Abortion access and reproductive justice - Part 1

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0:00:00.0 Elizabeth Mosley: We are talking about situations where people will not have lifesaving care, and I'm not sure that everyone understands that because we talk about abortion in this very simplistic way, but abortion care is quite ubiquitous. It's one of the most common medical procedures. One in four American women in their lifetime will have an abortion. It's gonna be devastating, these effects.

0:00:29.4 Speaker 2: Although abortion has been an ever-present topic of discussion in the US for the past year, debates about reproductive rights have been prevalent over the preceding decades and centuries. Politics and moral arguments seem to crowd out other perspectives, but public health circles have long understood that abortion is ultimately a health topic and the health outcomes related to its access have significant consequences. In this two part episode, we brought together public health experts from the University of Michigan School of Public Health and beyond to discuss the ways in which abortion impacts public health, who suffers most when abortion access becomes limited, and why the voices of public health professionals are critical in the fight for reproductive rights and justice. Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important health topics, stuff that affects the health of all of us at a population level. From the microscopic to the macroeconomic, the social to the environmental, from cities to neighborhoods, states to countries and around the world.

0:01:43.7 S2: It's important to look at our history to understand how we got to where we are today. A landmark moment in the history of reproductive rights in this country was the Roe versus Wade decision in 1973, which protected access to abortion services under the 14th Amendment, In 2022 however, that ruling was overturned by the Dobbs v. Jackson Women's Health Organization Supreme Court decision. We sat down with Dr. Sioban Harlow, Professor Emerita at the University of Michigan School of Public Health, whose career has focused on reproductive health and women's health. Dr. Harlow reflects on that history and the impact Roe versus Wade had on the country and her own life at the time.

0:02:23.4 Sioban Harlow: Ever since this Supreme Court decision, appealing Roe v. Wade was announced, I have been thinking back to the time when Roe v Wade was passed.

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0:02:55.5 SH: At that time I was a teenager, I was 16, about to turn 17. And one of the things that's come back to me that I've begun to reflect upon is the sense of terror that we grew up with, the risk or the threat, or the fear, the menace of becoming pregnant. It was a time when one was... I was beginning to imagine my future, my life as a wife, as a mother. It was at a time when we were thinking much more about the careers we might have. It was a time that I was beginning to explore what it would mean to become a sexually active woman. And there was this background always of fear, which I hadn't probably put into words at the time, but there were the stories. There were the stories of the women in my sister's class who got pregnant and didn't finish school, or that suddenly were gone for periods of time.

0:03:56.8 SH: And so I remember vividly, there was a picture in the New York Times, one heard often the story of the back alley abortion. But there's a picture that I can see to this day of the woman who had died and she was on her knees with her bottom in the air naked having bled out. It was a terrifying picture. That was a terrifying picture, as a young teenage girl, 'cause that potential fate was always a specter in our lives at that time. And then I also remember the day that Roe v. Wade decision was announced. I was sitting in my living room, there was a breakthrough announcement on the radio, and I remember rushing and kneeling in between the speakers to hear the result, and the absolute joy that I felt when the decision was real. Because even as a very young woman, a girl still, I recognized how transformative this would be for my life.

0:04:55.1 SH: So when I think about the decision that has been made in the United States to roll back Roe v. Wade, particularly when we see the kinds of legislation that is being passed in many states, that is inconsistent with medical knowledge, both in terms of the importance of access to abortion care, but even in terms of understanding when it's even possible to know you're pregnant and the time it takes to recognize. Particularly for young women, I find it deeply saddening that young women and men will once again have to live with this specter, this fear. And I'm particularly troubled about the inequity, the fact that women with means, women with money have always been able to obtain a safe abortion. It's women with less means, women in rural areas where there's less access to care to begin with, women who are young and don't even know how to negotiate the healthcare system yet, women of color who disproportionately have less access to care, those are the ones at most risk. And it becomes yet another significant healthcare disparity in our country.

0:06:18.3 S2: As Dr. Harlow describes, access to abortion had and continues to have important implications for the lives of pregnant people. It can dictate someone's future in myriad ways, but why is this a public health issue? 

0:06:32.0 SH: Well, access to safe abortion services is really a fundamental component of reproductive healthcare. It is essential to safeguarding both women's lives and women's health. And therefore, to the right of women and men and families, to make private decisions related to childbearing, it is important to remember also that restrictions on abortion access never fall equally across society. There's a very long history of criminal penalties in the reproductive health area or emulated to reproductive healthcare being enforced unequally. And that tends to, for example, unequally fall on women who are poor and on women of color. Therefore, if we think about access to safe abortion services, we have to recognize that they're actually essential to preserving both women's right to the autonomy over their own body, but also to ensuring racial justice. So it's long been recognized that abortion, an unsafe abortion is an important contribution to maternal death.

0:07:41.9 SH: It's estimated that somewhere around 13 to 15% of maternal deaths across the globe are associated with unsafe abortion. There's a classic example of Romania, which in 1965 criminalized abortion. And at that point there was a big increase in maternal death associated with abortion going from 15 to 140 deaths per 100,000 verse. So the WHO, the World Health Organization has for a long time, for the last 20 years, really focused on the importance of having access to safe abortion as an important component of efforts to reduce maternal mortality worldwide. So it's important to remember that in many countries, maternal mortality is the leading cause of death of women of reproductive age. And one analysis that have been done, that have looked at the level of legal restriction or the level of criminalization of abortion have shown, if you look across countries, those countries, as you increase the level of restriction to safe abortion, the rates of maternal death go up.

0:09:03.0 SH: If we just look at what has been happening over the last five years, even for example, what we can see is the trend globally is actually to decriminalize abortion and to reduce restrictions. So for example, Chile in 2017 lifted the absolute ban on abortion, and in 2021 greatly expanded access to abortion. Mexico, in 2021, the Supreme Court declared that the criminal penalties that had been in existence for quite a long time were unconstitutional. In Columbia, again, the Constitutional Court in 2022 legalized abortion up to 24 weeks. And so what we see happening in the United States is really unfortunate in we look at the global environment where there's increasing recognition of the critical role that access to safe abortion plays in reproductive healthcare. And the fact that the data also show that when one has fewer laws or fewer restrictions on abortion, the numbers of abortion actually tend to go down generally because this occurs in the context of improving reproductive healthcare overall.

0:10:23.5 SH: So since the 1990s, there's been a lot of work both improving the data on the incredible number of women. In some countries, one in seven women died a maternal death. And in a number of countries the number is still quite high. But as a part of that, you had the number. So it became clear this is a healthcare problem, but also began to understand, well, what are the contributors to maternal death? And you can't ignore the fact that lack of access to safe abortion is an important contributor to maternal death. It was true in the United States before the passage of Roe v. Wade, as it is true in many countries where it's still illegal. So the move globally is related to an increased understanding that if we want to reduce maternal deaths, providing access to safe abortion is a critical issue.

0:11:21.8 SH: So when we think about the importance of safeguarding access to safe abortions, we have to recognize that pregnancy itself is not without risk. Pregnancy remains a significant cause of death, maternal death for women of reproductive age and the various complications of pregnancy can lead both to morbidity and to mortality, to illness and death. If we think, for example, about miscarriage, so miscarriages are in fact quite common, up to 50% of actually fertile eggs, fertilized eggs never actually reach clinical pregnancy or clinically recognizable pregnancy. And eight to 15%, some people say 10 to 20% of detectable pregnancies can end in miscarriage. Now most of those are relatively early and carry less risk. But as one as late, goes later in pregnancy, the risks increase. And up to one to 2% of miscarriages happen in the second trimester. Later in pregnancy, if there's retained tissue that can lead to hemorrhage or infection, both of which threaten the life of a mother and are leading causes of maternal death.

0:12:41.6 SH: Another consequence of pregnancy is sometimes, there's something called an ectopic pregnancy. When the pregnancy actually implants outside of the womb, for example, in the fallopian tube, if unattended, that can burst and again, lead to hemorrhage and infection and is actually an important cause of maternal death and remains so in the United States. So when access to abortion is restricted, both a woman may be concerned about going in and fear of criminal prosecution, and physicians may be afraid of treating a woman. And if a medical provider fears prosecution may lead to very dangerous delays in treatment, it's important to get timely care for a miscarriage. And I think we've heard of examples of this, of physicians feeling they had to, instead of intervening early, they had to wait till the fallopian tube actually burst, putting the mother at much greater risk. In addition to those aspects of pregnancy, it's also important to recognize, particularly in the United States where we have brought maternal death rates down, cardiovascular disease is the leading cause of maternal mortality in the United States.

0:13:54.0 SH: So pregnancy actually carries with it cardiovascular risks. But pregnancy can also exacerbate cardiovascular risk in women with cardiovascular disease and risks of stroke, for example, with it... A much higher risk actually in Black women compared to White women. So there's a numerous examples of ways in which the risks of pregnancy may be involved in women's decision about whether it is safe for her to carry this pregnancy to term, as well as examples where problems that occur during pregnancy, if not attended to quickly because there's a delay in care, we are once again putting women's health and women's lives at risk.

0:14:42.7 S2: Since the Supreme Court overturned Roe versus Wade in June of 2022, there's been a lot of confusion for both individual providers and entire healthcare systems. They've been challenged to figure out what this change means for the care of their patients, especially when laws vary across state lines.

0:15:00.1 SH: One of the big problems right now is that there's so much confusion about what the state of the law is and how the state of the law is changing rapidly. So the legislature might pass a certain law, when does it go into effect, even though it's not quite in effect yet, will I still be prosecuted if I do something now? And then a court delays decision. What does that mean? Do I have access? Do I not have access? There's a great deal of confusion both for women, their partners, and for medical care providers. We know now that there are many women who do not have access in the state in which they live. And so the need to identify resources to be able to travel to a place where they may be able to receive care, to find the resources financial for the transportation, for the housing that they will need, it has become a big issue.

0:16:06.5 SH: And then even in states where it is legal. So for example, here in Michigan, there's still a problem of the increased pressure on the healthcare services in states where it is legal because of the sudden volume of demand coming from women who live in states where it is not legal. So we are creating a problem for the system, both because of the confusion and because of this shifting demand where the resources, the infrastructure wasn't there to meet that demand. If Roe v. Wade or the decision to repeal Roe v. Wade stands, and we continue to have the situation where a woman and men and families have a right in one state and not in other states, we will continue to have the kind of confusion that we currently have. A lack of clarity. Women and men in a number of states will certainly be living with this specter, this danger of, if I have an unwanted pregnancy, what do I do? If I have a pregnancy that puts my life at risk, what do I do? So I think in the end it's untenable to be a nation with such widely divergent laws that go to such a fundamental aspect of the right to health and the right to care.

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0:17:42.5 S2: Michigan Public Health alumna, Elizabeth Mosley is an assistant professor of medicine at the University of Pittsburgh School of Medicine and a researcher at the Center for Reproductive Health Research. Like Dr. Harlow, Dr. Mosley is keenly interested in how the decisions of the past are continuing to impact access to better health outcomes for so many people now. She provided more context to the current policy situation around abortion access and how these policies may play out for women in the present day.

0:18:07.3 EM: As soon as Roe v. Wade passed in 1973, there were immediate pushbacks and restrictions enacted against abortion. Many states enacted what's called trigger bans, meaning that as soon as Roe v. Wade falls, their trigger ban laws will go into effect. And most of those outlaw abortion almost under any circumstances.

0:18:29.0 EM: We also saw things like the The Hyde Amendment, which is probably one of the most harmful restrictions that we've seen federally, which outlawed federal funding for abortions except for very severe cases like rape, incest, or the life of the person who's pregnant. Low-income folks have never been able to access abortion in that way through insurance, unless they live in a few states that have passed state level Medicaid funding. But that's very rare. We've seen restrictions from day one, at the state level, this has been very prolific and very effective. They weren't having success outlying at the federal level, but states were able to enact everything from gestational age limits to targeted regulation of abortion providers, to mandatory waiting periods, mandated counseling that's really inaccurate and misleading. And those have been mounting over the last couple of decades. Dozens and dozens of bills being passed by states over the last few years.

0:19:24.1 EM: Examples being Georgia's six-week limit and others like it. The difference with this, there have been many Supreme Court cases where the strength of Roe v. Wade has been tested, and essentially a lot of the federal court cases have landed on states cannot outlaw abortion before viability, which is around 20 to 22 weeks. Any fetus before then can't survive outside of a womb. But with medical advances, 20 to 22 weeks is considered viability. Up until now, when states tried to outlaw abortion before viability, they were met with federal resistance. At this point, with the Supreme Court composed as it is of conservative justices, they're now poised to undo that viability rule. Dobbs will essentially allow the court to say, we no longer federally protect abortion before viability, and the states will now have the obligation and the power to regulate abortion as they see fit.

0:20:21.9 EM: And what this essentially does is strips Roe v. Wade, off the record, it gets rid of things like Plessy versus Ferguson and Casey versus Planned Parenthood, other federal cases that had kind of regulated abortion at the national level and says that the states now get to choose, which is very unfortunate. We are talking about the outlying of abortion for these circumstances where it is medically necessary. So in a lot of states, for example, ectopic pregnancies, which require an abortion to save the life of the person because no ectopic pregnancy is viable, and every ectopic pregnancy has the potential to kill that pregnant person, that pregnancy cannot be re-implanted into the uterus that ectopic pregnancy needs an abortion, the same with a late term miscarriage that needs to be assisted along with abortion procedures. Or like some of my dear friends, including one in Michigan who very late in pregnancy after 22 weeks, learned that the pregnancy was no longer viable.

0:21:18.5 EM: The pregnancy had stopped developing. There was no heartbeat. And my friend had to go through a very long abortion procedure to deliver that pregnancy. And had she not had that option, she likely would've developed abscess and died. When we outlaw abortion, when these politicians try to outlaw abortion, what they don't understand is that they're also criminalizing miscarriage management and ectopic pregnancy management. The clinicians that I work with are very clear that it is already very challenging to walk that line and what they call Peri-viability care because it's so regulated as abortion. But we are talking about situations where people will not have lifesaving care. It's gonna be devastating. These effects. I think the constitutionality for abortion argument is a bit of a red herring. Many things that we have the right to are not in our constitution, and that includes things like the right to healthcare.

0:22:08.9 EM: To me, there's human rights, and then there's constitutional rights, and human rights supersede constitutional rights. And abortion is considered a human right because reproductive autonomy is a human right. So to say that it's not in the Constitution, first of all, ignores international human rights convention and law that does say access to reproductive healthcare, including abortion and contraception are human rights. And then a lot of things are not in our constitution as well because they're not federally protected. And it doesn't mean that they aren't meant to be accessible. Things like heart surgery are also not in our constitution, but we aren't trying to regulate whether or not people have the right to have open heart surgery when they need a quadruple bypass. It's a way of keeping the focus on the legal argument rather than bringing it down to earth and reminding people that, so I'm an abortion doula. I provide support to people during abortion, reminding them of the circumstances that people are navigating when they access abortion, everything from domestic violence to ectopic pregnancies to poverty that wouldn't allow them to raise that child in the supportive and healthy way they would want.

0:23:23.6 EM: And so when we talk about constitutionality, it draws attention away from the lived experiences of people who are having abortions and need abortions. And so to me, it's one of those arguments that is just a red herring.

0:23:37.8 EM: The public health consequences of Roe being overturned are infinite, and they can't be understated. We need to be clear about what the risks and the costs that this will be. In the US right now if someone gets turned away from having an abortion, the chances of them self-managing that abortion at home are higher. And we know that sometimes self-managed abortion might not be as safe, especially in restricted settings. We know that getting turned away for abortions means that those patients and their children are more likely to be living in poverty later. So outlawing abortion will increase the percentage of people and children in poverty. We know that turning people away from abortions means they're more likely to be stuck in domestic violence situations. And so overturning Roe, outlawing abortion will increase the incidence of domestic violence, the severity of domestic violence, and increase the percentage of children who are experiencing child abuse.

0:24:29.8 EM: We also know that getting turned away increases mental health symptoms like anxiety, depression, and even substance use. And probably the most harrowing of all is that when we outlaw abortion, maternal mortality increases, that's pregnancy related deaths. Deaths that are caused by pregnancy, that happen during pregnancy, during childbirth, or within the first six weeks, Postpartum. Studies from the United States and from around the world are very clear that when you outlaw abortion, pregnancy related deaths will increase. And that's usually through two mechanisms. The first is that pregnancy is higher risk than abortion, especially in the United States. We have the worst maternal mortality statistics in the developed world. For high-income countries we have over double the number of maternal or pregnancy related deaths compared to any other high income country. And then if you divide that by race ethnicity, we know that black women, black people are three to four times more likely to die during pregnancy than white people.

0:25:30.4 EM: And so simply by having folks continue their pregnancies and not terminate as they might have wanted to, the number of deaths will increase simply because pregnancy is still risky and people still die during pregnancy, childbirth, and postpartum here in the United States. And so we know without a doubt that outlawing abortion, especially in as many states as we're looking at, maternal mortality from unsafe abortion will increase. And we know that maternal mortality simply from pregnancy related complications will also increase. So we're talking about life or death. We're talking about people's ability to get out of poverty or to live above the poverty level. We're talking about increased violence for families because we know abortion is a very important part of people navigating their way out of domestic violence.

0:26:18.3 EM: We're also talking about mental health effects that includes suicide. People who are pregnant and don't want to be pregnant will find a way to get out of that. And unfortunately, sometimes that is self-harm. We know that suicide is one of the leading causes of maternal death in our country. Depression as well, postpartum depression. And so I could imagine that we would see an increase in all of those. And then at the end of the day, we're looking at a lack of reproductive autonomy. When people can't control their bodies, they can't control their lives. And overturning abortion means that people who can become pregnant, no longer have control over their bodies, and therefore won't have control over their lives.

0:26:55.5 S2: While uncertainty remains across the country. Voters in several states, including here in Michigan, have recently passed measures protecting abortion access and reproductive rights. Public health professionals like Dr. Mosley continue to advocate for reproductive autonomy because they're motivated by a vision for the future. So what could a future with reproductive justice look like? 

0:27:15.5 EM: I think it looks like people having access, all people of all genders, of all economic groups, of all race ethnicities, all languages, to have access to all of the reproductive health services and care that they need in order to achieve reproductive autonomy. And so for some folks, that's gonna be access to safe abortion care, but that could look different for different people. A lot of my research has taught me that self-managed abortion, for example, is an option that some people want and need. And so making even access to self-managed abortion safe and accessible is part of that vision. Part of that vision is also making sure that people have the economic resources they need to parent children if they want to do that. A lot of our history in the US and internationally has been one of population control, and so reproductive justice reminds us that it's not just about the right to abortion and contraception.

0:28:09.9 EM: It's also about the right to have children if you want that, and to parent those children in healthy and safe environments free of reproductive coercion or structural violence. But also that we have a society where there's paid maternity and paternity leave, that there's infant formula for the parents who are feeding infants and need formula, that there are economic supports for low-income families so that they can raise those children. A lot of abortion is because people can't afford another child, and that's not reproductive justice. Other things might include access to infertility services, which are now only accessible for high-income people. And again, all of the social services needed to make our community safe. So addressing police violence is part of that vision, addressing environmental degradation or housing segregation. All of that fits into our vision of reproductive justice because it includes all of the human rights, not just abortion care.

0:29:12.1 S2: Dr. Mosley says there is plenty that individuals can do to continue the conversation about reproductive rights and advocate for reproductive justice.

0:29:20.6 EM: The main thing is to stay active. Don't let your anger dissipate and then disengage. This is a marathon and we're in it for the long haul. Find an organization in your area that does reproductive justice work and get involved with them. Become a volunteer. Don't just stop at the protests and the marches or even donating your money. Figure out a way to get involved. As public health practitioners and researchers, we have a lot of skills and a lot of power that can be put to use. An example of that is I've been testifying at the state capitol ever since our six week ban came into our legislative assembly back in 2019. I go every session and testify as a public health expert against these abortion restrictions. And with your MPH or your PhD, or even your BS in public health, that matters and your voice matters. You can write letters, you can call, you can testify. There's a lot of ways to get involved. Think about it. What is your role? How can you help? And then just stay committed because this is gonna be a lifelong journey and a lifelong fight.

0:30:27.3 S2: Join us next time for part two of abortion access and Reproductive Justice. We'll be joined by Whitney Peoples and Paul Fleming from the University of Michigan School of Public Health for a conversation that further explores public health's role in the fight for reproductive justice.

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0:30:52.0 S2: Thanks for listening to this episode of Population Healthy from the University of Michigan School of Public Health. We're glad you decided to join us and hope you learn something that'll help you improve your own health or make the world a healthier place. If you enjoyed the show, please subscribe or follow this podcast on iTunes, apple Podcast, Google Play, Stitcher, Spotify, or wherever you listen to podcasts. Be sure to follow us @umichsph on Twitter, Instagram, and Facebook so you can share your perspectives on the issues we discuss. Learn more from Michigan public health experts and share episodes of the podcast with your friends on social media. You're invited to subscribe to our weekly newsletter. To get the latest research, news, and analysis from the University of Michigan School of Public Health. Visit publichealth.umich.edu/news/newsletter to sign up. You can also check out the show notes on our website, population-healthy.com. For more resources on the topics discussed in this episode. We hope you can join us for our next edition, where we'll dig in further to public health topics that affect all of us at a population level.