Insights and Impact

After the Fall 


pregnant woman cradling her belly and crossing her fingers
Illustration by Oivind Hovland

When the United States Supreme Court overturned Roe v. Wade on June 24, it ushered in an America not seen in nearly half a century—one where the legal status of abortion is left entirely to the states. Sociology professor Tracy Weitz, who joins the College of Arts and Sciences this fall, is one of the nation’s leading voices on abortion care and reproductive health. Here, she helps us navigate a post-Roe world.
Now that Roe v. Wade has been overturned, what’s happening across the country? 
Nine states have already implemented abortion bans and another dozen are in the process. Legal chaos is occurring as injunctions against individual state laws are being lifted and pre-Roe bans are being interpreted. In a few states, new injunctions are being issued before laws can go into effect. Governors of states that have not yet fully banned abortion are contemplating whether to call special sessions of the legislature to consider doing so.  

Abortion providers in all the banned and several of the in-process states have stopped providing abortion care or limited the type of care they offer. People with previously scheduled appointments are scrambling to find new ones in states where abortion is still available—including places like Florida, Ohio, and Georgia, where there are new gestational limits for abortion but not yet complete bans.  

Abortion clinics in states where abortion remains legal—including Illinois and Kansas—are working hard to expand appointment availability by hiring new staff and increasing the physical plant of their facilities. Clinics in the in-process states are doing their best to manage increased patient demand in the present, even as they are preparing for a future in which they may not be able to continue offering abortions.

Who will be most impacted—and what will happen if people can’t access abortions? 
Childbirth carries a risk of death 14 times greater than that of abortion. So, in denying a person access to a wanted abortion, states are compelling people to assume significant medical risk. A recent study out of Colorado predicts a significant rise in the maternal mortality rate—especially among Black women who already experience an unacceptably high rate of death in childbearing.

Research from the University of California San Francisco’s Turnaway Study demonstrates other deleterious impacts of being denied a wanted abortion. The study followed about 1,000 self-identified women for five years after receiving or being denied a wanted abortion. They found that denying these women an abortion creates economic hardship and insecurity that persists for years. Compared with women who obtained their desired abortion, women denied the procedure had lowered credit scores as well as increased debt, bankruptcies, and evictions. Women turned away from getting an abortion were also more likely to stay in contact with a violent partner. The financial well-being and development of prior and subsequent children was also negatively impacted. Finally, giving birth was connected to more serious long-term health problems than having an abortion. 

Who is accessing abortion services? 
Almost 75 percent of US abortion patients live at or below 250 percent of the federal poverty level; more than 50 percent are women of color; and 60 percent already have children. Abortion is a health care option most frequently needed by people affected by the structural inequalities of poverty, racism, and xenophobia.

What does this mean for doctors who perform abortions in states where it will be curtailed or outlawed?
In all the states where abortion is being banned, physicians stopped providing abortion care immediately after the decision, or will do so after their state law takes effect.  

In some states where abortion is now banned, significant medical care was provided by physicians who traveled from out of state. These physicians will likely start providing care in places where abortions remain legal, and demand is increasing. However, there are other skilled and dedicated physicians who have provided abortion care for decades to women in their communities. Some of these physicians offer other types of health care and will continue to do so, without offering the abortion care their patients need. Those physicians who only provided abortions will need to decide whether to retire or relocate.  
Other clinical staff including nurses, social workers, patient counselors, and medical assistants are also losing their jobs and their ability to provide economically for their families. Women in communities across the abortion-banned states have relied on these teams of providers to care for them during an important time in their lives. 

What’s the difference between emergency contraception and medication abortion?  
They are not the same thing—they use different drugs that work differently on the body. Emergency contraception stops pregnancy from happening, while medication abortion ends an already existing pregnancy. One brand of emergency contraception, Plan B, is available over the counter without a prescription. Medication abortion requires a clinical consultation (either via a telehealth visit or in person. Emergency contraception can be used up to 72 hours after unprotected sex, while medication abortion is used between the time of a missed period (usually four weeks) and 11 weeks after the first day of the last normal menstrual period.
How does the ruling affect people’s access to each? 
At this time, abortion bans include bans of medication abortion—but not emergency contraception. However, the two issues are often linked, so we may see efforts to restrict access to emergency contraception in the future. The FDA could help expand access by approving the second emergency contraception option, Ella, as an over-the-counter drug. 

Right now, clinicians who provide medication abortion via telehealth can only do so in states where abortion remains legal. Abortion-supportive states that wish to ensure access to abortion in states where it is banned could protect clinicians in their state who provide abortion care to people in banned states. The federal government could explore ways to protect this practice. Until then, people who need medication abortion in states where abortion is banned can self-source these medications from international telehealth providers or international pharmacies.

Almost 90 percent of abortions occur in the first 12 weeks of pregnancy. Why might someone need one later?  
Many people do not know they are pregnant until after the 12th week: some are still bleeding, others are on medications that caused cycle changes, and still others do not have symptoms.  

Another reason people pass the 12th week of pregnancy is that gathering the money to pay for the abortion is extremely hard. Currently, the federal government and 33 states prohibit people from using Medicaid to pay for abortions. Yet the majority of people who need abortion live at or below the poverty level. So they forgo paying rent or food bills, which delays their ability to obtain an abortion when they first want one. And after they pass the 12-week mark, the cycle perpetuates itself. The cost of the abortion begins to increase as the clinical care becomes more complex, thus requiring more money and causing more delays.  

For still others, the abortion decision is made after learning something about their own health status or that of the fetus. Medical complications in pregnancy increase as people get further along, and some do not occur until later in pregnancy. Issues with the growth of the fetus occur as it develops and are not diagnosable until later in pregnancy.

With bans now in place in some states, what will happen now if a mother’s life is in danger? 
We do not have data on how often a pregnancy threatens a person’s life because this care often occurs in hospital settings, which do not routinely advertise that they do abortions. Physicians who treat these pregnancies, including maternal fetal medicine and complex family planning physicians, rarely discuss these cases publicly—in part because of the social discomfort with abortions later in pregnancies. Limited research on hospital policies regarding abortion care demonstrates significant barriers to obtaining institutional support for abortions, regardless of the reason.  

Now that abortion is banned in some states, it is likely that access to abortion care in life- threatening circumstances will be even harder to provide. The media is already reporting cases in which life-saving care was denied to pregnant patients. We can expect to see more of this since the penalty for violating an abortion ban is criminal jail time for the physician and other legal consequences for the institution. The federal government can help ensure that needed care is provided by identifying and prosecuting denials of care under the federal Emergency Medical Treatment and Labor Act and covering such life-saving care under the exceptions to the federal Hyde amendment.

Are you concerned about the fate of other rights that are not explicitly outlined in the Constitution, including the right to access contraception? 
I am not a legal scholar, so I cannot predict what the Supreme Court will do to other legal rights based in the constitutional right to privacy. What I can speak to is that most social conservatives do not draw a hard-line distinction between abortion and contraception. 
The Hobby Lobby decision allowed a corporation to not cover contraceptive methods that its owners believed were abortifacients—namely emergency contraception and intrauterine devices (IUDs). So, it is likely that some state legislatures will seek to limit access to some contraceptive methods or to further limit contraceptive access. Too frequently, people see abortion as the exception in law and policy. I would suggest that it is exemplar. The 50-year effort to overturn Roe is part of a larger effort to reverse the wider progressive gains in social, economic, gender, and racial advancement.

What’s the bottom line? What should Americans know right now? 
I have heard a lot of people are concerned about the risk of people dying from unsafe abortions. One positive advancement since the pre-Roe days is the availability of abortion pills that people can use to end a pregnancy safely with minimal clinical involvement. Today in the United States, these pills are dispensed by abortion clinics as part of a health care visit and are increasingly available through telehealth. As abortion providers become unavailable in many places, people will turn to the internet to order these pills directly, either through an international telehealth service like Aid Access or from an online pharmacy operating outside the US. 

Data from studies around the world show us that such self-sourcing of abortion pills is safe, effective, and acceptable for people. So even as the public expresses their anger about the elimination of the fundamental rights of people to bodily autonomy, they should not exaggerate the medical risk of self-managed abortions. Deaths will happen—but likely resulting from people carrying pregnancies to term against their will. Self-managed abortion with pills is safe—that is what I want people to know. What is so wrong is that people who would prefer to receive this care from a trusted health care provider will instead have to shop for drugs online, potentially putting themselves at criminal risk for breaking the law.