Second Anniversary of Dobbs Decision Shows Vastly Different World for Pregnant Americans

EXECUTIVE SUMMARY

Pregnancy in the United States has changed dramatically in the two years since the U.S. Supreme Court overturned abortion rights.

• Changes include more women forced to remain pregnant and being turned away from hospitals and emergency departments when they need miscarriage care.

• Despite abortion bans throughout the Southeast, West, and Midwest, the nation’s abortion rate is on the rise. The abortion rate in 2023 was a 10% increase over 2020.

• One positive change is that some states have passed laws and constitutional amendments to enshrine the right to contraception and abortion services.

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The two years following the U.S. Supreme Court’s decision to overturn Roe v. Wade and women’s right to privacy in their most intimate healthcare decisions have created an entirely different landscape for people capable of pregnancy in America.

Healthcare procedures and protections they had taken as an inalienable right for nearly five decades disappeared overnight in many states and have been eroded considerably in many more. For instance, states like Arizona have resurrected anti-abortion laws that date back 150 years.

A new study revealed that one in four women in the United States has undergone an abortion in her lifetime. That percentage has remained fairly stable in the years leading up to the Dobbs v. Jackson Women’s Health Organization decision in June 2022.¹

“The methodology that we use is based on a large-scale survey of people accessing abortion care,” says Rachel K. Jones, PhD, study author and principal research scientist at the Guttmacher Institute. “We do a national survey of over 6,000 people.”

Emerging data suggest that despite abortion bans in 14 states, the overall rate of abortions in the United States is on the rise. According to the Guttmacher Institute’s monthly abortion provision study, an estimated 1,026,690 abortions occurred in the formal healthcare system in 2023, the first full year after the Dobbs decision. The 2023 abortion rate of 15.7 abortions per 1,000 women of reproductive age in the United States is a 10% increase since 2020 — the highest number and rate in more than a decade.²

“That is only counting abortions that occurred in formal healthcare systems and do not count self-managed abortions,” Jones adds.

Since the Food and Drug Administration (FDA) lifted restrictions on the abortion medication mifepristone and allowed it to be prescribed virtually and sent through mail-order pharmacy services, many more people are accessing self-managed medication abortions than before the 2021 change. Because of abortion bans in states across the South, Midwest, and West, 160,000 people traveled out of state in 2023 to access abortion care.²

“[Research] demonstrates that a lot of women access abortion care, and when you try to restrict or outlaw it, you’re impacting a lot of people,” Jones says. “Banning abortion has not made it go away; more people are getting abortions now than before the bans.”

Abortion bans are greatly affecting women’s lives — even if the bans are not ending abortion care, as they are intended to do. There have been dramatic negative changes affecting women’s fertility and health in abortion-ban states. Some examples:

• Some women in Alabama no longer have access to in vitro fertilization (IVF) services after the state supreme court ruled that extrauterine embryos have full rights of personhood. The Alabama legislature passed a bill to allow IVF services in the state, but at least one hospital stopped these services out of continuing legal concerns.³

• Hospitals and emergency departments (EDs) in abortion-ban states have stopped or slowed down miscarriage and childbirth care because of legal concerns and the lack of labor and delivery services at rural hospitals. This resulted in a Texas woman miscarrying in the lobby restroom of Sacred Heart Emergency Center in Houston. This incident occurred as the Supreme Court heard a challenge to the federal Emergency Medical Treatment and Labor Act (EMTALA) that requires EDs to treat or stabilize patients who are in active labor.⁴

• A 25-year-old woman from Dayton, OH, was denied chemotherapy treatment because she was eight weeks pregnant. At that time, she was unable to obtain an abortion in Ohio.⁵

• A 10-year-old rape victim was denied an abortion in Ohio and had to travel to Indiana for care. The physician who treated her in Indiana faced false accusations by the state’s attorney general and had to defend her actions in court. Later, the state banned all abortions.^5,6

• Women underwent hysterectomies because of dangerous pregnancies where they were denied health-preserving abortion care.⁷

• An estimated 64,000 people gave birth after rape in states with total abortion bans.⁸

“Victims of rape have been having babies from rape forever, but obviously that is just going to be happening more and more frequently,” says Kelly Cue Davis, PhD, MS, professor at Edson College of Nursing and Health Innovation at Arizona State University.

People forced to give birth after rape often have experienced trauma that has a downstream effect as they parent children born under those circumstances. “Experiencing sexual violence has long-term negative physical health outcomes as well,” Davis says. “I also have concerns on how [abortion bans that penalize people who help someone obtain an abortion] could impact victims’ feeling comfortable telling other people about what happened to them for fear of putting their friends and families in danger.”

There are many unforeseen consequences, and the people affected by sexual violence and abortion bans are the ones who suffer. (For more information, see the story in this issue on abortion and sexual violence.) Abortion bans have resulted in people being arrested and jailed for disposing of miscarried or aborted embryos. Prosecutors and lawmakers also have targeted people who drive a minor to an abortion clinic out of state. The bans have had a chilling effect on basic pregnancy care, such as safely ending ectopic pregnancies and treating women with incomplete miscarriages.

Some positive changes have occurred in states that passed bills or constitutional amendments to ensure access to abortion care. In Illinois, for example, the governor increased reimbursement rates for Medicaid coverage of abortion care after the Dobbs decision, says Lee Hasselbacher, JD, a research assistant professor in the department of obstetrics and gynecology at the University of Chicago.

“They recognized that providers are seeing more patients,” Hasselbacher notes. “The Medicaid payment rate had not changed since the 1970s, and federal money can only cover abortion in cases of rape, incest, and threat to the life of the patient.” It was a struggle to get abortion claims reimbursed until the rates increased, she adds. (More information on Illinois’ increased funding for abortions will be available in the July 2024 issue of Contraceptive Technology Update.)

At the time Illinois Gov. J.B. Pritzker announced the 20% increase in Medicaid reimbursement rates for abortion services, he said that Illinois abortion providers had been working overtime since the Supreme Court overturned Roe v. Wade, and they needed support as they took on a new burden. Pritzker also eliminated the Medicare denial requirement, making it easier for people who qualify for both Medicaid and Medicare to cover abortions. He also provided an additional $2 million to Title X family planning clinics to help them expand the number of providers offering Title X services.⁹

Voters in several states also supported lawmakers, bills, and constitutional amendments that would help women maintain their right to reproductive autonomy and abortion services in their states. For example:

• In 2022, Californians voted to add the right to abortion and contraception to the state’s constitution.^10,11

• Colorado Gov. Jared Polis signed a bill in 2022 to guarantee the right to obtain an abortion.¹⁰

• Connecticut lawmakers passed a bill to shield medical providers from lawsuits over the abortions they provide to out-of-state patients.¹⁰

• Maryland’s General Assembly overrode a veto from the state’s Republican governor and expanded the types of healthcare professionals who can perform abortions.¹⁰

• In 2022, Michigan voters approved an addition to their state constitution to ensure the right to abortion.¹¹

• A 2022 New Jersey bill codified the right to reproductive choice, including abortion services.¹⁰

• In 2023, Ohio voters approved a constitutional amendment that enshrines access to abortion and other reproductive healthcare.¹²

States that protect the right to an abortion have recognized that millions of American women have undergone an abortion in their lifetime. “We’ve seen states step up and say, ‘We’ll make abortion access protected in our state,’” Jones says. “Because everything is so new and changing and shifting, we don’t have research on the different factors contributing to [the increase in the abortion rate]. It could be there’s less stigma on abortions in some clinics and states.”

From the perspective of providers and researchers, the current ever-changing abortion access landscape holds both optimism and sorrow. “I have hope for this next generation, which is idealistic and able to fight,” says Maya M. Hammoud, MD, MBA, professor and director of the division of women’s health in the department of obstetrics and gynecology at the University of Michigan Medical School. “The sad part I see is we’re going backward in a lot of things. I cannot believe that some of the laws we pass in this country are worse than what we see in third-world countries, and we’re going back to the 1800s. It’s just so sad.”

REFERENCES

1. Jones RK. An estimate of lifetime incidence of abortion in the United States using the 2021-2022 Abortion Patient Survey. Contraception 2024;Apr 2:110445. doi: 10.1016/j.contraception.2024.110445. [Online ahead of print].
2. Maddow-Zimet I, Gibson C. Despite bans, number of abortions in the United States increased in 2023. Guttmacher Institute. March 19, 2024. https://www.guttmacher.org/2024/03/despite-bans-number-abortions-united-states-increased-2023
3. Rocha A. Alabama passed a new IVF law. But questions remain. Alabama Reflector. March 11, 2024. https://alabamareflector.com/2024/03/11/alabama-passed-a-new-ivf-law-but-questions-remain/
4. Seitz A. ERs refuse to treat pregnant women, leaving Texas woman to miscarry in lobby restroom. NBC DFW. April 19, 2024. https://www.nbcdfw.com/news/local/texas-news/er-refuse-pregnant-women-texas-miscarry-lobby/3519840/
5. Cassick C. Dayton woman denied life-saving chemotherapy due to pregnancy. WDTN.com. Sept. 15, 2022. https://www.wdtn.com/news/dayton-woman-denied-life-saving-chemotherapy-due-to-pregnancy/
6. Davies T. Indiana doctor faces discipline hearing over abortion for 10-year-old rape survivor. PBS. May 25, 2023. https://www.pbs.org/newshour/health/indiana-doctor-faces-discipline-hearing-over-abortion-for-10-year-old-rape-survivor
7. El-Bawab N. Tennessee woman gets emergency hysterectomy after doctors deny early abortion care. ABC News. May 31, 2023. https://abcnews.go.com/US/tennessee-woman-gets-emergency-hysterectomy-after-doctors-deny/story?id=99457461
8. Dickman SL, White K, Himmelstein DU, et al. Rape-related pregnancies in the 14 US states with total abortion bans. JAMA Intern Med 2024;184:330-332.
9. Office of the Governor. Gov. Pritzker announces Medicaid reimbursement increases and expanded Title X funds for reproductive health care providers. Aug. 4, 2022. https://hfs.illinois.gov/content/dam/soi/en/web/hfs/sitecollectiondocuments/governorpritzkerannouncesmedicaidreimbursementincreasesforreproductivehealthcareproviders.pdf
10. Sherman C, Witherspoon A, Glenza J, Noor P. Tracking abortion laws across the United States. The Guardian. April 24, 2024. https://www.theguardian.com/us-news/ng-interactive/2023/nov/10/state-abortion-laws-us
11. Bugos C. Voters protect abortion rights in the 5 states where it was on the ballot. Verywell Health. Nov. 11, 2022. https://www.verywellhealth.com/voters-in-5-states-vote-in-favor-of-abortion-rights-6827864
12. Smyth JC. Ohio voters enshrine abortion access in constitution in latest statewide win for reproductive rights. Associated Press. Nov. 7, 2023. https://apnews.com/article/ohio-abortion-amendment-election-2023-fe3e06747b616507d8ca21ea26485270