowledge that there was a majority scholarly position or even that there was meaningful disagreement on the subject."

In the mifepristone case, "there's a lot of supposition and speculation" in the argument about who has standing to sue, she explains. "There's a probability that people will take mifepristone and then there's a probability that they'll get complications and then there's a probability that they'll get treatment in the E.R. and then there's a probability that they'll encounter physicians with certain objections to mifepristone. So the question is, if this [retraction] knocks out one leg of the stool, does that somehow affect how the court is going to view standing? I imagine not."

It's impossible to know who will win the Supreme Court case, but Ziegler thinks that this retraction probably won't sway the outcome either way. "If the court is skeptical of standing because of all these aforementioned weaknesses, this is just more fuel to that fire," she says. "It's not as if this were an airtight case for standing and this was a potentially game-changing development."

Oral arguments for the case, Alliance for Hippocratic Medicine v. FDA , are scheduled for March 26 at the Supreme Court. A decision is expected by summer. Mifepristone remains available while the legal process continues.

• Abortion policy
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• judge matthew kacsmaryk
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The Science of Abortion Rights

Safe and accessible reproductive health care is a basic right that is supported by science, medicine and respect for human dignity

Genetic Counselors Scramble Post- Roe to Provide Routine Pregnancy Services without Being Accused of a Crime

The Supreme Court decision to overturn Roe v. Wade means that prenatal advice to patients can suffer and that counselors can face lawsuits and criminal charges

Laura Hercher

Graphic: Many States That Restrict or Ban Abortion Don’t Teach Kids about Sex and Pregnancy

States that protect abortion rights tend to have more comprehensive sex ed policies

Fionna M. D. Samuels

Police Who Tear-Gas Abortion-Rights Protesters Could Induce Abortion

Tear gas is widely used by law enforcement, even though it may cause spontaneous abortion

Matthew R. Francis

Abortion Restrictions Could Cause an Ob-Gyn Brain Drain

With  Roe v. Wade  overturned, banning abortion in many states could lead to a large number of ob-gyns avoiding practicing there or failing to receive crucial medical training

Monique Brouillette

New Abortion Laws Could Make Prenatal Genetic Screening Harder to Do

States that outlaw abortions after a certain number of weeks could make it difficult or impossible to terminate a pregnancy because of a serious genetic disorder

Sara Reardon, KFF Health News

How Abortion Misinformation and Disinformation Spread Online

With reproductive rights being dismantled, social media companies need to stop propagating lies

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Primary Care Providers Can Help Safeguard Abortion

As abortion access becomes more limited in the U.S., primary care providers can and should provide these services to people who need them

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Pregnancy Is Far More Dangerous Than Abortion

Restricting access to and prohibiting abortion in the U.S. will only increase maternal mortality in the nation that already ranks shockingly low in maternal health

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The Antiscience Supreme Court Is Hurting the Health of Americans

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Anti-abortion rights groups push abortion "reversal." States say that’s fraud.

Some anti-abortion rights groups are selling a procedure called “abortion pill reversal,” which they claim can help women halt medical abortions. That claim is now being challenged by state officials who allege the groups are veering into false advertising and fraud.

Heartbeat International, an anti-abortion rights group, and 11 other anti-abortion organizations were sued Monday by New York Attorney General Letitia James, who alleged the organizations are making “false and misleading statements to advertise an unproven treatment.” The complaint follows a similar lawsuit filed by California Attorney General Rob Bonta in September.

Heartbeat has countersued, asking the courts to throw out California’s lawsuit on the grounds that it infringes its First Amendment rights. It also asserts that abortion pill reversal is safe and effective.

The litigation comes at a time when the so-called abortion pill — actually a combination of two drugs — accounts for almost two-thirds of abortions in the U.S., according to the Guttmacher Institute, which researches reproductive rights. More women are turning to medication abortion, rather than surgery, partly because it allows them to seek care privately and manage the process at home.

Meanwhile, abortion access has faced growing restrictions across much of the U.S. following the Supreme Court’s 2022 decision overturning Roe v. Wade . The high court is also currently considering a case that could ultimately curtail use of the abortion pill across the U.S.

In taking aim at the anti-abortion groups, New York and California are turning to state laws that prohibit deceptive business practices as well as false advertising — in effect, both are asking courts to rule on whether the clinics’ advertisements for abortion pill reversal treatment amount to fraud.

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New York and California also want the courts to block Heartbeat and affiliated anti-abortion clinics from continuing to promote abortion pill reversal because they are allegedly misleading consumers.

For its part, Heartbeat International told CBS MoneyWatch that James’ lawsuit is a “clear attempt to censor speech.”

“By singling out these organizations solely because they offer an alternative to abortion, she is not only violating their rights but also denying women access to care and support as they seek to try and continue their pregnancies,” Heartbeat said in an email.

What is “abortion pill reversal”?

Medication abortion involves taking two pills: mifepristone, which was approved by the Food and Drug Administration in 2000, and misoprostol. To begin the process, a woman first takes mifepristone, which stops the pregnancy from growing. (The Supreme Court’s case involving the abortion pill is focused on mifepristone.)

About 24 to 48 hours after that, the woman takes misoprostol, which causes the uterus to contract and abort the fetus.

As this process has become the most common abortion treatment, anti-abortion clinics have turned to promoting a technique they claim can “reverse” the effect of the abortion pill. But that claim is misleading because it implies the treatment can undo an abortion, James alleges.

The anti-abortion clinics “imply the impossible — that fetal tissue that has been expelled from the uterus due to a completed abortion can be returned to the uterus. It cannot,” the New York lawsuit alleges.

In reality, the treatment is aimed at halting the medication abortion process midway by giving a woman a high dose of the hormone progesterone after she’s taken the first pill but before she’s ingested the second — at that point, an abortion hasn’t yet occurred.

Heartbeat International told CBS MoneyWatch the treatment has “saved” 5,000 babies of women who have sought to halt a medication abortion. It added that the cost of the treatment varies on the dose of progesterone used in the process. The group also vowed to “continue to offer support to those who seek it.”

Is abortion pill reversal safe?

Heartbeat’s website about abortion pill reversal claims the process is effective and says it “increases the chances” of a pregnancy continuing. The site also contends that the treatment can save 64% to 68% of pregnancies, although it only cites “initial studies” for the statistic, without identifying the specific research.

According to James’ suit, however, “no competent and reliable scientific evidence exists to substantiate these claimed success rates.” As a result, the complaint alleges such claims may mislead consumers about the treatment’s efficacy.

The lawsuit also claims that Heartbeat and other anti-abortion clinics describe the process as “proven safe and essentially risk-free,” while in fact the treatment hasn’t been tested in any reputable medical study.

In a response to CBS MoneyWatch, Heartbeat said the treatment “stands as a safe and effective option for women who change their minds immediately after taking the abortion pill, mifepristone.” The group noted that progesterone, the hormone used in the treatment, is an FDA-approved medication that has been used “for decades to prevent miscarriage and preterm birth.”

Heartbeat added that its assertions are supported by “both scientific evidence and the lived experience of women who are holding their babies in their arms today after starting a chemical abortion and experiencing a successful reversal.”

However, medical experts agree that abortion pill reversal hasn’t been proven safe, as the only double-blind, placebo-controlled, randomized clinical trial for the treatment had to be stopped after some women experienced “life-threatening complications like hemorrhage,” said Dr. Stacy Sun, an obstetrician and gynecologist and a fellow with Physicians for Reproductive Health, a group of doctors that advocates for reproductive health.

“This dangerous, non-evidence based regimen is used to prey on people making thoughtful decisions about their bodies, families and futures,” Dr. Sun told CBS MoneyWatch. “It is infantilizing and manipulative.”

In its countersuit, Heartbeat said that its claims the treatment has been effective in 64% to 68% of pregnancies are based on a 2018 study by Dr. George Delgado, a family physician who created the abortion pill reversal treatment. But James’ lawsuit notes that the study was based on tracking women who called the abortion pill reversal hotline and wasn’t a randomized, placebo-controlled trial.

Meanwhile, some states — primarily those that have restricted abortion access after Roe v. Wade was overturned — “actually require misinformation about medication abortion” to be provided to women who are seeking abortions, the Guttmacher Institute said in an email.

Planned Parenthood said implementaton of six week abortion ban is a dark day for Florida

For instance, Nebraska requires that such patients be told: “If you change your mind and want to continue your pregnancy after taking mifepristone, it may not be too late.” They are then directed to Heartbeat’s abortion pill reversal hotline.

“Note that this is misinformation about medication abortion generally, and some of these states put it out in their materials” even if it isn’t required by statutes or regulations, the Guttmacher Institute said.

Heartbeat in February filed a suit seeking to throw out the California case, arguing that the organization is protected by the First Amendment in providing information about abortion pill reversal. The group’s complaint also argues that it is “not appropriate to litigate the merits of scientific studies in the judicial system.”

Heartbeat, which doesn’t itself operate any clinics but provides support to about 3,000 anti-abortion rights centers, said it “receives no kickback or other payment for referring a woman to a physician” in the network of clinics offering abortion pill reversal, according to its suit.

“With this lawsuit, (Attorney General) James is protecting Big Abortion in New York while denying women in her state the right to continue their own pregnancies,” said Jor-El Godsey, president of Heartbeat International, said in the statement sent to CBS MoneyWatch.

Aimee Picchi is the associate managing editor for CBS MoneyWatch, where she covers business and personal finance. She previously worked at Bloomberg News and has written for national news outlets including USA Today and Consumer Reports.

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New York Is Suing Crisis Pregnancy Centers for Promising “Abortion Reversal”

Anti-choice groups still wield a strong presence in blue states. attorney general letitia james is the latest prosecutor to take them on..

Julianne McShane

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Mother Jones; Lev Radin/Sipa USA/AP

Abortion rights advocates might be surprised to learn that, in deep-blue New York, anti-abortion crisis pregnancy centers outnumber abortion clinics. 

There are more than 120 such centers (known as CPCs, though they also go by other names ) throughout New York, according to a coalition of abortion rights groups in the state, compared to a little more than 100 in-person abortion providers . In places like New York—where abortion is legal through 24 weeks’ gestation, and lawmakers have enacted legislation protecting abortion access—CPCs are particularly insidious: They lure struggling pregnant people in with promises of financial and emotional support, and then actively discourage them from obtaining abortions—often, in part, through medical misinformation delivered mostly by volunteers, not medical professionals. One of their favorite deceptive tactics is to hawk so-called “abortion pill reversal” regimens , which they falsely claim can stop a medication abortion in its tracks, allowing someone to continue a pregnancy. 

On Monday, New York State Attorney General Letitia James announced she is suing the anti-abortion group Heartbeat International—which claims to operate more than 3,000 CPCs worldwide—and 11 other CPCs   throughout the state for “using false and misleading statements” to “aggressively” advertise the so-called treatment, which involves taking repeated doses of progesterone—a hormone the body produces during pregnancy—after someone has taken mifepristone, the first of the two pills in the medication abortion regimen. (Mifepristone blocks progesterone, and misoprostol, the second pill taken in a medication abortion, expels the pregnancy.) Anti-abortion groups tend to highlight individual stories of people who allegedly followed this advice and were able to continue a pregnancy; they also often emphasize that immediate regret after seeking an abortion in the first place drove them to try to “reverse” that choice—even though research shows most people who obtain abortions ultimately feel it was the right decision.

But as James’ office—and the American College of Obstetricians and Gynecologists —point out, the claims underlying so-called “abortion pill reversal” are unsupported by scientific evidence, and a 2020 study that aimed to examine the safety and efficacy of it was halted early due to safety concerns after three patients experienced severe hemorrhaging. On the other hand, more than 100 published studies have shown that medication abortion is safe and effective, including when the pills are prescribed remotely and mailed to patients—which directly contradicts the false arguments conservatives have taken to the Supreme Court in a bid to drastically restrict access to abortion pills, as I have previously reported .

But none of this stops CPCs from claiming otherwise. James alleges their statements “constitute persistent fraud and illegality…and deceptive business and false advertising practices”; her office wants the court to rule that the CPCs must remove all false and misleading claims from their promotional materials and pay out civil penalties. In a statement, James said that, in light of rising reproductive health restrictions post- Dobbs , “we must protect pregnant people’s right to make safe, well-informed decisions about their health.” Heartbeat International and a group of CPCs are countersuing the AG’s office, alleging that CPCs have been “unfairly singled out…because they offer alternatives to abortion.” The Thomas More Society, the conservative Catholic legal group representing the group pro bono, alleges that the statements that are the subject of the litigation are protected free speech. (Heartbeat does not operate all of the CPCs that James is suing, but those CPCs “all advertise or promote Heartbeat” and abortion pill reversal, according to a spokesperson for the AG’s office.)

The lawsuit is a reminder that abortion opponents will do anything they can to curtail abortion access post- Dobbs — even in places where voters have moved to protect abortion rights , and even if it means perpetrating myths about how and why people get abortions. It also comes as the latest example of a Democratic Attorney General using state law to crack down on CPCs. In March, Arizona Attorney General Kris Mayes issued a consumer alert outlining how CPCs “may make misleading statements about the services they provide, or otherwise attempt to deceive patients in medically vulnerable situations.” Last September, California Attorney General Rob Bonta sued Heartbeat International and a chain of five CPCs in the state in a lawsuit that also took aim at their “fraudulent and misleading claims” about so-called abortion pill reversal. And in 2022, New Jersey Attorney General Matthew Platkin, alongside the state Department of Consumer Affairs, announced they were also issuing a consumer alert about CPCs. As a note published in the Cornell Law Review in January points out, state attorneys general are uniquely positioned to take on CPCs given both the broad powers and extensive tools they wield to file lawsuits in the public interest, and their important roles in state governments, particularly post- Dobbs . 

Looking at the list of CPCs James is suing, it was jarring to see two located in New York City—one in Brooklyn, and one in Queens. “People think that there’s no, like, real need to advance or end stigma here,” Elizabeth Estrada of the  National Latina Institute for Reproductive Justice told the New York Times in a 2022 story about CPCs in the city. “But that’s not true, especially when we’re seeing so many crisis pregnancy centers proliferating .”

Aviva Zadoff, director of advocacy and volunteer engagement at the National Council of Jewish Women New York, which leads a campaign to track CPCs in the state, told me that “these groups have gotten away with spreading disinformation for far too long.” The 2022 Times report provides an example of the consequences, telling the story of a woman who visited a CPC in the Bronx—located across the street from a Planned Parenthood—for advice and wound up continuing her pregnancy, despite her hesitation and financial struggles, after CPC staffers promised her material support. But that never came through, she told the Times : “They would say they know somebody that could probably refer me somewhere, that could help me financially, diapers and stuff like that. But I never received any phone call from anybody.”

These false promises, coupled with medical misinformation, are exactly why CPCs are so dangerous—even in places, like New York, that claim to protect abortion rights.

“When faced with an unplanned pregnancy,” Zadoff said, “everyone is entitled to judgement-free care and honest information.”

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Florida’s 6-week abortion ban takes effect today

A stricter abortion law that takes effect in Florida on Wednesday — dropping the state’s 15-week ban to a six-week ban — will likely affect thousands of people seeking abortion care within the first month alone.

Florida has become a key abortion access point amid widespread restrictions that have taken hold in the region in the two years since the US Supreme Court’s Dobbs decision overturned Roe v. Wade. It’s also one of the country’s most populous states.

Last year, 1 of every 3 abortions in the South — and about 1 in every 12 nationwide — happened in Florida, according to data from the Guttmacher Institute, a research and policy organization focused on sexual and reproductive health that supports abortion rights. In 2023, there were about 7,000 abortions in Florida each month, and more than 9,000 people traveled from other states to get an abortion in Florida throughout the year, the data shows.

Many women don’t know that they’re pregnant six weeks  after their last menstrual period, and other states that have enacted laws with this early gestation limit saw significant cuts to abortion care. In Texas, the number of abortions provided within the formal health-care system dropped by about  half  after a six-week abortion ban took effect in 2021, and there were thousands more  births  than expected in the following year. In South Carolina, there was a 70% decrease in abortions just one month after the state enforced a six-week limit.

But tighter restrictions in Florida could have an even more significant effect than historical trends suggest because Florida has been absorbing patients from other states that already have stricter limits. So far this year, more than 1,300 people from other states have traveled to Florida for an abortion, according to data from the state health agency — nearly a tenth of all abortions in the state so far in 2024.

Of the 16 states in the South, nine have banned abortion. Florida joins Georgia and South Carolina with a six-week ban. This leaves just three states in this US Census region — Delaware, Maryland and Virginia — where abortion remains legal past the first trimester and North Carolina with a 12-week limit.

“In terms of the number of people impacted, this certainly has the potential to be one of the most impactful policy changes that has happened in the recent months — and that’s not to minimize these other policy changes, which also have caused enormous amounts of harm and real barriers to access,” Isaac Maddow-Zimet, a data scientist with the Guttmacher Institute who is a lead researcher for an ongoing project tracking abortions in the US, told CNN. “It’s all so interrelated. As more and more barriers to access happen, and especially in the Southeast, and as options for care become more and more limited, it really exacerbates these obstacles even more than we would otherwise have thought.”

A 2022 study found that the average travel time to an abortion facility more than tripled in the first few months after the Dobbs decision. The effects were significantly severe in some southern states such as Texas and Louisiana, where average travel times to the nearest abortion facility were seven hours longer, adding nearly a full workday in travel time to get an abortion.

For that study, researchers considered abortion facilities in states with complete bans and those with six-week limits to be inactive. The newly implemented bans cut the number of active providers by about a tenth. In the year and a half since, the abortion landscape in the US has only become more fractured, and Florida’s new six-week ban would affect a significant number of facilities that remain in the South.

Providers and patients had 30 days to prepare since the Florida Supreme Court first posted the decision that paved the way for the new restrictions.

Amber Gavin, vice president of advocacy and operations for A Woman’s Choice, an independent abortion clinic with locations in Florida, North Carolina and Virginia, said that questions from patients started pouring in right after the April 1 ruling. Any time abortion is in the news, chaos and confusion follow, she said.

The clinic in Florida is committed to staying open and providing care as long as it can — and ensuring that’s communicated well, Gavin said. It’s also preparing for the possibility of another change come November.

Florida is one of three states, along with Maryland and New York, that has secured abortion measures on the 2024 election ballot . In Florida, the Amendment to Limit Government Interference with Abortion would protect the right to an abortion up to the point of “viability” or to protect the patient’s health as determined by their health care provider. Ten other states are considering adding abortion-related measures, some to protect access and others that could restrict access.

“(The Florida Supreme Court decision) was a really worst-case scenario decision for us because it did overturn 40 years of precedent,” Gavin said. “But I think it also hopefully will motivate folks and get folks out in November to make sure that the government isn’t interfering in these really personal decisions.”

In the meantime, abortion funds across the US are preparing for a surge in need from patients who may be displaced by Florida’s more restrictive law.

The Tampa Bay Abortion Fund anticipates that at least 90% of people who call their hotline will be impacted by a six-week abortion ban and will need to seek abortion care outside of Florida. The Chicago Abortion Fund has bolstered programs and capacity in direct anticipation of this decision from Florida’s high court, and staffers estimate that they’ll need an additional $100,000 each month to absorb the surge of Floridians and other Southerners seeking support for an abortion.

“Every caller to TBAFund is already facing one or more barriers to care, such as a lack of funding, transportation, childcare, or a nearby abortion clinic in their community. The six-week ban will only exacerbate those barriers in the cruelest fashion,” Kris Lawler, president of the Tampa Bay Abortion Fund Board said in a statement.

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Louisiana lawmakers reject adding exceptions of rape and incest to abortion ban

FILE - Abortion-rights supporters protest on the steps of the John Minor Wisdom United States of Appeals Fifth Circuit Building after the Supreme Court decision to overturn Roe v. Wade, in New Orleans, Friday, June 24, 2022. Democratic lawmakers in Louisiana are pushing bills to add exceptions, including in cases of rape and incest, to the state’s near-total abortion ban. A GOP-dominated House committee began its review of those measures Tuesday, April 30, 2024, but similar proposals for loosening one of the country’s strictest abortion laws effectively died there last year. (Sophia Germer/The Times-Picayune/The New Orleans Advocate via AP, File)

FILE - Louisiana Gov. Jeff Landry addresses members of the House and Senate on opening day of a legislative special session focusing on crime, Feb. 19, 2024, in the House Chamber at the State Capitol in Baton Rouge, La. Democratic lawmakers in Louisiana are pushing bills to add exceptions to abortion bans, including in cases of rape and incest, to the state’s near-total abortion ban. A GOP-dominated House committee began its review of those measures Tuesday, April 30, 2024, but similar proposals for loosening one of the country’s strictest abortion laws effectively died there last year. (Hilary Scheinuk/The Advocate via AP, File)

Louisiana Democratic state Rep. Delisha Boyd works at her desk at her office May 3, 2024, in New Orleans. As Boyd faces an uphill battle in Louisiana, as she attempts to advance a bill that would add cases of rape and incest as exceptions to Louisiana’s near total abortion ban, the Democrat opens opening up about her mother’s harrowing story and how it effected them. (AP Photo/Stephen Smith)

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Despite pleas from Democrats and gut-wrenching testimony from doctors and rape survivors, a GOP-controlled legislative committee rejected a bill Tuesday that would have added cases of rape and incest as exceptions to Louisiana’s abortion ban.

In the reliably red state, which is firmly ensconced in the Bible Belt and where even some Democrats oppose abortions, adding exceptions to Louisiana’s strict law has been an ongoing battle for advocates — with a similar measure failing last year. Currently, of the 14 states with abortion bans at all stages of pregnancy, six have exceptions in cases of rape and five have exceptions for incest.

“I will beg (committee) members to come to common sense,” Democratic state Rep. Alonzo Knox said to fellow lawmakers ahead of the vote, urging them to give approval to the exceptions. “I’m begging now.”

Lawmakers voted against the bill along party lines, with the measure failing 4-7.

A nearly identical bill met the same fate last year, effectively dying in the same committee. In the hopes of advancing the legislation out of committee and to the House floor for full debate, bill sponsor Democratic state Rep. Delisha Boyd added an amendment to the measure so that the exceptions would only apply to those who are younger than 17. However, the change was still not enough to sway opponents.

“We have cases here in Louisiana with children being raped and then subjected to carrying a child to term,” Boyd, a Democrat who has told her own mother’s story in an effort to fight for passage of the bil l. “I hope we take a look at the fact that this is to protect the most vulnerable, our children.”

Boyd said she will continue to try to get the bill onto the floor, possibly asking the House chamber to vote to bypass the committee. However, the technique is rarely successful for Democrats in the Legislature where Republicans hold a supermajority.

While most of those who voted against the bill did not give a reason for their vote, GOP state Rep. Dodie Horton offered her thoughts, saying that while she believes convicted rapists should receive the maximum penalty possible, she can’t in good conscience allow for abortions. She described the fetuses as “innocent children.”

“I think we should punish the perpetrator to the nth degree, I’d love to hang them from the high street if it was in my power to do so. But I cannot condone killing the innocent,” Horton said.

As in multiple other Republican states, Louisiana’s abortion law went into effect in 2022 following the U.S. Supreme Court ruling that overturned Roe v. Wade, ending a half-century of the nationwide right to abortion. The only exceptions to the ban are if there is substantial risk of death or impairment to the mother if she continues the pregnancy or in the case of “medically futile” pregnancies — when the fetus has a fatal abnormality.

Democrats have repeatedly fought — and failed — to loosen the law by clarifying vague language, abolishing jail time for doctors who perform illegal abortions and adding exceptions.

“It’s disgusting to me that we have a society where we can’t make exceptions in a situation where a young girl’s innocence has been taken away in the most vile way... and now she’s impregnated and somebody, somewhere, wants to force a nine, 10, 11, 12, 13-year-old child to have a baby for the monster that took away her innocence?” Knox said.

The bill attracted dozens of people to testify, including rape survivors who shared their own stories and doctors who argued that their hands are tied by the current law.

OB-GYN Dr. Neelima Sukhavasi told lawmakers that since the abortion ban has gone into effect, she and other colleagues have delivered babies who are birthed by teenagers who have been raped.

“One of these teenagers delivered a baby while clutching a Teddy Bear — and that’s an image that once you see that, you can’t unsee it,” Sukhavasi said.

In 2021, there were 7,444 reported abortions in Louisiana, according to the U.S. Centers for Disease Control and Prevention. Of those, 27 were obtained by people younger than 15. Nationwide, 1,338 pregnant patients under 15 received abortions, according to the CDC.

A study released by the Journal of the American Medical Association found that between July 2022 and January 2024, there were more than 64,000 pregnancies resulting from rape in states where abortion has been banned in all or most cases.