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How the Right to Legal Abortion Changed the Arc of All Women’s Lives

By Katha Pollitt

Prochoice demonstrators during the March for Women's Lives rally organized by NOW Washington DC April 5 1992.

I’ve never had an abortion. In this, I am like most American women. A frequently quoted statistic from a recent study by the Guttmacher Institute, which reports that one in four women will have an abortion before the age of forty-five, may strike you as high, but it means that a large majority of women never need to end a pregnancy. (Indeed, the abortion rate has been declining for decades, although it’s disputed how much of that decrease is due to better birth control, and wider use of it, and how much to restrictions that have made abortions much harder to get.) Now that the Supreme Court seems likely to overturn Roe v. Wade sometime in the next few years—Alabama has passed a near-total ban on abortion, and Ohio, Georgia, Kentucky, Mississippi, and Missouri have passed “heartbeat” bills that, in effect, ban abortion later than six weeks of pregnancy, and any of these laws, or similar ones, could prove the catalyst—I wonder if women who have never needed to undergo the procedure, and perhaps believe that they never will, realize the many ways that the legal right to abortion has undergirded their lives.

Legal abortion means that the law recognizes a woman as a person. It says that she belongs to herself. Most obviously, it means that a woman has a safe recourse if she becomes pregnant as a result of being raped. (Believe it or not, in some states, the law allows a rapist to sue for custody or visitation rights.) It means that doctors no longer need to deny treatment to pregnant women with certain serious conditions—cancer, heart disease, kidney disease—until after they’ve given birth, by which time their health may have deteriorated irretrievably. And it means that non-Catholic hospitals can treat a woman promptly if she is having a miscarriage. (If she goes to a Catholic hospital, she may have to wait until the embryo or fetus dies. In one hospital, in Ireland, such a delay led to the death of a woman named Savita Halappanavar, who contracted septicemia. Her case spurred a movement to repeal that country’s constitutional amendment banning abortion.)

The legalization of abortion, though, has had broader and more subtle effects than limiting damage in these grave but relatively uncommon scenarios. The revolutionary advances made in the social status of American women during the nineteen-seventies are generally attributed to the availability of oral contraception, which came on the market in 1960. But, according to a 2017 study by the economist Caitlin Knowles Myers, “The Power of Abortion Policy: Re-Examining the Effects of Young Women’s Access to Reproductive Control,” published in the Journal of Political Economy , the effects of the Pill were offset by the fact that more teens and women were having sex, and so birth-control failure affected more people. Complicating the conventional wisdom that oral contraception made sex risk-free for all, the Pill was also not easy for many women to get. Restrictive laws in some states barred it for unmarried women and for women under the age of twenty-one. The Roe decision, in 1973, afforded thousands upon thousands of teen-agers a chance to avoid early marriage and motherhood. Myers writes, “Policies governing access to the pill had little if any effect on the average probabilities of marrying and giving birth at a young age. In contrast, policy environments in which abortion was legal and readily accessible by young women are estimated to have caused a 34 percent reduction in first births, a 19 percent reduction in first marriages, and a 63 percent reduction in ‘shotgun marriages’ prior to age 19.”

Access to legal abortion, whether as a backup to birth control or not, meant that women, like men, could have a sexual life without risking their future. A woman could plan her life without having to consider that it could be derailed by a single sperm. She could dream bigger dreams. Under the old rules, inculcated from girlhood, if a woman got pregnant at a young age, she married her boyfriend; and, expecting early marriage and kids, she wouldn’t have invested too heavily in her education in any case, and she would have chosen work that she could drop in and out of as family demands required.

In 1970, the average age of first-time American mothers was younger than twenty-two. Today, more women postpone marriage until they are ready for it. (Early marriages are notoriously unstable, so, if you’re glad that the divorce rate is down, you can, in part, thank Roe.) Women can also postpone childbearing until they are prepared for it, which takes some serious doing in a country that lacks paid parental leave and affordable childcare, and where discrimination against pregnant women and mothers is still widespread. For all the hand-wringing about lower birth rates, most women— eighty-six per cent of them —still become mothers. They just do it later, and have fewer children.

Most women don’t enter fields that require years of graduate-school education, but all women have benefitted from having larger numbers of women in those fields. It was female lawyers, for example, who brought cases that opened up good blue-collar jobs to women. Without more women obtaining law degrees, would men still be shaping all our legislation? Without the large numbers of women who have entered the medical professions, would psychiatrists still be telling women that they suffered from penis envy and were masochistic by nature? Would women still routinely undergo unnecessary hysterectomies? Without increased numbers of women in academia, and without the new field of women’s studies, would children still be taught, as I was, that, a hundred years ago this month, Woodrow Wilson “gave” women the vote? There has been a revolution in every field, and the women in those fields have led it.

It is frequently pointed out that the states passing abortion restrictions and bans are states where women’s status remains particularly low. Take Alabama. According to one study , by almost every index—pay, workforce participation, percentage of single mothers living in poverty, mortality due to conditions such as heart disease and stroke—the state scores among the worst for women. Children don’t fare much better: according to U.S. News rankings , Alabama is the worst state for education. It also has one of the nation’s highest rates of infant mortality (only half the counties have even one ob-gyn), and it has refused to expand Medicaid, either through the Affordable Care Act or on its own. Only four women sit in Alabama’s thirty-five-member State Senate, and none of them voted for the ban. Maybe that’s why an amendment to the bill proposed by State Senator Linda Coleman-Madison was voted down. It would have provided prenatal care and medical care for a woman and child in cases where the new law prevents the woman from obtaining an abortion. Interestingly, the law allows in-vitro fertilization, a procedure that often results in the discarding of fertilized eggs. As Clyde Chambliss, the bill’s chief sponsor in the state senate, put it, “The egg in the lab doesn’t apply. It’s not in a woman. She’s not pregnant.” In other words, life only begins at conception if there’s a woman’s body to control.

Indifference to women and children isn’t an oversight. This is why calls for better sex education and wider access to birth control are non-starters, even though they have helped lower the rate of unwanted pregnancies, which is the cause of abortion. The point isn’t to prevent unwanted pregnancy. (States with strong anti-abortion laws have some of the highest rates of teen pregnancy in the country; Alabama is among them.) The point is to roll back modernity for women.

So, if women who have never had an abortion, and don’t expect to, think that the new restrictions and bans won’t affect them, they are wrong. The new laws will fall most heavily on poor women, disproportionately on women of color, who have the highest abortion rates and will be hard-pressed to travel to distant clinics.

But without legal, accessible abortion, the assumptions that have shaped all women’s lives in the past few decades—including that they, not a torn condom or a missed pill or a rapist, will decide what happens to their bodies and their futures—will change. Women and their daughters will have a harder time, and there will be plenty of people who will say that they were foolish to think that it could be otherwise.

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The Messiness of Reproduction and the Dishonesty of Anti-Abortion Propaganda

By Jia Tolentino

A Supreme Court Reporter Defines the Threat to Abortion Rights

By Isaac Chotiner

By Susan B. Glasser

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.

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.

Abboud, Ali, 2019. “The Impact of Early Fertility Shocks on Women’s Fertility and Labor Market Outcomes.” Available from SSRN: https://ssrn.com/abstract=3512913

Anderson, Deborah J., Binder, Melissa, and Kate Krause, 2002. “The motherhood wage penalty: Which mothers pay it and why?” The American Economic Review 92(2). Retrieved from https://www.aeaweb.org/articles?id=10.1257/000282802320191606

Ananat, Elizabeth Oltmans, Gruber, Jonathan, Levine, Phillip and Douglas Staiger, 2009. “Abortion and Selection.” The Review of Economic Statistics 91(1). Retrieved from https://direct.mit.edu/rest/article-abstract/91/1/124/57736/Abortion-and-Selection?redirectedFrom=fulltext .

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Angrist, Joshua D., and William N. Evans, 1996. “Schooling and Labor Market Consequences of the 1970 State Abortion Reforms.” National Bureau of Economic Research Working Paper 5406. Retrieved from https://www.nber.org/papers/w5406 .

Angrist, Joshua D., and Jörn-Steffen Pischke, 2010. “The Credibility Revolution in Empirical Economics: How Better Research Design Is Taking the Con out of Econometrics.” Journal of Economic Perspectives 24(2). Retrieved from https://www.aeaweb.org/articles?id=10.1257/jep.24.2.3

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Bitler, Marianne, and Madeline Zavodny, 2002a. “Did Abortion Legalization Reduce the Number of Unwanted Children? Evidence from Adoptions.” Perspectives on Sexual and Reproductive Health, 34 (1): 25-33. Retrieved from https://www.jstor.org/stable/3030229?origin=JSTOR-pdf

Bitler, Marianne, and Madeline Zavodny, 2002b. “Child Abuse and Abortion Availability.” American Economic Review , 92 (2): 363-367. Retrieved from https://www.aeaweb.org/articles?id=10.1257/000282802320191624

Bitler, Marianne, and Madeline Zavodny, 2004. “Child Maltreatment, Abortion Availability, and Economic Conditions.” Review of Economics of the Household 2: 119-141. Retrieved from https://doi.org/10.1023/B:REHO.0000031610.36468.0e

Farin, Sherajum Monira, Hoehn-Velasco, Lauren, and Michael Pesko, 2021. “The Impact of Legal Abortion on Maternal Health: Looking to the Past to Inform the Present.” Retrieved from SSRN: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3913899

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Finer, Lawrence B., Lindberg, Laura, D., and Sheila Desai. “A prospective measure of unintended pregnancy in the United States.” Contraception 98(6). Retrieved from https://pubmed.ncbi.nlm.nih.gov/29879398/

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Guldi, Melanie, 2008. “Fertility effects of abortion and birth control pill access for minors.” Demography 45 . Retrieved from https://doi.org/10.1353/dem.0.0026

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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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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) .

Keiser, David, and Joseph Shapiro, 2019. “Consequences of the Clean Water Act and the Demand for Water Quality.” The Quarterly Journal of Economics 134 (1).

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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

Lindo, Jason M., Pineda-Torres, Mayra, Pritchard, David, and Hedieh Tajali, 2020. “Legal Access to Reproductive Control Technology, Women’s Education, and Earnings Approaching Retirement.” AEA Papers and Proceedings 110. Retrieved from https://www.aeaweb.org/articles?id=10.1257/pandp.20201108

Lindo, Jason M., and Mayra Pineda-Torres, 2021. “New Evidence on the Effects of Mandatory Waiting Periods for Abortion.” J ournal of Health Econ omics. Retrieved from https://pubmed.ncbi.nlm.nih.gov/34607119/

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Miller, Sarah, Wherry, Laura R., and Diana Greene Foster, 2020. “The Economic Consequences of Being Denied an Abortion.” National Bureau of Economic Research, Working Paper 26662 . Retrieved from https://www.nber.org/papers/w26662 .

Myers, Caitlin Knowles, 2017. “The Power of Abortion Policy: Reexamining the Effects of Young Women’s Access to Reproductive Control” Journal of Political Economy 125(6) . Retrieved from https://doi.org/10.1086/694293 .

Myers, Caitlin Knowles, Jones, Rachel, and Ushma Upadhyay, 2019. “Predicted changes in abortion access and incidence in a post-Roe world.” Contraception 100(5). Retrieved from https://pubmed.ncbi.nlm.nih.gov/31376381/

Myers, Caitlin Knowles, 2021. “Cooling off or Burdened? The Effects of Mandatory Waiting Periods on Abortions and Births.” IZA Institute of Labor Economics No. 14434. Retrieved from https://www.iza.org/publications/dp/14434/cooling-off-or-burdened-the-effects-of-mandatory-waiting-periods-on-abortions-and-births

Quast, Troy, Gonzalez, Fidel, and Robert Ziemba, 2017. “Abortion Facility Closings and Abortion Rates in Texas.” Inquiry: A Journal of Medical Care Organization, Provision and Financing 54 . Retrieved from https://journals.sagepub.com/doi/full/10.1177/0046958017700944

Rossin-Slater, Maya, 2017. “Maternity and Family Leave Policy.” National Bureau of Economic Research Working Paper 23069. Retrieved from https://www.nber.org/papers/w23069

Venator, Joanna, and Jason Fletcher, 2020. “Undue Burden Beyond Texas: An Analysis of Abortion Clinic Closures, Births, and Abortions in Wisconsin.” Journal of Policy Analysis and Management 40(3). Retrieved from https://doi.org/10.1002/pam.22263

Waldfogel, Jane, 1998. “The family gap for young women in the United States and Britain: Can maternity leave make a difference?” Journal of Labor Economics 16(3).

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 in Support of Petitioners, No. 19-1392.
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
Whitehurst, Grover J., April 19, 2018. “What is the market price of daycare and preschool?” Brookings Institution. Retrieved from https://www.brookings.edu/research/what-is-the-market-price-of-daycare-and-preschool/; Chien, Nina, 2021. “Factsheet: Estimates of Child Care Eligibility & Receipt for Fiscal Year 2018.” U.S. Department of Health and Human Services. Retrieved from https://aspe.hhs.gov/sites/default/files/20 21-08/cy-2018-child-care-subsidy-eligibility.pdf
Advancing New Standards in Reproductive Health (NSIRH). “The Turnaway Study.” Retrieved from https://www.ansirh.org/research/ongoing/turnaway-study.
Center for Reproductive Rights, 2021. “What If Roe Fell?” Retrieved from https://maps.reproductiverights.org/what-if-roe-fell

Economic Studies

Center for Economic Security and Opportunity

William A. Galston

May 1, 2024

John J. DiIulio, Jr.

April 15, 2024

April 4, 2024

The negative health implications of restricting abortion access

December 13, 2021— Ana Langer is professor of the practice of public health and coordinator of the Women and Health Initiative at Harvard T.H. Chan School of Public Health.

Q: Roe v. Wade may soon be overturned by the Supreme Court, while at the same time other countries are loosening restrictions around abortion rights. What are your thoughts on the current climate around this issue?

A: The trend over the past several decades is clear: Safe and legal abortion has become more widely accessible to women globally, with nearly 50 countries including Mexico, Argentina, New Zealand, Thailand, and Ireland liberalizing their abortion laws. During the same period, however, a few countries have made abortion more restricted or totally illegal, including El Salvador, Nicaragua, and Poland.

In the U.S., legal frameworks are increasingly limiting access to abortion. Even while Roe is in place, many people are currently unable to receive abortion care.

If the Supreme Court were to limit or overturn Roe, abortion would remain legal in 21 states and could immediately be prohibited in 24 states and three territories. Millions of people would be forced to travel to receive legal abortion care, something that would be impossible for many due to a range of financial and logistical reasons.

This situation does not surprise me because of the deep polarization that characterizes public views on abortion, and the growing power and relentless efforts of anti-choice groups. Furthermore, it does not surprise me because of the important gender gap that exists in this country, which is to a great extent due to the lack of strong and consistent policies and legal frameworks to support women in their efforts to better integrate their reproductive and professional roles and responsibilities.

The U.S. legalized abortion nearly 50 years ago, at a time when it was legally restricted in many countries around the world, setting an important international precedent and example. It disappoints me to see that while important progress has been made towards equality in other culturally polarized areas such as same-sex marriage, women’s right to terminate an unwanted or mistimed pregnancy is now severely threatened.

Q: How do laws that restrict abortion access impact women’s health?

A: Restricting women’s access to safe and legal abortion services has important negative health implications. We’ve seen that these laws do not result in fewer abortions. Instead, they compel women to risk their lives and health by seeking out unsafe abortion care.

According to the World Health Organization, 23,000 women die from unsafe abortions each year and tens of thousands more experience significant health complications globally. A recent study estimated that banning abortion in the U.S. would lead to a 21% increase in the number of pregnancy-related deaths overall and a 33% increase among Black women, simply because staying pregnant is more dangerous than having an abortion. Increased deaths due to unsafe abortions or attempted abortions would be in addition to these estimates.

If the current trend in the U.S. persists, “back alley” abortions will be the last resource for women with no access to safe and legal services, and the horrific consequences of such abortions will become a major cause of death and severe health complications for some of the most vulnerable women in this country.

The legal status of abortion also defines whether girls will be able to complete their educations and whether women will be able to participate in the workforce, and in public and political life.

Improving social safety net programs for women reduces gender gaps and improves girls’ and women’s health and chances to fulfill their potential, and could help reduce the number of abortions over time. Women who are better educated, have better access to comprehensive reproductive health care , and are employed and fairly remunerated will be better positioned to avoid a mistimed and unwanted pregnancy, hence the need for termination will become less common.

Q: Should abortion be considered a human right?

A: Numerous international and regional human rights treaties and national-level constitutions around the world protect the right to safe and legal abortion as a fundamental human right. Access to safe abortion is included in a constellation of rights, including the rights to life, liberty, privacy, equality and non-discrimination, and freedom from cruel, inhuman, and degrading treatment. Human rights bodies have repeatedly condemned restrictive abortion laws as being incompatible with human rights norms.

While a supportive legal framework for abortion care is critical, it is not enough to ensure access for everyone who seeks the service. For universal access to become a reality, policies that cover the cost of abortion care and its integration into the health care system, in addition to societal measures that destigmatize the procedure, are needed.

— Amy Roeder

Open access
Published: 28 June 2021

Impact of abortion law reforms on women’s health services and outcomes: a systematic review protocol

Foluso Ishola ORCID: orcid.org/0000-0002-8644-0570 1 ,
U. Vivian Ukah 1 &
Arijit Nandi 1

Systematic Reviews volume 10 , Article number: 192 ( 2021 ) Cite this article

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A country’s abortion law is a key component in determining the enabling environment for safe abortion. While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, with the majority of them moving away from an absolute ban. However, the implications of these reforms on women’s access to and use of health services, as well as their health outcomes, is uncertain. First, there are methodological challenges to the evaluation of abortion laws, since these changes are not exogenous. Second, extant evaluations may be limited in terms of their generalizability, given variation in reforms across the abortion legality spectrum and differences in levels of implementation and enforcement cross-nationally. This systematic review aims to address this gap. Our aim is to systematically collect, evaluate, and synthesize empirical research evidence concerning the impact of abortion law reforms on women’s health services and outcomes in LMICs.

We will conduct a systematic review of the peer-reviewed literature on changes in abortion laws and women’s health services and outcomes in LMICs. We will search Medline, Embase, CINAHL, and Web of Science databases, as well as grey literature and reference lists of included studies for further relevant literature. As our goal is to draw inference on the impact of abortion law reforms, we will include quasi-experimental studies examining the impact of change in abortion laws on at least one of our outcomes of interest. We will assess the methodological quality of studies using the quasi-experimental study designs series checklist. Due to anticipated heterogeneity in policy changes, outcomes, and study designs, we will synthesize results through a narrative description.

This review will systematically appraise and synthesize the research evidence on the impact of abortion law reforms on women’s health services and outcomes in LMICs. We will examine the effect of legislative reforms and investigate the conditions that might contribute to heterogeneous effects, including whether specific groups of women are differentially affected by abortion law reforms. We will discuss gaps and future directions for research. Findings from this review could provide evidence on emerging strategies to influence policy reforms, implement abortion services and scale up accessibility.

Systematic review registration

PROSPERO CRD42019126927

Peer Review reports

An estimated 25·1 million unsafe abortions occur each year, with 97% of these in developing countries [ 1 , 2 , 3 ]. Despite its frequency, unsafe abortion remains a major global public health challenge [ 4 , 5 ]. According to the World health Organization (WHO), nearly 8% of maternal deaths were attributed to unsafe abortion, with the majority of these occurring in developing countries [ 5 , 6 ]. Approximately 7 million women are admitted to hospitals every year due to complications from unsafe abortion such as hemorrhage, infections, septic shock, uterine and intestinal perforation, and peritonitis [ 7 , 8 , 9 ]. These often result in long-term effects such as infertility and chronic reproductive tract infections. The annual cost of treating major complications from unsafe abortion is estimated at US$ 232 million each year in developing countries [ 10 , 11 ]. The negative consequences on children’s health, well-being, and development have also been documented. Unsafe abortion increases risk of poor birth outcomes, neonatal and infant mortality [ 12 , 13 ]. Additionally, women who lack access to safe and legal abortion are often forced to continue with unwanted pregnancies, and may not seek prenatal care [ 14 ], which might increase risks of child morbidity and mortality.

Access to safe abortion services is often limited due to a wide range of barriers. Collectively, these barriers contribute to the staggering number of deaths and disabilities seen annually as a result of unsafe abortion, which are disproportionately felt in developing countries [ 15 , 16 , 17 ]. A recent systematic review on the barriers to abortion access in low- and middle-income countries (LMICs) implicated the following factors: restrictive abortion laws, lack of knowledge about abortion law or locations that provide abortion, high cost of services, judgmental provider attitudes, scarcity of facilities and medical equipment, poor training and shortage of staff, stigma on social and religious grounds, and lack of decision making power [ 17 ].

An important factor regulating access to abortion is abortion law [ 17 , 18 , 19 ]. Although abortion is a medical procedure, its legal status in many countries has been incorporated in penal codes which specify grounds in which abortion is permitted. These include prohibition in all circumstances, to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, and on request with no requirement for justification [ 18 , 19 , 20 ].

Although abortion laws in different countries are usually compared based on the grounds under which legal abortions are allowed, these comparisons rarely take into account components of the legal framework that may have strongly restrictive implications, such as regulation of facilities that are authorized to provide abortions, mandatory waiting periods, reporting requirements in cases of rape, limited choice in terms of the method of abortion, and requirements for third-party authorizations [ 19 , 21 , 22 ]. For example, the Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds. It is considered liberal, as it permits legal abortions for more indications than most countries in Sub-Saharan Africa; however, abortions must only be provided in registered hospitals, and three medical doctors—one of whom must be a specialist—must provide signatures to allow the procedure to take place [ 22 ]. Given the critical shortage of doctors in Zambia [ 23 ], this is in fact a major restriction that is only captured by a thorough analysis of the conditions under which abortion services are provided.

Additionally, abortion laws may exist outside the penal codes in some countries, where they are supplemented by health legislation and regulations such as public health statutes, reproductive health acts, court decisions, medical ethic codes, practice guidelines, and general health acts [ 18 , 19 , 24 ]. The diversity of regulatory documents may lead to conflicting directives about the grounds under which abortion is lawful [ 19 ]. For example, in Kenya and Uganda, standards and guidelines on the reduction of morbidity and mortality due to unsafe abortion supported by the constitution was contradictory to the penal code, leaving room for an ambiguous interpretation of the legal environment [ 25 ].

Regulations restricting the range of abortion methods from which women can choose, including medication abortion in particular, may also affect abortion access [ 26 , 27 ]. A literature review contextualizing medication abortion in seven African countries reported that incidence of medication abortion is low despite being a safe, effective, and low-cost abortion method, likely due to legal restrictions on access to the medications [ 27 ].

Over the past two decades, many LMICs have reformed their abortion laws [ 3 , 28 ]. Most have expanded the grounds on which abortion may be performed legally, while very few have restricted access. Countries like Uruguay, South Africa, and Portugal have amended their laws to allow abortion on request in the first trimester of pregnancy [ 29 , 30 ]. Conversely, in Nicaragua, a law to ban all abortion without any exception was introduced in 2006 [ 31 ].

Progressive reforms are expected to lead to improvements in women’s access to safe abortion and health outcomes, including reductions in the death and disabilities that accompany unsafe abortion, and reductions in stigma over the longer term [ 17 , 29 , 32 ]. However, abortion law reforms may yield different outcomes even in countries that experience similar reforms, as the legislative processes that are associated with changing abortion laws take place in highly distinct political, economic, religious, and social contexts [ 28 , 33 ]. This variation may contribute to abortion law reforms having different effects with respect to the health services and outcomes that they are hypothesized to influence [ 17 , 29 ].

Extant empirical literature has examined changes in abortion-related morbidity and mortality, contraceptive usage, fertility, and other health-related outcomes following reforms to abortion laws [ 34 , 35 , 36 , 37 ]. For example, a study in Mexico reported that a policy that decriminalized and subsidized early-term elective abortion led to substantial reductions in maternal morbidity and that this was particularly strong among vulnerable populations such as young and socioeconomically disadvantaged women [ 38 ].

To the best of our knowledge, however, the growing literature on the impact of abortion law reforms on women’s health services and outcomes has not been systematically reviewed. A study by Benson et al. evaluated evidence on the impact of abortion policy reforms on maternal death in three countries, Romania, South Africa, and Bangladesh, where reforms were immediately followed by strategies to implement abortion services, scale up accessibility, and establish complementary reproductive and maternal health services [ 39 ]. The three countries highlighted in this paper provided unique insights into implementation and practical application following law reforms, in spite of limited resources. However, the review focused only on a selection of countries that have enacted similar reforms and it is unclear if its conclusions are more widely generalizable.

Accordingly, the primary objective of this review is to summarize studies that have estimated the causal effect of a change in abortion law on women’s health services and outcomes. Additionally, we aim to examine heterogeneity in the impacts of abortion reforms, including variation across specific population sub-groups and contexts (e.g., due to variations in the intensity of enforcement and service delivery). Through this review, we aim to offer a higher-level view of the impact of abortion law reforms in LMICs, beyond what can be gained from any individual study, and to thereby highlight patterns in the evidence across studies, gaps in current research, and to identify promising programs and strategies that could be adapted and applied more broadly to increase access to safe abortion services.

The review protocol has been reported using Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines [ 40 ] (Additional file 1 ). It was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database CRD42019126927.

Eligibility criteria

Types of studies.

This review will consider quasi-experimental studies which aim to estimate the causal effect of a change in a specific law or reform and an outcome, but in which participants (in this case jurisdictions, whether countries, states/provinces, or smaller units) are not randomly assigned to treatment conditions [ 41 ]. Eligible designs include the following:

Pretest-posttest designs where the outcome is compared before and after the reform, as well as nonequivalent groups designs, such as pretest-posttest design that includes a comparison group, also known as a controlled before and after (CBA) designs.

Interrupted time series (ITS) designs where the trend of an outcome after an abortion law reform is compared to a counterfactual (i.e., trends in the outcome in the post-intervention period had the jurisdiction not enacted the reform) based on the pre-intervention trends and/or a control group [ 42 , 43 ].

Differences-in-differences (DD) designs, which compare the before vs. after change in an outcome in jurisdictions that experienced an abortion law reform to the corresponding change in the places that did not experience such a change, under the assumption of parallel trends [ 44 , 45 ].

Synthetic controls (SC) approaches, which use a weighted combination of control units that did not experience the intervention, selected to match the treated unit in its pre-intervention outcome trend, to proxy the counterfactual scenario [ 46 , 47 ].

Regression discontinuity (RD) designs, which in the case of eligibility for abortion services being determined by the value of a continuous random variable, such as age or income, would compare the distributions of post-intervention outcomes for those just above and below the threshold [ 48 ].

There is heterogeneity in the terminology and definitions used to describe quasi-experimental designs, but we will do our best to categorize studies into the above groups based on their designs, identification strategies, and assumptions.

Our focus is on quasi-experimental research because we are interested in studies evaluating the effect of population-level interventions (i.e., abortion law reform) with a design that permits inference regarding the causal effect of abortion legislation, which is not possible from other types of observational designs such as cross-sectional studies, cohort studies or case-control studies that lack an identification strategy for addressing sources of unmeasured confounding (e.g., secular trends in outcomes). We are not excluding randomized studies such as randomized controlled trials, cluster randomized trials, or stepped-wedge cluster-randomized trials; however, we do not expect to identify any relevant randomized studies given that abortion policy is unlikely to be randomly assigned. Since our objective is to provide a summary of empirical studies reporting primary research, reviews/meta-analyses, qualitative studies, editorials, letters, book reviews, correspondence, and case reports/studies will also be excluded.

Our population of interest includes women of reproductive age (15–49 years) residing in LMICs, as the policy exposure of interest applies primarily to women who have a demand for sexual and reproductive health services including abortion.

Intervention

The intervention in this study refers to a change in abortion law or policy, either from a restrictive policy to a non-restrictive or less restrictive one, or vice versa. This can, for example, include a change from abortion prohibition in all circumstances to abortion permissible in other circumstances, such as to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, or on request with no requirement for justification. It can also include the abolition of existing abortion policies or the introduction of new policies including those occurring outside the penal code, which also have legal standing, such as:

National constitutions;

Supreme court decisions, as well as higher court decisions;

Customary or religious law, such as interpretations of Muslim law;

Medical ethical codes; and

Regulatory standards and guidelines governing the provision of abortion.

We will also consider national and sub-national reforms, although we anticipate that most reforms will operate at the national level.

The comparison group represents the counterfactual scenario, specifically the level and/or trend of a particular post-intervention outcome in the treated jurisdiction that experienced an abortion law reform had it, counter to the fact, not experienced this specific intervention. Comparison groups will vary depending on the type of quasi-experimental design. These may include outcome trends after abortion reform in the same country, as in the case of an interrupted time series design without a control group, or corresponding trends in countries that did not experience a change in abortion law, as in the case of the difference-in-differences design.

Outcome measures

Primary outcomes.

Access to abortion services: There is no consensus on how to measure access but we will use the following indicators, based on the relevant literature [ 49 ]: [ 1 ] the availability of trained staff to provide care, [ 2 ] facilities are geographically accessible such as distance to providers, [ 3 ] essential equipment, supplies and medications, [ 4 ] services provided regardless of woman’s ability to pay, [ 5 ] all aspects of abortion care are explained to women, [ 6 ] whether staff offer respectful care, [ 7 ] if staff work to ensure privacy, [ 8 ] if high-quality, supportive counseling is provided, [ 9 ] if services are offered in a timely manner, and [ 10 ] if women have the opportunity to express concerns, ask questions, and receive answers.

Use of abortion services refers to induced pregnancy termination, including medication abortion and number of women treated for abortion-related complications.

Secondary outcomes

Current use of any method of contraception refers to women of reproductive age currently using any method contraceptive method.

Future use of contraception refers to women of reproductive age who are not currently using contraception but intend to do so in the future.

Demand for family planning refers to women of reproductive age who are currently using, or whose sexual partner is currently using, at least one contraceptive method.

Unmet need for family planning refers to women of reproductive age who want to stop or delay childbearing but are not using any method of contraception.

Fertility rate refers to the average number of children born to women of childbearing age.

Neonatal morbidity and mortality refer to disability or death of newborn babies within the first 28 days of life.

Maternal morbidity and mortality refer to disability or death due to complications from pregnancy or childbirth.

There will be no language, date, or year restrictions on studies included in this systematic review.

Studies have to be conducted in a low- and middle-income country. We will use the country classification specified in the World Bank Data Catalogue to identify LMICs (Additional file 2 ).

Search methods

We will perform searches for eligible peer-reviewed studies in the following electronic databases.

Ovid MEDLINE(R) (from 1946 to present)

Embase Classic+Embase on OvidSP (from 1947 to present)

CINAHL (1973 to present); and

Web of Science (1900 to present)

The reference list of included studies will be hand searched for additional potentially relevant citations. Additionally, a grey literature search for reports or working papers will be done with the help of Google and Social Science Research Network (SSRN).

Search strategy

A search strategy, based on the eligibility criteria and combining subject indexing terms (i.e., MeSH) and free-text search terms in the title and abstract fields, will be developed for each electronic database. The search strategy will combine terms related to the interventions of interest (i.e., abortion law/policy), etiology (i.e., impact/effect), and context (i.e., LMICs) and will be developed with the help of a subject matter librarian. We opted not to specify outcomes in the search strategy in order to maximize the sensitivity of our search. See Additional file 3 for a draft of our search strategy.

Data collection and analysis

Data management.

Search results from all databases will be imported into Endnote reference manager software (Version X9, Clarivate Analytics) where duplicate records will be identified and excluded using a systematic, rigorous, and reproducible method that utilizes a sequential combination of fields including author, year, title, journal, and pages. Rayyan systematic review software will be used to manage records throughout the review [ 50 ].

Selection process

Two review authors will screen titles and abstracts and apply the eligibility criteria to select studies for full-text review. Reference lists of any relevant articles identified will be screened to ensure no primary research studies are missed. Studies in a language different from English will be translated by collaborators who are fluent in the particular language. If no such expertise is identified, we will use Google Translate [ 51 ]. Full text versions of potentially relevant articles will be retrieved and assessed for inclusion based on study eligibility criteria. Discrepancies will be resolved by consensus or will involve a third reviewer as an arbitrator. The selection of studies, as well as reasons for exclusions of potentially eligible studies, will be described using a PRISMA flow chart.

Data extraction

Data extraction will be independently undertaken by two authors. At the conclusion of data extraction, these two authors will meet with the third author to resolve any discrepancies. A piloted standardized extraction form will be used to extract the following information: authors, date of publication, country of study, aim of study, policy reform year, type of policy reform, data source (surveys, medical records), years compared (before and after the reform), comparators (over time or between groups), participant characteristics (age, socioeconomic status), primary and secondary outcomes, evaluation design, methods used for statistical analysis (regression), estimates reported (means, rates, proportion), information to assess risk of bias (sensitivity analyses), sources of funding, and any potential conflicts of interest.

Risk of bias and quality assessment

Two independent reviewers with content and methodological expertise in methods for policy evaluation will assess the methodological quality of included studies using the quasi-experimental study designs series risk of bias checklist [ 52 ]. This checklist provides a list of criteria for grading the quality of quasi-experimental studies that relate directly to the intrinsic strength of the studies in inferring causality. These include [ 1 ] relevant comparison, [ 2 ] number of times outcome assessments were available, [ 3 ] intervention effect estimated by changes over time for the same or different groups, [ 4 ] control of confounding, [ 5 ] how groups of individuals or clusters were formed (time or location differences), and [ 6 ] assessment of outcome variables. Each of the following domains will be assigned a “yes,” “no,” or “possibly” bias classification. Any discrepancies will be resolved by consensus or a third reviewer with expertise in review methodology if required.

Confidence in cumulative evidence

The strength of the body of evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system [ 53 ].

Data synthesis

We anticipate that risk of bias and heterogeneity in the studies included may preclude the use of meta-analyses to describe pooled effects. This may necessitate the presentation of our main findings through a narrative description. We will synthesize the findings from the included articles according to the following key headings:

Information on the differential aspects of the abortion policy reforms.

Information on the types of study design used to assess the impact of policy reforms.

Information on main effects of abortion law reforms on primary and secondary outcomes of interest.

Information on heterogeneity in the results that might be due to differences in study designs, individual-level characteristics, and contextual factors.

Potential meta-analysis

If outcomes are reported consistently across studies, we will construct forest plots and synthesize effect estimates using meta-analysis. Statistical heterogeneity will be assessed using the I 2 test where I 2 values over 50% indicate moderate to high heterogeneity [ 54 ]. If studies are sufficiently homogenous, we will use fixed effects. However, if there is evidence of heterogeneity, a random effects model will be adopted. Summary measures, including risk ratios or differences or prevalence ratios or differences will be calculated, along with 95% confidence intervals (CI).

Analysis of subgroups

If there are sufficient numbers of included studies, we will perform sub-group analyses according to type of policy reform, geographical location and type of participant characteristics such as age groups, socioeconomic status, urban/rural status, education, or marital status to examine the evidence for heterogeneous effects of abortion laws.

Sensitivity analysis

Sensitivity analyses will be conducted if there are major differences in quality of the included articles to explore the influence of risk of bias on effect estimates.

Meta-biases

If available, studies will be compared to protocols and registers to identify potential reporting bias within studies. If appropriate and there are a sufficient number of studies included, funnel plots will be generated to determine potential publication bias.

This systematic review will synthesize current evidence on the impact of abortion law reforms on women’s health. It aims to identify which legislative reforms are effective, for which population sub-groups, and under which conditions.

Potential limitations may include the low quality of included studies as a result of suboptimal study design, invalid assumptions, lack of sensitivity analysis, imprecision of estimates, variability in results, missing data, and poor outcome measurements. Our review may also include a limited number of articles because we opted to focus on evidence from quasi-experimental study design due to the causal nature of the research question under review. Nonetheless, we will synthesize the literature, provide a critical evaluation of the quality of the evidence and discuss the potential effects of any limitations to our overall conclusions. Protocol amendments will be recorded and dated using the registration for this review on PROSPERO. We will also describe any amendments in our final manuscript.

Synthesizing available evidence on the impact of abortion law reforms represents an important step towards building our knowledge base regarding how abortion law reforms affect women’s health services and health outcomes; we will provide evidence on emerging strategies to influence policy reforms, implement abortion services, and scale up accessibility. This review will be of interest to service providers, policy makers and researchers seeking to improve women’s access to safe abortion around the world.

Abbreviations

Cumulative index to nursing and allied health literature

Excerpta medica database

Low- and middle-income countries

Preferred reporting items for systematic review and meta-analysis protocols

International prospective register of systematic reviews

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The authors acknowledge funding from the Fonds de recherche du Quebec – Santé (FRQS) PhD doctoral awards and Canadian Institutes of Health Research (CIHR) Operating Grant, “Examining the impact of social policies on health equity” (ROH-115209).

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Key facts about the abortion debate in America

A woman receives medication to terminate her pregnancy at a reproductive health clinic in Albuquerque, New Mexico, on June 23, 2022, the day before the Supreme Court overturned Roe v. Wade, which had guaranteed a constitutional right to an abortion for nearly 50 years.

The U.S. Supreme Court’s June 2022 ruling to overturn Roe v. Wade – the decision that had guaranteed a constitutional right to an abortion for nearly 50 years – has shifted the legal battle over abortion to the states, with some prohibiting the procedure and others moving to safeguard it.

As the nation’s post-Roe chapter begins, here are key facts about Americans’ views on abortion, based on two Pew Research Center polls: one conducted from June 25-July 4 , just after this year’s high court ruling, and one conducted in March , before an earlier leaked draft of the opinion became public.

This analysis primarily draws from two Pew Research Center surveys, one surveying 10,441 U.S. adults conducted March 7-13, 2022, and another surveying 6,174 U.S. adults conducted June 27-July 4, 2022. Here are the questions used for the March survey , along with responses, and the questions used for the survey from June and July , along with responses.

Everyone who took part in these surveys is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP’s methodology .

A majority of the U.S. public disapproves of the Supreme Court’s decision to overturn Roe. About six-in-ten adults (57%) disapprove of the court’s decision that the U.S. Constitution does not guarantee a right to abortion and that abortion laws can be set by states, including 43% who strongly disapprove, according to the summer survey. About four-in-ten (41%) approve, including 25% who strongly approve.

A bar chart showing that the Supreme Court’s decision to overturn Roe v. Wade draws more strong disapproval among Democrats than strong approval among Republicans

About eight-in-ten Democrats and Democratic-leaning independents (82%) disapprove of the court’s decision, including nearly two-thirds (66%) who strongly disapprove. Most Republicans and GOP leaners (70%) approve , including 48% who strongly approve.

Most women (62%) disapprove of the decision to end the federal right to an abortion. More than twice as many women strongly disapprove of the court’s decision (47%) as strongly approve of it (21%). Opinion among men is more divided: 52% disapprove (37% strongly), while 47% approve (28% strongly).

About six-in-ten Americans (62%) say abortion should be legal in all or most cases, according to the summer survey – little changed since the March survey conducted just before the ruling. That includes 29% of Americans who say it should be legal in all cases and 33% who say it should be legal in most cases. About a third of U.S. adults (36%) say abortion should be illegal in all (8%) or most (28%) cases.

A line graph showing public views of abortion from 1995-2022

Generally, Americans’ views of whether abortion should be legal remained relatively unchanged in the past few years , though support fluctuated somewhat in previous decades.

Relatively few Americans take an absolutist view on the legality of abortion – either supporting or opposing it at all times, regardless of circumstances. The March survey found that support or opposition to abortion varies substantially depending on such circumstances as when an abortion takes place during a pregnancy, whether the pregnancy is life-threatening or whether a baby would have severe health problems.

While Republicans’ and Democrats’ views on the legality of abortion have long differed, the 46 percentage point partisan gap today is considerably larger than it was in the recent past, according to the survey conducted after the court’s ruling. The wider gap has been largely driven by Democrats: Today, 84% of Democrats say abortion should be legal in all or most cases, up from 72% in 2016 and 63% in 2007. Republicans’ views have shown far less change over time: Currently, 38% of Republicans say abortion should be legal in all or most cases, nearly identical to the 39% who said this in 2007.

A line graph showing that the partisan gap in views of whether abortion should be legal remains wide

However, the partisan divisions over whether abortion should generally be legal tell only part of the story. According to the March survey, sizable shares of Democrats favor restrictions on abortion under certain circumstances, while majorities of Republicans favor abortion being legal in some situations , such as in cases of rape or when the pregnancy is life-threatening.

There are wide religious divides in views of whether abortion should be legal , the summer survey found. An overwhelming share of religiously unaffiliated adults (83%) say abortion should be legal in all or most cases, as do six-in-ten Catholics. Protestants are divided in their views: 48% say it should be legal in all or most cases, while 50% say it should be illegal in all or most cases. Majorities of Black Protestants (71%) and White non-evangelical Protestants (61%) take the position that abortion should be legal in all or most cases, while about three-quarters of White evangelicals (73%) say it should be illegal in all (20%) or most cases (53%).

A bar chart showing that there are deep religious divisions in views of abortion

In the March survey, 72% of White evangelicals said that the statement “human life begins at conception, so a fetus is a person with rights” reflected their views extremely or very well . That’s much greater than the share of White non-evangelical Protestants (32%), Black Protestants (38%) and Catholics (44%) who said the same. Overall, 38% of Americans said that statement matched their views extremely or very well.

Catholics, meanwhile, are divided along religious and political lines in their attitudes about abortion, according to the same survey. Catholics who attend Mass regularly are among the country’s strongest opponents of abortion being legal, and they are also more likely than those who attend less frequently to believe that life begins at conception and that a fetus has rights. Catholic Republicans, meanwhile, are far more conservative on a range of abortion questions than are Catholic Democrats.

Women (66%) are more likely than men (57%) to say abortion should be legal in most or all cases, according to the survey conducted after the court’s ruling.

More than half of U.S. adults – including 60% of women and 51% of men – said in March that women should have a greater say than men in setting abortion policy . Just 3% of U.S. adults said men should have more influence over abortion policy than women, with the remainder (39%) saying women and men should have equal say.

The March survey also found that by some measures, women report being closer to the abortion issue than men . For example, women were more likely than men to say they had given “a lot” of thought to issues around abortion prior to taking the survey (40% vs. 30%). They were also considerably more likely than men to say they personally knew someone (such as a close friend, family member or themselves) who had had an abortion (66% vs. 51%) – a gender gap that was evident across age groups, political parties and religious groups.

Relatively few Americans view the morality of abortion in stark terms , the March survey found. Overall, just 7% of all U.S. adults say having an abortion is morally acceptable in all cases, and 13% say it is morally wrong in all cases. A third say that having an abortion is morally wrong in most cases, while about a quarter (24%) say it is morally acceptable in most cases. An additional 21% do not consider having an abortion a moral issue.

A table showing that there are wide religious and partisan differences in views of the morality of abortion

Among Republicans, most (68%) say that having an abortion is morally wrong either in most (48%) or all cases (20%). Only about three-in-ten Democrats (29%) hold a similar view. Instead, about four-in-ten Democrats say having an abortion is morally acceptable in most (32%) or all (11%) cases, while an additional 28% say it is not a moral issue.

White evangelical Protestants overwhelmingly say having an abortion is morally wrong in most (51%) or all cases (30%). A slim majority of Catholics (53%) also view having an abortion as morally wrong, but many also say it is morally acceptable in most (24%) or all cases (4%), or that it is not a moral issue (17%). Among religiously unaffiliated Americans, about three-quarters see having an abortion as morally acceptable (45%) or not a moral issue (32%).

Religion & Abortion

Commodo Duis is a research analyst focusing on social and demographic research at Pew Research Center.

What the data says about abortion in the U.S.

Support for legal abortion is widespread in many countries, especially in europe, nearly a year after roe’s demise, americans’ views of abortion access increasingly vary by where they live, by more than two-to-one, americans say medication abortion should be legal in their state, most latinos say democrats care about them and work hard for their vote, far fewer say so of gop, most popular.

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What are the Implications of the Dobbs Ruling for Racial Disparities?

Latoya Hill , Samantha Artiga , Usha Ranji , Ivette Gomez , and Nambi Ndugga Published: Apr 24, 2024

Issue Brief

Note: Figures 12 and 13 were updated on April 26, 2024.

Introduction

The June 2022 Supreme Court ruling in the case Dobbs v. Jackson Women’s Health Organization has significant implications for racial disparities in health and health care. The decision overturned the longstanding Constitutional right to abortion and eliminated federal standards on abortion access that had been in place for nearly 50 years in all states across the country. As a result of Dobbs , large swaths of the country lack abortion access, with a disproportionate impact on those residing in the South and Midwest.

As of April 2024, 14 states have implemented abortion bans, 11 states have placed gestational limits on abortion between 6 and 22 weeks, and 25 states and the District of Columbia provide broader access to abortions after 22 weeks gestation. (This reflects Arizona being counted in the gestational limits category, as implementation of a recently upheld Civil War-era law banning nearly all abortions in the state is still pending amid ongoing court actions.)

Pregnant women seeking abortion that reside in states that prohibit or restrict abortions either have to travel out of state or try to obtain medication abortion pills via a telehealth appointment with an out-of-state clinician, but these options are not accessible to everyone. Some women may turn to self-managed abortions, but some will not be able to obtain an abortion and have to continue a pregnancy they do not want. Additionally, there have been reports of clinicians in states with bans and early gestational limits leaving their states due to the restrictions and criminalization for care that they provide, potentially exacerbating provider shortages in some areas.

With these state-level restrictions in place, people of color residing in those states may face disproportionately greater challenges accessing abortions due to longstanding underlying social and economic inequities, which could exacerbate existing disparities in maternal and infant health. This analysis examines the implications of state restrictions on abortion coverage for racial disparities in access to care and health outcomes. It is based on KFF analysis of data from the Centers for Disease Control and Prevention (CDC), American Community Survey (ACS), Behavioral Risk Factor Surveillance Survey (BRFSS), and Survey of Household Economics and Decisionmaking (SHED) (see Methods ). Throughout this brief we refer to “women” but recognize that some individuals who have abortions do not identify as women, including transgender. Key takeaways include the following:

Black and American Indian and Alaska Native (AIAN) women ages 18-49 are more likely than other groups to live in states with abortion bans and restrictions . About six in ten Black (60%) and AIAN (59%) women ages 18-49 living in states with abortion bans or restrictions compared with just over half (53%) of White, less than half of Hispanic (45%), and about three in ten Asian (28%) and Native Hawaiian or Pacific Islander (NHPI) (29%) women ages 18-49.
Many groups of women of color have higher uninsured rates compared to their White counterparts, and, a cross racial and ethnic groups, uninsured rates are higher in states with abortion bans or restrictions than in those that provide broader abortion access . Among women ages 18-49, roughly a fifth of AIAN (22%) and Hispanic (21%) women are uninsured as are 14% of NHPI women and 11% of Black women compared with less than one in ten (7%) of White women. Moreover, uninsured rates for women ages 18-49 are at least twice as high in states that banned abortion compared to those in states with broader access for White (10% vs. 5%), Hispanic (33% vs. 15%), Black (14% vs. 7%), and Asian (10% vs. 5%) women, and nearly three times higher for NHPI women (29% vs. 10%).
Women of color have more limited financial resources and transportation options than White women, making it more difficult for them to travel out-of-state for an abortion . Some may also face linguistic barriers and have immigration-related fears that create additional challenges to accessing abortions.
The bans and restrictions on abortions may widen the already stark racial disparities in maternal health, especially since some states do not explicitly have exceptions that allow abortion services when pregnancy is jeopardizing a woman’s health . The restrictions may also contribute to growing provider shortages in some areas, as clinicians are responding to concerns about criminalization and prohibited from offering the full spectrum of pregnancy care. Moreover, abortion restrictions may have negative economic consequences on families and put pregnant people at increased risk for criminalization.

While there have been large inequities in abortion access for many years, the Dobbs ruling opened the door to widening those differences further. Black and AIAN women are more likely to live in states with abortion bans or restrictions. While data on the impact of Dobbs to date on health outcomes is limited to date, many indicators suggest that the ruling may exacerbate longstanding large disparities in maternal and infant health. The issue also has moved to the forefront of policy debates in the U.S. Sixteen percent of women voters, rising to 28% of Black women voters, say abortion is the “ most important issue ” to their vote in the 2024 presidential election.

How do Abortion Rates Vary by Race and Ethnicity?

Data on abortions by race and ethnicity are limited . The federal Abortion Surveillance System from the CDC has been providing annual national and state-level statistics on abortion for decades, based on data that is voluntarily reported by states, DC, and New York City. While most states participate, one notable exception is California, which has many protections for abortion access and is one of the most racially diverse states in the nation. Furthermore, availability of data by race and ethnicity varies among states. The most recent data in the Abortion Surveillance System, from 2021, only includes racial and ethnic data from 31 states and DC and is generally only available for White, Black, and Hispanic women. While we present the data from the Abortion Surveillance System in this brief, we recognize these limitations.

Prior to Dobbs , the abortion rate was higher among Black and Hispanic women compared to their White peers . As of 2021, the abortion rate was 28.6 per 1,000 women among Black women, compared to 12.3 per 1,000 among Hispanic women, and 6.4 per 1,000 among White women (Figure 1). Data for other racial and ethnic groups were not available. The vast majority of abortions across racial and ethnic groups are in the first trimester . Approximately eight in ten abortions among White (82%), Hispanic (82%), and Black women (80%) occur by nine weeks of pregnancy. While data on the number of abortions post- Dobbs has been released by both the #WeCount project from the Society for Family Planning and the Guttmacher Institute’s Monthly Abortion Provision Study , neither sets of data have reported demographic characteristics of abortion patients.

There are many reasons why abortion rates are higher among some women of color . As discussed below, Black, Hispanic, American Indian and Alaska Native (AIAN), and Native Hawaiian or Pacific Islander (NHPI) women have more limited access to health care, which affects their access to contraception and other sexual health services that are important for pregnancy planning. Data show that contraception use is higher among White women (69%) compared to Black (61%) and Hispanic (61%) women. Some women of color live in areas with more limited access to comprehensive contraceptive options. In addition, the health care system has a long history of racist practices targeting the sexual and reproductive health of people of color, including forced sterilization, medical experimentation, the systematic reduction of midwifery, just to name a few . Many women of color also report discrimination by providers, with reports of dismissive treatment, assumption of stereotypes, and inattention to conditions that take a disproportionate toll on women of color and certain conditions, such as uterine fibroids . These factors have contributed to medical mistrust, which some women cite as a reason that they may not access contraception. In addition, inequities across broader social and economic factors — such as income, housing, safety and education—that drive health, often referred to as social determinants of health, affect decisions related to family planning and reproductive health.

How Do State Abortion Policies Vary Across Racial and Ethnic Groups?

Overall, 16.3 million or 25% of women ages 18-49 in the US live in one of the 14 states where abortion is banned, and another 16.9 million, or 26%, live in one of the 11 states with gestational limits between 6 and 22 weeks LMP. The remaining 32.8 million, or roughly 50%, live in states that provide broader access to abortions.

White, Black, and American Indian and Alaska Native women account for larger shares of women ages 18-49 in states that have banned or limited abortion access compared to states that provide broader access to abortion . Most of the states that have banned or restricted abortion are in the South, where more than half of the Black population and roughly a third of the White (36%) and AIAN (31%) population reside. In contrast, Hispanic and Asian women make up larger shares of women ages 18-49 in states that provide broader access to abortion compared to states with abortion bans or limits. (See Appendix Table B for the racial and ethnic distribution of women ages 18-49 by state).

Six in ten of Black (60%) and AIAN (59%) women ages 18-49 live in states with abortion bans or restrictions (Figure 3) . Just over half (53%) of White women ages 18-49 live in states with bans or restrictions, while less than half of Hispanic (45%) and about three in ten Asian (28%) and NHPI (29%) women ages 18-49 live in these states. Of note, in April 2024, the Arizona State Supreme Court upheld a Civil War era law banning nearly all abortions in the state. While that law is not currently in effect, if it were to go into effect in the future, the share of AIAN women living in a state with an abortion ban would rise from about three in ten (31%) to about four in ten (41%), and the share of Hispanic women living in a state with an abortion ban would increase from 24% to 28%.

How do potential barriers to accessing abortions vary by race and ethnicity?

Variation in abortion policies by state due to the Dobbs decision will likely result in women of color facing disproportionate access barriers since they face underlying disparities in health coverage and have more limited financial resources that may make it challenging to obtain an abortion out-of-state or via telehealth.

Health Coverage

Lack of health insurance limits women’s access to a broad range of health services, including contraception and pregnancy care, and leaves them at risk for significant out of pocket expenses for care. However, having coverage does not guarantee that it includes abortion benefits. In general coverage of abortion is more limited than for many other common health services. Some states prohibit coverage of abortion in state-regulated private insurance plans, and federal law bars the use of federal dollars for abortion, including in Medicaid, the national health coverage program for low-income individuals.

AIAN, Hispanic, NHPI, and Black women between ages 18-49 have higher uninsured rates compared to their White counterparts . Among women in this age group, roughly a fifth of AIAN (22%) and Hispanic (21%) women are uninsured as are 14% of NHPI women and 11% of Black women. In contrast, less than one in ten (7%) of White women lack insurance (Figure 4). These differences in uninsured rates are driven by lower rates of private coverage among these groups. Medicaid coverage helps to narrow these differences but does not fully offset them.

Across racial and ethnic groups, uninsured rates for women ages 18-49 in states that have banned or limited abortion are higher than rates in states where abortion is available beyond 22 weeks . Overall, 16% of women ages 18-49 in states that have banned abortion are uninsured compared to 12% in states that have gestational limits on abortions less than 22 weeks and 8% in states that have broader access to abortions. Uninsured rates for women ages 18-49 are at least twice as high in states that banned abortion compared to those in states with broader access for White (10% vs. 5%), Hispanic (33% vs. 15%), Black (14% vs. 7%), and Asian (10% vs. 5%) women, and nearly three times higher for NHPI women (29% vs. 10%) (Figure 5). However, even in states where abortion is not banned, many women do not have coverage, and uninsured rates remain higher for AIAN, Hispanic, and NHPI women compared to White women.

AIAN, Black, NHPI, and Hispanic women are more likely than their White counterparts to be covered by Medicaid, which provides limited coverage for abortions . For decades, the Hyde Amendment has prohibited the use of federal funds for coverage of abortion under Medicaid, except in cases of rape, incest, or life endangerment for the pregnant person. States can choose to use state funds to pay for abortions under Medicaid in other instances. However, among the 36 states that do not ban abortion, 17 use state funds to pay for abortions beyond the Hyde limitations for Medicaid enrollees. The other 19 states and DC continue to follow the Hyde limits, meaning women in these states covered by Medicaid likely must pay out of pocket for an abortion unless they meet the narrow circumstances of the Hyde Amendment.

Social and Economic Access Barriers

Women of color have more limited financial resources and transportation options than White women, making it more difficult for them to travel out-of-state for an abortion. The median self-pay cost of obtaining an abortion exceeded $500 in 2021, but costs can vary depending on the type of abortion, location, and if an individual has coverage. Traveling out of state raises the cost of abortion due to added costs for transportation, accommodation, and childcare. Moreover, it may result in more missed work, meaning greater loss of pay. Data suggest that women of color would have more difficulty than White women affording these increased costs and may face other barriers that could prevent them from traveling to obtain an abortion and instead turning to self-managed abortions or continuing the pregnancies.

Overall, AIAN (48%), Black (43%), NHPI (41%) and Hispanic (40%) women ages 18-49 are nearly twice as likely as their White counterparts (24%) to have low incomes (below 200% of the federal poverty level or $46,060 for a family of three as of 2022) (Figure 6) . Moreover, across most racial and ethnic groups, women in states that have banned abortion are more likely to have low incomes than women in states that allow abortions beyond 22 weeks. For example, 48% of NHPI women in states that have banned abortion have low incomes compared to 38% of NHPI women in states where abortion is available after 22 weeks gestation. (See Appendix Table C for state-level data on the share of women who are low-income by race and ethnicity.)

Over half of Hispanic (57%) and Black women (58%) ages 18-49 could not cover an emergency expense of at least $500 using their current savings compared to 36% of White women in this age group (Figure 7) . (Data for this measure were not available for other racial groups.) Women who have fewer resources for an emergency expense may be more likely to seek assistance from an abortion fund , which help cover the costs of abortions for people who cannot afford them. However, abortion funds are not able to keep up with the demand and support all those seeking assistance.

Black women ages 18-49 are more likely than their White counterparts to live in a household without access to a vehicle (12% vs. 4%), and Asian and AIAN women in this age group are more likely than White women to lack vehicle access (9% and 8%, respectively, vs. 4%) (Figure 8) . Hispanic and NHPI women are also more likely than White women to lack vehicle access, although the difference is smaller (6% and 6%, respectively, vs 4%). Research shows that out-of-state travel for abortion care has risen significantly since Dobbs, but women without vehicle access may face greater challenges to traveling out of state.

Immigration-related fears make some women reluctant to travel out of state for an abortion . Among women ages 18-49, about one-third of Asian women (33%) and roughly a quarter of Hispanic (24%) and NHPI (22%) women are noncitizens, who include lawfully present and undocumented immigrants (Figure 9). Many citizen women may also live in mixed immigration status families, which may include noncitizen family members. Noncitizen women and those living in mixed immigration status families may fear that traveling out of state could put them or a family member at risk for negative impacts on their immigration status or detention or deportation, especially in states that have moved to criminalize abortions. For example, some states have enacted laws that make it illegal to “ aid or abet ” someone in obtaining an abortion while some are trying to make it illegal to take a minor across state lines to obtain an abortion.

Differences in language barriers and access to technology may also contribute to racial disparities in abortion access . Roughly a quarter of Hispanic (26%) and Asian (25%) women ages 18-49 speak English “less than very well,” as do one in ten NHPI women (10%) compared to just 1% of White women (Figure 10). This can affect their ability to find information about abortions and locate a clinic that offers abortion services. In a national KFF survey of women conducted just before the Dobbs ruling, nearly three in ten Hispanic women (29%) said if they needed an abortion, they did not know where to go or find the information, higher than other groups. Internet access is another important factor for finding information about abortion care and also for telehealth appointments, which comprise a growing share of abortion care. Among women ages 18-49, 8% of AIAN and 6% of NHPI (6%) women live in a household without internet access, compared to 2% of White women (Figure 10).

What are the Potential Implications of Abortion Restrictions on Racial Disparities in Health, Finances, and Criminal Penalties?

Stark racial disparities in maternal and infant health predate the Dobbs decision but may widen due to the new restrictions on abortions since abortion services can be a key factor in managing pregnancy complications and emergencies that can lead to poor outcomes. Data suggest that the abortion restrictions may also contribute to growing provider shortages in some areas, which may increase access challenges and have negative impacts on health. Moreover, abortion restrictions may have negative economic consequences on families and put people at increased risk for criminalization.

Maternal Health

Prior to the Dobbs ruling there were already significant racial disparities in pregnancy-related and infant mortality, which may widen due to abortion restrictions . NHPI, Black and AIAN people are more likely to die while pregnant or within a year of the end of pregnancy compared to White people (62.8, 39.9 and 32.0 per 100,000 births vs. 14.1 per 100,000 births) (Figure 11). Restrictions on access to abortions limit options to terminate pregnancies for medical reasons. While all state bans have some limited exceptions to preserve the life of pregnant women, the language of these exceptions is vague and narrow, and far fewer have health exceptions. This means that some people have been forced to remain pregnant even when the pregnancy is threatening their health , which could further widen disparities. One study estimated that a total abortion ban in the U.S. would increase the number of pregnancy-related deaths by 21% for all women and 33% among Black women.

There also are racial disparities in certain birth risks and adverse birth outcomes which may be exacerbated by the abortion restrictions . Specifically, as of 2022, higher shares of births to Hispanic, Black, AIAN and NHPI people were among those who received late or no prenatal care, or were preterm, or low birthweight, compared to White people (Figure 12). Timely prenatal care is particularly important for people with higher-risk pregnancies, yet research suggests that restrictive abortion policies may be causing people to start prenatal care later in pregnancy, which is already a concern for women of color who are more likely to experience delays in prenatal care initiation. Births among Asian people were also more likely to be low birthweight than those of White people. Moreover, while the birth rate among teens has been declining over time for all groups, the rate for Black, Hispanic, AIAN, and NHPI teens was over two times higher than the rate among White and Asian teens in 2021 (Figure 13). Research has also found that state-level abortion restrictions that were in place prior to Dobbs were associated with disproportionately higher rates of adverse birth outcomes, including preterm birth, for Black individuals, and that inequities widened as states became more restrictive.

Abortion bans and restrictions limit care for people experiencing a pregnancy loss, which some groups of women of color are at higher risk of experiencing compared to their White counterparts . Pregnancy loss, which includes miscarriage and stillbirth, is common , occurring in up to an estimated 20% of all pregnancies. Data on racial and ethnic disparities in miscarriage is limited, but research shows that the rates of fetal mortality (fetal demise following 20 weeks of gestation) are higher among Black, AIAN, and NHPI women compared to White women (Figure 14). While some miscarriages, particularly earlier in pregnancy, pass without any medical intervention, some people seek medical care to complete a miscarriage and/or because their health may worsen with the continuation of an unviable pregnancy. Almost all medications and procedures used to manage miscarriages and stillbirths are identical to those used in abortions. As a result, clinicians may hesitate to provide care even when medically indicated because of concerns they could be conflated with providing an abortion and therefore risk criminalization or penalties as a result. Since the Dobbs ruling, there have been several high-profile cases of people experiencing pregnancy losses who could not obtain timely miscarriage care due to state abortion bans, jeopardizing their health as a result. In KFF’s national survey of OBGYNs after the Dobbs decision, more than half (55%) of OBGYNs practicing in states where abortion is banned said their ability to practice within the standard of care has worsened since Dobbs .

In states where abortion is banned or severely restricted, the number of women forced to continue a pregnancy is likely to rise, with data suggesting disproportionate increases among women of color . While it is relatively early to see the impact of the Dobbs ruling on births, initial research suggests that birth rates could increase as a result. One study to date has estimated that there have been approximately 32,000 “ additional ” births as a result of the ruling, primarily concentrated in states that have banned abortions and with a disproportionate effect among people of color. A study in Texas , which had implemented a ban on abortions after six weeks gestation starting September 2021 (prior to Dobbs ), found a 2% rise in the state’s fertility rate after the law’s implementation, with the sharpest increase among Hispanic women (8%).

Provider Access and Shortages

The Dobbs decision may exacerbate health care workforce shortages, particularly among clinicians providing obstetric and gynecologic care . State-level abortion bans criminalize clinicians who provide abortion care, and this has cascading effects on other aspects of maternity care. Even prior to Dobbs , there were concerns about workforce shortages in maternity care. The estimates that more than 5 million women of reproductive age in the U.S. live in counties that have few or no obstetric providers, with the largest gaps in rural communities as well as areas with higher rates of poverty, and larger shares of Black women. Many of these areas are in states with abortion bans and gestational restrictions, and there are reports of clinicians leaving these states because they are prohibited from and criminalized for offering the full scope of services they trained for and that comport with medical standards. Abortion restrictions may also affect the pipeline of new clinicians. A few studies to date, have found declines in US medical school graduates applying to OBGYN residency positions in states with abortion bans. While all positions were filled and the changes to date have been relatively small, they could suggest that future clinicians may prefer not to practice in states that ban abortion, potentially widening existing gaps in workforce capacity.

Many OBGYNs say that the Dobbs decision has had a negative impact on racial and ethnic inequities and the broader field of maternity care . In a national KFF survey , seven in ten OBGYNs say that since the Dobbs decision, racial and ethnic inequities in maternal health (70%) as well as management of pregnancy-related medical emergencies (68%) have gotten worse. Over half think that the ability to attract new OBGYNs to the profession has worsened (55%) and 64% think the same about pregnancy-related mortality (Figure 15).

Economic Circumstances

Denying women access to abortion services has negative economic consequences . Many women who are not able to obtain abortions will have children that they hadn’t planned for and face the associated costs of raising a child. In addition to the direct costs, lack of abortion access can affect women’s longer-term educational and career opportunities. Research from the Turnaway Study , which examined the impact of an unwanted pregnancy on women’s lives, found a range of negative economic effects of abortion denials, including higher poverty rates, financial debt , and poorer credit scores among women who were not able to obtain abortions compared to women who received abortions. The study also found negative socioeconomic impacts for the children born to women who were denied abortions, which may exacerbate existing racial disparities in income. Poverty rates are already much higher among children of color than White children, and research shows children in families with lower incomes experience negative long-term outcomes, including lower earnings and income, increased use of public assistance, greater likelihood of committing crimes, and more health problems.

Criminalization

People of color may be at increased risk for criminalization in the post- Roe environment . A long history of racism in judicial policy in this country has led to disproportionately higher rates of criminalization among people of color and is likely to grow as abortion care is criminalized. Prior to the Dobbs ruling, there were already cases of women criminalized for their own miscarriages, stillbirths, or infant death, due in part to the establishment of laws that protect and prioritize “ fetal personhood .” The women charged were disproportionately women with lower incomes, Black women, and women living in southern states that have subsequently banned or greatly restricted abortion access. None of the state-level abortion bans specifically criminalize women for getting an abortion, but fetal personhood laws can conflate miscarriage and abortion. For example, in one high-profile case, Brittany Watts is an Ohio woman who faced criminal charges after she had a miscarriage at home in Fall 2023. While Ms. Watts sought medical care, other pregnant people experiencing a miscarriage or other complications may be deterred from seeking care, since treatment could be conflated with an abortion, putting their own health at risk as a result. Furthermore, many accusations of fetal harm are initiated by health care providers . State laws that penalize people who aid and abet abortion access and those that grant fetal personhood can perpetuate the culture of criminalizing pregnancy, particularly among communities of color.

Women's Health Policy
Racial Equity and Health Policy
Race/Ethnicity

Also of Interest

Key Facts on Abortion in the United States
Abortions Later in Pregnancy in a Post-Dobbs Era
The Hyde Amendment and Coverage for Abortion Services Under Medicaid in the Post-Roe Era
Abortion in the United States Dashboard

5 Takeaways From the Supreme Court Arguments on Idaho’s Abortion Ban

The court’s ruling could extend to at least half a dozen other states that have similarly restrictive bans, and the implications of the case could stretch beyond abortion.

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Idaho’s attorney general, Raúl Labrador, speaks into microphones while surround by a group of people. In the background is the Supreme Court.

By Pam Belluck

April 24, 2024

The abortion case before the Supreme Court on Wednesday featured vigorous questioning and comments, particularly by the three liberal justices. At issue is whether Idaho’s near-total ban on abortion is so strict that it violates a federal law requiring emergency care for any patient, including providing abortions for pregnant women in dire situations.

A ruling could reverberate beyond Idaho, to at least half a dozen other states that have similarly restrictive bans.

The implications of the case could also extend beyond abortion, including whether states can legally restrict other types of emergency medical care and whether the federal law opens the door for claims of fetal personhood.

Here are some takeaways:

The case centers on whether Idaho’s abortion ban violates federal law.

Idaho’s ban allows abortion to save the life of a pregnant woman, but not to prevent her health from deteriorating. The federal government says it therefore violates the Emergency Medical Treatment and Labor Act, or EMTALA, which was enacted nearly 40 years ago.

EMTALA says that when a patient goes to an emergency room with an urgent medical issue, hospitals must either provide treatment to stabilize the patient or transfer the patient to a medical facility that can, regardless of the patient’s ability to pay. It says that if a state law conflicts with the federal law, the federal law takes precedence.

A lawyer representing Idaho, Joshua Turner, told the Supreme Court that the state does not believe its abortion ban conflicts with the federal law. He said the ban allows emergency departments to provide abortions if a pregnant woman has a medical problem that is likely to lead to her death, not just if she is facing imminent death.

The three liberal justices strongly objected to Mr. Turner’s interpretation and pointed out situations in which women in critical situations would be denied abortions under Idaho’s ban. When Justice Sonia Sotomayor asked if the ban would prevent abortion in a situation where a woman would otherwise lose an organ or have serious medical complications, Mr. Turner acknowledged that it would. “Yes, Idaho law does say that abortions in that case aren’t allowed,” he said.

The real-world consequences of Idaho’s ban for abortion and other medical care were apparent.

Solicitor General Elizabeth B. Prelogar, representing the federal government, said Idaho’s abortion ban, which was allowed to take effect this year, had significant consequences for pregnant women and emergency room doctors.

“Today, doctors in Idaho and the women in Idaho are in an impossible position,” she said. “If a woman comes to an emergency room facing a grave threat to her health, but she isn’t yet facing death, doctors either have to delay treatment and allow her condition to materially deteriorate or they’re airlifting her out of the state so she can get the emergency care that she needs.”

Justice Samuel A. Alito Jr., one of the most conservative justices, asserted that the federal government and the liberal justices were giving hypothetical examples. But Justice Elena Kagan, a liberal, noted that the hospital with the most advanced emergency room services in Idaho had needed to transfer six women to other states for emergency abortions so far this year.

There was also discussion about potential consequences for other types of medical care if Idaho’s ban was allowed to stand. Justice Sotomayor said that would allow states to pass laws saying “don’t treat diabetics with insulin, treat them only with pills,” contradicting the best medical judgment of a doctor who “looks at a juvenile diabetic and says, ‘Without insulin, they’re going to get seriously ill.’”

Conservative justices raised questions about fetal rights.

Justice Alito, in particular, focused on the fact that EMTALA includes several mentions of the phrase “unborn child.”

“Doesn’t that tell us something?” he asked. He suggested that it meant that “the hospital must try to eliminate any immediate threat to the child,” and that “performing an abortion is antithetical to that duty.”

That was an argument that supports efforts by abortion opponents to establish “fetal personhood” rights and declare that life begins at conception. Idaho’s lawyer, Mr. Turner, said on Wednesday that “there are two patients to consider” when pregnant women seek emergency room care.

The federal government has pointed out that three of the four mentions of “unborn child” in EMTALA refer only to when a woman in labor might be transferred to another hospital.

Ms. Prelogar described the intent of the fourth reference to “unborn child,” which was added to the law later. She said it referred to situations in which a pregnant woman goes to an emergency room and her pregnancy is in danger but her own health is not currently at risk. In that case, the law would require hospitals to do what they could to save the pregnancy. That would not be a situation where an abortion would be provided, she said.

Ms. Prelogar also emphasized that usually in the kinds of pregnancy emergencies in which an abortion is typically required, there is no possibility for a live birth. “In many of these cases, the very same pregnancy complication means the fetus can’t survive regardless,” she said. “There’s not going to be any way to sustain that pregnancy.”

In such cases, she said, “what Idaho is doing is waiting for women to wait and deteriorate and suffer the lifelong health consequences with no possible upside for the fetus. It stacks tragedy upon tragedy.”

The U.S. government disputed conservative claims that the federal law allows abortion for mental health emergencies.

Mr. Turner said that EMTALA would allow emergency rooms to provide abortions for pregnant women who are experiencing depression and other mental health issues. Abortion opponents have said that this could be used as a loophole to allow many patients to obtain abortions despite state bans.

Justice Amy Coney Barrett, another conservative, expressed some skepticism about Idaho’s claim. Justice Alito pressed the solicitor general about it.

“Let me be very clear about our position,” Ms. Prelogar replied. “That could never lead to pregnancy termination because that is not the accepted standard of practice to treat any mental health emergency.”

She said antipsychotic drugs and other psychiatric treatments would be administered to such patients. The treatment would not be abortion, she said, because “that won’t do anything to address the underlying brain chemistry issue that’s causing the mental health emergency in the first place.”

The federal emergency care law doesn’t require doctors who are morally opposed to abortion to provide them, the government said.

Justice Barrett and Chief Justice John G. Roberts Jr. asked if EMTALA’s requirement for emergency medical care prevented emergency room doctors or hospitals with moral or religious objections from opting out of providing abortions.

The solicitor general said that federal conscience protections take precedence. So individual doctors can invoke conscience rights to avoid providing abortions, Ms. Prelogar said. And although she said it would be rare for an entire hospital to invoke a moral objection to terminating pregnancies in the kinds of medical emergencies that EMTALA applies to, hospitals with such objections could opt out as well.

Pam Belluck is a health and science reporter, covering a range of subjects, including reproductive health, long Covid, brain science, neurological disorders, mental health and genetics. More about Pam Belluck

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I Served on the Florida Supreme Court. What the New Majority Just Did Is Indefensible.

On April 1, the Florida Supreme Court, in a 6–1 ruling, overturned decades of decisions beginning in 1989 that recognized a woman’s right to choose—that is, whether to have an abortion—up to the time of viability.

Anchored in Florida’s own constitutional right to privacy, this critical individual right to abortion had been repeatedly affirmed by the state Supreme Court, which consistently struck down conflicting laws passed by the Legislature.

As explained first in 1989:

Florida’s privacy provision is clearly implicated in a woman’s decision of whether or not to continue her pregnancy. We can conceive of few more personal or private decisions concerning one’s body in the course of a lifetime.

Tellingly, the justices at the time acknowledged that their decision was based not only on U.S. Supreme Court precedent but also on Florida’s own privacy amendment.

I served on the Supreme Court of Florida beginning in 1998 and retired, based on our mandatory retirement requirement, a little more than two decades later. Whether Florida’s Constitution provided a right to privacy that encompassed abortion was never questioned, even by those who would have been deemed the most conservative justices—almost all white men back in 1989!

And strikingly, one of the conservative justices at that time stated: “If the United States Supreme Court were to subsequently recede from Roe v. Wade , this would not diminish the abortion rights now provided by the privacy amendment of the Florida Constitution.” Wow!

In 2017 I authored an opinion holding unconstitutional an additional 24-hour waiting period after a woman chooses to terminate her pregnancy. Pointing out that other medical procedures did not have such requirements, the majority opinion noted, “Women may take as long as they need to make this deeply personal decision,” adding that the additional 24 hours stipulated that the patient make a second, medically unnecessary trip, incurring additional costs and delays. The court applied what is known in constitutional law as a “strict scrutiny” test for fundamental rights.

Interestingly, Justice Charles Canady, who is still on the Florida Supreme Court and who participated in the evisceration of Florida’s privacy amendment last week, did not challenge the central point that abortion is included in an individual’s right to privacy. He dissented, not on substantive grounds but on technical grounds.

So what can explain this 180-degree turn by the current Florida Supreme Court? If I said “politics,” that answer would be insufficient, overly simplistic. Unfortunately, with this court, precedent is precedent until it is not. Perhaps each of the six justices is individually, morally or religiously, opposed to abortion.

Yet, all the same, by a 4–3 majority, the justices—three of whom participated in overturning precedent—voted to allow the proposed constitutional amendment on abortion to be placed on the November ballot. (The dissenters: the three female members of the Supreme Court.) That proposed constitutional amendment:

Amendment to Limit Government Interference With Abortion: No law shall prohibit, penalize, delay, or restrict abortion before viability or when necessary to protect the patient’s health, as determined by the patient’s healthcare provider. This amendment does not change the Legislature’s constitutional authority to require notification to a parent or guardian before a minor has an abortion.

For the proposed amendment to pass and become enshrined in the state constitution, 60 percent of Florida voters must vote yes.

In approving the amendment to be placed on the ballot at the same time that it upheld Florida’s abortion bans, the court angered those who support a woman’s right to choose as well as those who are opposed to abortion. Most likely the latter groups embrace the notion that fetuses are human beings and have rights that deserve to be protected. Indeed, Chief Justice Carlos Muñiz, during oral argument on the abortion amendment case, queried the state attorney general on precisely that issue, asking if the constitutional language that defends the rights of all natural persons extends to an unborn child at any stage of pregnancy.

In fact, and most troubling, it was the three recently elevated Gov. Ron DeSantis appointees—all women—who expressed their views that the voters should not be allowed to vote on the amendment because it could affect the rights of the unborn child. Justice Jamie Grosshans, joined by Justice Meredith Sasso, expressed that the amendment was defective because it failed to disclose the potential effect on the rights of the unborn child. Justice Renatha Francis was even more direct, writing in her dissent:

The exercise of a “right” to an abortion literally results in a devastating infringement on the right of another person: the right to live. And our Florida Constitution recognizes that “life” is a “basic right” for “[a]ll natural persons.” One must recognize the unborn’s competing right to life and the State’s moral duty to protect that life.

In other words, the three dissenting justices would recognize that fetuses are included in who is a “natural person” under Florida’s Constitution.

What should be top of mind days after the dueling decisions? Grave concern for the women of our state who will be in limbo because, following the court’s ruling, a six-week abortion ban—at a time before many women even know they are pregnant—will be allowed to go into effect. We know that these restrictions will disproportionately affect low-income women and those who live in rural communities.

But interestingly, there is a provision in the six-week abortion ban statute that allows for an abortion before viability in cases of medical necessity: if two physicians certify that the pregnant patient is at risk of death or that the “fetus has a fatal fetal abnormality.”

The challenge will be finding physicians willing to put their professional reputations on the line in a state bent on cruelly impeding access to needed medical care when it comes to abortion.

Yet, this is the time that individuals and organizations dedicated to women’s health, as well as like-minded politicians, will be crucial in coordinating efforts to ensure that abortions, when needed, are performed safely and without delay. This is the time to celebrate and support organizations, such as Planned Parenthood and Emergency Medical Assistance , as well as our own RBG Fund , which provides patients necessary resources and information. Floridians should also take full advantage of the Repro Legal Helpline .

We all have a role in this—women and men alike. Let’s get out, speak out, shout out, coordinate our efforts, and, most importantly, vote . Working together, we can make a difference.

Florida's 6-week abortion ban takes effect, and impact takes a quick toll

Inside a one-story clinic about 40 miles from the Georgia border, Kelly Flynn’s staff has provided abortions to women from across the Southeast since the Supreme Court overturned Roe v. Wade in 2022.

But on Tuesday, A Woman’s Choice clinic in Jacksonville, Florida, was seeing its last patients who fell outside of Florida’s strict new abortion law taking effect on Wednesday. The legislation prohibits most abortions after about six weeks – before many people know they’re pregnant.

Some arrived from Mississippi and Louisiana. One client was a college student who had learned last week that she was pregnant, said Flynn, fueling a quick decision as she and others scrambled to get care ahead of the new law.

"‘You know, I'm a college student. I'm not ready for this,’” Flynn recounted the student telling her.

Florida’s Supreme Court gave the state's new restrictions the greenlight in April. Now, those who are seeking an abortion beyond about six weeks of pregnancy are being redirected to clinics in North Carolina, Virginia, New Jersey, or other states – often setting up a daunting struggle to get time off work, obtain child care and afford costly travel.

Prep for the polls: See who is running for president and compare where they stand on key issues in our Voter Guide

Florida's court last month also cleared the way for a constitutional amendment protecting abortion access up to viability, often around 24 weeks, to be on November’s ballot.

While the outcome of that measure could override the state's current restrictions, abortion advocates and providers told USA TODAY the law's impact in the meantime is expected to ripple well beyond the state to other parts of the South.

Florida Gov. Ron DeSantis has celebrated legislation that bars a wide swath of abortions , saying last month that his home state is "proud to support life and family."

Florida residents face immediate effects

Abortions have been limited in Florida after 15 weeks, a cutoff DeSantis signed into law in 2022 when the Supreme Court overturned Roe v. Wade and almost 50 years of national abortion access. While more restrictive than the limits established by Roe, Florida’s 15-week ban was more than what many neighboring Southeastern states allowed, making it a common access point for out-of-state patients.

This new law includes exceptions for rape or incest if a person can provide documentation, such as a restraining order or police report. The ban also prohibits abortion drugs by mail.

In 2023, state data shows there were around 84,000 abortions performed in Florida and more than 4,200 abortions in Duval County, where the Jacksonville A Woman's Choice clinic is located. Flynn expects that number to tumble, and experts now anticipate an increase in women in Florida traveling for the procedure.

For patients who measure past six weeks in the coming days, Flynn said, “We’ll help them figure out – what do you want to do at this point? Your options are going to North Carolina or going to Virginia.”

The process will be burdensome for many , said Dr. Katherine Farris, chief medical officer for Planned Parenthood South Atlantic, which covers North and South Carolina, West Virginia and the western half of Virginia.

“Patients are going to have to jump over the states with total bans, like Alabama, jump over Georgia and South Carolina that have similar bans to Florida, and come up to North Carolina, Virginia, and areas to the northeast where there are fewer restrictions to abortion,” she said.

Abortion funds have worked to help women across the U.S. afford airfare, gas, time off work or child care to travel for an abortion. But Flynn worries that limited funds will quickly become overstretched.

However, while Florida’s law bans doctors from prescribing abortion pills through telehealth and mailing them to people, many residents will likely be able to use out-of-state telehealth to receive pills by mail. That's something that has been seen as difficult to stop, said Cheyenne Drews, deputy communications director for the nonprofit group Progress Florida.

Florida joins rest of South with abortion ban

Farris said abortion restrictions in the South since Roe was overturned have been “absolutely devastating.”

“The bans are creating chaos,” she said .

Abortion opponents, though, are celebrating the Sunshine State’s new law going into effect and what it means for the region, said Caitlin Connor, southern regional director for Susan B. Anthony Pro-Life America.

“I don't think that that's what the voters of Florida wanted to see their state be known for, as an abortion destination, if you will,” Connors said. “Now, the state of Florida will join the rest of the Southeast, but also states across the country who have put this protection in place.”

With Florida’s law going into effect, only two Southern states will allow abortion after six weeks of pregnancy: North Carolina, which permits the procedure through 12 weeks with exceptions, and Virginia, where abortion is banned in the third trimester or around 27 weeks.

Ahead of Florida's new law taking effect on Wednesday, Connors told USA TODAY that mothers and families − and American voters − "understand the humanity of the unborn.”

Voters will decide on abortion limits in 2024

Anna Hochkammer, executive director of Florida Women’s Freedom Coalition, one of many groups behind the state’s upcoming abortion ballot measure, said she believes the new ban goes beyond what most Floridians want, alleging it's "out of line."

A USA TODAY/Ipsos poll last month found 50% of Florida voters said they would favor an amendment protecting abortions – the measure will need a 60% majority to pass.

Voters will have the chance to weigh in this fall when the state’s proposed constitutional amendment appears on the ballot.

Effects of the six-week ban could tip the scales in abortion rights advocates’ favor, Hochkammer predicted, though the issue remains divisive among many Floridians.

"This is no longer trying to talk to people about the hypothetical outcomes of really bad policy. They will be living with the consequences of a near total abortion ban,” she argued.

Even if Florida voters do opt to protect abortion rights in their state constitution, the law in the state will not reverse immediately, said Florida state Senate Minority Leader Lauren Book, a Democrat.

“Come November, if, when this amendment passes, that is not going to turn the spigot on or change things overnight,” Book told reporters Tuesday. “This is a reality that women and girls will have to live under for quite some time before a change is made.”

Trump says it’s up to states whether to punish, monitor women for abortions

Former president Donald Trump said in an interview published Tuesday that he would not intervene in state decisions on abortion policy, including in situations where states seek to monitor women’s pregnancies and prosecute those who violate abortion bans.

Trump also declined during the interview with Time magazine to commit to veto any additional federal restrictions if they were to come to his desk upon a possible return to the White House.

Asked by Time if he would be comfortable with states prosecuting women for having abortions outside limited periods permitted by state laws, Trump suggested the federal government should have no role.

“It’s irrelevant whether I’m comfortable or not,” Trump said. “It’s totally irrelevant, because the states are going to make those decisions.”

Trump’s comments highlight the fraught politics of the stance on abortion that he outlined earlier this month.

Trump announced on social media that policy should be left to the states, after months of mixed signals about his position. Trump has consistently taken credit for overturning Roe v. Wade — three of the justices who ruled on the case were appointed by him — yet has distanced himself from the political repercussions of the decision.

Shortly after Trump articulated his states-rights stance this month, Arizona’s Supreme Court revived an 1864 law passed before it was granted statehood that forbids abortions except to save a mother’s life and punishes providers with prison time. In that case, Trump said the state had gone too far.

During the Time interview, however, Trump repeatedly emphasized his support for state autonomy, at least in concept.

When asked, for instance, about the federal Republican-sponsored Life at Conception Act, which would grant “full legal rights to embryos,” Trump said: “I’m leaving everything up to the states.”

He declined to say whether he would veto such a bill, suggesting he wouldn’t be presented with that decision.

“I don’t have to do anything about vetoes,” Trump said, “because we now have it back in the states.”

Asked by Time if states should monitor women’s pregnancies to detect whether they get abortions after a ban takes effect, Trump said: “I think they might do that.”

“Again, you’ll have to speak to the individual states,” he said. “Look, Roe v. Wade was all about bringing it back to the states.”

Democrats have sought to make abortion the dominant issue in the 2024 elections, highlighting Trump’s role in appointing the three conservative Supreme Court justices who helped overturn a constitutional right to abortion in 2022, and legislation pushed by Republican lawmakers to ban or severely restrict access to the procedure.

President Biden’s campaign seized on the Time interview after it was published Tuesday.

Biden campaign manager Julie Chavez Rodriguez said Trump’s latest remarks are proof that reproductive health care is at stake in the election.

“Donald Trump’s latest comments leave little doubt: if elected he’ll sign a national abortion ban, allow women who have an abortion to be prosecuted and punished, allow the government to invade women’s privacy to monitor their pregnancies, and put IVF and contraception in jeopardy nationwide,” Rodriguez said in a statement. “Simply put: November’s election will determine whether women in the United States have reproductive freedom, or whether Trump’s new government will continue its assault to control women’s health care decisions.”

Trump declined to answer directly when asked by Time if he thinks women should be able to obtain the abortion pill mifepristone .

“Well, I have an opinion on that, but I’m not going to explain. I’m not gonna say it yet.” He said he would announce his position “probably over the next week.” When pressed for an answer, Trump sought more time. “I will be making a statement on that over the next 14 days.”

Trump spoke with writer Eric Cortellessa at his home in Florida on April 12 and had a follow-up phone interview April 27, the magazine reported. On Tuesday it published a story about the interview along with a transcript .

The interview comes as Republicans brace for fallout from their newly pushed restrictions.

Florida’s ban on abortion after six weeks of pregnancy takes effect this week, one of the strictest in the nation.

The Republican-led Arizona Senate is expected to vote on a repeal of the state’s near total abortion ban after the state Supreme Court ruled a Civil War-era bill can take effect following the overturning of Roe v. Wade . Arizona’s House last week voted to repeal the law, after prominent antiabortion Republicans such as Senate candidate Kari Lake reversed course on the issue .

Trump, who once described himself as “very pro-choice,” said in 2000 that he would “indeed support a ban.” As a candidate, Trump struggled to adopt a position to fully satisfy leading members of the antiabortion movement while shielding himself and Republicans from blowback at the ballot box.

During the GOP nominating contests, Trump declined to take a firm stance on federal legislation and criticized Florida’s six-week abortion ban as a “terrible mistake.” In a CNN town hall last year, Trump would not say whether he would sign a federal abortion ban. Instead he said the antiabortion movement was in a “very good negotiating position” after the Supreme Court overturned Roe.

As president, Trump backed a 20-week abortion ban that did not have the votes to pass Congress and at the time conflicted with Roe, which gave Americans nationwide a right to abortion until a fetus was viable outside the womb, often pegged at roughly 24 weeks of pregnancy.

After publication of the Time interview Tuesday, Trump celebrated the piece while speaking to reporters outside the courtroom in New York, where he is on trial.

“I want to thank the Time magazine,” he said. “They did a cover story, which is very nice.”

“It’s at least 60 percent correct, which is all I could ask for,” Trump said, without identifying anything that he might say were inaccuracies. Trump walked away and ignored questions shouted by reporters.

Isaac Arnsdorf contributed to this report.

U.S. abortion access, reproductive rights

Tracking abortion access in the United States: Since the Supreme Court struck down Roe v. Wade , the legality of abortion has been left to individual states. The Washington Post is tracking states where abortion is legal, banned or under threat.

Abortion and the election: Voters in about a dozen states could decide the fate of abortion rights with constitutional amendments on the ballot in a pivotal election year. Biden supports legal access to abortion , and he has encouraged Congress to pass a law that would codify abortion rights nationwide. After months of mixed signals about his position, Trump said the issue should be left to states . Here’s how Biden and Trump’s abortion stances have shifted over the years.

New study: The number of women using abortion pills to end their pregnancies on their own without the direct involvement of a U.S.-based medical provider rose sharply in the months after the Supreme Court eliminated a constitutional right to abortion , according to new research.

Abortion pills: The Supreme Court seemed unlikely to limit access to the abortion pill mifepristone . Here’s what’s at stake in the case and some key moments from oral arguments . For now, full access to mifepristone will remain in place . Here’s how mifepristone is used and where you can legally access the abortion pill .

States where abortion is on the ballot in the 2024 election April 15, 2024 States where abortion is on the ballot in the 2024 election April 15, 2024
States where abortion is legal, banned or under threat May 1, 2024 States where abortion is legal, banned or under threat May 1, 2024
Tears and despair at Florida abortion clinic in final hours before ban May 1, 2024 Tears and despair at Florida abortion clinic in final hours before ban May 1, 2024

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Supreme Court appears skeptical that state abortion bans conflict with federal health care law

Dueling protests were taking place outside the U.S. Supreme Court in Washington. The court was hearing arguments Wednesday over whether state abortion bans enacted after its sweeping ruling overturning Roe v. Wade can extend to medical emergencies. (AP video: Rick Gentilo, Dan Huff)

Abortion-rights activists rally outside the Supreme Court, Wednesday, April 24, 2024, in Washington. (AP Photo/Jose Luis Magana)

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Anti-Abortion activists rally outside the Supreme Court, Wednesday, April 24, 2024, in Washington. (AP Photo/Jose Luis Magana)

Anti-Abortion and Abortion-rights activists rally outside the Supreme Court, Wednesday, April 24, 2024, in Washington. (AP Photo/Jose Luis Magana)

Abortion rights activists, covered in blankets with red paint, lie down as they rally outside the Supreme Court, Wednesday, April 24, 2024, in Washington. (AP Photo/Jose Luis Magana)

Abortion-rights activists rally outside the Supreme Court on Wednesday, April 24, 2024, in Washington. (AP Photo/Mariam Zuhaib)

Follow the AP’s live coverage of arguments in the Supreme Court

WASHINGTON (AP) — Conservative Supreme Court justices appeared skeptical Wednesday that state abortion bans enacted after the overturning of Roe v. Wade violate federal health care law, though some also questioned the effects on emergency care for pregnant patients.

The case marks the first time the Supreme Court has considered the implications of a state ban since overturning the nationwide right to abortion. It comes from Idaho, which is among 14 states that now ban abortion at all stages of pregnancy with very limited exceptions .

The high court has already allowed the state ban to go into effect, even in medical emergencies, and it was unclear whether members of the conservative majority were swayed by the Biden administration’s argument that federal law overrides the state in rare emergency cases where a pregnant patient’s health is at serious risk.

The closely watched case tests how open the court is to carving out limited exceptions to state abortion bans. Their ruling, expected by late June, will also affect a similar case in Texas and could have wide implications amid a spike in complaints that pregnant women have been turned away from emergency rooms care since Roe was overturned.

File - The Supreme Court is seen on Friday, April 21, 2023, in Washington. The U.S. Supreme Court will hear arguments Wednesday in a case that could determine whether doctors can provide abortions to pregnant women with medical emergencies in states that enact abortion bans. (AP Photo/Alex Brandon, File)

The Biden administration says abortion care must be allowed in those cases under a law that requires hospitals accepting Medicare to provide emergency care regardless of patients’ ability to pay.

Justice Samuel Alito, who wrote the decision overturning Roe v. Wade, was doubtful. “How can you impose restrictions on what Idaho can criminalize, simply because hospitals in Idaho have chosen to participate in Medicare?” Alito said.

Idaho contends its ban does have exceptions for life-saving abortions, and the administration wants to wrongly expand the times when it’s allowed to turn hospitals into “abortion enclaves .”

But liberal justices detailed cases of pregnant women hemorrhaging or having to undergo hysterectomies after abortion care was denied or delayed in states with bans.

“Within these rare cases, there’s a significant number where the woman’s life is not in peril, but she’s going to lose her reproductive organs. She’s going to lose the ability to have children in the future unless an abortion takes place,” said Justice Elena Kagan.

Conservative Justice Amy Coney Barrett, meanwhile, said she was “kind of shocked” that an attorney for Idaho appeared to hedge when asked whether the state would allow abortions in cases like those. Attorney Joshua N. Turner responded that doctors can use their “good faith” medical judgment under Idaho’s life-saving exception, but Barrett continued to press: “What if the prosecutor thinks differently?”

Turner acknowledged that a doctor could face a criminal case in that situation. Performing an abortion outside of limited exceptions in Idaho is a felony punishable by up to five years in prison.

Most Republican-controlled states have started enforcing new bans or restrictions since Roe was overturned, and Turner said those laws all have narrower exceptions than the federal law.

“This isn’t going to end with Idaho. This question is going to come up in state after state,” he said.

Doctors have said Idaho’s abortion ban has already affected emergency care. More women whose conditions are typically treated with abortions must now be flown out of state for care, since doctors must wait until they are close to death to provide terminations within the bounds of state law.

Abortion opponents say doctors have mishandled maternal emergency cases, and argue the Biden administration overstates health care woes to undermine state abortion laws.

The justices also heard another abortion case this term seeking to restrict access to abortion medication . It remains pending, though the justices overall seemed skeptical of the push.

The Justice Department originally brought the case against Idaho, arguing the state’s abortion law conflicts with the 1986 Emergency Medical Treatment and Active Labor Act, known as EMTALA . It requires hospitals that accept Medicare to provide emergency care to any patient regardless of their ability to pay. Nearly all hospitals accept Medicare.

A federal judge initially sided with the administration and ruled that abortions were legal in medical emergencies. After the state appealed, the Supreme Court allowed the law to go fully into effect in January.

The audience was sparse inside the court, with several benches empty or sparingly used. But outside, dueling protesters gathered with signs such as “Abortion saves lives,” from one side of the crowd and “Emergency rooms are not abortion clinics” from abortion opponents.

___ Associated Press writers Gary Fields and Mark Sherman contributed to this report.

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It also monitors the global burden of unsafe abortion and its consequences. 1. Bearak J, Popinchalk A, Ganatra B, Moller A-B, Tunçalp Ö, Beavin C et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990-2019. Lancet Glob Health. 2020 Sep; 8(9):e1152-e1161 ...
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We are just starting to quantify and qualify their effects. Two recent studies published in JAMA offer early indications of the effects of draconian bans. In "Association of Texas' 2021 Ban on Abortion in Early Pregnancy with the Number of Facility-Based Abortion in Texas and Surrounding States," White et al. used a large dataset ...
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WASHINGTON (AP) — Nearly two years after overturning the constitutional right to abortion, the Supreme Court will consider Wednesday how far state bans can extend to women in medical emergencies.. The justices are weighing a case from Idaho, where a strict abortion ban went into effect shortly after the high court's 2022 decision overturning Roe v. Wade.
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