“I heard you flew here from Texas?” I say to my patient as I enter the room. “I’m so sorry you had to come this far.”
We are in an abortion clinic in New York City, a long way from her home. As I sit down next to her, her eyes fill up with tears and she begins to tell me how she couldn’t get an appointment in Texas. The demand is so high that they could only offer her an appointment three weeks out, she explained, and she knew by then it would be too late.
The famous Supreme Court case legalizing abortion in 1973, Roe v. Wade, made abortion legal up to “viability,” a nebulous concept that varies but is commonly defined as 24 weeks. In 2021, Texas enacted a new anti-abortion law (called “SB8”) that made abortion illegal past about six weeks — a time when most people don’t even realize they’re pregnant. Although this law is still being fought in federal courts, it has remained in effect for over eight months, which has directly impacted pregnant people that need to exercise their rights in a timely fashion. Every week, I am seeing more people from Texas with the same barriers to care.
The Supreme Court draft opinion written by Justice Samuel Alito that was leaked earlier this week reveals that Roe v. Wade, and all subsequent cases reaffirming the right to abortion, will likely be overturned this summer. It’s important to know that abortion is still legal in all 50 states. If you have an appointment, don’t be afraid to go in and get the care you need. The leaked document is just a draft, and we can’t be sure what the final decision will be, but we are bracing for the worst.
Let’s be clear. Pregnancy is a deeply personal decision that should be left to individuals and their families. The criminalization of abortion will cause scrutiny of all pregnant people, and puts all of our communities at risk. The anti-abortion movement is a modern phenomenon that is rooted in racism and does not have a basis in our legal or religious traditions. The real issues we need to tackle are improving prenatal health care, including abortion care, and reducing racial and socioeconomic disparities. But we are not going back to 1973. The threat to our communities comes from anti-abortion laws themselves, not abortion.
Back in my office, my patient’s ultrasound shows that she’s nine weeks pregnant. She expected this after all the delays caused by coordinating travel across the country. She tells me that she is staying at a hotel a few blocks away and the empty hotel room will be good for her. She has a 2-year-old and a 4-year-old at home, and they can make it hard to study. Dad is watching the kids and her grad school finals are coming up, so after the procedure today she’ll be able to focus on studying before her flight back tomorrow.
Flying to New York City for abortion care may seem unreasonable — and for most people, this is inaccessible due to cost of taking time off work, finding child care, and paying for travel — but people who can fly to New York are able to access health care without the medically unnecessary array of laws aimed at limiting abortion access in many states. These types of laws are commonly referred to as TRAP laws (targeted regulation of abortion providers). For example, many states require people to look at the ultrasound and wait 24 hours or more for a second appointment that is not medically necessary and only further increases the cost to the patient, causing them to spend more time away from home, work and family. Some states mandate that doctors give pregnant people medically inaccurate information about abortion by reading scripts written by the state filled with fear-mongering lies that abortion causes breast cancer (it does not) or that it may impact future fertility (it does not). Is there any other medical care where the law requires that doctors knowingly lie to their patients?
I am a family medicine doctor by training and I practice full-spectrum primary care in my clinic, with my patients ranging from tiny newborns to centennials. My practice has a focus on reproductive health, gender-affirming care and trauma-informed care, and most of my patients are reproductive-age people. In this position, I do cervical cancer screening and treatment. I place and remove long-acting contraception like intrauterine devices (IUDs). I offer prenatal dating ultrasounds, ongoing prenatal care for desired pregnancies, and, yes, abortion care. When someone walks into my office pregnant, I am ready to support them with whatever choice they make — my patients don’t have to be referred to an additional clinic in order to get the care they need for themselves and their families.
Though this kind of medicine may seem intuitive, this type of integrated care is hard to find in the U.S. Two days a week I work at an abortion clinic, where I perform abortions for people who don’t have access to a primary care clinic like mine. There will also always be people who need or prefer services at an abortion clinic. In this setting, I am meeting many patients for the first time, like the woman who came to see me from Texas, and I may never see them again. We play music, talk about their lives outside the office — their kids, the food they’re planning to eat afterwards, or how they’re going to spend their weekend. My team tries to make it a safe space where people can talk about their feelings and be supported. I often think about how fortunate I am to offer people this life-changing care that will alter their trajectory for the better.
Science tells us it really is for the better when people are able to access the abortion care they want and need. After their abortions, most people express gratitude and relief, but a complex range of emotions are normal. The famous Turnaway Study looked at women who were “turned away” from wanted abortion care compared to those who were able to access the abortion care they needed. The study followed 8,000 women over five years and found that women who were able to get an abortion were better off on every metric examined — including mental health outcomes, poverty level, education and more. An astounding 99% of the women interviewed said they didn’t regret their decision to have an abortion. Please note that I am using “women” here because that is how the study was designed, but we know that people of all genders need and get abortions. In places where I use “women,” please know that data is not always gender-inclusive.
The landmark case of Roe v. Wade made this all possible. It was restricted by later cases, such as Planned Parenthood v. Casey in 1992, which applied a standard that states couldn’t impose an “undue burden” on people seeking abortion. This concept is not well defined, and many states have continue to use legal restrictions without medical basis to obstruct abortion access. Even though abortion has been technically legal in the United States for almost 50 years, it is extremely hard to access in many parts of the country. Long travel times and requirements for multiple appointments make it nearly impossible for many low-income and underserved communities to access abortion care. And then there’s the cost.
The Hyde Amendment, which was first added as a rider to the federal spending budget in 1980 and has been added annually since then, makes it illegal for federal funds to cover the cost of abortion. This means that people employed by the government, armed service members, Indigenous people who are insured through the Indian Health Service, AmeriCorps workers, everyone whose insurance is federal Medicaid, and D.C. residents, among others, are required to pay for abortion out of pocket. Many states have banned public insurance programs, such as Medicaid and Medicare, from funding abortion as well. This means that the people with the lowest income in our country, who are disproportionately Black, Indigenous, and people of color, are also asked to pay the full cost of this essential medical care. In some states it’s even illegal for private insurance companies to offer coverage.
After all, the United States is not a friendly place for pregnant people, infants, or children. The U.S. ranks approximately 57th in the world for maternal mortality according to the World Health Organization. This figure means that Americans die at a rate almost 10 times higher from childbirth complications than people in countries that have the lowest maternal mortality rates. Over 700 Americans died from childbirth in 2019 alone. Infant and early childhood deaths in the U.S. are not much better — we rank 47th. Those are stark numbers for a country that often claims to have the greatest health care on Earth. There’s a lot of reasons for this, but one of the biggest causes is poor access to comprehensive prenatal care and abortion care, particularly in marginalized communities.
Pregnancy is risky for the body. It often worsens preexisting medical conditions and causes new ones. It is typical for people to suffer from worsened symptoms of asthma, blood pressure, and blood sugar — all of which can be life-threatening. During pregnancy, patients cannot get medical treatment for cancer, certain rheumatologic conditions, and other severe and life-threatening medical problems because the treatments available would cause potential harm or even the death of a fetus. Sometimes the pregnancy itself can cause death. It’s not a benign thing to ask someone to put their body through pregnancy. Even without medical concerns, all reasons for seeking abortion are valid and normal. Let’s be clear: Adoption isn’t an alternative to abortion. It’s an alternative to parenting.
It’s also important to acknowledge that criminalizing abortion results in criminalizing pregnant people more broadly. There is no blood test for doctors to detect medication abortion pills in the body, and it is impossible to distinguish an abortion from miscarriage. Anyone who experiences pregnancy loss could be prosecuted if abortion is illegal. This isn’t theorizing — this is something that is already happening. In 2020, Brittney Poolaw, an Indigenous woman in Oklahoma, was sentenced to four years in prison for seeking medical care when she started bleeding during her pregnancy. Approximately one in four pregnancies ends in miscarriage, putting every family at risk of legal scrutiny, but particularly people from marginalized communities like Poolaw.
People have also been criminalized for seeking medical care during pregnancy deemed inappropriate by lawmakers, even when directed by their doctor. In 2019, Lindsay Rigdell was charged with child neglect after testing positive for cannabis. She had severe nausea and vomiting during her pregnancy, called hyperemesis gravidarum, and was treated with medical cannabis by her doctor in Arizona, where it was legal. Severe hyperemesis can also cause miscarriage, so either option would have left her open to criminal prosecution. These cases have garnered a lot of media attention, but there are countless more.
Justice Alito asserts in his draft opinion that the word “abortion” does not appear in the Constitution, and he’s not wrong. Of course, at the time of its writing, the “people” were only land-owning white men. Since then, the law has expanded “people” to include women and Black and Indigenous people, among others. As the rest of us have gained the rights originally reserved for only land-owning white men, the right to bodily autonomy comes with our personhood.
Let me give you an example. Overturning Roe v. Wade means that the government can mandate that someone use their body to support a developing fetus. This is completely inconsistent with the fact that no person is required to use their body to the benefit of someone else. If a newborn requires a life-saving blood transfusion, personal autonomy rights protect the person who just gave birth and they could not legally be compelled to donate the life-saving blood. So why would the government have the right to demand the use of their body for the previous nine months?
It’s telling that Justice Alito’s opinion also states that there is no constitutional basis for Loving v. Virginia, the case that legalized interracial marriage, and Obergefell v. Hodges, the case that legalized same-sex marriage. In both of these cases, the rights asserted are for people who weren’t considered “people” in the original writing of the Constitution. As these groups have gained legal status in the U.S., however, there is no basis to argue that the rights already afforded to land-owning white men in the Constitution wouldn’t apply to everyone who has since been included in our country. It’s shocking to think the Supreme Court is asserting that these rights shouldn’t exist for Americans in 2022.
Although abortion is a politically charged issue in the U.S., it’s a lot less controversial to everyday Americans. According to the Pew Research Center, in March 2022, 61% of Americans believed that abortion should be legal in all or most cases, a number that has gradually increased over the last few decades. Only 37% of Americans, on the other hand, believe it should be illegal in all or most cases. Most issues in the U.S. are much more contentious.
Another important fact is that abortion used to be much less controversial. Abortion restrictions don’t begin to appear in the United States until the 1820s, and laws weren’t widespread until the American Medical Association started opposing abortion in the 1860s (the organization’s stance has since changed — the AMA now affirms that abortion is safe, essential health care). The opposition to abortion by doctors was largely driven by abortions being performed by midwives and women in the community, who doctors saw as a threat to their medical practice. That means that the legacy of abortion prohibition in this country only lasted for about 100 years, from the 1860s to 1973. The majority opinion for Roe v. Wade was written by Justice Harry Blackmun, a Republican.
Even the widespread religious opposition to abortion in the U.S. is modern. Before Roe v. Wade, the Clergy Consultation Service for Abortion, made up of Protestant ministers and Jewish rabbis, helped connect people to safe abortion in the 1960s. Most major Protestant churches continued to support abortion rights after Roe v. Wade as a matter of their strong belief in religious freedom, specifically from the Catholic Church, who opposed abortion. The Southern Baptist Convention, the largest protestant group in the U.S., openly supported the court’s decision in 1973 and for years after.
Nothing about abortion prohibition is fundamental to the cultural norms or common law of the U.S. In reality, the anti-abortion movement is rooted in white supremacist values, and the legacy of trying to control reproduction of Black and Brown people. When anti-abortion sentiment rose in the U.S., much of the concern focused on Black and Brown women having more children than white women. Though the anti-abortion movement has changed the way it frames this narrative, the patriarchal concept of purporting to know what’s best for the pregnant person remains unchanged. The pregnant person is always the most qualified to make decisions about their own bodies, not the government.
All birthing people should have the ability to control their reproductive lives, which includes access to safe pregnancy or abortion care. According to the Centers for Disease Control and Prevention, the mortality rate for Black and Indigenous women is four to five times higher compared to their white counterparts, and maternal mortality in the U.S. is actually increasing, unlike most other countries. The same states trying to restrict abortion coincidentally also have the worst maternal and infant outcomes — and the worst racial disparities. Louisiana, a state rampant with abortion restrictions, has the highest maternal mortality rate in the country at three times the national average, with 59% of Black maternal deaths found to be “preventable” compared to only 9% of white maternal deaths.
If anti-abortion activists want to be truly pro-family, I have some recommendations. Let’s put resources toward funding pregnancy and postpartum care. Why don’t we expand paid parental leave, something that has been shown to improve outcomes for children? We could fund child care costs and increase access to healthy food. We should require infertility treatment as part of insurance coverage, giving people from all socioeconomic backgrounds the tools to build their families — reproductive freedom means you have access to both. Let’s focus our money and time on addressing the grotesque maternal health disparities found between Black and white communities.
Finally, I want to dispel the idea that the fall of Roe v. Wade could take us back to 1973, when self-managed abortion was often dangerous. Many of us conjure the image of a coat hanger when thinking about the repercussions of anti-abortion laws. Today, we have medication abortion with mifepristone and misoprostol, which is a much safer alternative. Telemedicine clinics like Hey Jane are a great option for people who want a doctor-led medication abortion. People in hostile states are turning to the internet to self-manage with abortion pills by ordering them online and having them delivered. Websites like Plan C and Aid Access are resources for anyone looking to self-manage an abortion. If you have concerns or questions about a self-managed abortion, there are places to get confidential medical advice from clinicians — check out the M+A Hotline.
What can we do now? My patient from Texas was able to pay for her own flight and hotel to access abortion care; this is rare. Many people turn to abortion funds for help. These are community organizations that attempt to cover the cost of the procedure, travel, and other expenses but rely on donations and just don’t have enough money to help everyone in need. If you are looking for a place to start, to help people who need care, check out the National Network of Abortion Funds. Become a member, make a donation to the broad group of abortion funds or pick one that directly impacts your community — everything helps. If you need care, check out their resources and get connected to support. We can support legislative initiatives that would allow clinicians to provide telemedicine abortion care across state lines, from “blue” states into “red” states. All of us can make our voices heard: protest, post on social media, call your lawmakers, make noise! We know that one in four women in this country has had an abortion and everyone loves someone who has had an abortion. If it’s safe for you, break the stigma and silence surrounding abortion care and tell your story.
Together, we can change the narrative on pregnancy and abortion on this country — after all, we are already the majority.
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