a case study on abortion

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The public health case for abortion rights

Joanne rosen from the johns hopkins center for law and the public's health discusses dobbs v. jackson women's health organization, which heads to the supreme court dec. 1.

By Annalies Winny, Alissa Zhu, and Lindsay Smith Rogers

This article is adapted from a special episode of the Public Health On Call podcast called Public Health in the Field. Hear the full episode online .

Editor's note: The terms "woman" and "women" are used throughout this article because that is how the CDC and other sources record related data.

A potentially landmark battle is in play over abortion rights, and it's headed to the U.S. Supreme Court on Dec. 1.

In 2018, the Mississippi legislature passed and the governor signed House Bill 1510, known as the Gestational Age Act, which bans abortions after 15 weeks. There are exceptions if the life of the fetus or parent is at risk—but not in cases of rape or incest. The law violated Roe v. Wade, the 1973 Supreme Court decision that legalized abortion nationwide and protects the right to abortion prior to "viability" of the fetus, which is at around 24 weeks. House Bill 1510 was quickly blocked by lower federal courts but now the law's fate is up to the Supreme Court.

The outcome of this case—Dobbs v. Jackson Women's Health Organization—has implications for abortion rights far beyond Mississippi: A decision that previability bans are not unconstitutional could upend longstanding protections established by Roe v. Wade.

The conversation about abortion rights in the U.S. is a noisy one involving politics, precedents, and personal beliefs. What often gets short shrift, however, is the public health reality that restricting access to abortion frequently results in erosion of the health of women, especially low-income women and women of color. This is why abortion is so much more than a legal battle.

According to The Turnaway Study , a 10-year study that followed nearly 1,000 women who either had or were denied abortions, any women who were denied wanted abortions had higher levels of household poverty, debt, evictions, and other economic hardships and instabilities, says Joanne Rosen , associate director of the Johns Hopkins Center for Law and the Public's Health.

"The study also found that women who were seeking but unable to obtain abortions endured higher levels of physical violence from the men who had fathered these children," Rosen says. "And people who were turned away when seeking abortions endured more health problems than women who were able to obtain [them], as well as more serious health problems. That gives you a sense of the ways in which being unable to obtain abortions had really long lasting impacts on these peoples' lives."

A 2020 study in the American Journal of Preventive Medicine found that women living in states with less restrictive reproductive health policies were less likely to give birth to low-weight babies. Other research published in The Lancet found that restrictive abortion laws actually mean a higher rate of abortion-related maternal deaths.

Restrictive abortion laws affect more than just the health of individuals and families—they affect the economy, too. Research from The Lancet found that "ensuring women's access to safe abortion services does lower medical costs for health systems."

The Institute for Women's Policy Research has a host of data around how reproductive health restrictions impact women's earning potential, including an interactive map tool, Total Economic Losses Due to State-level Abortion Restrictions. In Mississippi, for example, the data indicate that removing restrictions to abortion would translate to a 1.8% increase of Black women in the labor force, over 2% for Hispanic women, and a leap of more than 2.6% for women who identify as Asian-Pacific Islander. This same tool calculates that removing restrictions on abortion access would translate to an estimated $13.4 million in increased earnings at the state level for Black women alone.

Abortion restrictions disproportionately affect people of color and those with low-incomes. According to data from the CDC, Black women are five times more likely to have an abortion than white women, and Latinx women are two times as likely as whites. Seventy-five percent of people who have abortions are low-income or poor.

Mississippi, Texas, and the Supreme Court

On Dec. 1, the Supreme Court will hear Dobbs v. Jackson Women's Health Organization and Rosen thinks it's unlikely the court would agree to hear the case if they were just going to affirm the status quo.

The case isn't the only one on the docket, however. Texas' Senate Bill 8, which bans abortion after six weeks of pregnancy, made headlines earlier this month and may impact the court's ultimate decision on the Mississippi case. The high-profile law came before the Supreme Court in November 2021 and Rosen said the important thing to note is that the justices didn't actually address whether the six-week ban is constitutional. Rather, they examined the unusual enforcement scheme of the law—where, when, and by whom the Texas law could be challenged.

Rosen says that the justices may compare the Texas law with the Mississippi law and, when considering a six-week abortion ban, a 15-week ban may seem less extreme. In this way, the Texas case could give the court some cover to uphold Mississippi's 15-week ban.

It's likely to be months before an opinion is released; Rosen says the court typically releases its decisions on high-stakes or controversial cases in June. And high stakes this is: for the future of abortion, for reproductive health rights, and for public health.

Posted in Health , Politics+Society

Tagged supreme court , reproductive health , abortion

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• Published: 14 June 2019

“Regardless, you are not the first woman”: an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua

• Samantha M. Luffy 1 ,
• Dabney P. Evans   ORCID: orcid.org/0000-0002-2201-5655 1 &
• Roger W. Rochat 1  

BMC Women's Health volume  19 , Article number:  76 ( 2019 ) Cite this article

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Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, public health practicioners and human rights advocates have made great strides to advance our understanding of sexual and reproductive rights and how they should be protected. The overall aim of the study was to understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua, from June to July 2014.

Case presentation

This case study focuses on the story of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her case, detailed under the pseudonym Ana Maria, presents unique challenges related to the fulfillment of sexual and reproductive rights due to the restrictive social norms related to sexual health, ubiquitous violence against women (VAW) and the total ban on abortion in Nicaragua. The case also provides a useful lens through which to examine individual sexual and reproductive health (SRH) experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; this in-depth analysis identifies the contextual risk factors that contributed to Ana Maria’s experience.

Conclusions

Far too many women experience their sexuality in the context of individual and structural violence. Ana Maria’s case provides several important lessons for the realization of sexual and reproductive health and rights in countries with restrictive legal policies and conservative cultural norms around sexuality. Ana Maria’s experience demonstrates that an individual’s health decisions are not made in isolation, free from the influence of social norms and national laws. We present an overview of the key risk and contextual factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion.

Peer Review reports

Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, however, the international community, States, and advocates have made great strides to advance our understanding of sexual and reproductive rights and how they can be protected at the national and international levels. The 1994 Cairo Declaration began this process by including sexual health under the umbrella of reproductive health and recognized the impact of violence on an individual’s sexual and reproductive health (SRH) decision-making. [ 1 ] One year later, the 1995 Beijing Platform for Action specifically addressed the issues of unintended pregnancy and abortion by emphasizing that improved family planning services should be the main method by which unintended pregnancies and unsafe abortions are prevented. [ 2 ]

A recent World Health Organization (WHO) report on the relationships between sexual health, human rights, and State’s laws sets the foundation for our contemporary understanding of these issues. The 2015 report describes sexual health as, “a state of physical, emotional, mental and social well-being in relation to sexuality.” [ 3 ] That state includes control over one’s fertility via access to health services such as abortion; it also includes the right to enjoy sexual experiences free from coercion, discrimination, and violence. [ 3 ] Whether experienced alone or in combination, rape, unintended pregnancy, and abortion are important SRH issues on which public health can and should intervene.

In the public health field, case studies provide a useful lens through which to examine individual women’s sexual and reproductive health experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; an in-depth analysis of these personal experiences can identify contextual risk factors and missed opportunities for public health rights-based  intervention. This type of analysis is especially cogent when legal policies and social factors, such as gender inequality, may influence one’s SRH decision-making process. On an individual level, bearing witness to women’s stories through in-depth interviews helps document their lived experience; surveying these experiences within the context of laws related to SRH provides important evidence for the impact of such policies on women’s well-being.

We present the case of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her complex experience of violence, unintended pregnancy, and unsafe abortion represent a series of contextual factors and missed opportunities for public health and human rights intervention. Ana Maria’s story, told through the use of a pseudonym, takes place in a city located in North Central Nicaragua – a country that presents unique challenges related to its citizens’ fulfillment of their sexual and reproductive health and rights.

Violence against women in Nicaragua

Along with 189 States, Nicaragua is a party to the United Nations (UN) Convention on the Elimination of All Forms of Discrimination against Women, which includes State obligations to protect and promote the health and well-being of Nicaraguan women. [ 4 ] As defined by human rights documents, the right to health includes access to health care services, as well as provisions for the underlying social determinants of health, such as personal experiences of structural violence. [ 5 ]

In the Nicaraguan context, political and sociocultural institutions support unequal power relations between genders. [ 6 ] Machismo is one such form of structural violence that perpetuates gender inequality and has been identified as a barrier to SRH promotion in Nicaragua. [ 7 , 8 ] The term ‘ machismo ’ is most commonly used to describe male behaviors that are sexist, hyper masculine, chauvinistic, or violent towards women. [ 9 ] These behaviors often legitimize the patriarchy, reinforce traditional gender roles, and are used to limit or control the actions of women, who are often perceived as inferior. [ 10 ]

The vast majority (89.7%) of Nicaraguan women have experienced some form of gender-based violence  during their lifetime, which poses a serious public health problem. The latest population-based Demographic and Health Survey showed that at least 50% of Nicaraguan women surveyed had experienced either verbal/psychological, physical, or sexual violenceduring their lifetime. An additional 29.3% of women reported having experienced both physical and sexual violence at least once, while another 10.4% reported having experienced all three types of violence. [ 11 ]

In 2012, Nicaragua joined a host of other Central and South American countries that have implemented laws to eliminate all forms of violence against women VAW, including rape and femicide. [ 12 ] Nicaragua’s federal law against VAW, Law 779, intends to eradicate such violence in both public and private spheres. [ 13 ] On paper, Law 779 guarantees women freedom from violence and discrimination, but it is unclear if the law is being adequately enforced; it has been reported that some women believe VAW has increased since the law’s implementation. [ 14 ]

Before Law 779, violent acts like rape, particularly of young women ages 15–24, were endemic in Nicaragua. Approximately two-thirds of rapes reported in Nicaragua between 1998 and 2008 were committed against girls under 17 years of age; most of these acts were committed by a known acquaintance. [ 15 ] Due to a lack of reporting and to culturally propagated stigma regarding rape, no reliable data suggest that Law 779 has been effective in reducing the incidence of rape in Nicaragua. For women who wish to terminate a pregnancy that resulted from rape, access to abortion services is vital, yet completely illegal. [ 16 ] In contrast, technical guidance from the WHO recommends that health systems include access to safe abortion services for women who experience unintended pregnancy or become pregnant as a result of rape. [ 17 ]

Family planning and unintended pregnancy in Nicaragua

Like violence, unintended pregnancies -- not only those that result from rape -- pose a widespread public health problem in Nicaragua. National data suggest that 65% of pregnancies among women ages 15–29 were unintended. [ 11 ] Oftentimes, unintended pregnancy results from a complex combination of social determinants of health including: low socioeconomic status (SES), low education level, lack of access to adequate reproductive health care, and restrictive reproductive rights laws. [ 18 , 19 , 20 ] Nicaraguan women of low SES with limited access to family planning services are at an increased risk of depression, violence, and unemployment due to an unintended pregnancy. [ 19 , 20 ]

The UN Committee on the Elimination of all forms of Discrimination Against Women (CEDAW) has expressed concern regarding the lack of comprehensive sexual education programs, as well as inadequate family planning services, and high rates of unintended pregnancy throughout Nicaragua. [ 21 ] Due to a lack of sexual education, Nicaraguan adolescents, if they use contraceptives like male condoms or oral contraceptive pills, often do so inconsistently or incorrectly. [ 22 ]

Deeply rooted cultural stigma surrounding unmarried women’s sexual behavior contributes to the harsh criticism of young women in Nicaragua that use a method of family planning or engage in sexual relationships outside of a committed union. [ 18 , 22 ] Also, young women who are not in a formal union may experience unplanned sex (consensual or nonconsensual) and are unlikely to be using contraception, which further increases the risk of unintended pregnancy. [ 22 ] These social and cultural factors, in conjunction with restrictive reproductive rights laws, may contribute to a high incidence of unintended pregnancy among young Nicaraguan women.

The total ban on abortion in Nicaragua

Compounding the economic, social, and emotional burden of unintended pregnancy on women’s lives is the current prohibition of abortion in Nicaragua. In 2006, the National Assembly unanimously passed a law to criminalize abortion, which had been legal in Nicaragua since the late 1800s. [ 20 ] Researchers often refer to this law as the “total ban” on abortion. [ 20 , 23 ] The total ban prohibits the termination of a pregnancy in all cases, including incest, rape, fetal anomaly, and danger to the life of the woman. Laws that prohibit medical procedures are, by definition, barriers to access; equitable access to safe medical services is a critical element of the right to health. [ 3 , 5 ] The UN Committee on Civil and Political Rights (CCPR) has also recognized the discriminatory and harmful nature of criminalizing medical procedures that only women undergo. [ 24 ]

Nicaragua is one of the few countries in the world to completely ban abortion in all circumstances. In States where illegal, abortion does not stop. Instead, women are forced to obtain abortions from unskilled providers in conditions that are often unsafe and unhygienic. [ 25 ] Unsafe abortions are among the main preventable causes of maternal morbidity and mortality worldwide and can be avoided through decriminalization of such services. [ 26 ]

The Nicaraguan ban includes serious legal penalties for women who obtain illegal abortions, as well as for the medical professionals who perform them, which can have profound negative effects on women’s health. [ 20 , 23 ] Women who need or want an abortion face not only the health risks that accompany an unsafe procedure, but additional criminal penalties. The total ban on abortion violates the human rights of both health care providers and women nationwide, as well as the confidentiality inherent in the patient-provider relationship. [ 20 ] It also results in a ‘chilling effect’ where health care providers are unwilling to provide both abortion and postabortion care (PAC) services for fear of prosecution. [ 20 ]

In response to the negative impacts of the total ban on maternal morbidity and mortality in Nicaragua, as well as detrimental effects on women’s physical, mental, and emotional health, CEDAW has recommended that the Nicaraguan government review the total ban and remove the punitive measures imposed on women who have abortions. [ 21 ] While the Nicaraguan government may not view abortion as a human right per se, women should not face morbidity or mortality as a result of illegal or unsafe abortion. [ 27 ]

Criminalizing abortion also increases stigma around this issue and significantly reduces people’s willingness to speak openly about abortion and related SRH services. Qualitative research conducted in Nicaragua suggests that women who have had unsafe abortions rarely discuss their experiences openly due to the illegal and highly stigmatized nature of such procedures. [ 18 ] Therefore, the overall aim of the study was to better understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua from June to July 2014. This private method of data collection allowed for the detailed exploration of each young woman’s personal experience with an unintended pregnancy, including the decision-making process she went through regarding how to respond to the pregnancy. Given the personal nature of this experience – including the criminalization and stigmatization of women who obtain abortions – IDIs allowed the participants to share intimate details and information that would be inappropriate or dangerous to share in a group setting. One case, presented here, emerged as salient for understanding the intersections of violence, unintended pregnancy, and abortion – and the missed opportunities for rights-based public health intervention.

Emory University’s Institutional Review Board ruled the study exempt from review because it did not meet the definition of “research” with human subjects as set forth in Emory policies and procedures and federal rules. Nevertheless, procedural steps were taken to protect the rights of participants and ensure confidentiality throughout data collection, management, and analysis. The first author reviewed the informed consent form in Spanish with each participant and then acquired each participant’s signature and verbal informed consent before the IDIs were conducted. The investigators developed a semi-structured interview guide with open-ended questions and piloted the guide twice to improve the cultural appropriateness of the script (Additional file 1 ). The investigators also collaborated with local partners to design and implement the research according to local cultural and social norms. Due to the contentious topics discussed in this study, these collaborators prefer to not be mentioned by name. Interviews were conducted in Spanish in a private location and audio taped to protect the participants’ privacy. Recordings were transcribed verbatim and transcripts were coded and analyzed using MAXQDA11 software (VERBI GmbH, Berlin, Germany).

Initially, participants were recruited for interviews through purposive sampling of individuals who had disclosed a personal experience with unintended pregnancy during focus group discussions (FGDs) conducted in a larger parent study. At the end of each interview, participants were asked to refer other young women they knew who may have experienced an unintended pregnancy to participate in an interview. This form of respondent-driven sampling created a network of participants with a wide variety of experiences with unintended pregnancy. Of the ten interviewees, two had experienced unintended pregnancy as a result of rape, though both used the phrase “ sexo no consensual ” or “nonconsensual sex” in lieu of “ violación, ” the Spanish word for rape. One of these women shared her personal experience receiving an unsafe abortion to terminate an unintended pregnancy that had resulted from rape. Her story, shared under the use of the pseudonym Ana Maria, is presented here in order to:

Illustrate the harmful impact of restrictive abortion laws on the health and well-being of women – especially those who do not have access to abortion in the case of rape; and

Exemplify the nexus of contextual risk factors that impact women’s SRH decision-making, such as conservative social norms and restrictive legal policies.

Through thorough analysis, we examine the impact of these contextual factors that impacted Ana Maria’s experience.

When she was 19, Ana Maria was raped by her godfather, a close friend of her family.

In an in-depth interview, Ana Maria described enduring incessant verbal harassment from her godfather – her elder brother’s best friend – in the months before the assault. He constantly called and texted her cell phone in order to interrogate her about platonic relationships with other men in town and to convince her to spend time alone with him. Even though he was married with children and she repeatedly dismissed his advances, he continued to engage in this form of psychological violence with his goddaughter. Ana Maria described eventually “giving in” and meeting him – not knowing that this encounter would result in her forcible rape.

The disclosure of Ana Maria’s rape during her interview was spontaneous and unexpected. Ana Maria was unwilling to disclose explicit details of the sexual assault. Instead, she stated multiple times that the sexual contact was nonconsensual and she did not want to have sex with him. When asked if she told anyone about this experience, she said no because she did not want others to judge her for what had happened.

Approximately a month of scared silence after she was raped, Ana Maria noticed that her period had not come. Nervous, she bought a pregnancy test from a local pharmacy. To her dismay, the test was positive. In order to confirm the pregnancy, she traveled alone to the nearby health center in her town to obtain a blood test. Again, the test was positive. She had never been pregnant before and she was terrified. In the midst of her fear, she shared the results with her rapist, her godfather.

His response: get an abortion. He did not want to lose his wife and children if they found out about the pregnancy.

Other than their illegal nature, Ana Maria knew nothing about abortions – where to get one, how it was done, what it felt like. She asked her neighbors to explain it to her. They said “it was worse than having a baby and [experiencing] childbirth.”

Though Ana Maria did not want to get the abortion, her godfather continued to pressure her to get the procedure saying, “Regardless, you must get the abortion… you are not the first woman to have ever had one.” Similar to the emotional violence before he raped her, he called and texted Ana Maria every day telling her to, “do it as fast as you can.” He forbade her from telling anyone about the pregnancy and Ana Maria didn’t feel like she had anyone to confide in about the situation. She worried about people judging her for getting pregnant outside of a committed relationship – even though she was raped. Ana Maria described this difficult time:

“When he started to pressure me [to get the abortion], I felt alone. I did not have enough trust in anyone to tell them [what had happened] because… if I had had enough trust in someone, I know that they would not have let me do it. If I had been given advice, they would have said, ‘No, do not do it,’ but I did not have anyone and I felt so depressed. What made it worse, I couldn’t sleep; I could not sleep [because I was] thinking of everything he had told me. At night, I would remember how it all started and I do not know what he did to find that money, but he gave me the money to get the abortion.”

Her godfather gave her 3000 Córdobas (approximately USD112 at the time) and put her on a public bus, alone. He had arranged for her to receive the abortion from an older woman that practiced “natural medicine” in a nearby city. When Ana Maria arrived at the woman’s home, she was instructed to remove her pants and underwear and lie on a bed. Ana Maria did not receive any medication before the woman inserted a “device like the one used for a Papanicolau… and then another device like an iron rod” into her vagina.

After describing these devices, Ana Maria made a jerking motion back and forth with her arm to imitate the movement the woman used to perform the abortion.

Once it was over, the woman gave Ana Maria an injection of an unknown substance and told her that she would pass a few blood clots over the next few days. That night, however, Ana Maria’s condition worsened; she became feverish, felt disoriented, and began to pass dark, fetid clots of blood. She described the pain she experienced throughout the ordeal:

“I felt so much pain when they took her out of me. I felt pain when the blood was leaving my body and when I had the fever. I felt a terrible pain that only I suffered. I am [a] different [person] now because of those pains.”

Ana Maria was too afraid to tell her family about the assault or the abortion because she was uncertain how they would react. She was even more terrified of the potential legal repercussions that she could face for violating the total ban on abortion. Within a few days of the abortion, though, Ana Maria’s brother heard rumors of his sister’s situation from neighbors “in the street” and confronted her about what had happened. At first, Ana Maria denied that she had had an abortion, but her brother continued to ask for the truth. Though she was nervous, Ana Maria eventually told her brother everything that had happened – from her godfather’s incessant verbal harassment, to the rape, to the unsafe abortion she was forced to get.

Afraid for his sister’s life, Ana Maria’s brother contacted a local nurse who discreetly provides postabortion care (PAC) to women experiencing complications from unsafe abortion and other obstetric emergencies. This nurse is locally known to be one of the few health care providers who provide PAC despite many other providers’ fear of prosecution under the total ban. The nurse recommended that Ana Maria come to the hospital immediately.

Ana Maria spent almost two weeks as an inpatient at the only hospital in the region. She had become septic as a result of what she described as a “perforated uterus,” a common complication from unsafe abortion. [ 28 ] Upon her initial examination, the nurse was afraid that her uterus could not be repaired because the infection was so severe. Fortunately, the medical team administered an ultrasound, removed infected blood clots, and completed uterine surgery to repair the damage from the unsafe abortion. At the request of the gynecologist taking care of her, Ana Maria received the one-month contraceptive hormonal injection before being discharged. At the time of the interview, Ana Maria had not received the next month’s injection because she “didn’t have any use for a man.”

As a result of this experience, Ana Maria reported feelings of depression, isolation, and recurring dreams about a little girl, which she described in this way:

“After I was discharged, I always dreamt of a little girl and that she was mine, standing in my doorway and when I awoke, I couldn’t find her. I looked for her in my bed but she wasn’t there. And this has tormented me because, it’s true: I am the girl that committed this error, but the little girl was not at fault. He pressured me so strongly to get the abortion, so I did.”

Ana Maria had the same recurring dream every night for more than two weeks and she continued to feel depressed weeks after leaving the hospital. One of the sources of her depression was the isolation she felt because there was no one with whom she could share this experience.

According to Ana Maria, she longs to have other people to talk to about her experience – particularly those who may have had similar experiences. She also expressed a desire to pursue a law degree so that she can have a career in local government.

Discussion and conclusions

Ana Maria’s case provides insight into the contextual factors effecting her ability to realize her sexual and reproductive health and rights in Nicaragua where restrictive legal policies and conservative cultural norms around sexuality abound. These contextual risk factors include social norms related to sexual health, laws targeting VAW, and the criminalization of abortion.

Social norms related to sexual health

The fundamental relationship between structural inequality and sexual and reproductive rights has been duly noted; gender inequality, in particular, must be addressed in order to fulfill sexual rights for women. [ 29 ] As in many cases in Nicaragua, the fact that Ana Maria’s first sexual experience was nonconsensual and was initiated by an older male and trusted family friend highlights the uneven power relations between men and women in Nicaraguan culture, which propagate high instances of VAW and sexual assault. In a patriarchal society where machismo and gender inequality run rampant, women’s sexuality is further constrained by the stigmatization of sexual health and a culture of violence that limits women’s autonomy. The compound stigma surrounding sexual health in general, and rape in particular, negatively impacted Ana Maria’s knowledge and ability to access mental health and SRH services, including emergency contraception and post-rape care, which may have assisted her immediately following her assault. Before her brother intervened, Ana Maria’s fear of judgment and legal repercussions also prevented her from seeking PAC, which was necessary to save her life.

Comprehensive sexual education is a primary way to challenge these social norms and widespread stigma surrounding sexuality and SRH services, such as contraception and PAC, at the population level. Such education might have mitigated Ana Maria’s experience of unintended pregnancy through the provision of advance knowledge of emergency contraception and medical options in the event of pregnancy. CEDAW has recognized this missed opportunity for public health intervention in Nicaragua, and recommends sexual education as a means of addressing stigma related to sexuality, decreasing unintended pregnancy, and increasing the acceptability and use of family planning services throughout the country. [ 21 ] Furthermore, the lack of adolescent-friendly sexual education and SRH services symbolizes a social reluctance to acknowledge the reality that young people have sex. [ 30 ] Such ignorance results in a lack of information on healthy relationships and human reproduction, as well as experiences of unintended pregnancy, early motherhood, and unsafe abortion. Exposure to this type of information may have improved Ana Maria’s ability to protect herself, mitigated the impact of Nicaragua’s pervasive misogyny on her decision making, and lessened the influence of her godfather’s coercion before her experiences of rape and unsafe abortion.

Individual and structural violence against women

Though we do not know explicit details of Ana Maria’s rape, the act of rape is inherently violent. The assault violated her right to enjoy sexual experiences free from coercion and violence. [ 3 ] To further constrain her sexual and reproductive rights, Ana Maria’s experience of rape resulted in an unintended pregnancy and an unsafe abortion that she was pressured into undergoing. Along with physical sequelae as a result of the procedure, she also expressed feelings of depression and isolation, which are common symptoms of post-traumatic stress disorder (PTSD). [ 31 ] These mental health consequences are forms of emotional violence that Ana Maria continued to experience long after the initial insult of physical violence. We can’t distinguish whether her mental health symptoms were a pre-existing condition or a result of the traumatic experience presented here. It is likely, however, that all parts of this experience impacted her mental and physical health. As reported elsewhere, perceived social criticism and a lack of social support are barriers to the fulfillment of sexual and reproductive health among young Nicaraguan women. [ 18 ] These contextual risk factors undoubtedly played a role in Ana Maria’s ability to navigate the circumstances surrounding her assault and its aftermath.

What legal recourse was feasibly available to Ana Maria for the crime of her sexual assault? To our knowledge, Ana Maria did not report the rape to authorities nor did her godfather ever face criminal charges for his actions. Yet Ana Maria’s own fear of prosecution for undergoing the unsafe abortion, as well as shame and fear of being stigmatized by others in her community, strongly influenced her decision not to report the rape -- even though Law 779 contains sanctions specific to those who commit rape.

In the event she had reported the crime, however, it is unclear if Law 779 would have provided justice. There are no data to suggest that Law 779 has led to an increase in the reporting or prosecution of rape at the national level. To the contrary, qualitative work in Nicaragua found a perceived increase in VAW following the passage of the law. [ 14 ] In Nicaragua, the inconsistent or ineffective enforcement of Law 779 is another factor worthy of consideration in cases like Ana Maria’s where individuals do not report such crimes. Documents like the UN Women Model Protocol have recently been released to improve the enforcement of laws like Law 779 in Latin American countries, presenting an opportunity for the effective operationalization of the law in Nicaragua. [ 32 ] If Law 779 is not adequately enforced, women like Ana Maria face the potential for re-victimization through the structural violence of impuity and continued exposure to VAW. To our knowledge, Ana Maria’s perpetrator faced no consequences for his perpetration of harassment, coercion and rape of Ana Maria. Moreover, in countries where abortion is criminalized, such as El Salvador, it is most often women who face criminal sanctions. [ 33 ] Indeed, it was Ana Maria herself who bore the physical and mental burden that resulted from her assault, unintended pregnancy, and unsafe abortion.

The criminalization of abortion

The criminalization of health services is a strategy that governments use to regulate people’s sexuality and sexual activity. [ 34 ] The criminalization of services such as abortion limits women’s ability to make autonomous decisions about their SRH. By definition, laws that restrict access to health services exclude people from receiving the information and services necessary to realize the highest level of SRH possible. [ 5 ] The criminalization of abortion puts the health and well-being of individuals and communities at risk. Beyond the individual level, complications from unsafe abortion often put unnecessary and immeasurable financial burdens on health systems that are already stretched [ 28 ].

Ana Maria did not have a choice when it came to her abortion; the man who raped her coerced her to undergo an unsafe and illegal procedure. The criminalization of abortion in Nicaragua put Ana Maria’s health at risk in two ways: first, it prevented her from obtaining a safe abortion and second, it limited her access to comprehensive sexual health information that could have helped her address her unintended pregnancy, through emergency contraception. After the unsafe abortion procedure, her access to PAC was likely constrained by her own fear of the possible legal repercussions of undergoing an abortion, and was compounded by her inability to trust that a health care provider would maintain patient confidentiality and provide adequate PAC.

In Nicaragua, the total ban on abortion directly contradicts strategic objectives outlined in the Beijing Declaration, which guarantees women’s rights to comprehensive SRH care, including family planning and PAC services. Though providing PAC is not considered illegal under the total ban, many Nicaraguan health care providers refuse to treat women who have had unsafe abortions, which results in a ‘chilling effect’; providers do not want to be accused of being complicit in providing abortions so they refuse to provide PAC services. The ‘chilling effect’ put Ana Maria at risk of morbidity or mortality as a result of the complications that resulted from her unsafe abortion.

Equally troubling is the use of criminal law against individuals like Ana Maria as well as health care professionals that provide PAC. By requiring health care providers to report to the police women who have had abortions, the total ban violates the privacy inherent in the patient-provider relationship. Health care providers are faced with a dual loyalty to both the State’s laws and the confidentiality of their patients, which makes it difficult for providers to fulfill their professional obligations. It also makes health care professionals complicit in a discriminatory practice, one where women face legal sanctions in ways that men do not. The criminalization of abortion in Nicaragua therefore resulted in the fear, stigma, discrimination, and negative health outcomes observed in Ana Maria’s case.

The contextual risk factors that contributed to Ana Maria’s experience of rape, unintended pregnancy, and unsafe abortion are as follows: sexual assault, impunity for violence, gender inequality, restrictive social norms around SRH, stigma resulting from unintended pregnancy and abortion, harmful health impacts from an unsafe abortion, and fear of prosecution due to the total ban. Her first sexual experience was forced and nonconsensual and preceded by months of harassment. Social norms made taboo any discussion of the harassment and sexual violence she experienced at the hands of her godfather; without social support, she was coerced into undergoing an unsafe abortion that resulted in serious mental and physical health sequelae. The illegal nature of abortion in Nicaragua placed Ana Maria at risk for social stigma as well as criminal prosecution. Her subsequent underutilization of family planning services at the time of the interview also placed Ana Maria at risk for an unintended pregnancy in the future; other long-term physical and mental health effects of her experience remain unknown.

The realization of one’s sexual and reproductive rights guarantees autonomous decision-making over one’s fertility and sexual experiences. However, Ana Maria’s story demonstrates that an individual’s SRH decisions are not made in isolation, free from the influence of social norms and national laws. Far too many women experience their sexuality in the context of individual and structural violence, such as VAW and gender inequality. This case highlights the contextual risk factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion; we must continue to critically investigate these factors to ensure that experiences like Ana Maria’s do not become further normalized in Nicaragua. Due to restrictive social norms around SRH, Ana Maria grew up experiencing stigma and taboo associated with sex, sexuality, contraceptive use and abortion. She also lacked access to information regarding SRH, healthy relationships, and how to respond to VAW before she was assaulted. After her assault, she did not have access to post-rape care, emergency contraception, safe abortion services, or mental health services to help her process this trauma. Shame and fear of stigma also prevented Ana Maria from reaching out for social support from family, friends, or the health or legal system. From the legal perspective, inadequate enforcement of VAW laws and the criminalization of abortion further exacerbated the trauma Ana Maria experienced.

It would require active engagement from the Nicaraguan government to address the contextual risk factors identified herein to protect their citizens’ right to health and prevent future experiences like Ana Maria’s. These efforts are particularly relevant given recent political unrest throughout Nicaragua including anti-government protests demanding the president’s resignation. [ 35 ] Nicaraguans’ right to health is at risk not only due to the widespread violence, but also because health care workers are being dismissed and persecuted nationwide. [ 36 ] Sexual and reproductive health researchers, advocates, and the public will continue to monitor Nicaragua’s response to the immediate demands and needs of its citizens -- including the demand that Nicaraguan women like Ana Maria are able to fully exercise their sexual and reproductive rights in times of both conflict and peace.

Availability of data and materials

Deidentified data are available upon reasonable request.

Abbreviations

Committee on Civil and Political Rights

Committee on the Elimination of all forms of Discrimination Against Women

In-Depth Interviews

Postabortion Care

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Socioeconomic Status

Sexual and Reproductive Health

United Nations

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Acknowledgements

The authors thank the research team and in-country collaborators from Proyecto Paz y Amistad, as well as the Emory University Global Field Experience (GFE) Fund and the Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund for financially supporting this project. We are also grateful to Ellen Chiang for her editorial support.

This study was funded with support from the Emory University Global Field Experience (GFE) Fund and the Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund. The funders did not play any direct role in the design of the study; the collection, analysis, and interpretation of data; or the writing of the manuscript.

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All authors contributed extensively to the work presented in this manuscript. SML, DPE, and RWR jointly designed the study. SML performed data collection and data analysis. SML and DPE wrote the manuscript with significant input from RWR. DPE and RWR also provided support and supervision throughout the study. All authors read and approved the final manuscript.

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Emory University’s Institutional Review Board found the study exempt from review because it did not meet the definition of “research” with human subjects as set forth in Emory policies and procedures and federal rules. The authors partnered with Proyecto Paz y Amistad, a local organization to design and implement this study. Proyecto Paz y Amistad deferred to the Emory University IRB’s determination. Nicaragua is notably absent from the US Department of Health and Human Services, International Compilation of Human Research Standards ( https://www.hhs.gov/ohrp/sites/default/files/2018-International-Compilation-of-Human-Research-Standards.pdf ). To our knowledge, there were no existing national level human subjects requirements or exemptions at the time of data collection.

Though the project was exempt from full review by Emory University’s Institutional Review Board, procedural steps were taken to protect the rights of participants and ensure confidentiality throughout data collection, management, and analysis. Verbal informed consent was acquired from all participants before the IDIs were conducted and each participant signed a waiver to participate.

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Luffy, S.M., Evans, D.P. & Rochat, R.W. “Regardless, you are not the first woman”: an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua. BMC Women's Health 19 , 76 (2019). https://doi.org/10.1186/s12905-019-0771-9

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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.

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Pioneering applications of this approach include work by Angrist and Krueger (1991) leveraging variation in compulsory school attendance laws to measure the effects of schooling on earnings and work by Card and Krueger (1994) leveraging minimum wage variation across state borders to measure the effects of the minimum wages on employment outcomes. The use of these methods is now widespread, not just in economics, but in other social sciences as well. Fueled by advances in computing technology and the availability of data, quasi-experimental methodologies have become as ubiquitous as they are powerful, applied to answer questions ranging from the effects of economic shocks on civil conflict (Miguel, Sayanath, and Sergenti, 2004), to the effects of the Clean Water Act on water pollution levels (Keiser and Shapiro, 2019), and effects of access to food stamps in childhood on later life outcomes (Hoynes, Schanzenbach, Almond 2016; Bailey et al., 2020).

Research demonstrates that abortion access does, in fact, profoundly affect women’s lives by determining whether, when, and under what circumstances they become mothers.

Economists also have applied these tools to study the causal effects of abortion access. Research drawing on methods from the “credibility revolution” disentangles the effects of abortion policy from other societal and economic forces. This research demonstrates that abortion access does, in fact, profoundly affect women’s lives by determining whether, when, and under what circumstances they become mothers, outcomes which then reverberate through their lives, affecting marriage patterns, educational attainment, labor force participation, and earnings.

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.

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William A. Galston

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Anthony F. Pipa

July 24, 2023

William A. Galston, Jordan Muchnick

July 11, 2023

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Perspective article, the potential of self-managed abortion to expand abortion access in humanitarian contexts.

• 1 Ibis Reproductive Health, Oakland, CA, United States
• 2 Ipas, Chapel Hill, NC, United States
• 3 International Rescue Committee, Kinshasa, Democratic Republic of the Congo
• 4 African Population and Health Research Center, Nairobi, Kenya
• 5 Resilience Action International, Kakuma, Kenya
• 6 International Rescue Committee, New York, NY, United States

Refugees and displaced people face uniquely challenging barriers to abortion access, including the collapse of health systems, statelessness, and a lack of prioritization of sexual and reproductive health services by humanitarian agencies. This article summarizes the evidence around abortion access in humanitarian contexts, and highlights the opportunities for interventions that could increase knowledge and support around self-managed abortion. We explore how lessons learned from other contexts can be applied to the development of effective interventions to reduce abortion-related morbidity and mortality, and may improve access to information about safe methods of abortion, including self-management, in humanitarian settings. We conclude by laying out a forward-thinking research agenda that addresses gaps in our knowledge around abortion access and experiences in humanitarian contexts.

Introduction

The ability to control one's fertility is a fundamental human right ( 1 , 2 ). Unfortunately, this right is not universally enjoyed or accessible to all people, and reproductive oppression—the control and exploitation of women, girls, and individuals through their bodies, sexuality, labor, and reproduction—persists globally. The consequences of this oppression are inequitably magnified by statelessness, disrupted communities, and health systems. The World Health Organization (WHO) estimates that almost all of the annual 25.1 million unsafe abortions globally occur in low and middle income regions; unsafe abortion is responsible for an estimated 8–13% of global maternal deaths, with low and middle-income country-specific rates frequently much higher ( 3 ). Little is known about the magnitude of unsafe abortion and its associated outcomes in humanitarian settings, although both are thought to be much worse ( 4 ). While the need for abortion services likely increases during humanitarian crises, the abortion needs and experiences of people living in humanitarian settings are often ignored. Expanding access to abortion information, support, and services is critical to ensuring the reproductive autonomy of individuals in crisis settings, yet it is rarely prioritized.

Interventions that support people who are self-managing an abortion with misoprostol alone, or in combination with mifepristone, have the potential to dramatically increase safe abortion access ( 5 ). This type of autonomous management is commonly referred to as self-care. Self-care is defined by the WHO as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a healthcare provider,” and includes self-managed abortion with medications (SMA) as one of its recommended interventions ( 6 ). However, further research is needed to fully understand the scope of barriers and facilitators to increase access to self-managed abortion information and support for refugees and displaced people. This paper addresses the research gaps in our current understanding of abortion access in humanitarian contexts, explores existing barriers to safe abortion care in these settings, highlights the potential of SMA as a person-centered strategy to increase reproductive autonomy, and proposes priorities for future research in humanitarian contexts.

Abortion in Humanitarian Contexts

There is little to no published data documenting the incidence of or experiences with abortion among individuals living in refugee camps or settlements. Given what we know about the nature of humanitarian emergencies, the need for abortion services likely increases due to the collapse of health systems, disruptions in contraceptive use and access, and increased exposure to sexual violence or transactional sex ( 4 ). As a result, displaced and conflict-affected people may be at increased risk of the consequences of lack of abortion care access, including forced childbearing, and morbidity and mortality related to unsafe abortion. An estimated 61% of maternal deaths occur in fragile states, many of which are affected by conflict and recurring natural disasters. However, accurate estimation in individual conflict-affected areas remains a challenge. Recent studies have documented a nearly 2-fold increase in post-abortion care utilization between 2012–2013 and 2015–2017 in the Democratic Republic of Congo, Somalia, and Yemen, highlighting the critical role that comprehensive safe abortion services could play ( 7 , 8 ).

Despite the confluence of factors that highlight the need to prioritize abortion access, lack of research on the need for abortion services, misconceptions about the legality of abortion provision, lack of funding and donor attention, limited trained providers, and misperceptions around the technical difficulty of abortion care all serve as barriers to abortion provision from humanitarian organizations ( 4 ). Gaps in the health system, lack of commodities, lack of knowledge about the legal status of abortion and where to obtain safe services (particularly for those who are displaced across country borders), and high stigmatization of abortion are additional barriers specific to displaced people. In light of these challenges, the Inter-Agency Working Group on Reproductive Health in Crisis (IAWG) has developed a comprehensive field manual on sexual and reproductive health, which has included stand-alone chapters on safe abortion since 2010, and successfully advocated to include safe abortion in the Minimum Initial Service Package (MISP) for Sexual and Reproductive Health in 2018 ( 9 , 10 ). While the MISP includes safe abortion as a priority activity, safe abortion services are routinely excluded from reproductive health service provision in humanitarian settings, and research has shown that abortion care is almost non-existent in humanitarian programming or proposals ( 11 , 12 ). Citing their professional and moral responsibility to reducing maternal mortality, some humanitarian agencies, such as Médecins Sans Frontières, have explicitly stated their commitment to providing comprehensive abortion care in spite of global policy and legal barriers ( 13 ), and the International Rescue Committee has prioritized SMA in humanitarian settings as an organizational research and innovation priority. While there is some momentum in the provision of abortion care in these settings, progress has been slow, even as more nations expand the legal indications for abortion. Given these unique challenges, targeted interventions designed to increase abortion access are needed.

Research conducted among Congolese refugees in Uganda suggest many were unable to navigate the legal restrictions on abortion in that country and were instead engaging in unsafe abortion practices, such as ingesting detergents or pain medications or inserting crushed bottles and sticks into the uterus; legal restrictions on induced abortion also posed a barrier to the provision of post-abortion care ( 14 ). Additionally, recent studies on the experience of training and implementing safe abortion services in Bangladesh to Rohingya refugees highlights the immense need for abortion services: less than two years after the influx of refugees, almost 8,000 people had received abortion-related care, over 75% of which were legal induced abortions ( 15 , 16 ). This case study from Bangladesh translates evidence-based findings into common practice and documents the first time legal induced abortion care, in the form of menstrual regulation in Bangladesh, has been offered and brought to scale during an acute emergency, showing both the demand for and feasibility of such a response.

Despite the evidence suggesting the need for safe abortion services and consensus in the humanitarian community about the importance of providing comprehensive abortion care, only three peer-reviewed papers published in the past 10 years documenting detailed individual-level abortion experiences of those living in refugee camps or settlements were identified; data from all three papers are drawn from the same research study. In this study on women from the Democratic Republic of Congo who experienced sexual-violence related pregnancies, barriers to termination among those who carried these pregnancies to term included: fear of death from unsafe abortion procedures, lack of knowledge of where to access services, or a failed abortion or ongoing pregnancy after attempting to terminate with herbal remedies ( 17 ). Among those who did terminate their pregnancies, the majority used medications (most commonly, quinine) or traditional herbs (most commonly, cimpokolo, or Phytolacca dodecandra ) obtained on their own or through family, friends, or traditional healers ( 18 ). Many reported seeking medical care as a result of their symptoms; it is unknown whether the methods they used were successful on their own, or if participants obtained surgical procedures or other post-abortion care treatment in order to terminate their pregnancies after inducing bleeding. Findings from these studies corroborate other qualitative findings that have found a lack of access to information on abortion in humanitarian settings, and highlight the need for interventions that increase access to information on self-managed safe abortion.

Potential of Abortion Self-Care in Humanitarian Contexts

Within the humanitarian field, many of the calls for action have focused on overcoming barriers to facility-based abortion care provision ( 19 ). While these efforts are critical, this view often centers clinic-based care as the gold standard of abortion provision and ignores the reality that for many, “safety” of abortion care involves more than the location or provider involved ( 20 ). Evidence from other settings where SMA is common indicates that fear of mistreatment and stigma from providers, as well as concerns around privacy, are primary drivers for why people choose to self-manage despite the availability of abortion services within the formal healthcare system ( 21 – 23 ). Such concerns are likely heightened during displacement, where known caregivers and community intermediaries are replaced by systems managed by new state actors or international non-governmental organizations.

As a result of misconceptions about the legality of abortion provision, as well as perceived loss of funding or donor unwillingness to support abortion provision, humanitarian organizations responsible for provision of health care services in refugee camps, settlements, or conflict-affected areas, either do not provide abortion services, or are unable to meet the full need for abortion services in these contexts ( 4 , 24 ). Logie et al. have highlighted the potential of self-care interventions in advancing sexual and reproductive health in humanitarian settings, as they can increase lay health worker capacity and potentially better serve the needs of individuals who face additional marginalization such as adolescents, lesbian, gay, transgender, and gender expansive people, and people with disabilities ( 25 ). A growing body of evidence suggests that individuals can safely and effectively manage their abortions if they have access to WHO-approved medications for abortion (misoprostol alone, or misoprostol in combination with mifepristone) and information is available about how to take the pills, confirm abortion completion, and how to recognize warning signs that might warrant follow-up medical care ( 23 , 26 ). Indeed, the WHO has highlighted the potential of self-care interventions, including SMA, as a strategy that gives individuals greater control over their experience and privacy, while also overcoming challenges such as healthcare worker shortages and high out-of-pocket-costs ( 6 ).

Global evidence has demonstrated the safety and effectiveness of a range of models for providing information and support for SMA. Harm reduction programs are based within the formal healthcare system, where medical providers provide individuals with information before and after SMA, but do not directly provide individuals with the medications ( 27 ). Individuals might access medication from pharmacies or informal drug sellers; though the quality of the information that they receive can be variable ( 28 ). Abortion accompaniment networks , along with safe abortion hotlines , are run by lay counselors and feminist activists, and offer individualized evidence-based counseling and support, including information on how to self-assess eligibility for medications, how to procure medications, how to take the medications, how to manage abortion symptoms and assess completion, when to seek healthcare, and offer virtual or in-person guidance and support throughout the process ( 29 , 30 ). In community-distribution programs , community health workers, midwives, or lay providers are trained in providing counseling and support around medication abortion and directly distribute the medications to individuals to ensure quality of the drugs provided. While work by Foster et al. on the Thai-Burma border ( 31 ) among Burmese migrants and refugees provides important evidence for the safety, effectiveness, feasibility, and acceptability of this model of abortion care, it is one of the only research studies evaluating any abortion access intervention in a humanitarian context. Additional research is urgently needed to develop appropriate, context-specific interventions that provide information and support to people who are self-managing their abortion through a variety of different models of support ( 32 , 33 ).

There are many advantages to SMA—such as privacy, confidentiality, and affordability—that contribute to its potential to revolutionize safe abortion access in humanitarian settings. SMA interventions can be tailored to improve access for specific populations who are often not centered in intervention design or service provision, such as young people, LGBTQI individuals, and people with disabilities. Additionally, SMA can reduce the reliance on overburdened health systems, which may further increase access by providing people with an additional option for abortion care. The de-medicalization of this care is likely to be appealing to those who may have been persecuted or discriminated against prior to displacement and are still building trust in their new environments. Although the stigma of abortion is felt in both legally liberal and restrictive settings ( 34 ), additional cultural barriers and a loss of power and autonomy experienced by displaced people certainly magnifies these concerns.

However, there are additional considerations that are specific to humanitarian contexts. Which abortion medications are available and how are they accessed? How does access to water and sanitation facilities—especially shared toilets, lack of clean water, sanitary pads or cloths, which may make managing the products of conception and bleeding onerous and difficult to hide—affect abortion experiences? What are the impacts of poverty and a lack of access to cash, which can make purchasing abortion medications, pain control medications and hygiene materials, difficult decisions when placed against other individual and household needs? How does crowded housing and lack of privacy from other members of the household influence individual decisions around abortion methods and care seeking? What are the legal contexts, how are they understood and what are the contextual effects? These and other issues highlight the critical importance of empirical research on direct abortion experiences to understand the needs, barriers, and facilitating factors around abortion self-care.

Despite the many calls for additional research, funding, and attention toward provision of safe abortion services for those living in humanitarian contexts, little is known about the abortion experiences of individuals in these contexts. No peer-reviewed evidence exists on the incidence of abortion in any humanitarian context, nor have any studies sought to rigorously assess the information needs, knowledge gaps, or experiences with abortion among those living in protracted humanitarian emergencies, an increasingly common situation as most displaced people now spend over 17 years of their lives in displacement. Limited evidence has suggested that women in humanitarian settings often resort to using unsafe methods to terminate their pregnancies, and that a substantial proportion of maternal mortality in such settings may be related to complications from unsafe abortion. Even in contexts where health-implementing organizations are providing comprehensive abortion services, lack of knowledge, fear of legal repercussions, and abortion stigma may prevent people from accessing care from these providers.

Given the potential of SMA to revolutionize access to abortion in a variety of settings, including in humanitarian settings, additional research exploring the barriers and facilitators for SMA is sorely needed. For example, inclusive research should seek to understand what information people need, how it should be delivered, what their preferences are around support during their process, how to support linkages to formal healthcare systems when needed or desired, how to center concerns about privacy and individual legal considerations depending on the context, and how and where people are sourcing the medications and the medication quality, among others.

Efforts to increase information and support for SMA should occur in tandem with efforts to strengthen facility-based abortion care. While SMA interventions can reach multitudes of people with lifesaving information long before humanitarian agencies have the political will and technical abilities to provide this care, humanitarian agencies and advocates should renew and strengthen their efforts to make facility-based abortion care accessible, as individuals not only deserve the right to have an abortion, but to decide where, how, and with what support their abortion takes place.

There is a human rights imperative to expanding and ensuring global abortion access—and those living in humanitarian contexts should not be overlooked. Interventions that support people who are self-managing their abortion have the potential to increase both the extent and the quality of abortion access in these settings; future research efforts should focus on centering the information needs and priorities of individuals in need of safe abortion care in these contexts to inform the development of person-centered interventions.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Author Contributions

RJ, BP, TF, CG, RO, YW, EW, and UR conceptualized the perspective presented in this manuscript. RJ, BP, and TF drafted the manuscript. CG, EW, JK, RO, YW, and UR provided critical reviews and additions to the manuscript. All authors contributed to the article and approved the submitted version.

Funding for this work was supported by Elrha's Research for Health in Humanitarian Crises (R2HC) Programme, which aims to improve health outcomes by strengthening the evidence base of public health interventions in humanitarian crises. R2HC was funded by the UK Foreign, Commonwealth and Development Office (FCDO), Wellcome, and the UK National Institute for Health Research (NIHR). Visit elrha.org for more information about Elrha's work to improve humanitarian outcomes through research, innovation, and partnership.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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16. Sultana S, Tofigh S, Chowdhury R, Rubayet S, Samandari G, Edelman A. Expanding Access to Comprehensive Abortion Care in Humanitarian Contexts: Case Study from the Rohingya Refugee Camps in Bangladesh. Int Perspect Sexual Reproduct Health . (2020) 46(Suppl. 1):45–52. doi: 10.1363/46e0820

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Keywords: abortion, self-managed abortion, humanitarian contexts, refugees, self-care interventions, safe abortion care, humanitarian crises

Citation: Jayaweera R, Powell B, Gerdts C, Kakesa J, Ouedraogo R, Ramazani U, Wado YD, Wheeler E and Fetters T (2021) The Potential of Self-Managed Abortion to Expand Abortion Access in Humanitarian Contexts. Front. Glob. Womens Health 2:681039. doi: 10.3389/fgwh.2021.681039

Received: 15 March 2021; Accepted: 26 July 2021; Published: 13 August 2021.

Reviewed by:

Copyright © 2021 Jayaweera, Powell, Gerdts, Kakesa, Ouedraogo, Ramazani, Wado, Wheeler and Fetters. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Ruvani Jayaweera, rjayaweera@ibisreproductivehealth.org

This article is part of the Research Topic

Highlights in Contraception and Family Planning 2021/22

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America’s abortion quandary, a majority of americans say abortion should be legal in all or most cases, but many are open to restrictions; many opponents of legal abortion say it should be legal in some circumstances.

Pew Research Center conducted this study to examine the public’s attitudes about abortion in the United States. For this analysis, we surveyed 10,441 U.S. adults from March 7-13, 2022. Everyone who took part in the survey 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, which gives nearly all U.S. adults 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 . 

Here are the questions used for this analysis , along with responses, and its methodology . 

The Center undertook this survey because the U.S. Supreme Court is expected to announce a decision about abortion in Dobbs v. Jackson Women’s Health Organization before the end of its current term. Following the initial arguments, many observers anticipated that the high court could partially or completely overturn Roe v. Wade and Planned Parenthood v. Casey, two landmark decisions that prevented states from significantly restricting abortion before a fetus is considered viable outside the womb. And after this survey was completed, a  leaked draft of the majority opinion  in Dobbs published by Politico this week suggested that the court’s upcoming decision would indeed completely overturn Roe and Casey. In anticipation of the court’s decision,  several states already have made moves  in the direction of stricter abortion regulations, while others have  moved to protect abortion access . The new survey did not ask specifically about Roe, but  previous Center studies  have found that most Americans say the court should not completely overturn that decision.

Given the nuances of many people’s opinions on the topic, measuring views on abortion is not easy. There are a vast number of ways to frame questions about the legality (or morality) of abortion when combining multiple possible factors, such as the stage of the pregnancy, the circumstances of the pregnant person, the health of the fetus, and many other possible complications or scenarios. 

Nonetheless, the new survey seeks to explore some dimensions of the debate, beginning with the public’s views on whether abortion should broadly be legal or illegal, and then moving on to probe views on specific circumstances. Because the survey could not take every possible scenario into account, several questions offered respondents the option to say “it depends” rather than taking a more firm or clear position on whether abortion should be legal or illegal in particular situations. Respondents also were asked about whether women or their doctors should be punished for abortions performed illegally, how important the issue is to voters in the 2022 midterms, and how much influence religion has on their views of abortion.

The abortion debate in America is often framed as a legal binary, with “pro-life” people on one side, seeking to restrict abortion’s availability, and “pro-choice” people on the other, opposing government restrictions on abortion. 

But as the country approaches what could be a watershed moment in the history of abortion laws and policies, relatively few Americans on either side of the debate take an absolutist view on the legality of abortion – either supporting or opposing it at all times, regardless of circumstances. 

A new Pew Research Center survey explores in detail the nuances of the public’s attitudes on this issue. The survey was conducted March 7-13, 2022 – after the Supreme Court’s oral arguments on a case this term challenging the 1973 Roe v. Wade decision that established a federal right to abortion, but before the May 2  publication of a leaked draft  of a Supreme Court majority opinion that suggests the court is poised to strike down Roe.

Nearly one-in-five U.S. adults (19%) say that abortion should be legal in all cases, with no exceptions. Fewer (8%) say abortion should be illegal in every case, without exception. By contrast, 71% either say it should be mostly legal or mostly illegal, or say there are exceptions to their blanket support for, or opposition to, legal abortion. 

As in the past , more Americans say abortion should be legal in all or most circumstances (61%) than illegal in all or most circumstances (37%). But in many ways, the public’s attitudes are contingent upon such circumstances as when an abortion takes place during a woman’s pregnancy, whether the pregnancy endangers a woman’s life and whether a baby would have severe health problems. 

There is evidence that many people are cross-pressured on this issue. For example, more than half of Americans who generally support abortion rights – by saying it should be legal in “most” or “all” cases – also say the timing of an abortion (i.e., how far along the pregnancy is) should be a factor in determining its legality (56%).

The same share of people who generally support legal abortion say abortion providers should be required to get the consent of a parent or guardian before performing an abortion on a minor (56%). 

And about a third of Americans who generally support legal abortion (33%) say the statement “human life begins at conception, so a fetus is a person with rights” describes their own view at least “somewhat” well.

At the same time, large shares of those who generally oppose abortion say it should be legal in certain situations or say their position depends on the circumstances. For example, among those who say abortion should be against the law in most or all cases, nearly half (46%) say it should be legal if the pregnancy threatens the health or life of the woman. An additional 27% say “it depends” in this situation, while 27% say abortion should be illegal even in circumstances that threaten the health or life of the pregnant woman. 

More than a third of abortion opponents (36%) say it should be legal if the pregnancy results from rape, with 27% saying “it depends” and 37% expressing opposition to legal abortion even in this situation. And four-in-ten abortion opponents (41%) say the statement “the decision about whether to have an abortion should belong solely to the pregnant woman” describes their own view at least “somewhat” well.

Among Americans overall, most people (72%) say that “the decision about whether to have an abortion should belong solely to the pregnant woman” describes their views at least somewhat well, and more than half (56%) say the same about the statement “human life begins at conception, so a fetus is a person with rights.” 

A third of Americans hold these seemingly conflicting views about the autonomy of pregnant women and the rights of the fetus at the same time, saying that  both statements describe their views either extremely well, very well, or somewhat well. 

Moreover, the survey finds a distinction between how Americans feel about abortion in moral terms and in legal terms. While many (47%) see abortion as morally wrong in most or all cases, fewer (22%) say that abortion should be illegal in every situation where they believe it is immoral. Nearly half of U.S. adults (48%) say there are circumstances in which abortion is morally wrong but should nevertheless be legal.

And while nearly six-in-ten adults (57%) say they think stricter abortion laws would reduce the number of abortions performed in the United States, similar or larger shares say that increasing support for pregnant women (65%), expanding sex education (60%) and increasing support for parents (58%) would have the same effect.

These are among the key findings of a new Pew Research Center survey, conducted among 10,441 adults on the Center’s  American Trends Panel . The Center has asked the public about their opinions on abortion for decades, but many of the questions in this survey are new, aimed at providing a more nuanced picture of public opinion.

On the Center’s long-running question about the legality of abortion – which asks whether it should generally be illegal in all cases, illegal in most cases, legal in most cases, or legal in all cases – public views have remained relatively stable in recent years. But support for legal abortion is as high today as at any point in surveys asking this question since 1995.

Most Americans typically do not give a lot of thought to issues around abortion: 36% say, prior to taking the survey in March, they had given a lot of thought to abortion-related issues.

Broad public agreement that abortion should be legal if pregnancy endangers a woman’s health or is the result of rape 

While most Americans do not have absolutist views about abortion – desiring neither to see it completely outlawed nor permitted without exception – there are certain situations in which there is clear consensus abortion should be legal. 

Nearly three-quarters of adults (73%) say abortion should be legal if the woman’s life or health is endangered by the pregnancy, while just 11% say it should be illegal. And about seven-in-ten say abortion should be legal if the pregnancy is a result of rape, with just 15% saying it should be illegal in this case.

A smaller majority of U.S. adults (53%) say abortion should be legal if the baby is likely to be born with severe disabilities or health problems – though in this situation, too, a far larger share say abortion should be legal than say it should be against the law (19% say it should be illegal in such cases, while a quarter say “it depends”).

Most Americans open to some restrictions on abortion

At the same time, the survey shows that large numbers of Americans favor certain restrictions on access to abortions. For example, seven-in-ten say doctors should be required to notify a parent or legal guardian of minors seeking abortions. And most of those who say abortion should be legal in some cases and illegal in others say that how long a woman has been pregnant should be a factor in determining whether abortion is legal or illegal (56% among all U.S. adults). 

Combined with the 8% of U.S. adults who say abortion should be against the law in all cases with no exceptions, this means that nearly two-thirds of the public thinks abortion either should be entirely illegal at  every  stage of a pregnancy or should become illegal, at least in some cases,  at some point  during the course of a pregnancy. 

On the other side, combining the 56% of U.S. adults who say how long a woman has been pregnant should matter in determining the legality of abortion with the 19% who say abortion should be legal in all cases also means that about three-quarters of the public thinks abortion either should be entirely legal at  every  stage of a pregnancy or should be legal, at least in some cases,  at some point  in a pregnancy. 

When, exactly, during a pregnancy should abortion be legal, and at what point should it become illegal? To help answer this question, the survey posed follow-up queries about three periods: six weeks (when cardiac activity – sometimes called a fetal heartbeat – can be detected), 14 weeks (roughly the end of the first trimester), and 24 weeks (near the end of the second trimester).

The survey data shows that as pregnancy progresses, opposition to legal abortion grows and support for legal abortion declines. Americans are about twice as likely to say abortion should be legal at six weeks than to say it should be illegal at this stage of a pregnancy: 44% of U.S. adults say abortion should be legal at six weeks (including those who say it should be legal in  all  cases without exception), 21% say it should be illegal at six weeks (including those who say abortion should  always  be illegal), and another 19% say whether it should be legal or not at six weeks “depends.” (An additional 14% say the stage of pregnancy shouldn’t factor into determining whether abortion is legal or illegal, including 7% who generally think abortion should be legal, and 6% who generally think it should be illegal.)

At 14 weeks, the share saying abortion should be legal declines to 34%, while 27% say illegal and 22% say “it depends.” 

When asked about the legality of abortion at 24 weeks of pregnancy (described as a point when a healthy fetus could survive outside the woman’s body, with medical attention), Americans are about twice as likely to say abortion should be illegal as to say it should be legal at this time point (43% vs. 22%), with 18% saying “it depends.” 

However, in a follow-up question, 44% of those who initially say abortion should be illegal at this late stage go on to say that,  in cases where the woman’s life is threatened or the baby will be born with severe disabilities , abortion should be legal at 24 weeks. An additional 48% answer the follow-up question by saying “it depends,” and 7% reiterate that abortion should be illegal at this stage of pregnancy even if the woman’s life is in danger or the baby faces severe disabilities.

Views of penalties for abortion in situations where it is illegal 

If most people think there are at least some situations in which abortion should be against the law, an obvious follow-up question is: Who should face legal penalties if an abortion is performed illegally? And what should those penalties entail? 

The survey asked whether four types of people should face penalties if an abortion takes place in a situation where it is illegal: doctors or medical providers who perform abortions, women who have abortions, people who help pay for abortions and people who help find or schedule abortions. 

Six-in-ten U.S. adults say that if doctors and other providers perform abortions in situations where it is illegal, then they should face penalties – including 25% who say the doctors/providers should serve jail time for performing abortions illegally, 18% who say they should face fines or community service, and 17% who aren’t sure what type of penalty would be appropriate. In response to a separate question, 31% of Americans say doctors should lose their medical licenses for performing an abortion illegally.

Compared with views on penalizing doctors, there is less support for punishing women who obtain an abortion illegally or for punishing people who help find, schedule and pay for the procedures. Nearly half of U.S. adults (47%) say women who obtain an abortion illegally should be penalized for doing so, while half say such women should not face penalties. Roughly four-in-ten favor legal punishments for people who help pay for an abortion that is performed illegally (43%) or who help find and schedule it (41%).

Support for punishing those who perform or obtain abortions illegally is tied to views about whether abortion should be legal or illegal in the first place. Still, 55% of those who say abortion should be legal, with some exceptions, say doctors who perform abortions in situations where it is illegal should face penalties, as do overwhelming shares of those who say abortion should always or mostly be illegal. See Chapter 1 for details.

Partisan differences in views of abortion 

There are wide differences between the views of Democrats and Republicans on abortion. Democrats are far more likely than Republicans to say abortion should be legal in most or all cases, while Republicans are more likely than Democrats to say it should be  illegal  in most or all cases. 

And in every specific scenario asked about in the survey – including situations where pregnancy threatens the life or health of the woman, or where pregnancy is the result of rape – Democrats are more likely than Republicans to say abortion should be legal.

Still, most Democrats say there are at least some instances in which abortion should be illegal, and most Republicans say there are at least some instances in which abortion should be legal, including when the life or health of the pregnant woman is at risk and when the pregnancy is the result of rape. 

About half of Democrats and roughly two-thirds of Republicans say the stage of pregnancy should be a factor in determining abortion’s legality. Four-in-ten Democrats and independents who lean toward the Democratic Party (40%) say the statement “human life begins at conception, so a fetus is a person with rights” describes their own view at least somewhat well, and more than half of Republicans and GOP leaners (55%) say the same about the statement “the decision about whether to have an abortion should belong solely to the pregnant woman.” 

Women are more likely than men to have thought ‘a lot’ about abortion, but there are only modest gender differences in views of legality

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

The survey also finds that by some metrics, women report being closer to the issue than men. For example, women are more likely than men to say they have thought “a lot” about abortion (40% vs. 30%). They are also considerably more likely to say they personally know someone who has had an abortion (66% vs. 51%) – a gap that is evident across age groups, political parties and religious groups. 

But there are only modest gender differences on the survey’s questions about abortion’s legality; women and men mostly agree with each other that abortion should be legal in cases of danger to the life or health of the pregnant woman and in the case of rape. More than half of both women and men agree that how long a woman has been pregnant should be a factor in determining whether abortion is legal in any given case. And while women are slightly more likely than men to say abortion should be legal in all cases with no exceptions (21% vs. 17%), large majorities of both women (68%) and men (74%) say there are some cases where abortion should be legal and others where it should be illegal.

White evangelicals are most opposed to abortion – but majorities across Christian subgroups see gray areas

Among religious groups analyzed in the survey, White evangelical Protestants are most opposed to abortion. Nearly three-quarters say that abortion should be against the law in all cases without exception (21%) or that it should be illegal in most cases (53%). White evangelicals are also far more likely than U.S. adults who identify with other religious groups to say that life begins at conception and that the fetus is thus a person with rights; 86% of White evangelicals express this view. White evangelicals are also more likely than those in other Christian groups to say their opinions on abortion are influenced by their religious beliefs.

At the other end of the spectrum, religious “nones” – U.S. adults who describe themselves, religiously, as atheists, agnostics or “nothing in particular” – are most supportive of legal abortion. Among religious “nones,” upwards of eight-in-ten say abortion should be legal in all cases with no exceptions (34%) or that it should be legal in most cases (51%). Self-described atheists are more absolutist in their opinions about abortion than any other religious group analyzed in the survey, with 53% saying abortion should be legal in all cases, no exceptions. 

White Protestants who are not evangelical, Black Protestants, and Catholics tend to be less opposed to legal abortion than White evangelicals, but they are also less supportive of it than religious “nones.”

One commonality across these groups is that sizable numbers in all of them see the issue of abortion in shades of gray. Large majorities in every group – ranging from 63% of religious “nones” to 78% of White non-evangelical Protestants – say abortion should be legal in some circumstances and illegal in others. Half of White evangelicals (51%) say abortion should be legal if the pregnancy threatens the life or health of the woman. Half of religious “nones” (50%) say the stage of pregnancy should factor into decisions about whether abortion should be legal. 

Although the survey was conducted among Americans of all religious backgrounds, including Jews, Muslims, Buddhists and Hindus, it did not obtain enough respondents who are religiously affiliated with non-Christian groups to report separately on their responses. Small subgroups of Christians are unable to be analyzed separately for the same reason.

Guide to this report

The remainder of this report discusses these findings in additional detail. Chapter 1 focuses on legal questions surrounding abortion. Chapter 2 examines the broader moral and religious questions surrounding the topic. Chapter 3 discusses the public’s experiences and engagement with abortion.

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Table of contents, majority of public disapproves of supreme court’s decision to overturn roe v. wade, wide partisan gaps in abortion attitudes, but opinions in both parties are complicated, key facts about the abortion debate in america, about six-in-ten americans say abortion should be legal in all or most cases, fact sheet: public opinion on abortion, most popular.

About Pew Research Center Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of The Pew Charitable Trusts .

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• 16 November 2021

Yes, science can weigh in on abortion law

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Diana Greene Foster is director of research at Advancing New Standards in Reproductive Health at the University of California, San Francisco, and author of the book The Turnaway Study (2020).

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The world is moving towards greater reproductive rights for women. More than 50 countries have liberalized their abortion laws in the past 25 years, informed by scientific research. Studies find that unsafe abortion is responsible for one in eight maternal deaths globally ( E. Ahman and I. H. Shah Int. J. Gynaecol. Obstet . 115 , 121–126; 2011 ), concentrated in low-income countries where abortion is illegal. Preventing unsafe abortion is a priority — 193 countries signed up to the United Nations Sustainable Development Goals, which call for reductions in maternal mortality.

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Study Examines The Lasting Effects Of Having — Or Being Denied — An Abortion

Terry Gross

In The Turnaway Study, Diana Greene Foster shares research conducted over 10 years with about 1,000 women who had or were denied abortions, tracking impacts on mental, physical and economic health.

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. When Mike Pence was running for vice president, he said, if we appoint strict constructionists to the Supreme Court, as Donald Trump intends to do, I believe we will see Roe v. Wade consigned to the ash heap of history where it belongs. Since then, Trump has appointed two conservative justices. The arguments used against abortion often refer to the medical risks of the procedure and the guilt and loss of self-esteem suffered by women who have abortions.

In order to explore what the impact of abortion is on women's health and women's lives, my guest, Diana Greene Foster, became the principal investigator of a 10-year study comparing women who had abortions at the end of the deadline allowed by the clinic and those who just missed the deadline and were turned away. The study focuses on the emotional health and socioeconomic outcomes for women who received a wanted abortion and those who were denied one.

Her goal is for judges and policymakers to understand what banning abortion would mean for women and children. The results of the study are published in Foster's new book "The Turnaway Study: Ten Years, A Thousand Women, And The Consequences Of Having - Or Being Denied - An Abortion." Turnaway refers to the women who were turned away from having an abortion. Foster is a professor at the University of California, San Francisco in the department of obstetrics, gynecology and reproductive sciences.

Diana Greene Foster, welcome to FRESH AIR. Before we get to the results of the study, what impact do you think the pandemic is having on access to abortion?

DIANA GREENE FOSTER: Thank you for having me. The pandemic has definitely made abortion a lot harder for women to access in certain states. There were a handful of states that tried to declare that abortion wasn't an essential service. And that shut down clinics. And then a judge would put a hold on that. And they would open. But then they would have too many people waiting. And they couldn't see everyone. It was, I think, particularly a nightmare in Texas, with a lot of people unable to be seen and people traveling hundreds of miles at a time when they should've been able to shelter in place.

GROSS: So why did you want to do this study comparing women who had abortions at the end of the deadline allowed by the clinic and women who just missed the deadline and were turned away?

FOSTER: The idea that abortion hurts women has been put forth by people who are opposed to abortion. And it really has resonated. So state governments have imposed restrictions in response to the idea that abortion hurts women, so telling clinics that they have to counsel women on the harms of abortion. And that idea made it all the way up to the Supreme Court so that Justice Kennedy, in 2007, used the idea that abortion hurts women as an excuse - or as a reason - for banning one procedure.

And what he said in 2007 was that while we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude that some women come to regret their choice to abort the infant life they once created and sustained. Severe depression and loss of esteem can follow. And critics of this statement have said this is patronizing that women would need to be protected from their own decisions.

But the one thing I like about this quote is that he admits that there aren't reliable data. And so my goal with the Turnaway Study was to create reliable data, so have a scientific study where the two groups of women are similar. But their outcomes are different because one group received an abortion and one was denied.

GROSS: You write that anti-abortion activists have shifted the debate from the rights of women versus the rights of fetuses to abortion being a woman's health issue. How are people who are using women's health to frame the issue, how are they using it? What is the argument they're making?

FOSTER: I think, from both sides, there's an emphasis on the danger of abortion. So if you ask most people, they would say abortion is dangerous. And anti-abortion people think that the complications are much greater than they are. And even pro-abortion rights people talk about how dangerous it was before it was legal. And so there, I think, people have an idea that it's extremely dangerous.

But the truth is, in terms of complication rates, that abortion is safer than very common procedures like tonsillectomy and wisdom tooth removal. And it's certainly much safer than having childbirth. So - and the National Academy of Sciences, Engineering and Medicine has just come out with a report summarizing the complication data for abortion that concludes with this, that abortion is not a dangerous procedure.

GROSS: Give us a sense of how you conducted this 10-year study, how you chose the women, how you got information from them about the consequences of having or not having an abortion.

FOSTER: So what we did to do this study was we went to 30 abortion facilities across the country who had the latest gestational age within 150 miles. So if you are too late - if you showed up at a clinic too late for that clinic, there was no one - no other facility within 150 miles who would do an abortion for you. And from each of these clinics we recruited, for every one woman they turned away, two women who were just under the gestational limit.

And because most of these sites had limits in the second trimester but 90% of American women who have abortions have them in the first trimester, we also recruited one woman from the first trimester. And another point is that these facilities had varying limits, all the way from 10 weeks up through the end of the second trimester. And so you could be denied an abortion in Fargo and receive an abortion at that very same gestation if you went to Dallas or New York.

GROSS: And then you - someone from your team interviewed each of the women how often over the course of the 10 years?

FOSTER: So we interviewed them one week after they either received or were denied an abortion, and then every six months for five years. And these interviews were not mostly about the abortion or even unwanted pregnancy. We were interested in their mental health, their physical health, their family's economic well-being, how they were caring for the children they already have and whether they were having more children over the course of the five years.

GROSS: Your study found that women denied abortion had worse mental health problems - for instance, high levels of anxiety, lower self-esteem - than women who received abortions. Judging from what the women told you in this study, what accounts for that?

FOSTER: So we did find that there - an association between abortion and mental health. But it was exactly opposite to what has been said in the popular media. It's not that receiving an abortion was associated with worse mental health, but in the short run, being denied the abortion was - so higher anxiety, lower self-esteem, lower life satisfaction. For up until the first six months, the women who were denied fared worse.

And, in part, it's because they were still looking for another facility that could do their abortion. Or they were coming to terms with the fact that they were about to have a baby that they had previously felt that they weren't able to take care of. So the anxiety and depression actually are, surprisingly, the same between women who receive and who are denied abortions after six months. The big differences that we find in this study over time are not about mental health.

GROSS: What are they about, the big differences?

FOSTER: So when you ask women, why do you want to have an abortion? - they give reasons. The most common is that they can't afford to have a child, or they can't afford to have another child. And we see very large differences in economic well-being over time. Another surprising fact is that most women who have abortions - 60% of women who have abortions in the United States are already mothers. And so a common reason is that they want to take care of the children they already have.

And we find that, in fact, there are differences in women's ability to take care of their existing kids based on whether they received or were denied an abortion. Another reason is that they feel like their relationship with the man involved in the pregnancy isn't strong enough to support having a child together.

GROSS: So let me ask you about the financial question because a lot of people would say, well, if you can't afford to have a baby, that's not a good reason not to have the baby. You know, people have babies all the time. You'll find a way to make it work. So when you say that there are financial consequences about being denied an abortion, what are some of those financial consequences, short term and long term?

FOSTER: There are immediate differences in women's ability to hold a full time job. And their reporting that they have enough money to meet basic living needs, like food, housing and transportation. And I completely understand people who who would like there not to be economic costs to having kids. And we could have a society with much more generous policies towards low-income moms. And that would be a good thing regardless of whether women have abortions or not.

I think one important point to note about financial reasons for abortion is that they were rarely the only reason. So 40% said they had financial reasons for having an abortion. But for only 6% was it their only reason. So people are just are weighing a whole host of life considerations when they're deciding whether to have a baby or not. What's important, I think, about the financial issues is that that it has long-term effects on people's well-being.

And when we compare women who are denied an abortion and have a baby - their economic well-being to women who receive an abortion but have another child later within the study period, those later children, the subsequent to an abortion - they are raised in better economic circumstances. So when a woman says that she can't afford to have a child, she actually does better if she's able to wait to have a child. Even just a few years. Her child is less likely to be raised in poverty and less likely to be raised in a house without enough money.

GROSS: Are you looking at women in the study of a social - of a certain financial status?

FOSTER: Yeah, so women who seek abortions nationally are disproportionately low-income And that's - particularly they're low-income if they are seeking abortion later in pregnancy. And why is because it's all of the costs associated with getting an abortion are much harder to overcome quickly or to gather the money quickly if you're already trying to raise a family of four on $11,000 a year. So there are already - women who seek abortions are disproportionately poor. And when they're denied an abortion, there's a large economic cost.

GROSS: And talk a little bit about the economic cost. Why is there an economic cost to being denied an abortion if you're already financially challenged?

FOSTER: So women who are denied an abortion are less likely to be able to continue working at the same rate. And in addition to not being able to work, they do often get some kind of public assistance, but it's not enough to meet the massive costs of having a baby. So it's diapers and child care if you are able to work and a place to live. It's not a surprise to anyone that having a child is expensive.

But when you're wanting to have a child, it's often because you feel like you have the resources to do that and that you have the social support to help you support that child. And when women are turned away from abortion we don't find the same kind of family support that women would need in order to feel economically secure. So when we look at women who receive abortions and women who are denied, over five years, the women who are denied are much more likely to be living alone, raising kids without other adult family members and without a partner, compared to women who receive an abortion.

GROSS: One of the reasons you found many women want to have an abortion is that they don't want to remain tied to the man they got pregnant with. This might be because the man is abusive. It might be that the woman just doesn't want to stay with him. It might be the marriage is already dissolving. Can you talk about that a little bit and why that's such an important issue for the women?

FOSTER: Yeah. The - about a third of women seeking abortions have a reason that's associated with the man involved in the pregnancy. And when we have a woman who tells her story and she's in a violent relationship and she explains how it's very difficult to find a job when you're pregnant, to keep a job when you're pregnant or find and maintain a job with a baby - and she attributes - says that the incidents of domestic violence skyrockets 'cause you're financially dependent on your partner because you have to be home with the kid. And we actually find that women who receive abortions - their exposure to domestic violence goes down dramatically after receiving an abortion and that there is no decrease for years among women who are turned away. So being denied an abortion increases the chance that you're tethered to a violent partner.

GROSS: Let me reintroduce you here. If you're just joining us, my guest is Diana Foster. Her new book is called "The Turnaway Study: Ten Years, A Thousand Women, And The Consequences Of Having - Or Being Denied - An Abortion." We'll talk more after we take a short break. This is FRESH AIR.

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GROSS: This is FRESH AIR. Let's get back to my interview with Diana Foster. Her new book, "The Turnaway Study," is about her 10-year study comparing women who had an abortion just before the clinic's deadline and women who arrived just a few days too late and were denied an abortion. The study compares the physical health, mental health, financial circumstances and family life of these two sets of women.

I think it's fair to say your biggest finding in your study is - correct me if I'm wrong here - that there's no major consequences that you could find that most women have as a result of an abortion.

FOSTER: No negative consequences. We find that 95% of women who receive an abortion later report that it was the right decision for them. So I think it's a surprising fact people assume that women feel regret. And I think it's not that they don't realize that there are moral questions involved, but they're weighing their whole life responsibilities and plans and decide this is the right decision for them. And interestingly, I think people have been told so many times that abortion is wrong. But they know that they've been responsible in their own decision-making and that they haven't done something wrong.

And so they assume it's other women. But, you know, everyone is doing that. Everyone is assuming, well, if abortion is wrong but my abortion isn't wrong, I'm just an exception. But, I think, if we talked more to people who had abortions, we would hear that everyone is doing the best they can and trying to make responsible choices that take care of themselves and their children.

GROSS: Well, a lot of people ask, well, if you didn't want to have a baby, why didn't you use contraception and prevent yourself from getting pregnant? So for people who ask that question, what are the answers you found in your study?

FOSTER: Yeah. Many women who have abortions are using contraception. Two-thirds of the women in our study were using a contraceptive method in the month that they became pregnant. And note that not using a contraceptive method is not guaranteed to result in a pregnancy. Lots of people take risks. And not everyone becomes pregnant. So you know, there are very few people who've never had sex at a time that they weren't seeking to have a baby. And contraceptives are expensive. They - many have side effects. We make them as difficult to access as possible. And then we're horrified when people don't use them consistently.

So there was a woman named Chiara (ph) who was from Kentucky. And she had lapsed in her birth control by just a few days because the resupply hadn't come in time. And her hope was everything would be OK, and then it wasn't. You know, it's surprisingly difficult to constantly be vigilant on contraception, especially if you're the kind of person who doesn't like the available methods.

GROSS: So what about women who were turned away from having an abortion and carried the child to term and kept the child? Did they end up, in the long run, being glad they had the child? And was there a difference between the short-term and long-term reaction to having that child?

FOSTER: Women who were denied an abortion - at the first interview, just one week later, two-thirds of them were still wishing that they could have an abortion. It goes down to about 12% at six months, down to 4% after they've had the child. And who is particularly at risk for wishing they had not had the child are people who place the child for adoption because I think there's something about having a kid on your knee. You're much less likely to say that you wish you hadn't had that child. So people do report that they are glad that they had the child.

But we have another way of measuring how people feel about their child and it's through a maternal bonding scale. So we asked women a series of questions about how they feel about their infant. And we asked women who were denied the abortion about the child they had because they were denied. And we asked women who had a subsequent pregnancy later that they carried to term. So it's a series of questions like, I feel happy when my child laughs, or, I feel trapped as a mother.

And women who were denied the abortion are less likely to say, I feel happy when my child laughs and more likely to say, I feel trapped as a mother compared to women who were able to get their abortion and had another child later. And when you use this kind of objective measure of maternal bonding, you see that women who are denied an abortion are more likely to have poor bonding with that child than women who get an abortion and have another child later. It doesn't say that these children are all unwanted at all. People are very resilient. And people do the absolute best they can with their children.

GROSS: Let's take another break here and then talk some more. If you're just joining us, my guest is Diana Greene Foster. Her new book is called "The Turnaway Study: Ten years, A Thousand Women, And The Consequences Of Having - Or Being Denied - An Abortion." We'll talk more after a break. I'm Terry Gross. And this is FRESH AIR.

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GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to my interview with Diana Greene Foster. Her new book, "The Turnaway Study," is about her 10-year study comparing women who had an abortion just before the clinic's deadline and women who arrived just a few days too late and were denied an abortion. The study compares the physical health, mental health, financial circumstances and family life of these two sets of women. Foster is a professor at the University of California, San Francisco in the department of obstetrics, gynecology and reproductive sciences.

How would you like to see your research used for policy relating to abortion?

FOSTER: I would love, first, to have its policy more broadly, which is much more generous assistance and less punitive assistance for low-income women who have kids regardless of whether their pregnancy was planned or not. We have welfare caps, where if you have an additional child, you don't get any more assistance, which is draconian and cruel. So we need much more generous policies and child care so that nobody is making the decision just for economic reasons.

In terms of abortion, if we want abortions to happen earlier in pregnancy, then many restrictions should be taken off the books because they don't improve women's health. And they cause abortions to happen later. For example, the one that would have the biggest effect in making abortions happen sooner would be to drop the Hyde Amendment, which is a ban on the federal government paying for any abortions.

The people who rely on the federal government for their health insurance - that's people on Medicaid, people in the military and people who are in the Peace Corps - all of those people are subject to this Hyde Amendment. And it means their public insurance program won't cover their abortion. And so they have to raise the whole cost of it themselves. We even have some states that ban private insurance from covering abortion. So it's not just a matter of not wanting your tax money paying for the abortion, it's really, those laws seem to make it clear that it's about making women pay the price themselves.

GROSS: A lot of people who oppose abortion oppose it because they equate abortion with murder. And in that respect, no amount of research that you can offer about the consequences of being denied an abortion on a woman's life and even on her child's life or the rest of her family's lives, no amount of that research is going to convince somebody that abortion isn't murder.

And in that sense, no amount of research is going to sway those people. Do you feel, in that respect, that your research is kind of futile because a lot of opponents of abortion oppose it because they think of it as murder?

FOSTER: Yeah. I'm under no illusions that this study will change somebody's mind if they think that the embryo or fetus is a person. This study can't resolve the question of when, in pregnancy, the embryo or fetus becomes a person or when the rights of the fetus would outweigh the person who carries it. That's not what this study is about. What this study is is about what the consequences of either receiving or being denied an abortion are on women's lives.

And Roe v. Wade talked about the tension between women's bodily autonomy and the state's interest in a developing fetus. And the law tried to strike a balance there. And what this study adds to that difficult set of issues is that there is more at stake than just women's bodily autonomy and the well-being of a fetus who will become a baby.

It's not just her body, but her whole life trajectory, her chance of having a wanted baby later, her chance of having a good, positive romantic relationship and her chance of supporting herself and her family. It affects their existing children and the well-being of her future children. It can't resolve personhood. But it points out that if we make laws that make assumptions or make decisions about when personhood begins, it has huge ramifications for many other people.

GROSS: Let's get to the Supreme Court. There are now two conservative Trump appointees on the bench. The Supreme Court is expected to hand down a pretty major abortion decision this month. And it pertains to Louisiana and whether doctors performing abortions need to have admitting rights in a nearby hospital. There was a similar case in Texas a few years ago. So tell us about this case and what kind of precedent it would set and what it might tell us about the new Supreme Court and abortion.

FOSTER: So June Medical Services v. Russo is the case that is about Louisiana's admitting privileges law. It's the same type of restriction that was ruled unconstitutional in Whole Woman's Health v. Hellerstedt by the Supreme Court in 2016. But since then, we've gained two conservative justices. And what they decide here will send very large signals to abortion rights advocates and abortion rights opponents.

At issue is the same law about admitting privileges. But what the Supreme Court said in the earlier case, Whole Woman's Health v. Hellerstedt, is that states need to weigh the scientific evidence about the burdens and benefits of restrictions. And they can't pass laws that will have no benefit, but only burden. And so if the Supreme Court decides differently here, it's another nod of our current government to saying that science will not be taken seriously and that it's political ideology that gets to decide laws.

GROSS: What do you think are the odds that the Supreme Court will just overturn Roe v. Wade at some point?

FOSTER: Right now, the Supreme Court doesn't have to overturn Roe v. Wade to make it nearly impossible for women to access abortions. Simply by allowing more and more restrictions to be implemented, they can make abortion nearly impossible to access. I think it's a kind of a political question whether they would want to take such a stand on a law that actually is politically popular. So I don't know, politically, whether they would do that. Apparently, Gorsuch and Kavanaugh were selected from a list of potential justices that had at least voiced that they were opposed to abortion rights. So they may have the desire. But I don't know if they would take that political risk.

GROSS: What are the most significant findings for you from your study that we haven't already discussed?

FOSTER: I think the most important idea that I would like to convey is to correct the idea that abortion is always a hard decision and that women need more time to think about it and that they can't be trusted to make a decision that's best for themselves. So in this study, about half the women say that the decision to have an abortion was easy or straightforward. And half say it was somewhat or very difficult. But having a decision be easy doesn't mean that they weren't thoughtful about it, that they were weighing all of the considerations, all of their responsibilities and deciding what was best for them. And I think it's safe to say they were making good decisions in that when they say why they want to have an abortion, all of their concerns are borne out in the experiences of women who are denied abortions. So they're worried they're not financially prepared. And there are economic costs if you're denied. They say it's not the right time for a baby. And if they're able to delay having a child, that child does better.

So I would love to impart first how common it is to have an abortion. About between 1 in 3 and 1 in 4 American women will have an abortion in her lifetime. You know, it's people like the people you know. And they're making decisions based on their life and what they think the consequences would be of having a baby when they weren't ready.

GROSS: Let's take a short break here. And then we'll talk some more. If you're just joining us, my guest is Diana Foster. Her new book is called "The Turnaway Study: Ten Years, A Thousand Women, And The Consequences Of Having - Or Being Denied - An Abortion." After we take a break, we'll talk about abortions in her family. We'll be right back. This is FRESH AIR.

(SOUNDBITE OF RED HEART THE TICKER SONG, "SLIGHTLY UNDER WATER")

GROSS: This is FRESH AIR. Let's get back to my interview with Diana Greene Foster. Her new book, "The Turnaway Study," is about her 10-year study comparing women who had an abortion just before the clinic's deadline and women who arrived just a few days too late and were therefore denied an abortion. The study compares the physical health, mental health, financial circumstances and family life of these two sets of women.

Diana, you had grandmothers on each side of your family that had unwanted pregnancies. One grandmother carried to term. That baby became your mother. The other grandmother had an abortion. So let's talk about that. Let's start with the grandmother on your father's side of the family. Let's start with how she became pregnant and why she didn't want to carry to term.

FOSTER: The sad thing is that she died while I was in high school, so I never got to ask her these questions. I know that she became pregnant while she was living with my grandfather early in their marriage in New York City during the Depression. And she felt that they couldn't afford to have a baby. And she - at the time, abortion was illegal. And she had to go to Puerto Rico to get an abortion. And I never got to ask her about her experiences.

I do know that when she died, you know - no mention was made of abortion over my childhood that I can remember. But when she died, my grandfather asked that all donations be made to Planned Parenthood. So I think that though it wasn't talked about, it had a large impact on her life. And she went on to have three kids and was a loving, happy mother.

GROSS: Did anyone in your family actually come out and tell you that she had an abortion?

FOSTER: I heard it both from my mother and my father. So she must have had a quiet conversation with my mother at some point - is my guess. I doubt - I would be surprised if she directly told my father. It's the kind of thing women might talk about with each other. And it's really too bad that we don't talk about our unwanted pregnancies because it gives the impression that it rarely happens when, in fact, many people have unwanted pregnancies. And we could have a little more empathy if we understood how common it was.

GROSS: Well, let's look at your mother's side. Your maternal grandmother, Dorothy (ph), got pregnant at the age of 19 from her golf instructor. The implication in the way you tell the story is that she did not want to have sex with him.

FOSTER: It was her funny way of talking. I don't - what she says is that he taught her more than she needed to know. So I don't know how coerced that was. He was married at the time and supposedly in the process of separating - is what he had told her. But when she told him she was pregnant, he said that he would get all his friends to say it could be theirs if she told anyone that it was his. So he was clearly a total jerk.

And she told her parents, who were very conservative Christians. And they were appalled, you know, horrified at the unwanted, out-of-wedlock pregnancy. And they begged her to get an abortion. And she - for reasons that she never fully explained to me, she refused. So she went to the Salvation Army home for unwed moms - mothers. And she gave birth to my mom and placed my mom for adoption.

And the kind of saddest part of her story comes next, which is her parents hadn't visited her while she was at the Salvation Army home for unwed moms. And so she didn't know if she had a home to go home to. And so after delivery, which was, like the women in my study, very complicated with a period of - a long period of disability after, she went home with another woman she'd met there.

And that brother, the brother of the one she went home with raped Dorothy. What he told her was she was already no good. So the idea that she was spoiled or tainted and so had lost all claims over her body - and that, I think, was even worse than the rejection by her parents and the placing a child for adoption, which can be very difficult. This idea that she was forever tainted was deeply harmful. And it's an idea you hear still that somehow, if you become pregnant when you aren't intending to, you lose say over what happens to your body.

GROSS: And your mother was able to track down her birth mother when your mother was in her mid-40s, and her birth mother, your grandmother, was in her mid-60s. Did you get to meet her?

FOSTER: I sure did. A friend of my mom's did the geneology investigation, found Dorothy's birth certificate, which had a note from Dorothy's mom changing the spelling of Dorothy's father's name. And that note had a date, which put Dorothy in high school. And the friend of my mom called the high school alumni association and said she was looking for Dorothy. And the man said - oh, Dorothy, I had a drink with her last week.

GROSS: Oh (laughter).

FOSTER: So it was the first news we had that she was alive and well. And you know, tentatively - oh, well, could we have that phone number, please? (Laughter). And we called.

I grew up in Maryland. And when I went to college, I went to UC Berkeley in California. And Dorothy, who was living in Santa Cruz, was my closest relative. So she picked me up from the airport with all my stuff and dropped me at my dorms and was, you know, a close - just the greatest relationship through my college years of getting to visit her in Santa Cruz.

GROSS: Oh, what a great story.

FOSTER: Yeah, she never actually went on to have other children after my mom, and that's something we also find in "The Turnaway Study" is that if you carry an unwanted pregnancy to term, it creates a detour in your life. And you're actually less likely to have wanted children later. So she tried to have other children, and it just didn't work out.

GROSS: Well, in your grandmother's case, the pregnancy and the birth were so traumatic, especially being raped afterwards, while she was having a very difficult recovery from childbirth. That's horrible to think about. But she had a decent life. Her life worked out for her, right?

FOSTER: Yeah, she was adventurous and ahead of her time in many ways of, you know, owning businesses and traveling. And she, you know, wasn't a feminist in the way that we would say now. She really viewed that success was finding a man who would take care of you. And I think it's 'cause that was the road she got off of, and she never got on it again. So she had - you know, she never had someone to just take care of her. So I might have gotten a Ph.D. from Princeton, but she was most happy that I was married and that the - my two children were my husband's children. Those were, from her perspective, my biggest accomplishments.

GROSS: I suspect a lot of our listeners are thinking that if your maternal grandmother had aborted her unwanted pregnancy that your mother wouldn't have been born and, therefore, you wouldn't have been born. So why do you support the right to abortion?

FOSTER: Dorothy refused an abortion and gave birth to my mother. If she'd had an abortion, I clearly wouldn't exist. And my dad's mother overcame great obstacles to get a wanted abortion and later gave birth to my father. So if she hadn't - if she had not had an abortion, I wouldn't exist.

Given how - the long history of abortion in our country, many of us are alive today 'cause our mothers and grandmothers were able to avoid carrying an unwanted pregnancy to term. And this study shows that abortion may end the possibility of one life, but it enables women to take care of the children she already has and, if she chooses, makes it possible for her to have a baby under more favorable circumstances later.

GROSS: Well, Diana Foster, thank you so much for talking with us.

FOSTER: Thank you so much for having me and discussing "The Turnaway Study."

GROSS: Diana Greene Foster is the author of the new book "The Turnaway Study: Ten Years, A Thousand Women, And The Consequences Of Having - Or Being Denied - An Abortion." She's a professor at the University of California, San Francisco in the department of obstetrics, gynecology and reproductive sciences.

This month, Turner Classic Movies is presenting a jazz and film series. Our jazz critic Kevin Whitehead has written a new book about jazz and film. After a break, he'll defend the much maligned genre of jazz biopics. This is FRESH AIR.

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• Rom J Morphol Embryol
• v.61(1); Jan-Mar 2020

A research on abortion: ethics, legislation and socio-medical outcomes. Case study: Romania

Andreea mihaela niţă.

1 Faculty of Social Sciences, University of Craiova, Romania

Cristina Ilie Goga

This article presents a research study on abortion from a theoretical and empirical point of view. The theoretical part is based on the method of social documents analysis, and presents a complex perspective on abortion, highlighting items of medical, ethical, moral, religious, social, economic and legal elements. The empirical part presents the results of a sociological survey, based on the opinion survey method through the application of the enquiry technique, conducted in Romania, on a sample of 1260 women. The purpose of the survey is to identify Romanians perception on the decision to voluntary interrupt pregnancy, and to determine the core reasons in carrying out an abortion.

The analysis of abortion by means of medical and social documents

Abortion means a pregnancy interruption “before the fetus is viable” [ 1 ] or “before the fetus is able to live independently in the extrauterine environment, usually before the 20 th week of pregnancy” [ 2 ]. “Clinical miscarriage is both a common and distressing complication of early pregnancy with many etiological factors like genetic factors, immune factors, infection factors but also psychological factors” [ 3 ]. Induced abortion is a practice found in all countries, but the decision to interrupt the pregnancy involves a multitude of aspects of medical, ethical, moral, religious, social, economic, and legal order.

In a more simplistic manner, Winston Nagan has classified opinions which have as central element “abortion”, in two major categories: the opinion that the priority element is represented by fetus and his entitlement to life and the second opinion, which focuses around women’s rights [ 4 ].

From the medical point of view, since ancient times there have been four moments, generally accepted, which determine the embryo’s life: ( i ) conception; ( ii ) period of formation; ( iii ) detection moment of fetal movement; ( iv ) time of birth [ 5 ]. Contemporary medicine found the following moments in the evolution of intrauterine fetal: “ 1 . At 18 days of pregnancy, the fetal heartbeat can be perceived and it starts running the circulatory system; 2 . At 5 weeks, they become more clear: the nose, cheeks and fingers of the fetus; 3 . At 6 weeks, they start to function: the nervous system, stomach, kidneys and liver of the fetus, and its skeleton is clearly distinguished; 4 . At 7 weeks (50 days), brain waves are felt. The fetus has all the internal and external organs definitively outlined. 5 . At 10 weeks (70 days), the unborn child has all the features clearly defined as a child after birth (9 months); 6 . At 12 weeks (92 days, 3 months), the fetus has all organs definitely shaped, managing to move, lacking only the breath” [ 6 ]. Even if most of the laws that allow abortion consider the period up to 12 weeks acceptable for such an intervention, according to the above-mentioned steps, there can be defined different moments, which can represent the beginning of life. Nowadays, “abortion is one of the most common gynecological experiences and perhaps the majority of women will undergo an abortion in their lifetimes” [ 7 ]. “Safe abortions carry few health risks, but « every year, close to 20 million women risk their lives and health by undergoing unsafe abortions » and 25% will face a complication with permanent consequences” [ 8 , 9 ].

From the ethical point of view, most of the times, the interruption of pregnancy is on the border between woman’s right over her own body and the child’s (fetus) entitlement to life. Judith Jarvis Thomson supported the supremacy of woman’s right over her own body as a premise of freedom, arguing that we cannot force a person to bear in her womb and give birth to an unwanted child, if for different circumstances, she does not want to do this [ 10 ]. To support his position, the author uses an imaginary experiment, that of a violinist to which we are connected for nine months, in order to save his life. However, Thomson debates the problem of the differentiation between the fetus and the human being, by carrying out a debate on the timing which makes this difference (period of conception, 10 weeks of pregnancy, etc.) and highlighting that for people who support abortion, the fetus is not an alive human being [ 10 ].

Carol Gilligan noted that women undergo a true “moral dilemma”, a “moral conflict” with regards to voluntary interruption of pregnancy, such a decision often takes into account the human relationships, the possibility of not hurting the others, the responsibility towards others [ 11 ]. Gilligan applied qualitative interviews to a number of 29 women from different social classes, which were put in a position to decide whether or not to commit abortion. The interview focused on the woman’s choice, on alternative options, on individuals and existing conflicts. The conclusion was that the central moral issue was the conflict between the self (the pregnant woman) and others who may be hurt as a result of the potential pregnancy [ 12 ].

From the religious point of view, abortion is unacceptable for all religions and a small number of abortions can be seen in deeply religious societies and families. Christianity considers the beginning of human life from conception, and abortion is considered to be a form of homicide [ 13 ]. For Christians, “at the same time, abortion is giving up their faith”, riot and murder, which means that by an abortion we attack Jesus Christ himself and God [ 14 ]. Islam does not approve abortion, relying on the sacral life belief as specified in Chapter 6, Verse 151 of the Koran: “Do not kill a soul which Allah has made sacred (inviolable)” [ 15 ]. Buddhism considers abortion as a negative act, but nevertheless supports for medical reasons [ 16 ]. Judaism disapproves abortion, Tanah considering it to be a mortal sin. Hinduism considers abortion as a crime and also the greatest sin [ 17 ].

From the socio-economic point of view, the decision to carry out an abortion is many times determined by the relations within the social, family or financial frame. Moreover, studies have been conducted, which have linked the legalization of abortions and the decrease of the crime rate: “legalized abortion may lead to reduced crime either through reductions in cohort sizes or through lower per capita offending rates for affected cohorts” [ 18 ].

Legal regulation on abortion establishes conditions of the abortion in every state. In Europe and America, only in the XVIIth century abortion was incriminated and was considered an insignificant misdemeanor or a felony, depending on when was happening. Due to the large number of illegal abortions and deaths, two centuries later, many states have changed legislation within the meaning of legalizing voluntary interruption of pregnancy [ 6 ]. In contemporary society, international organizations like the United Nations or the European Union consider sexual and reproductive rights as fundamental rights [ 19 , 20 ], and promotes the acceptance of abortion as part of those rights. However, not all states have developed permissive legislation in the field of voluntary interruption of pregnancy.

Currently, at national level were established four categories of legislation on pregnancy interruption area:

( i )  Prohibitive legislations , ones that do not allow abortion, most often outlining exceptions in abortion in cases where the pregnant woman’s life is endangered. In some countries, there is a prohibition of abortion in all circumstances, however, resorting to an abortion in the case of an imminent threat to the mother’s life. Same regulation is also found in some countries where abortion is allowed in cases like rape, incest, fetal problems, etc. In this category are 66 states, with 25.5% of world population [ 21 ].

( ii )  Restrictive legislation that allow abortion in cases of health preservation . Loosely, the term “health” should be interpreted according to the World Health Organization (WHO) definition as: “health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” [ 22 ]. This type of legislation is adopted in 59 states populated by 13.8% of the world population [ 21 ].

( iii )  Legislation allowing abortion on a socio-economic motivation . This category includes items such as the woman’s age or ability to care for a child, fetal problems, cases of rape or incest, etc. In this category are 13 countries, where we have 21.3% of the world population [ 21 ].

( iv )  Legislation which do not impose restrictions on abortion . In the case of this legislation, abortion is permitted for any reason up to 12 weeks of pregnancy, with some exceptions (Romania – 14 weeks, Slovenia – 10 weeks, Sweden – 18 weeks), the interruption of pregnancy after this period has some restrictions. This type of legislation is adopted in 61 countries with 39.5% of the world population [21].

The Centre for Reproductive Rights has carried out from 1998 a map of the world’s states, based on the legislation typology of each country (Figure ​ (Figure1 1 ).

The analysis of states according to the legislation regarding abortion. Source: Centre for Reproductive Rights. The World’s Abortion Laws, 2018 [ 23 ]

An unplanned pregnancy, socio-economic context or various medical problems [ 24 ], lead many times to the decision of interrupting pregnancy, regardless the legislative restrictions. In the study “Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008” issued in 2011 by the WHO , it was determined that within the states with restrictive legislation on abortion, we may also encounter a large number of illegal abortions. The illegal abortions may also be resulting in an increased risk of woman’s health and life considering that most of the times inappropriate techniques are being used, the hygienic conditions are precarious and the medical treatments are incorrectly administered [ 25 ]. Although abortions done according to medical guidelines carry very low risk of complications, 1–3 unsafe abortions contribute substantially to maternal morbidity and death worldwide [ 26 ].

WHO has estimated for the year 2008, the fact that worldwide women between the ages of 15 and 44 years carried out 21.6 million “unsafe” abortions, which involved a high degree of risk and were distributed as follows: 0.4 million in the developed regions and a number of 21.2 million in the states in course of development [ 25 ].

Case study: Romania

Legal perspective on abortion

In Romania, abortion was brought under regulation by the first Criminal Code of the United Principalities, from 1864.

The Criminal Code from 1864, provided the abortion infringement in Article 246, on which was regulated as follows: “Any person, who, using means such as food, drinks, pills or any other means, which will consciously help a pregnant woman to commit abortion, will be punished to a minimum reclusion (three years).

The woman who by herself shall use the means of abortion, or would accept to use means of abortion which were shown or given to her for this purpose, will be punished with imprisonment from six months to two years, if the result would be an abortion. In a situation where abortion was carried out on an illegitimate baby by his mother, the punishment will be imprisonment from six months to one year.

Doctors, surgeons, health officers, pharmacists (apothecary) and midwives who will indicate, will give or will facilitate these means, shall be punished with reclusion of at least four years, if the abortion took place. If abortion will cause the death of the mother, the punishment will be much austere of four years” (Art. 246) [ 27 ].

The Criminal Code from 1864, reissued in 1912, amended in part the Article 246 for the purposes of eliminating the abortion of an illegitimate baby case. Furthermore, it was no longer specified the minimum of four years of reclusion, in case of abortion carried out with the help of the medical staff, leaving the punishment to the discretion of the Court (Art. 246) [ 28 ].

The Criminal Code from 1936 regulated abortion in the Articles 482–485. Abortion was defined as an interruption of the normal course of pregnancy, being punished as follows:

“ 1 . When the crime is committed without the consent of the pregnant woman, the punishment was reformatory imprisonment from 2 to 5 years. If it caused the pregnant woman any health injury or a serious infirmity, the punishment was reformatory imprisonment from 3 to 6 years, and if it has caused her death, reformatory imprisonment from 7 to 10 years;

2 . When the crime was committed by the unmarried pregnant woman by herself, or when she agreed that someone else should provoke the abortion, the punishment is reformatory imprisonment from 3 to 6 months, and if the woman is married, the punishment is reformatory imprisonment from 6 months to one year. Same penalty applies also to the person who commits the crime with the woman’s consent. If abortion was committed for the purpose of obtaining a benefit, the punishment increases with another 2 years of reformatory imprisonment.

If it caused the pregnant woman any health injuries or a severe disablement, the punishment will be reformatory imprisonment from one to 3 years, and if it has caused her death, the punishment is reformatory imprisonment from 3 to 5 years” (Art. 482) [ 29 ].

The criminal legislation from 1936 specifies that it is not considered as an abortion the interruption from the normal course of pregnancy, if it was carried out by a doctor “when woman’s life was in imminent danger or when the pregnancy aggravates a woman’s disease, putting her life in danger, which could not be removed by other means and it is obvious that the intervention wasn’t performed with another purpose than that of saving the woman’s life” and “when one of the parents has reached a permanent alienation and it is certain that the child will bear serious mental flaws” (Art. 484, Par. 1 and Par. 2) [ 29 ].

In the event of an imminent danger, the doctor was obliged to notify prosecutor’s office in writing, within 48 hours after the intervention, on the performance of the abortion. “In the other cases, the doctor was able to intervene only with the authorization of the prosecutor’s office, given on the basis of a medical certificate from hospital or a notice given as a result of a consultation between the doctor who will intervene and at least a professor doctor in the disease which caused the intervention. General’s Office Prosecutor, in all cases provided by this Article, shall be obliged to maintain the confidentiality of all communications or authorizations, up to the intercession of any possible complaints” (Art. 484) [ 29 ].

The legislation of 1936 provided a reformatory injunction from one to three years for the abortions committed by doctors, sanitary agents, pharmacists, apothecary or midwives (Art. 485) [ 29 ].

Abortion on demand has been legalized for the first time in Romania in the year 1957 by the Decree No. 463, under the condition that it had to be carried out in a hospital and to be carried out in the first quarter of the pregnancy [ 30 ]. In the year 1966, demographic policy of Romania has dramatically changed by introducing the Decree No. 770 from September 29 th , which prohibited abortion. Thus, the voluntary interruption of pregnancy became a crime, with certain exceptions, namely: endangering the mother’s life, physical or mental serious disability; serious or heritable illness, mother’s age over 45 years, if the pregnancy was a result of rape or incest or if the woman gave birth to at least four children who were still in her care (Art. 2) [ 31 ].

In the Criminal Code from 1968, the abortion crime was governed by Articles 185–188.

The Article 185, “the illegal induced abortion”, stipulated that “the interruption of pregnancy by any means, outside the conditions permitted by law, with the consent of the pregnant woman will be punished with imprisonment from one to 3 years”. The act referred to above, without the prior consent from the pregnant woman, was punished with prison from two to five years. If the abortion carried out with the consent of the pregnant woman caused any serious body injury, the punishment was imprisonment from two to five years, and when it caused the death of the woman, the prison sentence was from five to 10 years. When abortion was carried out without the prior consent of the woman, if it caused her a serious physical injury, the punishment was imprisonment from three to six years, and if it caused the woman’s death, the punishment was imprisonment from seven to 12 years (Art. 185) [ 32 ].

“When abortion was carried out in order to obtain a material benefit, the maximum punishment was increased by two years, and if the abortion was made by a doctor, in addition to the prison punishment could also be applied the prohibition to no longer practice the profession of doctor”.

Article 186, “abortion caused by the woman”, stipulated that “the interruption of the pregnancy course, committed by the pregnant woman, was punished with imprisonment from 6 months to 2 years”, quoting the fact that by the same punishment was also sanctioned “the pregnant woman’s act to consent in interrupting the pregnancy course made out by another person” (Art. 186) [ 26 ].

The Regulations of the Criminal Code in 1968, also provided the crime of “ownership of tools or materials that can cause abortion”, the conditions of this holding being met when these types of instruments were held outside the hospital’s specialized institutions, the infringement shall be punished with imprisonment from three months to one year (Art. 187) [ 32 ].

Furthermore, the doctors who performed an abortion in the event of extreme urgency, without prior legal authorization and if they did not announce the competent authority within the legal deadline, they were punished by imprisonment from one month to three months (Art. 188) [ 32 ].

In the year 1985, it has been issued the Decree No. 411 of December 26 th , by which the conditions imposed by the Decree No. 770 of 1966 have been hardened, meaning that it has increased the number of children, that a woman could have in order to request an abortion, from four to five children [ 33 ].

The Articles 185–188 of the Criminal Code and the Decree No. 770/1966 on the interruption of the pregnancy course have been abrogated by Decree-Law No. 1 from December 26 th , 1989, which was published in the Official Gazette No. 4 of December 27 th , 1989 (Par. 8 and Par. 12) [ 34 ].

The Criminal Code from 1968, reissued in 1997, maintained Article 185 about “the illegal induced abortion”, but drastically modified. Thus, in this case of the Criminal Code, we identify abortion as “the interruption of pregnancy course, by any means, committed in any of the following circumstances: ( a ) outside medical institutions or authorized medical practices for this purpose; ( b ) by a person who does not have the capacity of specialized doctor; ( c ) if age pregnancy has exceeded 14 weeks”, the punishment laid down was the imprisonment from 6 months to 3 years” (Art. 185, Par. 1) [ 35 ]. For the abortion committed without the prior consent of the pregnant woman, the punishment consisted in strict prison conditions from two to seven years and with the prohibition of certain rights (Art. 185, Par. 2) [ 35 ].

For the situation of causing serious physical injury to the pregnant woman, the punishment was strict prison from three to 10 years and the removal of certain rights, and if it had as a result the death of the pregnant woman, the punishment was strict prison from five to 15 years and the prohibition of certain rights (Art. 185, Par. 3) [ 35 ].

The attempt was punished for the crimes specified in the various cases of abortion.

Consideration should also be given in the Criminal Code reissued in 1997 for not punishing the interruption of the pregnancy course carried out by the doctor, if this interruption “was necessary to save the life, health or the physical integrity of the pregnant woman from a grave and imminent danger and that it could not be removed otherwise; in the case of a over fourteen weeks pregnancy, when the interruption of the pregnancy course should take place from therapeutic reasons” and even in a situation of a woman’s lack of consent, when it has not been given the opportunity to express her will, and abortion “was imposed by therapeutic reasons” (Art. 185, Par. 4) [ 35 ].

Criminal Code from 2004 covers abortion in Article 190, defined in the same way as in the prior Criminal Code, with the difference that it affects the limits of the punishment. So, in the event of pregnancy interruption, in accordance with the conditions specified in Paragraph 1, “the penalty provided was prison time from 6 months to one year or days-fine” (Art. 190, Par. 1) [ 36 ].

Nowadays, in Romania, abortion is governed by the criminal law of 2009, which entered into force in 2014, by the section called “aggression against an unborn child”. It should be specified that current criminal law does not punish the woman responsible for carrying out abortion, but only the person who is involved in carrying out the abortion. There is no punishment for the pregnant woman who injures her fetus during pregnancy.

In Article 201, we can find the details on the pregnancy interruption infringement. Thus, the pregnancy interruption can be performed in one of the following circumstances: “outside of medical institutions or medical practices authorized for this purpose; by a person who does not have the capacity of specialist doctor in Obstetrics and Gynecology and the right of free medical practice in this specialty; if gestational age has exceeded 14 weeks”, the punishment is the imprisonment for six months to three years, or fine and the prohibition to exercise certain rights (Art. 201, Par. 1) [ 37 ].

Article 201, Paragraph 2 specifies that “the interruption of the pregnancy committed under any circumstances, without the prior consent of the pregnant woman, can be punished with imprisonment from 2 to 7 years and with the prohibition to exercise some rights” (Art. 201, Par. 1) [ 37 ].

If by facts referred to above (Art. 201, Par. 1 and Par. 2) [ 37 ] “it has caused the pregnant woman’s physical injury, the punishment is the imprisonment from 3 to 10 years and the prohibition to exercise some rights, and if it has had as a result the pregnant woman’s death, the punishment is the imprisonment from 6 to 12 years and the prohibition to exercise some rights” (Art. 201, Par. 3) [ 37 ]. When the facts have been committed by a doctor, “in addition to the imprisonment punishment, it will also be applied the prohibition to exercise the profession of doctor (Art. 201, Par. 4) [ 37 ].

Criminal legislation specifies that “the interruption of pregnancy does not constitute an infringement with the purpose of a treatment carried out by a specialist doctor in Obstetrics and Gynecology, until the pregnancy age of twenty-four weeks is reached, or the subsequent pregnancy interruption, for the purpose of treatment, is in the interests of the mother or the fetus” (Art. 201, Par. 6) [ 37 ]. However, it can all be found in the phrases “therapeutic purposes” and “the interest of the mother and of the unborn child”, which predisposes the text of law to an interpretation, finally the doctors are the only ones in the position to decide what should be done in such cases, assuming direct responsibility [ 38 ].

Article 202 of the Criminal Code defines the crime of harming an unborn child, pointing out the punishments for the various types of injuries that can occur during pregnancy or in the childbirth period and which can be caused by the mother or by the persons who assist the birth, with the specification that the mother who harms her fetus during pregnancy is not punished and does not constitute an infringement if the injury has been committed during pregnancy or during childbirth period if the facts have been “committed by a doctor or by an authorized person to assist the birth or to follow the pregnancy, if they have been committed in the course of the medical act, complying with the specific provisions of his profession and have been made in the interest of the pregnant woman or fetus, as a result of the exercise of an inherent risk in the medical act” (Art. 202, Par. 6) [ 37 ].

The fact situation in Romania

During the period 1948–1955, called “the small baby boom” [ 39 ], Romania registered an average fertility rate of 3.23 children for a woman. Between 1955 and 1962, the fertility rate has been less than three children for a woman, and in 1962, fertility has reached an average of two children for a woman. This phenomenon occurred because of the Decree No. 463/1957 on liberalization of abortion. After the liberalization from 1957, the abortion rate has increased from 220 abortions per 100 born-alive children in the year 1960, to 400 abortions per 100 born-alive children, in the year 1965 [ 40 ].

The application of provisions of Decrees No. 770 of 1966 and No. 411 of 1985 has led to an increase of the birth rate in the first three years (an average of 3.7 children in 1967, and 3.6 children in 1968), followed by a regression until 1989, when it was recorded an average of 2.2 children, but also a maternal death rate caused by illegal abortions, raising up to 85 deaths of 100 000 births in the year of 1965, and 170 deaths in 1983. It was estimated that more than 80% of maternal deaths between 1980–1989 was caused by legal constraints [ 30 ].

After the Romanian Revolution in December 1989 and after the communism fall, with the abrogation of Articles 185–188 of the Criminal Code and of the Decree No. 770/1966, by the Decree of Law No. 1 of December 26 th , 1989, abortion has become legal in Romania and so, in the following years, it has reached the highest rate of abortion in Europe. Subsequently, the number of abortion has dropped gradually, with increasing use of birth control [ 41 ].

Statistical data issued by the Ministry of Health and by the National Institute of Statistics (INS) in Romania show corresponding figures to a legally carried out abortion. The abortion number is much higher, if it would take into account the number of illegal abortion, especially those carried out before 1989, and those carried out in private clinics, after the year 1990. Summing the declared abortions in the period 1958–2014, it is to be noted the number of them, 22 037 747 exceeds the current Romanian population. A detailed statistical research of abortion rate, in terms of years we have exposed in Table ​ Table1 1 .

The number of abortions declared in Romania in the period 1958–2016

Source: Pro Vita Association (Bucharest, Romania), National Institute of Statistics (INS – Romania), EUROSTAT [ 42 , 43 , 44 ]

Data issued by the United Nations International Children’s Emergency Fund (UNICEF) in June 2016, for the period 1989–2014, in matters of reproductive behavior, indicates a fertility rate for Romania with a continuous decrease, in proportion to the decrease of the number of births, but also a lower number of abortion rate reported to 100 deliveries (Table ​ (Table2 2 ).

Reproductive behavior in Romania in 1989–2014

Source: United Nations International Children’s Emergency Fund (UNICEF), Transformative Monitoring for Enhanced Equity (TransMonEE) Data. Country profiles: Romania, 1989–2015 [ 45 ].

By analyzing data issued for the period 1990–2015 by the International Organization of Health , UNICEF , United Nations Fund for Population Activity (UNFPA), The World Bank and the United Nations Population Division, it is noticed that maternal mortality rate has currently dropped as compared with 1990 (Table ​ (Table3 3 ).

Maternal mortality estimation in Romania in 1990–2015

Source: World Health Organization (WHO), Global Health Observatory Data. Maternal mortality country profiles: Romania, 2015 [ 46 ].

Opinion survey: women’s opinion on abortion

Argument for choosing the research theme

Although the problematic on abortion in Romania has been extensively investigated and debated, it has not been carried out in an ample sociological study, covering Romanian women’s perception on abortion. We have assumed making a study at national level, in order to identify the opinion on abortion, on the motivation to carry out an abortion, and to identify the correlation between religious convictions and the attitude toward abortion.

Examining the literature field of study

In the conceptual register of the research, we have highlighted items, such as the specialized literature, legislation, statistical documents.

Formulation of hypotheses and objectives

The first hypothesis was that Romanian women accept abortion, having an open attitude towards this act. Thus, the first objective of the research was to identify Romanian women’s attitude towards abortion.

The second hypothesis, from which we started, was that high religious beliefs generate a lower tolerance towards abortion. Thus, the second objective of our research has been to identify the correlation between the religious beliefs and the attitude towards abortion.

The third hypothesis of the survey was that, the main motivation in carrying out an abortion is the fact that a woman does not want a baby, and the main motivation for keeping the pregnancy is that the person wants a baby. In this context, the third objective of the research was to identify main motivation in carrying out an abortion and in maintaining a pregnancy.

Another hypothesis was that modern Romanian legislation on the abortion is considered fair. Based on this hypothesis, we have assumed the fourth objective, which is to identify the degree of satisfaction towards the current regulatory provisions governing the abortion.

Research methodology

The research method is that of a sociological survey by the application of the questionnaire technique. We used the sampling by age and residence looking at representative numbers of population from more developed as well as underdeveloped areas.

Determination of the sample to be studied

Because abortion is a typical women’s experience, we have chosen to make the quantitative research only among women. We have constructed the sample by selecting a number of 1260 women between the ages of 15 and 44 years (the most frequently encountered age among women who give birth to a child). We also used the quota sampling techniques, taking into account the following variables: age group and the residence (urban/rural), so that the persons included in the sample could retain characteristic of the general population.

By the sample of 1260 women, we have made a percentage of investigation of 0.03% of the total population.

The Questionnaires number applied was distributed as follows (Table ​ (Table4 4 ).

The sampling rates based on the age, and the region of residence

Source: Sample built, based on the population data issued by the National Institute of Statistics (INS – Romania) based on population census conducted in 2011 [ 47 ].

Data collection

Data collection was carried out by questionnaires administered by 32 field operators between May 1 st –May 31 st , 2018.

The analysis of the research results

In the next section, we will present the main results of the quantitative research carried out at national level.

Almost three-quarters of women included in the sample agree with carrying out an abortion in certain circumstances (70%) and only 24% have chosen to support the answer “ No, never ”. In modern contemporary society, abortion is the first solution of women for which a pregnancy is not desired. Even if advanced medical techniques are a lot safer, an abortion still carries a health risk. However, 6% of respondents agree with carrying out abortion regardless of circumstances (Table ​ (Table5 5 ).

Opinion on the possibility of carrying out an abortion

Although abortions carried out after 14 weeks are illegal, except for medical reasons, more than half of the surveyed women stated they would agree with abortion in certain circumstances. At the opposite pole, 31% have mentioned they would never agree on abortions after 14 weeks. Five percent were totally accepting the idea of abortion made to a pregnancy that has exceeded 14 weeks (Table ​ (Table6 6 ).

Opinion on the possibility of carrying out an abortion after the period of 14 weeks of pregnancy

For 53% of respondents, abortion is considered a crime as well as the right of a women. On the other hand, 28% of the women considered abortion as a crime and 16% associate abortion with a woman’s right (Table ​ (Table7 7 ).

Opinion on abortion: at the border between crime and a woman’s right

Opinions on what women abort at the time of the voluntary pregnancy interruption are split in two: 59% consider that it depends on the time of the abortion, and more specifically on the pregnancy development stage, 24% consider that regardless of the period in which it is carried out, women abort a child, and 14% have opted a fetus (Table ​ (Table8 8 ).

Abortion of a child vs. abortion of a fetus

Among respondents who consider that women abort a child or a fetus related to the time of abortion, 37.5% have considered that the difference between a baby and a fetus appears after 14 weeks of pregnancy (the period legally accepted for abortion). Thirty-three percent of them have mentioned that the distinction should be performed at the first few heartbeats; 18.1% think it is about when the child has all the features definitively outlined and can move by himself; 2.8% consider that the difference appears when the first encephalopathy traces are being felt and the child has formed all internal and external organs. A percentage of 1.7% of respondents consider that this difference occurs at the beginning of the central nervous system, and 1.4% when the unborn child has all the features that we can clearly see to a newborn child (Table ​ (Table9 9 ).

The opinion on the moment that makes the difference between a fetus and a child

We noticed that highly religious people make a clear association between abortion and crime. They also consider that at the time of pregnancy interruption it is aborted a child and not a fetus. However, unexpectedly, we noticed that 27% of the women, who declare themselves to be very religious, have also stated that they see abortion as a crime but also as a woman’s right. Thirty-one percent of the women, who also claimed profound religious beliefs, consider that abortion may be associated with the abortion of a child but also of a fetus, this depending on the time of abortion (Tables ​ (Tables10 10 and ​ and11 11 ).

The correlation between the level of religious beliefs and the perspective on abortion seen as a crime or a right

The correlation between the level of religious beliefs and the perspective on abortion procedure conducted on a fetus or a child

More than half of the respondents have opted for the main reason for abortion the appearance of medical problems to the child. Baby’s health represents the main concern of future mothers, and of each parent, and the birth of a child with serious health issues, is a factor which frightens any future parent, being many times, at least theoretically, one good reason for opting for abortion. At the opposite side, 12% of respondents would not choose abortion under any circumstances. Other reasons for which women would opt for an abortion are: if the woman would have a medical problem (22%) or would not want the child (10%) (Table ​ (Table12 12 ).

Potential reasons for carrying out an abortion

Most of the women want to give birth to a child, 56% of the respondents, representing also the reason that would determine them to keep the child. Morality (26%), faith (10%) or legal restrictions (4%), are the three other reasons for which women would not interrupt a pregnancy. Only 2% of the respondents have mentioned other reasons such as health or age.

A percentage of 23% of the surveyed people said that they have done an abortion so far, and 77% did not opted for a surgical intervention either because there was no need, or because they have kept the pregnancy (Table ​ (Table13 13 ).

Rate of abortion among women in the sample

Most respondents, 87% specified that they have carried out an abortion during the first 14 weeks – legally accepted limit for abortion: 43.6% have made abortion in the first four weeks, 39.1% between weeks 4–8, and 4.3% between weeks 8–14. It should be noted that 8.7% could not appreciate the pregnancy period in which they carried out abortion, by opting to answer with the option “ I don’t know ”, and a percentage of 4.3% refused to answer to this question.

Performing an abortion is based on many reasons, but the fact that the women have not wanted a child is the main reason mentioned by 47.8% of people surveyed, who have done minimum an abortion so far. Among the reasons for the interruption of pregnancy, it is also included: women with medical problems (13.3%), not the right time to be a mother (10.7%), age motivation (8.7%), due to medical problems of the child (4.3%), the lack of money (4.3%), family pressure (4.3%), partner/spouse did not wanted. A percentage of 3.3% of women had different reasons for abortion, as follows: age difference too large between children, career, marital status, etc. Asked later whether they regretted the abortion, a rate of 69.6% of women who said they had at least one abortion regret it (34.8% opted for “ Yes ”, and 34.8% said “ Yes, partially ”). 26.1% of surveyed women do not regret the choice to interrupted the pregnancy, and 4.3% chose to not answer this question. We noted that, for women who have already experienced abortion, the causes were more diverse than the grounds on which the previous question was asked: “What are the reasons that determined you to have an abortion?” (Table ​ (Table14 14 ).

The reasons that led the women in the sample to have an abortion

The majority of the respondents (37.5%) considered that “nervous depression” is the main consequence of abortion, followed by “insomnia and nightmares” (24.6%), “disorders in alimentation” and “affective disorders” (each for 7.7% of respondents), “deterioration of interpersonal relationships” and “the feeling of guilt”(for 6.3% of the respondents), “sexual disorders” and “panic attacks” (for 6.3% of the respondents) (Table ​ (Table15 15 ).

Opinion on the consequences of abortion

Over half of the respondents believe that abortion should be legal in certain circumstances, as currently provided by law, 39% say it should be always legal, and only 6% opted for the illegal option (Table ​ (Table16 16 ).

Opinion on the legal regulation of abortion

Although the current legislation does not punish pregnant women who interrupt pregnancy or intentionally injured their fetus, survey results indicate that 61% of women surveyed believe that the national law should punish the woman and only 28% agree with the current legislation (Table ​ (Table17 17 ).

Opinion on the possibility of punishing the woman who interrupts the course of pregnancy or injures the fetus

For the majority of the respondents (40.6%), the penalty provided by the current legislation, the imprisonment between six months and three years or a fine and deprivation of certain rights for the illegal abortion is considered fair, for a percentage of 39.6% the punishment is too small for 9.5% of the respondents is too high. Imprisonment between two and seven years and deprivation of certain rights for an abortion performed without the consent of the pregnant woman is considered too small for 65% of interviewees. Fourteen percent of them think it is fair and only 19% of respondents consider that Romanian legislation is too severe with people who commit such an act considering the punishment as too much. The imprisonment from three to 10 years and deprivation of certain rights for the facts described above, if an injury was caused to the woman, is considered to be too small for more than half of those included in the survey, 64% and almost 22% for nearly a quarter of them. Only 9% of the respondents mentioned that this legislative measure is too severe for such actions (Table ​ (Table18 18 ).

Opinion on the regulation of abortion of the Romanian Criminal Code (Art. 201)

Conclusions

After analyzing the results of the sociological research regarding abortion undertaken at national level, we see that 76% of the Romanian women accept abortion, indicating that the majority accepts only certain circumstances (a certain period after conception, for medical reasons, etc.). A percentage of 64% of the respondents indicated that they accept the idea of abortion after 14 weeks of pregnancy (for solid reasons or regardless the reason). This study shows that over 50% of Romanian women see abortion as a right of women but also a woman’s crime and believe that in the moment of interruption of a pregnancy, a fetus is aborted. Mostly, the association of abortion with crime and with the idea that a child is aborted is frequently found within very religious people. The main motivation for Romanian women in taking the decision not to perform an abortion is that they would want the child, and the main reason to perform an abortion is the child’s medical problems. However, it is noted that, in real situations, in which women have already done at least one abortion, most women resort to abortion because they did not want the child towards the hypothetical situation in which women felt that the main reason of abortion is a medical problem. Regarding the satisfaction with the current national legislation of the abortion, the situation is rather surprising. A significant percentage (61%) of respondents felt as necessary to punish the woman who performs an illegal abortion, although the legislation does not provide a punishment. On the other hand, satisfaction level to the penalties provided by law for various violations of the legal conditions for conducting abortion is low, on average only 25.5% of respondents are being satisfied with these, the majority (average 56.2%) considering the penalties as unsatisfactory. Understood as a social phenomenon, intensified by human vulnerabilities, of which the most obvious is accepting the comfort [ 48 ], abortion today is no longer, in Romanian society, from a legal or religious perspective, a problem. Perceptions on the legislative sanction, moral and religious will perpetual vary depending on beliefs, environment, education, etc. The only and the biggest social problem of Romania is truly represented by the steadily falling birth rate.

Conflict of interests

The authors declare that they have no conflict of interests.

The Most Important Study in the Abortion Debate

Researchers rigorously tested the persistent notion that abortion wounds the women who seek it.

The demographer Diana Greene Foster was in Orlando last month, preparing for the end of Roe v. Wade , when Politico published a leaked draft of a majority Supreme Court opinion striking down the landmark ruling. The opinion, written by Justice Samuel Alito, would revoke the constitutional right to abortion and thus give states the ability to ban the medical procedure.

Foster, the director of the Bixby Population Sciences Research Unit at UC San Francisco, was at a meeting of abortion providers, seeking their help recruiting people for a new study . And she was racing against time. She wanted to look, she told me, “at the last person served in, say, Nebraska, compared to the first person turned away in Nebraska.” Nearly two dozen red and purple states are expected to enact stringent limits or even bans on abortion as soon as the Supreme Court strikes down Roe v. Wade , as it is poised to do. Foster intends to study women with unwanted pregnancies just before and just after the right to an abortion vanishes.

Read: When a right becomes a privilege

When Alito’s draft surfaced, Foster told me, “I was struck by how little it considered the people who would be affected. The experience of someone who’s pregnant when they do not want to be and what happens to their life is absolutely not considered in that document.” Foster’s earlier work provides detailed insight into what does happen. The landmark Turnaway Study , which she led, is a crystal ball into our post- Roe future and, I would argue, the single most important piece of academic research in American life at this moment.

The legal and political debate about abortion in recent decades has tended to focus more on the rights and experience of embryos and fetuses than the people who gestate them. And some commentators—including ones seated on the Supreme Court—have speculated that termination is not just a cruel convenience, but one that harms women too . Foster and her colleagues rigorously tested that notion. Their research demonstrates that, in general, abortion does not wound women physically, psychologically, or financially. Carrying an unwanted pregnancy to term does.

In a 2007 decision , Gonzales v. Carhart , the Supreme Court upheld a ban on one specific, uncommon abortion procedure. In his majority opinion , Justice Anthony Kennedy ventured a guess about abortion’s effect on women’s lives: “While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort the infant life they once created and sustained,” he wrote. “Severe depression and loss of esteem can follow.”

Was that really true? Activists insisted so, but social scientists were not sure . Indeed, they were not sure about a lot of things when it came to the effect of the termination of a pregnancy on a person’s life. Many papers compared individuals who had an abortion with people who carried a pregnancy to term. The problem is that those are two different groups of people; to state the obvious, most people seeking an abortion are experiencing an unplanned pregnancy, while a majority of people carrying to term intended to get pregnant.

Foster and her co-authors figured out a way to isolate the impact of abortion itself. Nearly all states bar the procedure after a certain gestational age or after the point that a fetus is considered viable outside the womb . The researchers could compare people who were “turned away” by a provider because they were too far along with people who had an abortion at the same clinics. (They did not include people who ended a pregnancy for medical reasons.) The women who got an abortion would be similar, in terms of demographics and socioeconomics, to those who were turned away; what would separate the two groups was only that some women got to the clinic on time, and some didn’t.

In time, 30 abortion providers—ones that had the latest gestational limit of any clinic within 150 miles, meaning that a person could not easily access an abortion if they were turned away—agreed to work with the researchers. They recruited nearly 1,000 women to be interviewed every six months for five years. The findings were voluminous, resulting in 50 publications and counting. They were also clear. Kennedy’s speculation was wrong: Women, as a general point, do not regret having an abortion at all.

Researchers found, among other things, that women who were denied abortions were more likely to end up living in poverty. They had worse credit scores and, even years later, were more likely to not have enough money for the basics, such as food and gas. They were more likely to be unemployed. They were more likely to go through bankruptcy or eviction. “The two groups were economically the same when they sought an abortion,” Foster told me. “One became poorer.”

Read: The calamity of unwanted motherhood

In addition, those denied a termination were more likely to be with a partner who abused them. They were more likely to end up as a single parent. They had more trouble bonding with their infants, were less likely to agree with the statement “I feel happy when my child laughs or smiles,” and were more likely to say they “feel trapped as a mother.” They experienced more anxiety and had lower self-esteem, though those effects faded in time. They were half as likely to be in a “very good” romantic relationship at two years. They were less likely to have “aspirational” life plans.

Their bodies were different too. The ones denied an abortion were in worse health, experiencing more hypertension and chronic pain. None of the women who had an abortion died from it. This is unsurprising; other research shows that the procedure has extremely low complication rates , as well as no known negative health or fertility effects . Yet in the Turnaway sample, pregnancy ended up killing two of the women who wanted a termination and did not get one.

The Turnaway Study also showed that abortion is a choice that women often make in order to take care of their family. Most of the women seeking an abortion were already mothers. In the years after they terminated a pregnancy, their kids were better off; they were more likely to hit their developmental milestones and less likely to live in poverty. Moreover, many women who had an abortion went on to have more children. Those pregnancies were much more likely to be planned, and those kids had better outcomes too.

The interviews made clear that women, far from taking a casual view of abortion, took the decision seriously. Most reported using contraception when they got pregnant, and most of the people who sought an abortion after their state’s limit simply did not realize they were pregnant until it was too late. (Many women have irregular periods, do not experience morning sickness, and do not feel fetal movement until late in the second trimester.) The women gave nuanced, compelling reasons for wanting to end their pregnancies.

Afterward, nearly all said that termination had been the right decision. At five years, only 14 percent felt any sadness about having an abortion; two in three ended up having no or very few emotions about it at all. “Relief” was the most common feeling, and an abiding one.

From the May 2022 issue: The future of abortion in a post- Roe America

The policy impact of the Turnaway research has been significant, even though it was published during a period when states have been restricting abortion access. In 2018, the Iowa Supreme Court struck down a law requiring a 72-hour waiting period between when a person seeks and has an abortion, noting that “the vast majority of abortion patients do not regret the procedure, even years later, and instead feel relief and acceptance”—a Turnaway finding. That same finding was cited by members of Chile’s constitutional court  as they allowed for the decriminalization of abortion in certain circumstances.

Yet the research has not swayed many people who advocate for abortion bans, believing that life begins at conception and that the law must prioritize the needs of the fetus. Other activists have argued that Turnaway is methodologically flawed; some women approached in the clinic waiting room declined to participate, and not all participating women completed all interviews . “The women who anticipate and experience the most negative reactions to abortion are the least likely to want to participate in interviews,” the activist David Reardon argued in a 2018 article in a Catholic Medical Association journal.

Still, four dozen papers analyzing the Turnaway Study’s findings have been published in peer-reviewed journals; the research is “the gold standard,” Emily M. Johnston, an Urban Institute health-policy expert who wasn’t involved with the project, told me. In the trajectories of women who received an abortion and those who were denied one, “we can understand the impact of abortion on women’s lives,” Foster told me. “They don’t have to represent all women seeking abortion for the findings to be valid.” And her work has been buttressed by other surveys, showing that women fear the repercussions of unplanned pregnancies for good reason and do not tend to regret having a termination. “Among the women we spoke with, they did not regret either choice,” whether that was having an abortion or carrying to term, Johnston told me. “These women were thinking about their desires for themselves, but also were thinking very thoughtfully about what kind of life they could provide for a child.”

The Turnaway study , for Foster, underscored that nobody needs the government to decide whether they need an abortion. If and when America’s highest court overturns Roe , though, an estimated 34 million women of reproductive age will lose some or all access to the procedure in the state where they live. Some people will travel to an out-of-state clinic to terminate a pregnancy; some will get pills by mail to manage their abortions at home; some will “try and do things that are less safe,” as Foster put it. Many will carry to term: The Guttmacher Institute has estimated that there will be roughly 100,000 fewer legal abortions per year post- Roe . “The question now is who is able to circumvent the law, what that costs, and who suffers from these bans,” Foster told me. “The burden of this will be disproportionately put on people who are least able to support a pregnancy and to support a child.”

Ellen Gruber Garvey: I helped women get abortions in pre- Roe America

Foster said that there is a lot we still do not know about how the end of Roe might alter the course of people’s lives—the topic of her new research. “In the Turnaway Study, people were too late to get an abortion, but they didn’t have to feel like the police were going to knock on their door,” she told me. “Now, if you’re able to find an abortion somewhere and you have a complication, do you get health care? Do you seek health care out if you’re having a miscarriage, or are you too scared? If you’re going to travel across state lines, can you tell your mother or your boss what you’re doing?”

In addition, she said that she was uncertain about the role that abortion funds —local, on-the-ground organizations that help people find, travel to, and pay for terminations—might play. “We really don’t know who is calling these hotlines,” she said. “When people call, what support do they need? What is enough, and who falls through the cracks?” She added that many people are unaware that such services exist, and might have trouble accessing them.

People are resourceful when seeking a termination and resilient when denied an abortion, Foster told me. But looking into the post- Roe future, she predicted, “There’s going to be some widespread and scary consequences just from the fact that we’ve made this common health-care practice against the law.” Foster, to her dismay, is about to have a lot more research to do.

A research on abortion: ethics, legislation and socio-medical outcomes. Case study: Romania

Affiliation.

• 1 Faculty of Social Sciences, University of Craiova, Romania; andreea_nita[email protected], [email protected], [email protected].
• PMID: 32747924
• PMCID: PMC7728127
• DOI: 10.47162/RJME.61.1.35

This article presents a research study on abortion from a theoretical and empirical point of view. The theoretical part is based on the method of social documents analysis, and presents a complex perspective on abortion, highlighting items of medical, ethical, moral, religious, social, economic and legal elements. The empirical part presents the results of a sociological survey, based on the opinion survey method through the application of the enquiry technique, conducted in Romania, on a sample of 1260 women. The purpose of the survey is to identify Romanians perception on the decision to voluntary interrupt pregnancy, and to determine the core reasons in carrying out an abortion.

Publication types

• Case Reports
• Abortion, Induced / ethics*
• Ethics, Medical*

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Ross Douthat

The Case Against Abortion

By Ross Douthat

Opinion Columnist

A striking thing about the American abortion debate is how little abortion itself is actually debated. The sensitivity and intimacy of the issue, the mixed feelings of so many Americans, mean that most politicians and even many pundits really don’t like to talk about it.

The mental habits of polarization, the assumption that the other side is always acting with hidden motives or in bad faith, mean that accusations of hypocrisy or simple evil are more commonplace than direct engagement with the pro-choice or pro-life argument.

And the Supreme Court’s outsize role in abortion policy means that the most politically important arguments are carried on by lawyers arguing constitutional theory, at one remove from the real heart of the debate.

But with the court set this week to hear Dobbs v. Jackson Women’s Health Organization, a direct challenge to Roe v. Wade, it seems worth letting the lawyers handle the meta-arguments and writing about the thing itself. So this essay will offer no political or constitutional analysis. It will simply try to state the pro-life case.

At the core of our legal system, you will find a promise that human beings should be protected from lethal violence. That promise is made in different ways by the Constitution and the Declaration of Independence; it’s there in English common law, the Ten Commandments and the Universal Declaration of Human Rights. We dispute how the promise should be enforced, what penalties should be involved if it is broken and what crimes might deprive someone of the right to life. But the existence of the basic right, and a fundamental duty not to kill, is pretty close to bedrock.

There is no way to seriously deny that abortion is a form of killing. At a less advanced stage of scientific understanding, it was possible to believe that the embryo or fetus was somehow inert or vegetative until so-called quickening, months into pregnancy. But we now know the embryo is not merely a cell with potential, like a sperm or ovum, or a constituent part of human tissue, like a skin cell. Rather, a distinct human organism comes into existence at conception, and every stage of your biological life, from infancy and childhood to middle age and beyond, is part of a single continuous process that began when you were just a zygote.

We know from embryology, in other words, not Scripture or philosophy, that abortion kills a unique member of the species Homo sapiens, an act that in almost every other context is forbidden by the law.

This means that the affirmative case for abortion rights is inherently exceptionalist, demanding a suspension of a principle that prevails in practically every other case. This does not automatically tell against it; exceptions as well as rules are part of law. But it means that there is a burden of proof on the pro-choice side to explain why in this case taking another human life is acceptable, indeed a protected right itself.

One way to clear this threshold would be to identify some quality that makes the unborn different in kind from other forms of human life — adult, infant, geriatric. You need an argument that acknowledges that the embryo is a distinct human organism but draws a credible distinction between human organisms and human persons , between the unborn lives you’ve excluded from the law’s protection and the rest of the human race.

In this kind of pro-choice argument and theory, personhood is often associated with some property that’s acquired well after conception: cognition, reason, self-awareness, the capacity to survive outside the womb. And a version of this idea, that human life is there in utero but human personhood develops later, fits intuitively with how many people react to a photo of an extremely early embryo ( It doesn’t look human, does it? ) — though less so to a second-trimester fetus, where the physical resemblance to a newborn is more palpable.

But the problem with this position is that it’s hard to identify exactly what property is supposed to do the work of excluding the unborn from the ranks of humans whom it is wrong to kill. If full personhood is somehow rooted in reasoning capacity or self-consciousness, then all manner of adult human beings lack it or lose it at some point or another in their lives. If the capacity for survival and self-direction is essential, then every infant would lack personhood — to say nothing of the premature babies who are unviable without extreme medical interventions but regarded, rightly, as no less human for all that.

At its most rigorous, the organism-but-not-person argument seeks to identify some stage of neurological development that supposedly marks personhood’s arrival — a transition equivalent in reverse to brain death at the end of life. But even setting aside the practical difficulties involved in identifying this point, we draw a legal line at brain death because it’s understood to be irreversible, the moment at which the human organism’s healthy function can never be restored. This is obviously not the case for an embryo on the cusp of higher brain functioning — and if you knew that a brain-dead but otherwise physically healthy person would spontaneously regain consciousness in two weeks, everyone would understand that the caregivers had an obligation to let those processes play out.

Or almost everyone, I should say. There are true rigorists who follow the logic of fetal nonpersonhood toward repugnant conclusions — for instance, that we ought to permit the euthanizing of severely disabled newborns, as the philosopher Peter Singer has argued. This is why abortion opponents have warned of a slippery slope from abortion to infanticide and involuntary euthanasia; as pure logic, the position that unborn human beings aren’t human persons can really tend that way.

But to their credit, only a small minority of abortion-rights supporters are willing to be so ruthlessly consistent. Instead, most people on the pro-choice side are content to leave their rules of personhood a little hazy, and combine them with the second potent argument for abortion rights: namely, that regardless of the precise moral status of unborn human organisms, they cannot enjoy a legal right to life because that would strip away too many rights from women.

A world without legal abortion, in this view, effectively consigns women to second-class citizenship — their ambitions limited, their privacy compromised, their bodies conscripted, their claims to full equality a lie. These kind of arguments often imply that birth is the most relevant milestone for defining legal personhood — not because of anything that happens to the child but because it’s the moment when its life ceases to impinge so dramatically on its mother.

There is a powerful case for some kind of feminism embedded in these claims. The question is whether that case requires abortion itself.

Certain goods that should be common to men and women cannot be achieved, it’s true, if the law simply declares the sexes equal without giving weight to the disproportionate burdens that pregnancy imposes on women. Justice requires redistributing those burdens, through means both traditional and modern — holding men legally and financially responsible for all the children that they father and providing stronger financial and social support for motherhood at every stage.

But does this kind of justice for women require legal indifference to the claims of the unborn? Is it really necessary to found equality for one group of human beings on legal violence toward another, entirely voiceless group?

We have a certain amount of practical evidence that suggests the answer is no. Consider, for instance, that between the early 1980s and the later 2010s the abortion rate in the United States fell by more than half . The reasons for this decline are disputed, but it seems reasonable to assume that it reflects a mix of cultural change, increased contraception use and the effects of anti-abortion legal strategies, which have made abortion somewhat less available in many states, as pro-choice advocates often lament.

If there were an integral and unavoidable relationship between abortion and female equality, you would expect these declines — fewer abortions, diminished abortion access — to track with a general female retreat from education and the workplace. But no such thing has happened: Whether measured by educational attainment, managerial and professional positions, breadwinner status or even political office holding, the status of women has risen in the same America where the pro-life movement has (modestly) gained ground.

Of course, it’s always possible that female advancement would have been even more rapid, the equality of the sexes more fully and perfectly established, if the pro-life movement did not exist. Certainly in the individual female life trajectory, having an abortion rather than a baby can offer economic and educational advantages.

On a collective level, though, it’s also possible that the default to abortion as the solution to an unplanned pregnancy actually discourages other adaptations that would make American life friendlier to women. As Erika Bachiochi wrote recently in National Review , if our society assumes that “abortion is what enables women to participate in the workplace,” then corporations may prefer the abortion default to more substantial accommodations like flexible work schedules and better pay for part-time jobs — relying on the logic of abortion rights, in other words, as a reason not to adapt to the realities of childbearing and motherhood.

At the very least, I think an honest look at the patterns of the past four decades reveals a multitude of different ways to offer women greater opportunities, a multitude of paths to equality and dignity — a multitude of ways to be a feminist, in other words, that do not require yoking its idealistic vision to hundreds of thousands of acts of violence every year.

It’s also true, though, that nothing in all that multitude of policies will lift the irreducible burden of childbearing, the biological realities that simply cannot be redistributed to fathers, governments or adoptive parents. And here, too, a portion of the pro-choice argument is correct: The unique nature of pregnancy means that there has to be some limit on what state or society asks of women and some zone of privacy where the legal system fears to tread.

This is one reason the wisest anti-abortion legislation — and yes, pro-life legislation is not always wise — criminalizes the provision of abortion by third parties, rather than prosecuting the women who seek one. It’s why anti-abortion laws are rightly deemed invasive and abusive when they lead to the investigation of suspicious-seeming miscarriages. It’s why the general principle of legal protection for human life in utero may or must understandably give way in extreme cases, extreme burdens: the conception by rape, the life-threatening pregnancy.

At the same time, though, the pro-choice stress on the burden of the ordinary pregnancy can become detached from the way that actual human beings experience the world. In a famous thought experiment, the philosopher Judith Jarvis Thomson once analogized an unplanned pregnancy to waking up with a famous violinist hooked up to your body, who will die if he’s disconnected before nine months have passed. It’s a vivid science-fiction image but one that only distantly resembles the actual thing that it describes — a new life that usually exists because of a freely chosen sexual encounter, a reproductive experience that if material circumstances were changed might be desired and celebrated, a “disconnection” of the new life that cannot happen without lethal violence and a victim who is not some adult stranger but the woman’s child.

One can accept pro-choice logic, then, insofar as it demands a sphere of female privacy and warns constantly against the potential for abuse, without following that logic all the way to a general right to abort an unborn human life. Indeed, this is how most people approach similar arguments in other contexts. In the name of privacy and civil liberties we impose limits on how the justice system polices and imprisons, and we may celebrate activists who try to curb that system’s manifest abuses. But we don’t (with, yes, some anarchist exceptions) believe that we should remove all legal protections for people’s property or lives.

That removal of protection would be unjust no matter what its consequences, but in reality we know that those consequences would include more crime, more violence and more death. And the anti-abortion side can give the same answer when it’s asked why we can’t be content with doing all the other things that may reduce abortion rates and leaving legal protection out of it: Because while legal restrictions aren’t sufficient to end abortion, there really are a lot of unborn human lives they might protect.

Consider that when the State of Texas put into effect this year a ban on most abortions after about six weeks, the state’s abortions immediately fell by half. I think the Texas law, which tries to evade the requirements of Roe v. Wade and Planned Parenthood v. Casey by using private lawsuits for enforcement, is vulnerable to obvious critiques and liable to be abused. It’s not a model I would ever cite for pro-life legislation.

But that immediate effect, that sharp drop in abortions, is why the pro-life movement makes legal protection its paramount goal.

According to researchers at the University of Texas at Austin, who surveyed the facilities that provide about 93 percent of all abortions in the state, there were 2,149 fewer legal abortions in Texas in the month the law went into effect than in the same month in 2020.

About half that number may end up still taking place, some estimates suggest, many of them in other states. But that still means that in a matter of months, more than a thousand human beings will exist as legal persons, rights-bearing Texans — despite still being helpless, unreasoning and utterly dependent — who would not have existed had this law not given them protection.

But, in fact, they exist already. They existed, at our mercy, all along.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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Ross Douthat has been an Opinion columnist for The Times since 2009. He is the author of several books, most recently, “The Deep Places: A Memoir of Illness and Discovery.” @ DouthatNYT • Facebook

How Ohio voters' decision on Issue 1 could impact abortion access in the state

Posted: November 7, 2023 | Last updated: November 7, 2023

Ohio voters are casting their ballots on Tuesday to decide whether a proposed amendment will enshrine abortion in the state's constitution.

The ballot measure, known as Issue 1 , would change the Ohio constitution to establish "an individual right to one's own reproductive medical treatment, including but not limited to abortion." Treatment includes contraception, fertility treatments and miscarriage care.

If the amendment passes, it will create legal protection for a person or entity who assists someone receiving an abortion and prevent Ohio from "directly or indirectly burdening, penalizing or prohibiting abortion" before viability, generally considered between 24 and 26 weeks of gestation.

In Ohio, abortion is currently banned at 22 weeks or later, according to the Guttmacher Institute , a research group that studies sexual and reproductive rights.

Patients seeking an abortion are forced to make two trips, first for an in-person counseling session and the second at least 24 hours later for the procedure itself.

Additionally, only a physician is able to perform an abortion and not another qualified health care professional.

Under the proposed amendment, the state can ban abortion after viability except when the life or health of the mother is in danger.

What's more, a woman's physician will be able to determine "on a case-by-case basis" whether the fetus is viable.

There is no language in the proposal about what type of health care professional is allowed or not allowed to perform an abortion.

Last year , voters in three states -- California, Michigan and Vermont -- enshrined abortion rights in their constitutions. Residents of Kentucky and Montana, however, voted against further restricting access to abortion services in 2022.

What's more, during the 2022 primary election, voters in Kansas struck down a proposal to remove the right to abortion from the state's constitution.

If Ohioans vote in favor of the amendment, the state would become the seventh to protect abortion rights via the ballot box since the Supreme Court overturned Roe v. Wade in June 2022.

If the amendment is not passed, it could potentially pave the way for a six-week abortion ban to be reinstated.

In 2019, Ohio lawmakers passed a so-called heartbeat bill that bans abortions after cardiac activity can be detected, which occurs as early as six weeks of pregnancy, before many women know they're pregnant. It was signed into law by Gov. Mike DeWine.

The ban had no exceptions for rape or incest. The only exceptions were cases of ectopic pregnancies and to prevent the mother's death or impairment of a major bodily function.

A federal judge blocked the ban in 2019 but it was reinstated just hours after the Supreme Court decision to overturn Roe.

Stories of the ban's impact quickly emerged and gained national attention, including that of a 10-year-old girl who was raped and had to travel from Ohio to Indiana for an abortion.

In September 2022, an Ohio lower court granted a temporary restraining order before granting a preliminary injunction a few weeks later. The state's Supreme Court is now considering whether to lift the injunction while legal challenges play out in the lower court.

If Issue 1 passes, the Supreme Court decision would have no standing. However, if it fails to pass, the court would have the opportunity reinforce the six-week ban.

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Sixty-one people in US criminalized for alleged self-managed abortions, report finds

Justice group calls some charges in past 20 years ‘illegitimate uses of state power’ and says over 40% of cases involved people of color

Between 2000 and 2020, 61 people, including seven minors, were criminally investigated or arrested for allegedly ending their own pregnancies or helping someone else do so, according to a Monday report from If/When/How, a reproductive justice group that helps people deal with legal cases related to pregnancy.

Only 14 of those cases arose in the seven states that had bans on “self-managed abortion” on the books between 2000 and 2020. The report found that the vast majority of those cases were charged under other kinds of laws – ones that prosecutors had made elastic enough to fit the supposed crime.

“This criminalization is happening in spite of the law, not because of it,” said Laura Huss, a senior researcher at If/When/How. “It’s really important also to acknowledge, to name and to recognize that the wrongful charges that we’ve seen are illegitimate uses of state power and must be challenged.”

In late 2022, just months after the overturning of Roe v Wade , If/When/How released a report revealing how at least 61 people had faced criminal consequences linked to self-managed abortions. But the Monday report offers a deeper dive into those cases.

Out of 54 cases that involved adults, 42 proceeded through the criminal court process and more than 40% of the cases involved people of color. In 45% of cases, it was healthcare providers or social workers who tipped off police to the suspected self-managed abortion – even though, according to If/When/How, there is no state or federal law that requires these providers to report self-managed abortions to law enforcement. In fact, by doing so, providers might be violating their patients’ privacy rights.

Most of the cases found by If/When/How allegedly involved people inducing an abortion using pills, a method that medical experts can agree is safe if used early on in pregnancy. In 9% of cases, people allegedly used some kind of herb or “botanic medicinals”, while people allegedly used physical force in 7% of cases. People also allegedly used household or toxic poison in 4% of cases.

Thirty cases involved people facing criminal consequences for their own suspected self-managed abortions, rather than helping someone else, the report found. Seven were charged under self-managed abortion bans, eight under abortion bans, four under “fetal harm” laws, and another 12 were charged using a variety of crimes, including child abuse, felony assault or assault of an unborn child, practicing medicine without a license, or even homicide and murder.

In 2002, an Ohio woman hurt herself in an attempt to end her pregnancy, the report found. Even though the pregnancy wasn’t terminated, law enforcement charged her with felony assault. That charge was then dismissed, because the charge was meant to be used against people who hurt others, not themselves. Instead, prosecutors charged the woman with practicing medicine and surgery without a certification.

Eventually, the charges were dropped – but only after the woman had been jailed while pregnant, according to the report.

Just one state, Nevada, still maintains a ban on self-managed abortion. But the cases uncovered by If/When/How occurred across 26 states, including states from across the political spectrum, like California, Texas, Florida and New York – all of which did not have a self-managed abortion ban during the two-decade span of the report.

“When someone is seeking care after self-managing, or ends up being criminalized while they’re still pregnant, that means that they are then being interrogated by police at their bedside and hospitals,” Huss said. “That means that someone is being held in jail for the remainder of their pregnancy.”

In some cases, people were stranded in jail for longer than their ultimate sentences, the report found. In one case, a woman, unable to pay for $200,000 bail, was left behind bars for more than a year. By the time she was convicted, she was immediately released because she had in effect already served her sentence.

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Another woman was sentenced to four months in jail – after she had already spent four months there, unable to pay the $25,000 bail or to live with her children. One woman ended up going to labor in jail; she was transported to the hospital in shackles and then was only able to breastfeed her newborn daughter while locked to the bed, according to the report.

At least three women lost their jobs because of an alleged self-managed abortion, the report found. Just one of those three was convicted. A fourth woman pleaded guilty to a more severe crime in order to avoid losing her job.

“Whether folks were convicted or not, several people did lose custody of their children temporarily or permanently,” Huss said. “Thirty per cent of the known parents temporarily or permanently lost custody of their children in conjunction with a criminal intervention relating to allegations of self-managed abortion. And this is especially concerning as over half of people who seek abortions are parents.”

If/When/How, which also runs a hotline for people with legal questions as well as a legal defense fund, has discovered at least 11 more cases of people being criminalized for suspected self-managed abortions since 2020. Researchers said they were not yet sure whether more people are being investigated or arrested over self-managed abortions post-Roe.

“I think the wrong question to ask is about how we’re seeing increases or if that’ll happen,” Huss said. “Any particular case that happens is a case to worry about.”

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Sex work, migration, and reproductive (in)justice in medellín, colombia.

Since 2010, Venezuela has been facing an escalated socioeconomic and political crisis that has affected the daily life of its inhabitants and institutions, including its health system. Precarious conditions, including shortage of medicines, supplies, and vaccines, force people to choose between buying these items in the black market or not being able to access them at all (Rada 2022). The material scarcity sums to a massive emigration of human resources, including physicians, nurses, and other medical workforce, affecting the system's ability to provide essential services (MSPSC 2019). In Venezuela, hospitals barely cover the needs for reproductive and sexual health. The country has no updated numbers on the unmet need for contraceptives (Rivillas-García et al. 2021), and between 2015 and 2016, child deaths increased by 30.1% and maternal mortality by 64.4% (Rada 2022). Along with the precarious economic and social situation, international organizations and NGOs have reported that the need for reproductive and children’s healthcare is one of the principal motivations for leaving the country.

Colombia is the leading receptor country in the region for Venezuelan migration. Like other refugee crises, the constant flow of Venezuelan families to Colombia represented a challenge for the receptor country’s institutions, including its health system. Public hospitals had to explore ways to adapt to the population increase and to respond with emergency services to migrants without health insurance or legal documentation. In Medellin, one of the key receptor cities, Venezuelan migrant mothers describe their lives as a "daily struggle." A person walking downtown may find them asking for money in the streets, working in the service industry, or looking for clients in the red-light districts. Their lives are in tension with institutional control, economic insecurity, systemic violence, xenophobia, and sexism. In this article, I focus on the struggles experienced by Venezuelan women who left their homeland in search of better economic opportunities and ended up working in the sex industry in Medellín. I use the reproductive justice framework to argue that their difficulties accessing reproductive care result from the incapacity of local institutions and providers to attend to their necessities as migrants, sex workers, and mothers. My analysis derives from my ethnographic fieldwork in Medellin in 2022, which included 26 in-depth interviews with sex workers and healthcare professionals and participant observation in reproductive health events [1] .

Reproductive justice is a theoretical and political framework that women of color, feminist scholars, and health professionals developed to understand people’s reproductive needs using human rights and intersectional/decolonial feminism. Its foreground principles are "(1) the right not to have a child; (2) the right to have a child; and (3) the right to parent children in safe and healthy environments" (Ross and Solinger 2017, 9). Recently, the right to maintain personal bodily autonomy and sexual pleasure was added to the list (SisterSong 2023). Reproductive justice draws attention to the context in which individuals live and make decisions. It "insists on the social, economic, and political transformations that would allow all families and communities to thrive" (Murillo and Fixmer-Oraiz 2021, 762) and contributes to expanding the traditional notions of family, gender, and sexual pleasure (Stacey 2018). In what follows, I use reproductive justice to expose the landscapes of precarity in Medellin derived from the entanglements of sex work, migration, and reproductive health.

• The right not to have a child.

Venezuelan migrants in Colombia have experienced problems getting health insurance, primary care, and out-of-pocket expenses (Rivillas-García et al. 2021). Mobility restrictions, unstable employment, and bureaucratic barriers increase their difficulties accessing contraceptives and abortion in Medellin. Religious beliefs also conflict with providing or receiving an abortion in Medellin. Artemisa, an obstetrician, explains: "Here, the issue of abortion is a mess. In 2013, a nurse explained to me that only one doctor performed abortions in the public network. The rest claimed objection of consciousness because of their Catholic beliefs." These situations result in vulnerable populations like victims of human trafficking or rape, and those engaging in sex work lacking essential methods to protect their sexual health (Rivillas-García et al. 2021).

In some cases, sex workers perform “unsafe sex” (sex without a condom) because of the client's coercion. This situation affects their consistency in maintaining contraception. Flor, a mother of two, told me: "In Venezuela, I got the subdermal implant, but I have to replace it. Here, I don't have the money for that. It's going to rot in there!" More desperately, Alexandra will attempt to extract the implant herself: "They told me that I had to pay 100,000 COP. I will cut my arm to remove it anyway, but I don't know what it looks like." Having an expired implant or attempting to remove it without medical training increases the risk of infection, breakage, or implant migration. In addition, it can lead to unwanted pregnancies, often experienced as economic burdens and stress factors (McClelland and Newell 2008).

• The right to have a child.

In Western culture, many believe that motherhood and prostitution are incompatible (Cristoffanini 2017). Women in the sex industry are often described as corrupt, addicted, degraded, prone to disease, and bad mothers (Dickson 2019). The stigma of their work creates increased challenges and may target them for eugenic-based programs. Casandra, who recently arrived at Medellin, visited an institution offering sterilizations to migrant women: "There are many Venezuelans being sterilized. They [the doctors] are like: 'knife goes in, guts come out.' It's something like that, very fast." Casandra narrates that she did not receive information about the potential risks of the procedure, and nurses scolded her for being "too anxious." Although there have not been reports of forced sterilizations in the city, my observations confirmed that NGOs and health centers concentrated their efforts on sex-working sites. In these contexts, the borders between facilitating access to family planning or targeting the rights of specific populations to reproduce are difficult to trace.

Some health professionals were also uncomfortable with sex workers getting pregnant. Merida, a nurse, told me that a different "management protocol" would be necessary due to "increased risks." Similarly, the obstetrician Violeta said that a pregnant sex worker would be considered high risk: "Above all, the risk is social, although she also has risks due to possible STIs, right?" Merida and Violeta assumed sex workers were prone to infections and additional risks during their pregnancies, probably because of how sexual behavior is understood in nursing and medical schools in Colombia as a risk factor. However, generalizations from school or daily clinical practice can easily become prejudices. Most women in my study told me they never engaged in sexual practices without protection, even when clients offered them more money. Prejudices around sex work and motherhood increase medical discrimination and restrict women's decisions to have children.

• The right to parent in safe environments.

Venezuelan women in Medellín are far from having safe and sustainable environments to parent, a common trend for sex workers around the globe (Beckham et al. 2015). I heard multiple stories of discrimination, harassment, and violence occurring in the city, at work, inside their families, and during institutional encounters. Mona reported that her clients often "had knives, scissors… they pull one's hair and hit us." Similarly, Oriana mentioned that the brothels had no safety conditions: "No one knows what is happening there; the man comes in and drugs you. When you wake up, you are robbed, naked, and hurt." Some of these reports have reached local media, including histories of torture, murder, dismemberment, and impalement. Susan Fernández, a 22-year-old Venezuelan trans woman who worked in the sex industry in Medellin, represents a recent case. Susan was murdered with a knife by a client in the clandestine brothel where she worked.  The client managed to escape and is still on the run (Carvajal Bolívar 2023).

Sex workers also avoid accessing healthcare and welfare services for fear of having their children apprehended by Child Protection Services (Duff et al. 2015). Oriana, with tears in her eyes, described how the police took away her son one time she had to carry him while selling candies: "I was dragging, I didn't want anyone to talk to me, I just wanted the earth to swallow me. The suffering lasted 15 days until I recovered my son." Other women narrated similar stories and believed the local police surveilled their families with more severity for the mere fact of being Venezuelan migrants.

• The right to maintain personal bodily autonomy and sexual pleasure.

According to Morison et al. (2022), "sexual and reproductive injustice is not restricted to sexual and reproductive healthcare spaces but part of the wider context in which sex workers live and work" (23). Unfortunately, reproductive justice has rarely been used to analyze and address the sexual and reproductive health needs of sex workers, including their parenting experiences. The only exception I found was the study of Stevens, Dlamini, and Louskieter in South Africa, published in Morison et al. (2022). So far, reproductive justice scholars have failed to research the labor conditions of women in the sex industry, defend their bodily autonomy and sexual choices, and work toward the eradication of human trafficking and child prostitution.

With the appropriate conditions and protections, sex work can be another strategy that adult women use to provide for themselves and their families; as Diana said: "I enjoy the job, one gets many friends and regular clients. This work is what I do to support my children, and I am not ashamed of it." Following the fourth pillar, reproductive justice should support women’s rights to decide over their bodies and fight against the prejudice surrounding sex work. It is time for prostitution to be included in conversations about justice, healthcare, and human rights.

The four pillars of reproductive justice help us broaden our vision and reflect on how Venezuelan migrants in the sex industry experience barriers to accessing sexual and reproductive healthcare in Medellin. Their migratory situation, economic precarity, and unsafe labor conditions impact the care they deserve and their opportunities to navigate the health system. Their testimonies demonstrate that reproductive justice should fight structural xenophobia, sexism, and classism if it wants to be effective. The ethnographic information presented in this article suggests the need for a stronger coalition between grassroots movements, local authorities, and NGOs to close the health access gap for migrants and sex workers in Medellin. Additional research should be done to understand the healthcare needs of migrant sex workers in other contexts and facilitate the creation of policies directed toward the specific needs of this population.

Works Cited

Beckham, Sarah W., Catherine R. Shembilu, Peter J. Winch, Chris Beyrer, and Deanna L. Kerrigan. 2015. "'If You Have Children, You Have Responsibilities': Motherhood, Sex Work and HIV in Southern Tanzania."  Culture, Health & Sexuality  17(2): 165-79. https://doi.org/10.1080/13691058.2014.961034  

Carvajal Bolívar, Sebastián. August 8, 2023. “Asesinaron a una mujer trans en barrio residencial de Medellín .” El Tiempo . https://www.eltiempo.com/colombia/medellin/medellin-asesinaron-a-una-mujer-trans-en-barrio-residencial-794209

Cristoffanini, Macarena Trujillo. 2017. "Maternidad Y Prostitución ¿contradictorias Y Excluyentes?"  Estudos Feministas  25(1): 167-85. https://doi.org/10.1590/1806-9584.2017v25n1p167

Dickson, Holly. 2019 "Sex Work, Motherhood, and Stigma."  Sexual and Relationship Therapy  34(3): 332-34. https://doi.org/10.1080/14681994.2019.1573980

Duff, Putu, Jean Shoveller, Jill Chettiar, Cindy Feng, Rachel Nicoletti, and Kate Shannon. 2015. "Sex Work and Motherhood: Social and Structural Barriers to Health and Social Services for Pregnant and Parenting Street and Off-Street Sex Workers."  Health Care for Women International  36(9): 1039-055. https://doi.org/10.1080/07399332.2014.989437

McClelland, Gabrielle Tracy, and Robert Newell. 2008. "A Qualitative Study of the Experiences of Mothers Involved in Street-based Prostitution and Problematic Substance Use."  Journal of Research in Nursing  13 (5): 437-47. https://doi.org/10.1177/1744987108095409 .

Ministerio de Salud y Protección Social Colombia (MSPSC). 2019. Plan de Respuesta del Sector Salud para el Fenómeno Migratorio. https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE%20/COM/plan-respuesta-salud-migrantes.pdf

Morison, Tracy, Jabulile Mary-Jane Jace Mavuso, Aneeqa Abrahams, Andrea Alexander, Kristen Beek, Kate Burry, Ryan Du Toit, Jessica Dutton, Dudu Dlamini, and Nicola Gavey. 2022. "Sex Worker Narratives in Accessing Sexual and Reproductive Justice in South Africa." In Sexual and Reproductive Justice . United States: Lexington Books/Fortress Academic.

Murillo, Lina-María and Fixmer-Oraiz, Natalie. 2021. “Chapter 48: Reproductive Justice in the Heartland. Mothering, Maternal Care, and Race in Twenty-First-Century Iowa”. In Maternal Theory. Essential Readings, The 2nd Edition. Edited by Andrea O’Reilly. Demeter Press: 761-777

Rada, Cindy Hawkins. 2022. "Forced migration and reproductive rights: Pregnant women fleeing Venezuela." Anuario Colombiano de Derecho Internacional 15: 223-265. https://doi.org/10.12804/revistas.urosario.edu.co/acdi/a.9188 .  

RedTraSex. 2021. "Colombia - Nuestra Historia." Accessed in 2023. http://www.redtrasex.org/-Sobre-Nosotras-

Rivillas-García, Juan Carlos, Ángela Cifuentes-Avellaneda, Johan Sebastián Ariza-Abril, Marcela Sánchez-Molano, and Danny Rivera-Montero. 2021. "Venezuelan migrants and access to contraception in Colombia: A mixed research approach towards understanding patterns of inequality." Journal of Migration and Health 3: 100027. https://doi.org/10.1016/j.jmh.2020.100027 .  

Ross, Loretta, and Rickie Solinger. 2017. Reproductive Justice: An Introduction / Loretta J. Ross and Rickie Solinger.  Reproductive Justice; 1. Oakland, California: University of California Press.

Sistersong. 2023. “Reproductive Justice.” Women of Color Reproductive Justice Collective. Accessed in 2023. https://www.sistersong.net/reproductive-justice .

Stacey, Judith. 2018. "Queer Reproductive Justice?"  Reproductive Biomedicine & Society Online  7: 4-7. https://doi.org/10.1016/j.rbms.2018.06.004

[1] This research had IRB approval and followed the required procedures for ethical research, including using pseudonyms. I want to thank the organization Putamente Poderosas for their invaluable contributions to making this research possible.

Case Study Hub | Samples, Examples and Writing Tips

Case study on abortion, free case study on abortion:.

Almost all students who study at High school, College and University will face the problem of writing a case study on abortion , because this topic is very important nowadays and attracts much attention of the public. Being a complicated topic, it requires only reliable data and minimum of imagined facts and narration, that is why students often apply for professional writing help in the Internet and read free samples of case studies on abortion there to raise their chances of writing a good case study paper.

Abortion is a procedure aimed to stop pregnancy. The general attitude towards abortion is extremely different and categorical. Many people, including doctors support abortion or at least some of its kinds but every scholar agrees that the procedure should be done as early as possible, because abortion at later terms is a big threat to the life of a woman.

We can write a Custom Case Study on Abortion for you!

The majority of conservative thinking people, various religious organizations are completely against of abortion claiming it is an inhumane action. Many countries treat abortion as a crime and the woman with the doctor who has practised the operation can be imprisoned. On the other hand, abortion is the only way out when pregnancy is a threat to a woman’s life and then the procedure is legal.

As you see abortion is quite a controversial topic and you are free to research it in your own way. You may concentrate your attention at the types of this procedure with the description how it is done and prepare a general case study analysis on abortion ethics. Next, abortion is really a dangerous and serious procedure, so you way dwell on the research of this side of the topic and write a case study on threatened abortion or a case study on incomplete abortion. Many women risk their lives and want to get rid of the pregnancy on the late terms, so present a research on the terms when the procedure is more or less safe in the case study on missed abortion.

In order to complete a successful case study one should read much about the topic. Read encyclopedias, articles on medicine by reliable scholars who illustrate the procedure and the condition of a woman (physical and psychological impact of abortion on the woman’s body and soul). It will be useful to take advantage of free examples of case studies on spontaneous abortion available in the web, so pay attention to these samples and understand to the way and the style of writing, type of the content and structure of the paper. In the end think over about effective methods to cope with the problem of abortion or how to make it safer for the woman’s body.

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As Trump's trials loom, US judicial panel to reexamine TV ban

Former U.S. President Donald Trump attends the Trump Organization civil fraud trial, in New York State Supreme Court in the Manhattan borough of New York City, U.S., October 25, 2023. REUTERS/Jeenah Moon/File Photo Acquire Licensing Rights

• Advisory Committee on Criminal Rules to reexamine broadcast ban
• Any rule change unlikely before Trump goes to trial

Oct 26 (Reuters) - A U.S. judicial panel on Thursday agreed to study relaxing a long-standing ban on broadcasting federal criminal proceedings at the urging of Democratic lawmakers and news organizations seeking to televise former President Donald Trump's trials.

But even as the U.S. Judicial Conference's Advisory Committee on Criminal Rules agreed to establish a subcommittee to examine the issue, its chair warned that any rule change would likely come too late for Trump's federal trials next year.

"Even moving at warp speed for our committee, any rule change would not take effect for three years at best, more likely four years," U.S. District Judge James Dever, the committee's chair, said during a meeting in Minneapolis.

Trump, the leading contender for the Republican nomination for the 2024 presidential election, is facing federal charges in Washington and Florida that he tried to overturn the 2020 election and mishandled classified documents.

A trial in the election subversion case is set for March, and the classified documents one is scheduled for May . Trump, who also is under indictment in separate state court cases in Georgia and New York, has pleaded not guilty.

Proceedings in the Georgia case have been streamed on YouTube. But federal courts, unlike many state courts, bar TV cameras and photography in courtrooms, meaning only a handful of people who go to court in-person will be able to watch his federal trials.

In an Aug. 3 letter , 38 Democratic members of the House of Representatives urged the Judicial Conference, the judiciary's policymaking body, to nonetheless allow Trump's trials to be broadcast, saying "it is hard to imagine a more powerful circumstance for televised proceedings."

The letter was signed by among others Representatives Adam Schiff of California, Hank Johnson of Georgia, Gerry Connolly of Virginia and Bennie Thompson of Mississippi.

Several media organizations later made a similar request , asking the judiciary to at least create an exception for an "extraordinary case."

But in a Sept. 14 memo , two law professors who serve as advisers to the committee concluded it lacked authority to create an exemption to the broadcasting ban and any action the committee could take would come too late for Trump's trials.

One of the professors, Sara Sun Beale of Duke University School of Law, said at Thursday's meeting the fastest it could legally under its processes finalize a rule change was December 2026.

Despite that reality, Dever, who sits in Raleigh, North Carolina, said the panel would establish a subcommittee to broadly reexamine the broadcasting ban in Rule 53 of the Federal Rules of Criminal Procedure, citing longstanding debates over televising trials.

Several news organizations have separately asked U.S. District Judge Tanya Chutkan in Washington, D.C., to hold that applying the broadcasting ban to Trump's "unprecedented" election subversion case would be unconstitutional. The U.S. Department of Justice is expected to oppose their request by Nov. 3.

ACLU urges judge to reconsider Trump gag order in DC election case

Trump DC trial set for March 2024, in thick of GOP presidential fight

Trial in Trump classified documents case set for May 2024

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Reporting by Nate Raymond in Boston

Our Standards: The Thomson Reuters Trust Principles.

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Nate Raymond reports on the federal judiciary and litigation. He can be reached at [email protected].

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