tag:theconversation.com,2011:/au/topics/abortion-law-4639/articlesAbortion law – The Conversation2024-03-26T20:54:50Ztag:theconversation.com,2011:article/2266702024-03-26T20:54:50Z2024-03-26T20:54:50ZAbortion drug access could be limited by Supreme Court − if the court decides anti-abortion doctors can, in fact, challenge the FDA<figure><img src="https://images.theconversation.com/files/584450/original/file-20240326-30-a29mv8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pro-abortion rights activists rally in front of the Supreme Court on March 26, 2024, the day justices heard oral arguments about the use of mifepristone.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/abortion-rights-activist-rally-in-front-of-the-us-supreme-news-photo/2107843451?adppopup=true">Drew Angerer/AFP via Getty Images </a></span></figcaption></figure><p><em>Who has the legal right to challenge decisions by the U.S. Food and Drug Administration? And should the moral umbrage of a group of anti-abortion rights doctors shift policy across the country, limiting women’s ability to get the widely used abortion drug mifepristone?</em></p>
<p><em>These are a few of the central questions that the <a href="https://www.cbsnews.com/news/supreme-court-abortion-pill-arguments-mifepristone/">Supreme Court fielded on March 26, 2024</a>, during the oral arguments in <a href="https://www.scotusblog.com/case-files/cases/food-and-drug-administration-v-alliance-for-hippocratic-medicine-2/">FDA v. Alliance for Hippocratic Medicine</a>. A group of doctors is challenging the FDA, saying that the federal agency’s decision allowing people to get mifepristone via telehealth, at up to 10 weeks of pregnancy, is causing some medical professionals harm.</em></p>
<p><em>Amy Lieberman, politics and society editor at The Conversation U.S., spoke with family law and reproductive justice scholars <a href="https://scholar.google.com/citations?user=gCJEShUAAAAJ&hl=en">Naomi Cahn</a> and <a href="https://www.law.gwu.edu/sonia-m-suter">Sonia Suter</a> to better understand what’s behind the oral arguments before the Supreme Court – and how the court’s eventual decision, expected in June, could affect people’s ability to get abortions by using mifepristone, one of two drugs used for medication abortion.</em> </p>
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<a href="https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="White boxes of Mifepristone are seen stacked in a shelf." src="https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A cabinet holds mifepristone at a health clinic in Casper, Wyo., in June 2023.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/cabinet-containing-mifepristone-seen-in-wellspring-health-news-photo/1258730531?adppopup=true">Rachel Woolf for The Washington Post via Getty Images</a></span>
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<p><strong>What is this case about?</strong></p>
<p><strong>Sonia Suter:</strong> It’s about whether the FDA’s regulations for the use of <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answers-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation">mifepristone were appropriately loosened in 2016 and 2021</a>. These changes generally make mifepristone more accessible by allowing people to have the medication prescribed via a telehealth visit and then getting the pill in the mail.</p>
<p><strong>Naomi Cahn:</strong> That 2016 regulation also extended the time during which mifepristone could be prescribed, increasing it from seven to 10 weeks gestation. Medication abortions accounted for <a href="https://www.guttmacher.org/2024/03/medication-abortion-accounted-63-all-us-abortions-2023-increase-53-2020">63% of all abortions</a> that occurred in the U.S. in 2023. This percentage has increased since the Supreme Court overturned the constitutional right to an abortion in 2022.</p>
<p><strong>Why are these guidelines being challenged?</strong></p>
<p><strong>Suter:</strong> A group of doctors and medical associations that oppose abortion <a href="https://www.nytimes.com/2024/03/26/us/erin-hawley-abortion-pill-supreme-court.html">are challenging these guidelines</a> and using this court case as a way, we believe, to limit the ability to get an abortion by using medication. </p>
<p>They challenged the drug’s initial approval by the FDA and the relaxed restrictions on how it is used. They claimed that the FDA exceeded its authority, did not rely on proper data and did not have adequate support from scientific studies for its decision that mifepristone could be safely prescribed. Their initial arguments, which the lower court accepted, would have banned mifepristone. But that decision was not upheld by the <a href="https://www.ca5.uscourts.gov/opinions/pub/23/23-10362-CV1.pdf">5th Circuit Court</a>. </p>
<p>Instead, the issues before the Supreme Court focus on whether the FDA should have expanded the use of mifepristone. Virtually all studies have shown that <a href="https://www.nytimes.com/interactive/2023/04/01/health/abortion-pill-safety.html">mifepristone is not dangerous</a>, even with the relaxed conditions on its use. </p>
<p><strong>What is the federal government’s central argument against these claims?</strong></p>
<p><strong>Cahn:</strong> The government is stating that the FDA appropriately reviewed all of the evidence and its decision was appropriate. </p>
<p>Indeed, the attorney representing the mifepristone manufacturer, <a href="https://www.supremecourt.gov/oral_arguments/argument_transcripts/2023/23-235_p8k0.pdf">Jessica Ellsworth</a>, pointed out that <a href="https://apnews.com/article/abortion-pill-mifepristone-redacted-studies-supreme-court-ebd60519fd44dc69c5ac213580d1c1ba#:%7E:text=A%20medical%20journal%20has%20retracted,and%20flaws%20in%20their%20research.">the studies cited by the challengers have either been</a> discredited <a href="https://www.npr.org/sections/health-shots/2024/02/09/1230175305/abortion-pill-mifepristone-retraction-supreme-court">or withdrawn because they were unreliable</a>. </p>
<p>Another critical issue, as <a href="https://www.nytimes.com/live/2024/03/26/us/abortion-pill-supreme-court">U.S. Solicitor General Elizabeth Prelogar said to the justices today</a>, is whether the organization challenging this ruling actually has legal standing – the right to sue – to bring a lawsuit against the FDA. </p>
<p><strong>Why is the question of who can sue the FDA important here?</strong></p>
<p><strong>Suter:</strong> Under U.S. law, you cannot succeed in court every time you are unhappy. The Supreme Court has ruled that the Constitution requires parties who bring suit in federal court to <a href="https://www.law.cornell.edu/constitution-conan/article-3/section-2/clause-1/standing-requirement-overview">have “standing.”</a> This means parties have to show that they have been injured in some tangible way or threatened with such an injury by the acts that are the basis of the lawsuit. In this case, a group of doctors morally opposed to abortion are saying they have been injured. Their claim is that with the changes in the FDA’s regulation of mifepristone prescriptions, patients will come to them in the emergency room, requiring medical care that violates these religious beliefs and causes them stress. </p>
<p>The government’s response is that the FDA is not making them do anything, including prescribe these pills or treat these patients. And <a href="https://www.hhs.gov/conscience/conscience-protections/index.html">there are conscience laws</a> that say if the treatment is against a health care provider’s beliefs, they do not need to provide that care. So the government asks: How are the doctors harmed here?</p>
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<a href="https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A line of people in formal clothing are seen behind barricades outside the Supreme Court on a grey day." src="https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">People wait outside the Supreme Court to hear oral arguments on mifepristone on March 26, 2024.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/people-wait-in-line-outside-us-supreme-court-to-hear-oral-news-photo/2107843290?adppopup=true">Drew Angerer/AFP via Getty Images</a></span>
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<p><strong>What is your impression from the justices, listening to these arguments?</strong></p>
<p><strong>Cahn:</strong> I was surprised by how much time the justices spent asking about legal standing and whether there was a direct enough connection between the plaintiffs and the FDA’s guidance. </p>
<p><strong>What’s the potential impact of the court’s eventual ruling on this case?</strong></p>
<p><strong>Cahn:</strong> The court’s decision has implications for the whole FDA approval process as well as access to medication abortion, including through telehealth and the mail. If the court rules for the doctors challenging the FDA, mifepristone would still be available, but access to it would be severely limited because people would need an in-person visit before they could get it.</p><img src="https://counter.theconversation.com/content/226670/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Two legal scholars who study abortion-related laws explain what happened at the Supreme Court in a case that could make it harder to get an abortion.Naomi Cahn, Professor of Law, University of VirginiaSonia Suter, Professor of Law, George Washington UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2254182024-03-14T19:58:07Z2024-03-14T19:58:07ZIn France, abortion rights and hijab bans highlight a double standard on women’s rights<figure><img src="https://images.theconversation.com/files/581779/original/file-20240313-26-4feh20.jpg?ixlib=rb-1.1.0&rect=56%2C153%2C5348%2C3443&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even though laws on religious symbols are worded neutrally, in practice, they are mostly applied to Muslim women’s attire.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>The French parliament recently voted in favour of enshrining the <a href="https://www.lemonde.fr/en/politics/article/2024/03/04/france-enshrines-freedom-to-abortion-in-constitution-in-world-first_6584252_5.html">right to abortion into the country’s constitution</a>. While crowds celebrated outside, the slogan “my body my choice” was projected onto the Eiffel Tower <a href="https://www.theguardian.com/commentisfree/2024/mar/06/france-abortion-rights-emmanuel-macron">in giant letters</a>.</p>
<p>Although concerns about <a href="https://www.hrw.org/news/2024/03/05/france-protects-abortion-guaranteed-freedom-constitution">barriers and access</a> still remain, women in France are now guaranteed the right to an abortion up to 14 weeks into their pregnancy, mirroring Spain but still <a href="https://www.hrw.org/news/2022/03/01/france-expands-abortion-access-two-key-moves">well behind</a> Sweden’s 18 weeks and the 24 weeks allowed in The Netherlands.</p>
<p>The decision comes at a time when women’s reproductive rights elsewhere are under threat. In contrast to the United States Supreme Court’s decision <a href="https://www.nytimes.com/2022/06/24/us/roe-wade-overturned-supreme-court.html">overturning abortion rights</a>, France’s vote to enshrine them into its constitution looks like a feminist dream. </p>
<p>In his triumphant speech, French Prime Minister Gabriel Attal said: <a href="https://www.nytimes.com/2024/03/04/world/europe/france-abortion-rights-constitution.html">“We are sending the message to all women: Your body belongs to you and no one has the right to control it in your stead.”</a> </p>
<p>Yet just last year, Attal, as education minister, banned Muslim girls from wearing <a href="https://www.politico.eu/article/french-education-minister-announces-ban-on-islamic-dress-in-schools/">abayas in schools</a>. His message — and France’s — to Muslim girls and women seems to be the opposite.</p>
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<h2>Hijab bans</h2>
<p>France’s double standard on women’s rights is most plainly seen in its treatment of Muslim women and girls. A week after its historic abortion vote, France marks 20 years since the adoption of the <a href="https://www.legifrance.gouv.fr/jorf/id/JORFTEXT000000417977">March 2004 law</a> that bans students in public schools from wearing conspicuous symbols or clothing that manifest a religious affiliation.</p>
<p>In principle, the 2004 law applies to all students and prohibits them from wearing religious symbols like crosses, kippas (yarmulkes) and hijabs. But in practice, it is a sexist and racist law that <a href="https://www.amnesty.org/en/documents/eur21/7280/2023/en/">disproportionately targets Muslim girls</a>. </p>
<p><a href="https://yorkspace.library.yorku.ca/items/a9fd3c25-946c-4486-8dd5-5d9d13da4a34">My doctoral research</a> showed how Muslim girls are racially and religiously profiled by school administrators and have been suspended or expelled for wearing hoodies, hats, <a href="https://www.liberation.fr/societe/2013/04/04/la-jupe-et-le-bandeau-lettre-a-sirine_893735/">headbands</a> and <a href="https://www.cairn.info/islamophobie-comment-les-elites-francaises--9782707189462.htm">even long skirts</a>. Last year, they were also <a href="https://www.education.gouv.fr/bo/2023/Hebdo32/MENG2323654N">banned from wearing abayas</a>, which are long garments that are worn over clothing.</p>
<p>In my research, I refer to these bans as “anti-veiling laws” because, although they speak of religious symbols in general, the primary motivation behind these is always Muslim women’s dress. </p>
<p>France’s law led other jurisdictions across Europe and North America to ban Muslim women’s attire in various contexts. <a href="https://www.justiceinitiative.org/uploads/0b300685-1b89-46e2-bcf6-7ae5a77cb62c/policy-brief-restrictions-on-muslim-women%27s-dress-03252022.pdf">A 2022 report</a> from the Open Society Justice Initiative found that out of the 27 European Union member countries, only five have never enacted, or attempted to enact, bans on veiling. </p>
<p>Meanwhile, Québec holds the distinction of being the only province in Canada to implement a <a href="https://www.legisquebec.gouv.qc.ca/en/document/cs/l-0.3">ban on religious symbols</a>.</p>
<p>Former Québec Premier Pauline Marois cited the French law as being an <a href="https://www.ledevoir.com/politique/quebec/395252/pauline-marois-et-jean-marc-ayrault-sont-sur-la-meme-longueur-d-onde?">“inspiration”</a> for her government’s failed <a href="https://www.assnat.qc.ca/en/travaux-parlementaires/projets-loi/projet-loi-60-40-1.html?appelant=MC">Bill 60</a>, known as the Charter of Québec Values. That bill was a precursor to <a href="https://ccla.org/major-cases-and-reports/bill-21/">Québec’s Bill 21</a>, which bans teachers, judges, prosecutors, police officers and other officials in positions of authority from wearing religious symbols.</p>
<h2>Discrimination against Muslim women</h2>
<p>Even though the laws are worded neutrally, claiming to defend abstract principles like secularism, religious neutrality, gender equality or “<a href="https://hudoc.echr.coe.int/fre#%7B%22itemid%22:%5B%22001-145466%22%5D%7D">living together</a>,” in practice they are <a href="https://www.e-elgar.com/shop/gbp/behind-the-veil-9781788970846.html">mostly applied to Muslim women’s attire</a>.</p>
<p>Human rights groups like <a href="https://www.amnesty.org/en/documents/eur21/7280/2023/en/">Amnesty International</a> and the <a href="https://ccieurope.org/report2023/">Collective Against Islamophobia in Europe</a> have demonstrated that the surveillance, suspension and expulsion of Muslim girls at school have led to a decrease in their <a href="https://doi.org/10.1017/S0003055420000106">educational and employment outcomes</a>. </p>
<p>In addition to <a href="https://ccieurope.org/wp-content/uploads/2021/02/report-ccie-2023.pdf">increasing discrimination</a> against them, these bans also violate their right to education without discrimination, a right that is upheld in several international treaties, including the United Nations <a href="https://www.ohchr.org/en/instruments-mechanisms/instruments/convention-rights-child">Convention on the Rights of the Child</a>.</p>
<p>However, the most insidious aspect of France’s 2004 law is how it has been used to justify even further restrictions on the rights of Muslim women and girls, such as women wearing <a href="https://www.legifrance.gouv.fr/jorf/id/JORFTEXT000022911670">face veils or niqabs</a>, mothers wishing to accompany their children on <a href="https://www.education.gouv.fr/circulaire-preparation-rentree-2012?cid_bo=59726">school outings</a> and <a href="https://www.france24.com/en/europe/20230629-top-court-rules-in-favour-of-hijab-ban-in-french-women-s-football">women athletes</a> who <a href="https://www.amnesty.org/en/latest/news/2024/03/france-ensure-muslim-women-and-girls-can-play-sports/">wear hijab</a>. </p>
<p>In fact, Muslim women are routinely told to take off their clothes or to wear less clothing, even in places or contexts where they legally have the right to wear whatever they want, including at <a href="https://doi.org/10.13169/islastudj.4.1.0101">public beaches</a> and <a href="https://www.bbc.com/news/world-europe-61883529">swimming pools</a>.</p>
<h2>Body sovereignty</h2>
<p>This brings us back to the issue of a woman’s right to make decisions about her own body. Access to abortion is an important right for women everywhere, but women’s rights extend beyond abortion.</p>
<p>The concept of body sovereignty was developed by Indigenous feminists and activists, and refers to a person’s autonomy over their own body as well as to their <a href="https://doi.org/10.1080/10130950.2017.1366179">relationship to land</a>, <a href="https://www.adiosbarbie.com/2016/01/a-critical-conversation-with-sheena-roetman-on-body-sovereignty-and-justice/">belief systems</a> and ways of being that are <a href="https://www.journal.mai.ac.nz/system/files/MAI_Jrnl_2020_V9_2_Gillon_FINAL.pdf">intersectional</a>, <a href="https://ro.uow.edu.au/jgi/vol1/iss1/4">sexually diverse</a>, non-Eurocentric, non-ableist and <a href="https://doi.org/10.1177/1440783319893506">non-fatist</a>. It includes everything from diet, clothing, sexual activity and beauty ideals to reproductive health and freedom from violence.</p>
<p>Anti-veiling laws discriminate against Muslim women and girls, <a href="https://doi.org/10.3138/cjwl.32.1.05">encourage violence against them</a> and undermine the principle of body sovereignty.</p>
<p>Feminists and pro-choice activists everywhere should pause and think about what it means for governments to guarantee abortion rights to women while denying them the more expansive concept of body sovereignty. If feminists and their allies are outraged when theocratic regimes impose religious dress on women, they should be similarly outraged when democratic governments also restrict what women can wear: these are two sides of the same coin. </p>
<p>Both undermine women’s freedom, body sovereignty and self-determination. It is time for feminists everywhere to demand an end to laws that force women to dress one way or another, regardless of where in the world they are enacted.</p><img src="https://counter.theconversation.com/content/225418/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Roshan Arah Jahangeer does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As France enshrines abortion rights in its constitution, the country’s ban on wearing religious symbols in schools turns 20 years old.Roshan Arah Jahangeer, Postdoctoral Researcher, Memorial University of NewfoundlandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2213892024-01-26T13:21:52Z2024-01-26T13:21:52ZMost state abortion bans have limited exceptions − but it’s hard to understand what they mean<figure><img src="https://images.theconversation.com/files/571261/original/file-20240124-27-dzfjqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women who were denied abortions, despite serious pregnancy complications, appear outside the Texas Supreme Court in November 2023, following arguments in a lawsuit they brought against the state. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/plaintiffs-including-amanda-zurowski-speaks-at-a-press-news-photo/1807598346?adppopup=true">Suzanne Cordeiro/AFP via Getty Images </a></span></figcaption></figure><p>More than a year after the Supreme Court found there is no <a href="https://www.oyez.org/cases/2021/19-1392">fundamental right to get an abortion</a>, <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">21 states have laws in effect</a> that ban abortion well before fetal viability, generally allowing it only in the first trimester. </p>
<p>Fourteen of these 21 states have also issued near-total bans on abortion from the point of conception. But it’s not clear when, if ever, an abortion would be permissible under these near-total bans.</p>
<p>Virtually all states, including Arkansas, North Dakota and Oklahoma, for example, allow an <a href="https://www.kff.org/womens-health-policy/state-indicator/gestational-limit-abortions/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">abortion when necessary</a> to save the life of the pregnant person. But the laws don’t explain just how close to death the person must be before the abortion can be performed. </p>
<p><a href="https://www.kff.org/womens-health-policy/issue-brief/a-review-of-exceptions-in-state-abortions-bans-implications-for-the-provision-of-abortion-services">Some states</a>, such as Georgia, Indiana and West Virginia, also include exceptions for health concerns, rape, incest or lethal fetal anomalies. </p>
<p>Most of these exceptions are <a href="https://www.nytimes.com/2023/12/17/opinion/kate-cox-abortion-texas-exceptions.html">vaguely worded</a>, leaving physicians and pregnant patients to navigate <a href="https://www.nashvillescene.com/news/citylimits/sarah-needed-an-abortion-her-doctors-needed-lawyers/article_472a621e-7fdb-11ed-bf8d-0797b6012be2.html">whether a particular abortion</a> <a href="https://www.washingtonpost.com/health/2022/07/16/abortion-miscarriage-ectopic-pregnancy-care/">would be legal</a>. </p>
<p><a href="https://www.law.virginia.edu/faculty/profile/nrc8g/2915359">As experts</a> on <a href="https://www.law.gwu.edu/sonia-m-suter">reproductive health and justice</a>, we are trying to untangle just what these different medical exceptions mean. This is an important question for legal experts, but also for doctors and caregivers, as well as people who are pregnant and their families – all trying to make sense of the various bans in effect. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/571258/original/file-20240124-17-qkkg3o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="People, some holding posters, march outside of a grey building that says 'Bans off our bodies' in white writing, against a hot pink backdrop." src="https://images.theconversation.com/files/571258/original/file-20240124-17-qkkg3o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571258/original/file-20240124-17-qkkg3o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571258/original/file-20240124-17-qkkg3o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571258/original/file-20240124-17-qkkg3o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571258/original/file-20240124-17-qkkg3o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571258/original/file-20240124-17-qkkg3o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571258/original/file-20240124-17-qkkg3o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Anti-abortion activists protest outside a Planned Parenthood clinic in Washington, D.C., on Jan 18, 2024.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/pro-and-anti-abortion-protesters-are-facing-off-in-front-of-news-photo/1935914291?adppopup=true">Aaron Schwartz/NurPhoto via Getty Images</a></span>
</figcaption>
</figure>
<h2>Steep penalties, murky legal language</h2>
<p>Because these different state laws use nonmedical language and threaten steep penalties – such as <a href="https://www.americanprogress.org/article/a-year-after-the-supreme-court-overturned-roe-v-wade-trends-in-state-abortion-laws-have-emerged/">life imprisonment</a> – for performing an abortion that violates the statute, some <a href="https://www.nbcnews.com/health/health-news/risky-pregnancy-abortion-doctors-consult-lawyers-rcna37651">physicians have been turning to lawyers for guidance</a>. </p>
<p>For example, Tennessee <a href="https://law.justia.com/codes/tennessee/2021/title-39/chapter-15/part-2/section-39-15-213/">has an exception</a> that allows abortions “necessary to prevent the death of the pregnant woman or to prevent serious risk of substantial and irreversible impairment of a major bodily function of the pregnant woman.” And West Virginia allows abortions for “nonviable” fetuses, <a href="https://code.wvlegislature.gov/16-2R-2/">defined as those with a “lethal anomaly</a> … incompatible with life outside of the uterus.”</p>
<p>These exceptions are confusing to health care providers, in part because the laws <a href="https://scholarship.shu.edu/shlr/vol53/iss5/2">assume a certainty in medicine that may not exist</a>. The laws also <a href="https://www.cnn.com/2023/12/15/us/texas-abortion-ban-emergency-medical-exception/index.html">do not rely on medical terms</a>. </p>
<p>This means that health care providers in states where abortion is banned – apart from these limited exceptions – are reluctant to provide abortions under any circumstances, <a href="https://www.latimes.com/world-nation/story/2022-07-29/fearful-of-prosecution-doctors-debate-how-to-treat-pregnant-patients">even in the face of life-threatening conditions</a> or severe <a href="https://jessica.substack.com/p/abortion-exceptions-dont-exist">fetal anomalies</a>. </p>
<p>The rate of abortions in the states where there is a near-total or total ban <a href="https://www.axios.com/2023/10/24/abortion-increase-roe-wade-state-ban">decreased by 100%</a> from April 2022, just before the <a href="https://www.oyez.org/cases/2021/19-1392">Supreme Court overturned</a> the right to an abortion, through June 2023.</p>
<h2>Legal action for answers</h2>
<p>Some health care providers and their patients have sued to find out just when abortions might be permitted. </p>
<p>Courts in different states, from the trial court to the supreme court level, are now being forced to consider these questions and have begun to weigh in with opinions that lead to even more uncertainty. At the heart of this litigation is <a href="https://scholarship.shu.edu/cgi/viewcontent.cgi?article=3550&context=shlr">how to balance doctors’ conflicting obligations</a>
to provide the best medical care, which could include offering an abortion that they fear state bans may prohibit. </p>
<p>And because each state uses its own language to define a ban and its exceptions, one court’s opinion regarding its ban does not dictate how another state’s ban should be interpreted. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/571484/original/file-20240125-21-169abh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman in a black outfit stands at a podium in front of a long row of women who stand looking forward." src="https://images.theconversation.com/files/571484/original/file-20240125-21-169abh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571484/original/file-20240125-21-169abh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571484/original/file-20240125-21-169abh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571484/original/file-20240125-21-169abh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571484/original/file-20240125-21-169abh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571484/original/file-20240125-21-169abh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571484/original/file-20240125-21-169abh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Center for Reproductive Rights attorney Molly Duane speaks outside the Texas Supreme Court in Austin, joined by the plaintiffs in the organization’s abortion clarification suit against the state.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/center-for-reproductive-rights-attorney-molly-duane-news-photo/1807623427?adppopup=true">Suzanne Cordeiro/AFP via Getty Images</a></span>
</figcaption>
</figure>
<h2>Texas’ abortion ban</h2>
<p>Texas is one of the states that banned nearly all abortions in 2022. Texas law allows an abortion only when there is a “medical emergency” for the pregnant person, defined as a “life-threatening physical condition” related to the pregnancy that “poses a serious risk of substantial impairment of a <a href="https://statutes.capitol.texas.gov/Docs/HS/htm/HS.170A.htm#:%7E:text=Sec.-,170A.,induce%2C%20or%20attempt%20an%20abortion.">major bodily function</a>.”</p>
<p>In March 2023, the advocacy group Center for Reproductive Rights filed a lawsuit on behalf of a group of Texas women and two obstetricians-gynecologists, seeking clarification over when Texas’ ban allows an abortion. </p>
<p><a href="https://reproductiverights.org/zurawski-v-texas-plaintiffs-stories-remarks/">The Texas women</a>, who faced serious pregnancy-related health risks or very low odds of their baby’s survival outside the womb, were denied abortions or told to wait until death was more imminent. Some of the women got abortions outside of Texas, and others gave birth to babies who lived only briefly because of serious fetal health problems.</p>
<p><a href="https://reproductiverights.org/case/zurawski-v-texas-abortion-emergency-exceptions/zurawski-v-texas/">The plaintiffs argued</a> that the law’s confusing language – as well as the <a href="https://www.nytimes.com/2023/12/14/podcasts/the-daily/texas-abortion-ban.html?showTranscript=1">threat to physicians</a> of 99 years in jail, $100,000 in fines and a loss of their medical license – led to delays or denials of medical treatment they needed. </p>
<p>In August 2023, a Texas trial court judge blocked enforcement of the state’s abortion ban when “in a physician’s good faith judgment and in consultation with the pregnant person, the pregnant person has an emergent medical <a href="https://statecourtreport.org/sites/default/files/fastcase/additionalPdfs/processed/District%20Court%20-Order%20Granting%20Injunction%20-08.04.2023.pdf">condition requiring abortion care</a>.” This could include medical conditions that make it unsafe to continue the pregnancy or diagnosis of a fetal abnormality that would not allow it to survive after birth. </p>
<p>Texas appealed this decision to the state Supreme Court. The lower court decision is on hold until the Supreme Court issues its final decision; the court has not <a href="https://www.texastribune.org/2023/11/28/texas-supreme-court-abortion/">said when it would rule</a>.</p>
<p>Because there is still no definitive decision on how to interpret the Texas law, pregnant patients have been left in limbo. </p>
<p>Katie Cox, for example, is a Texas woman who was diagnosed when she was 20 weeks pregnant with a <a href="https://msmagazine.com/2023/12/13/welcome-to-the-pro-life-dystopia/">severe fetal anomaly</a> called trisomy 18. Carrying the pregnancy to term would have threatened her fertility, potentially preventing the mother of two from birthing more children in the future. </p>
<p>After <a href="https://www.nytimes.com/2023/12/14/podcasts/the-daily/texas-abortion-ban.html?showTranscript=1">Cox’s doctor</a> explained it was not an option in Texas to terminate the pregnancy, Cox and her doctor went to court seeking judicial approval for <a href="https://www.texastribune.org/2023/12/07/texas-emergency-abortion-lawsuit/">an abortion</a>. </p>
<p>Travis County District Judge Maya Guerra Gamble granted permission in December 2023, finding that it would be a “miscarriage of justice” to prohibit <a href="https://abc13.com/texas-abortion-ban-attorney-general-ken-paxton-katie-cox-block-ruling/14155514/">Cox from ending her pregnancy</a>. </p>
<p>But days later, the Texas Supreme Court blocked the district court ruling. It <a href="https://www.txcourts.gov/media/1457645/230994pc.pdf">conceded that Cox’s pregnancy was “extremely complicated</a>,” but refused to find that state law permitted the abortion. Cox left the state to get an abortion. </p>
<p>The Texas Supreme Court opinion in December still left many questions unanswered. The court stated that a judicial order was not required to permit a doctor to perform an abortion in the case of a medical emergency. <a href="https://www.txcourts.gov/media/1457645/230994pc.pdf">But it also interpreted the law as setting an objective standard as to whether the exception applied</a>. </p>
<p>That left open the possibility that the state could find an expert witness to challenge the physician’s judgment. </p>
<h2>A thread of uncertainty</h2>
<p>Since 2022, the Center for Reproductive Rights has also brought <a href="https://apnews.com/article/supreme-court-abortion-medical-emergencies-idaho-8ca89d7de0c1fa9256dcd27d1847e144#:%7E:text=The%20Supreme%20Court%20is%20allowing,ban%2C%20even%20in%20medical%20emergencies&text=WASHINGTON%20(AP)%20%E2%80%94%20The%20Supreme,while%20a%20legal%20fight%20continues">lawsuits in Idaho</a>, <a href="https://apnews.com/article/abortion-tennessee-lawsuit-fd630c5f55f605597d8eaa2800abbcfd#:%7E:text=WHAT%20THE%20LAWSUIT%20SEEKS%20TO,to%20legally%20receive%20an%20abortion">Tennessee</a> <a href="https://www.reuters.com/world/us/women-denied-abortions-file-lawsuits-idaho-tennessee-oklahoma-over-bans-2023-09-12/">and Oklahoma</a>, <a href="https://reproductiverights.org/exceptions-complaints-idaho-tennessee-oklahoma/">seeking clarity</a> on medical emergency exceptions in the states’ abortion bans.</p>
<p>The lawsuit’s underlying claim is that uncertainty about the scope of the exceptions has, according to the Idaho complaint, “sown confusion, fear and chaos among the medical community, resulting in grave harms to pregnant patients whose health and safety hang in the <a href="https://reproductiverights.org/wp-content/uploads/2023/09/ID-Complaint-Final-9-12.pdf">balance across the state</a>.” </p>
<p>What all of these cases and stories show is that even when abortion bans claim to allow exceptions based on medical judgment, physicians – and their patients – <a href="https://scholarship.shu.edu/cgi/viewcontent.cgi?article=3550&context=shlr">know their decisions</a> can be second-guessed and challenged in court.</p><img src="https://counter.theconversation.com/content/221389/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Women in Texas and in other states with abortion bans are suing, asking for clarification on when medical exceptions could actually be granted.Naomi Cahn, Professor of Law, University of VirginiaSonia Suter, Professor of law, George Washington UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2130332023-09-21T15:09:15Z2023-09-21T15:09:15ZA brief history of abortion – from ancient Egyptian herbs to fighting stigma today<figure><img src="https://images.theconversation.com/files/547772/original/file-20230912-9241-k9yjta.jpg?ixlib=rb-1.1.0&rect=502%2C90%2C3621%2C4365&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The first recorded evidence of induced abortion is from an ancient Egyptian papyrus.</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/pro-choice-posters-at-a-building-5841259/">pexels/karolina grabowska</a></span></figcaption></figure><p>You might be forgiven for thinking of abortion as a particularly modern phenomenon. But there’s plenty of evidence to suggest that abortion has been a constant feature <a href="https://muvs.org/en/topics/termination-of-pregnancy/abortion-in-antiquity-en/">of social life for thousands of years</a>. The history of abortion is often told as a legal one, yet abortion has continued regardless of, perhaps even in spite of, legal regulation. </p>
<p>The need to regulate fertility before or after sex has existed for as long as pregnancy has. <a href="https://www.britannica.com/topic/Ebers-papyrus">The Ancient Egyptian Papyrus Ebers</a> is often seen as some of the first written evidence of abortion practice. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/547764/original/file-20230912-21-i2tyac.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/547764/original/file-20230912-21-i2tyac.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=623&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547764/original/file-20230912-21-i2tyac.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=623&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547764/original/file-20230912-21-i2tyac.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=623&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547764/original/file-20230912-21-i2tyac.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=783&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547764/original/file-20230912-21-i2tyac.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=783&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547764/original/file-20230912-21-i2tyac.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=783&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Ebers Papyrus (c. 1600 BC) from Ancient Egypt.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=18511551"> PEbers/Einsamer Schützederivative/Photohound (talk)</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Dating back to 1600BC, the text <a href="https://archive.org/details/contraceptionhis0000jutt/page/10/mode/2up">describes</a> methods by which “the woman empties out the conceived in the first, second or third time period”, recommending herbs, vaginal douches and suppositories. Similar methods of inducing abortion were <a href="https://archive.org/details/contraceptionhis0000jutt/page/10/mode/2up">recorded</a>, although not recommended, by Hippocrates around the fourth century BC. </p>
<p>Part of the daily life of ancient citizens, abortion also found its way into their art. Publius Ovidius Naso, commonly known as Ovid, was a Roman poet whose collection of works <a href="https://www.poetryintranslation.com/PITBR/Latin/AmoresBkII.php#anchor_Toc520535846">Amores</a> describes the narrator’s emotional turmoil as he watches his lover suffering from a mismanaged abortion: </p>
<blockquote>
<p>While she rashly is overthrowing the burden of her pregnant womb, weary Corinna lies in danger of her life. Having attempted so great a danger without telling me.
She deserves my anger, but my anger dies with fear. </p>
</blockquote>
<p>Ovid’s concern at first is with the risk of losing his love Corinna, not the potential child. Later, he asks the gods to ignore the “destruction” of the child and save Corinna’s life. This reveals some important aspects of historical attitudes towards abortion. </p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
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<p><em>This article is part of <a href="https://theconversation.com/uk/topics/womens-health-matters-143335">Women’s Health Matters</a>, a series about the health and wellbeing of women and girls around the world. From menopause to miscarriage, pleasure to pain the articles in this series will delve into the full spectrum of women’s health issues to provide valuable information, insights and resources for women of all ages.</em></p>
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<hr>
<p>While 21st-century abortion debates often revolve around questions of life and personhood, this was not always the case. The Ancient Greeks and Romans, for example, did not necessarily <a href="https://archive.org/details/contraceptionhis0000jutt/page/10/mode/2up">believe</a> that a foetus was alive. </p>
<p>Early thinkers such as St. Augustine (AD354-AD430), for example, distinguished between the <a href="https://archive.org/details/abortion0000pott/mode/2up">embryo “informatus”</a> (unformed) and “formatus” (formed and endowed with a soul). Over time, the most common distinction became drawn at what was known as the <a href="https://archive.org/details/abortion0000pott/mode/2up">“quickening”</a>, which was when the pregnant woman could feel the baby move for the first time. This determined that the foetus was alive (or had a soul).</p>
<p>As a delayed period was often the first sign something was amiss, and a woman may not have considered herself pregnant until much later, a lot of advice on abortion would focus on restoring <a href="https://www.routledge.com/Abortion-in-England-1900-1967/Brookes/p/book/9780415752466">menstrual irregularities</a> or blockages instead of terminating a potential pregnancy (or foetus). </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/547767/original/file-20230912-31-6n0182.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Drawing of a woman making herbs for an abortion with patient lying on a bed." src="https://images.theconversation.com/files/547767/original/file-20230912-31-6n0182.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547767/original/file-20230912-31-6n0182.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=442&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547767/original/file-20230912-31-6n0182.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=442&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547767/original/file-20230912-31-6n0182.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=442&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547767/original/file-20230912-31-6n0182.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=555&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547767/original/file-20230912-31-6n0182.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=555&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547767/original/file-20230912-31-6n0182.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=555&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Art from a 13th-century manuscript features a herbalist preparing a concoction containing pennyroyal for a woman. The tea made famous in the Nirvana song, Pennyroyal Tea, was used in folk medicine to induce abortion and alleviate menstrual symptoms.</span>
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<p>As a result, much of the abortion advice throughout history does not necessarily mention abortion at all. And it was often down to personal interpretation whether or not an abortion had even taken place. </p>
<p>Indeed, recipes for “abortifacients” (any substance that is used to terminate a pregnancy) could be found in medical texts like those from the German nun <a href="https://daily.jstor.org/abortion-remedies-medieval-catholic-nun/">Hildegard von Bingen</a> in 1150 and in <a href="https://archive.org/details/abortion0000pott/page/284/mode/2up">domestic recipe books</a> with treatments for other common ailments well into the 20th century. </p>
<p>In the west, the quickening distinction gradually <a href="https://archive.org/details/abortion0000pott/page/284/mode/2up">went out of fashion</a> over the late 19th and early 20th centuries. Yet women continued to have abortions despite changing beliefs about life and the law. In fact, some sources claimed, they seemed to be more common than ever. </p>
<h2>“An epidemic of abortions”</h2>
<p>In 1920, <a href="https://www.routledge.com/Abortion-in-England-1900-1967/Brookes/p/book/9780415752466">Russia</a> became the first state in the world to legalise abortion, and in 1929, famous birth control advocate <a href="https://wellcomecollection.org/works/c6yxqrgn">Marie Stopes</a> lamented that “an epidemic of abortions” was sweeping England. <a href="https://archive.org/details/abortion0000pott/page/284/mode/2up">Similar claims</a> from France and the US also indicate a perceived uptick. </p>
<p>These claims accompanied a wave of plays, poems and novels that included abortion. In fact, in 1923, Floyd Dell, the US magazine editor and writer, published a new work of fiction, <a href="https://www.amazon.co.uk/Janet-March-Floyd-Dell/dp/B00085CQAE">Janet March</a>, where the main character complains about the number of novels that feature abortions, stating there “were dreadful things enough in novels, but they happened only to poor girls – ignorant and reckless girls”. </p>
<p>But the literature of the early 20th century, with many stories based on women’s real experiences, attests to a wider range of abortions than the stereotypical image of the poor and destitute backstreet operations of the 1900s. </p>
<p>For example, the English novelist, Rosamond Lehmann records a seductive “feminine conspiracy” of aborting women waiting with “tact, sympathy, pills and hot-water bottles”, in her 1926 novel <a href="https://www.amazon.co.uk/Weather-Streets-Virago-Modern-Classics/dp/1844083063">The Weather in the Streets</a>. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/547765/original/file-20230912-29-ewkeg1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Abortion advert from newspaper" src="https://images.theconversation.com/files/547765/original/file-20230912-29-ewkeg1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/547765/original/file-20230912-29-ewkeg1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=482&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547765/original/file-20230912-29-ewkeg1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=482&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547765/original/file-20230912-29-ewkeg1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=482&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547765/original/file-20230912-29-ewkeg1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=605&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547765/original/file-20230912-29-ewkeg1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=605&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547765/original/file-20230912-29-ewkeg1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=605&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Advertisements for abortion services, like these in the New York Sun in 1842, were common during the Victorian era. At the time, abortion was illegal in New York.</span>
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</figure>
<p>These texts form part of a long tradition of abortion storytelling that is a predecessor to contemporary activism. For example, <a href="https://www.abortion.shop/">We Testify</a> is an organisation dedicated to the leadership and representation of people who have abortions. And <a href="https://shoutyourabortion.com/">Shout Your Abortion</a> is a social media campaign where people share their abortion experiences online without “sadness, shame or regret”.</p>
<p>Abortion has a long and varied history, but above all these texts – from the Egyptian papyri of 1600BC to the social media posts of today – show that abortion has been and remains central to our history, our lives and even our art.</p><img src="https://counter.theconversation.com/content/213033/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alisha Palmer does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Abortion has a long and varied history and remains central to our culture, our lives and even our art.Alisha Palmer, PhD Candidate in English Literature, The University of EdinburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2131792023-09-19T16:20:00Z2023-09-19T16:20:00ZMexican court ruling upholding women’s right to abortion shows global trend better than US Roe v Wade decision<p>It may surprise you to learn that, over the past 30 years, no fewer than <a href="https://reproductiverights.org/maps/worlds-abortion-laws/">60 countries</a> have liberalised their abortion laws while <a href="https://reproductiverights.org/maps/worlds-abortion-laws/">only four</a> have rolled back abortion rights. The United States is, of course, one of the latter group that has recently restricted women’s access to abortion. </p>
<p>Because the US looms so large in international news coverage of abortion, casual observers often assume that anti-abortion reforms in the US signal a broader global trend or will trigger a domino effect of abortion restrictions. But this view is misguided. It’s important to explore why this is. </p>
<p>In order to understand global abortion trends, we should look across America’s southern border to Mexico. On September 7, <a href="https://www.reuters.com/world/americas/mexicos-supreme-court-upholds-abortion-rights-nationwide-paving-way-federal-2023-09-06/">a landmark decision</a> by Mexico’s supreme court found that laws prohibiting abortion were unconstitutional violations of women’s rights. The decision lays the foundation for full decriminalisation of abortion in Mexico – but will have to be enacted in the legislature before it will be the law of the land. </p>
<p>Nonetheless, Mexico’s trajectory is more representative of what is happening across the globe than the US <a href="https://theconversation.com/us-supreme-court-decision-on-abortion-creates-patchwork-of-rights-based-on-where-you-live-186319">supreme court decision of 2022</a> that overturned the constitutional abortion right of Roe v Wade. </p>
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<a href="https://theconversation.com/us-supreme-court-decision-on-abortion-creates-patchwork-of-rights-based-on-where-you-live-186319">US Supreme Court decision on abortion creates 'patchwork of rights' based on where you live</a>
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<p>Progress on abortion rights is visible <a href="https://reproductiverights.org/maps/worlds-abortion-laws/">across the world</a>. Mexico is part of a “green wave” across Latin America that has also achieved reforms in <a href="https://www.bbc.co.uk/news/world-latin-america-64784660">Argentina</a> and <a href="https://read.dukeupress.edu/south-atlantic-quarterly/article/122/2/397/343181/Abortion-Reform-in-Colombia-From-Total-Prohibition">Colombia</a>. But progress is not limited to Latin America. In 2018, Irish voters <a href="https://www.irishtimes.com/news/politics/ireland-votes-to-remove-constitutional-ban-on-abortion-by-resounding-two-thirds-majority-1.3510068">overwhelmingly supported</a> a measure to remove a constitutional abortion ban. </p>
<p>Within the space of two years (2020-2022), Thailand moved from a criminal ban on abortion to <a href="https://time.com/6225758/thailand-abortion-access/">legal abortion up to 20 weeks</a>. In 2021, Benin adopted one of Africa’s <a href="https://www.theguardian.com/global-development/2023/feb/28/benin-africa-liberal-abortion-laws-women-still-dying#:%7E:text=Abortions%20can%20be%20carried%20out,most%20liberal%20laws%20in%20Africa.">most progressive abortion laws</a>, allowing for abortion on a range of grounds up to 12 weeks. India’s supreme court <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10321178/#">expanded abortion rights in 2022</a>, ruling that all Indian women must have the right to safe and legal abortion regardless of their marital status. </p>
<p>So countries such as the USA, <a href="https://www.hrw.org/news/2023/09/14/poland-abortion-witch-hunt-targets-women-doctors">Poland</a>, <a href="https://www.opendemocracy.net/en/5050/el-salvador-women-abortion-obstetric-problems-prison-fight/">El Salvador</a>, and <a href="https://www.hrw.org/news/2017/07/31/nicaragua-abortion-ban-threatens-health-and-lives">Nicaragua</a> – the four to roll back abortion rights in recent years – are global outliers. </p>
<h2>Building support for women’s right to choose</h2>
<p>How have these progressive reforms come about? Abortion advocates have achieved successes through engaging with political processes. Argentine activists built a broad-based social movement and multi-party coalition in the legislature to <a href="https://blog.petrieflom.law.harvard.edu/2023/03/03/decriminalizing-abortion-in-argentina-8-takeaways-from-the-inflection-point-of-legalization/">legalise abortion in 2020</a>. In Colombia and Mexico, activists used creative legal strategies to achieve change, bringing strategic litigation and establishing themselves as legal experts. </p>
<p>After Mexico’s supreme court struck down a criminal abortion law at the state level in 2021, ruling that <a href="https://www.aljazeera.com/news/2021/9/7/mexico-supreme-court-says-criminalising-abortion-unconstitutional">criminalising abortion was unconstitutional</a>, NGOs launched a legal campaign to expand that decision nationwide. In last week’s ruling, Mexican courts ruled that abortion <a href="https://www.aljazeera.com/news/2023/9/7/mexican-supreme-court-decriminalises-abortion-on-federal-level#">should be removed from the federal penal code</a>. </p>
<p>In Colombia, a 2006 court ruling limited legal abortion to a few very narrow grounds. Feminist activists there mobilised to develop and disseminate <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5473042/">progressive interpretations</a> of the law, working with doctors to ensure they could provide abortions while feeling protected from prosecution. In 2022, Colombia’s supreme court decriminalised abortion up to 24 weeks. A <a href="https://www.theguardian.com/global-development/2023/mar/24/historic-moment-as-el-salvador-abortion-case-fuels-hopes-for-expanded-access-across-latin-america#:%7E:text=In%20El%20Salvador%2C%20abortion%20is,to%2050%2Dyear%20prison%20sentence">pending case</a> before the Inter-american Court of Human Rights holds out the promise of progress for abortion rights in El Saldavor. </p>
<p>When social movements achieve change in political institutions, they are often capitalising on years of on-the-ground campaigning to shift public opinion on abortion. Latin American activists term this process “<a href="https://doi.org/10.1215/00382876-10405133">social decriminalisation</a>”. Even where criminal anti-abortion laws persist, its social status can change. </p>
<p>Reducing abortion stigma, normalising abortion as a part of reproductive life and mobilising the public against anti-abortion prosecutions are all part of this toolkit. </p>
<p>When public attitudes shift, anti-abortion laws can lose public legitimacy and political elites can find themselves out of step with public opinion. Ireland’s 2018 <a href="https://www.bbc.co.uk/news/world-europe-44256152">abortion referendum</a> showed us this dynamic: although years of opinion polls had consistently showed the constitutional abortion ban was unpopular, Irish politicians sought to avoid the issue. But in 2017, a <a href="https://2016-2018.citizensassembly.ie/en/The-Eighth-Amendment-of-the-Constitution/Final-Report-on-the-Eighth-Amendment-of-the-Constitution/">Citizens Assembly</a> was held on the issue which showed that the public urgently wanted reform. When the abortion ban was put to referendum in 2018, two-thirds of Irish voters supported legal abortion. </p>
<p>Growing availability of self-managed abortion is also an important factor in the global trend towards abortion reform. Self-managed abortion with pills means that safe abortion is easier to access outside of clinical settings and in restrictive contexts. </p>
<p>But self-managed abortion also highlights the political dilemma that governments face when they seek to enforce restrictive abortion laws. If abortion is as easy as taking a few pills that can be bought online, people will self-manage abortions regardless of the laws where they live. Efforts to prosecute them for doing so can provoke a backlash and highlight the illegitimacy of abortion bans. </p>
<p>Campaigners in Northern Ireland capitalised on changing public attitudes, as well as an inquiry by a <a href="https://www.ohchr.org/en/press-releases/2018/02/uk-violates-womens-rights-northern-ireland-unduly-restricting-access">human rights treaty body</a>, to secure a moratorium on prosecution of self-managed abortion. Abortion has been decriminalised there since 2019. </p>
<p>Abortion rights rollbacks in the US have understandably provoked outrage. Since Roe v Wade was overturned, American states have passed anti-abortion laws that are <a href="https://www.npr.org/sections/health-shots/2023/08/09/1187378801/texas-abortion-law-trial-reproductive-rights">cruel and dehumanising</a>. These anti-abortion laws disproportionately affect <a href="https://www.ifwhenhow.org/resources/self-care-criminalized-preliminary-findings/">the most marginalised</a> and are sure to widen gaps in an already deeply unequal society. </p>
<p>But the American story is an outlier. At a global scale, the trajectory we see on abortion rights is one of slow but continuous progress.</p><img src="https://counter.theconversation.com/content/213179/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sydney Calkin receives funding from the Leverhulme Trust and UKRI. She is a volunteer with the Abortion Support Network (UK). </span></em></p>The US is one of just four countries that have rolled back women’s abortion rights in recent years.Sydney Calkin, Reader in Geography, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2082762023-07-13T12:37:38Z2023-07-13T12:37:38ZPromising assisted reproductive technologies come with ethical, legal and social challenges – a developmental biologist and a bioethicist discuss IVF, abortion and the mice with two dads<figure><img src="https://images.theconversation.com/files/534595/original/file-20230628-23-se3fkd.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2000%2C1500&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A few days after successful fertilization, an embryo becomes a rapidly dividing ball of cells called a blastocyst.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/blastocyst-embryo-illustration-royalty-free-illustration/1498384521">Juan Gaertner/Science Photo Library via Getty Images</a></span></figcaption></figure><p><em>Assisted reproductive technologies are medical procedures that help people experiencing difficulty having or an inability to have biological children of their own. From in vitro fertilization to genetic screening to creation of viable eggs from the <a href="https://doi.org/10.1038/s41586-023-05834-x">skin cells of two male mice</a>, each new development speaks to the potential of reproductive technologies to expand access to the experience of pregnancy.</em> </p>
<p><em>Translating advances from the lab to the clinic, however, comes with challenges that go far beyond the purely technical.</em></p>
<p><em>Conversations around the ethics and implications of cutting-edge research often happen after the fact, when the science and technology have advanced beyond the point at which open dialogue could best protect affected groups. In the spirit of starting such cross-discipline conversations earlier, we invited developmental biologist <a href="https://scholar.google.com/citations?user=i6SghEMAAAAJ&hl=en">Keith Latham</a> of Michigan State University and bioethicist <a href="https://www.researchgate.net/profile/Mary-Faith-Marshall">Mary Faith Marshall</a> of the University of Virginia to discuss the ethical and technological potential of <a href="https://www.npr.org/sections/health-shots/2023/05/27/1177191913/sperm-or-egg-in-lab-breakthrough-in-reproduction-designer-babies-ivg">in vitro gametogenesis</a> and assisted reproductive technology post-Roe.</em></p>
<h2>How new are the ethical considerations raised by assisted reproductive technologies?</h2>
<p><strong>Keith</strong></p>
<p>Every new technology raises many of the same questions, and likely new ones. On the safety and risk-benefit side of the ethical conversation, there’s nothing here that we haven’t dealt with since the 1970s with other reproductive technologies. But it’s important to keep asking questions, because the benefits are hugely dependent on the success rate. There are potential biological costs, but also possible social costs, financial costs, societal costs and many others.</p>
<p><strong>Mary Faith</strong> </p>
<p>It’s probably been that way even longer. One of my mentors, Joseph Francis Fletcher, a pioneering bioethicist and Episcopal priest, wrote a book called “<a href="https://press.princeton.edu/books/hardcover/9780691635224/morals-and-medicine">Morals and Medicine</a>” in 1954. It was the first non-Roman Catholic treatment of bioethics. And he raised a lot of these issues there, including the <a href="https://theconversation.com/jurassic-world-scientists-still-havent-learned-that-just-because-you-can-doesnt-mean-you-should-real-world-genetic-engineers-can-learn-from-the-cautionary-tale-184369">technological imperative</a> – the idea that because we can develop the technology to do something, we therefore should develop it.</p>
<p>Fletcher also said that the use of artifice, or human-made creations, is supremely human. That’s what we do: We figure out how things work and we develop new technologies like vaccines and heart-lung machines based on evolving scientific knowledge.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/534596/original/file-20230628-30-nfjlun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Microscopy image of mouse ovum being fertilized by mouse sperm" src="https://images.theconversation.com/files/534596/original/file-20230628-30-nfjlun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534596/original/file-20230628-30-nfjlun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=388&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534596/original/file-20230628-30-nfjlun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=388&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534596/original/file-20230628-30-nfjlun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=388&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534596/original/file-20230628-30-nfjlun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=487&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534596/original/file-20230628-30-nfjlun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=487&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534596/original/file-20230628-30-nfjlun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=487&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Scientists were able to create a mouse egg from the skin cells of male mice.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/fertilization-of-mouse-ovum-royalty-free-image/523741410">Clouds Hill Imaging Ltd./Corbis Documentary via Getty Images</a></span>
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<p>I think that in most cases, scientists should be involved in thinking about the implications of their work. But often, researchers focus more on the direct applications of their work than the potential indirect consequences. </p>
<p>Given the evolution of assisted reproductive technology, and the fact that its evolution is going to continue, I think one of the central questions to consider is, what are the goals of developing it? For assisted reproduction, it’s to help infertile people and people in nontraditional relationships have children.</p>
<h2>What are some recent developments in the field of assisted reproductive technology?</h2>
<p><strong>Keith</strong></p>
<p>One recent advance in assisted reproductive technology is the expansion of <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/03/preimplantation-genetic-testing">pre-implantation genetic testing</a> methods, particularly DNA sequencing. Many genes come in different variants, or alleles, that can be inherited from each parent. Providers can determine whether an embryo bears a “bad” allele that may increase the risk of certain diseases and select embryos with “healthy” alleles.</p>
<p>Genetic screening <a href="https://doi.org/10.1016/j.fertnstert.2022.03.017">raises several ethical concerns</a>. For example, the parents’ genetic profiles could be unwillingly inferred from that of the embryo. This possibility may deter prospective parents from having children, and such knowledge may also have potential effects on any future child. The cost of screening and potential need for additional cycles of IVF may also increase disparities.</p>
<p>There are also considerations about the <a href="https://doi.org/10.1016/j.fertnstert.2022.03.019">accuracy of screening predictions</a> without accounting for environmental effects, and what <a href="https://doi.org/10.1007/s12687-021-00573-w">level of genetic risk</a> is “serious” enough for an embryo to be excluded. More extensive screening also raises concerns about possible misuse for purposes other than disease prevention, such as production of “<a href="https://theconversation.com/an-american-company-will-test-your-embryos-for-genetic-defects-but-designer-babies-arent-here-just-yet-126833">designer babies</a>.”</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/uhb5gd5B-7g?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">In vitro gametogenesis involves making egg or sperm cells from other adult cells in the body.</span></figcaption>
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<p>At a <a href="https://www.nationalacademies.org/news/2023/02/agenda-for-third-international-summit-on-human-genome-editing-march-6-8">genome-editing conference</a> in March 2023, researchers announced that they were able to <a href="https://doi.org/10.1038/s41586-023-05834-x">delete and duplicate whole chromosomes</a> from the skin cells of male mice to make eggs. This method is one potential way to make eggs that do not carry genetic abnormalities. </p>
<p>They were very upfront that this was done at 1% efficiency in mice, which could be lower in humans. That means something bad happened to 99% of the embryos. The biological world is not typically binary, so a portion of that surviving 1% could still be abnormal. Just because the mice survived doesn’t mean they’re OK. I would say at this point, it would be unethical to try this on people.</p>
<p>As with some forms of genetic screening, using this technique to reduce the risk of one disease could inadvertently increase the risk of another. Determining that it is absolutely safe to duplicate a chromosome would require knowing every allele of every gene on that chromosome, and what each allele could do to the health of a person. That’s a pretty tall order, as that could involve identifying hundreds to thousands of genes, and the effects of all their variants may not be known. </p>
<p><strong>Mary Faith</strong></p>
<p>That raises the issue of efficacy and costs to yet another order of magnitude.</p>
<p><strong>Keith</strong> </p>
<p>Genome editing with <a href="https://theconversation.com/human-genome-editing-offers-tantalizing-possibilities-but-without-clear-guidelines-many-ethical-questions-still-remain-200983">CRISPR technology</a> in people carries similar concerns. Because of potential limitations in how precise the technology can be, it may be difficult for researchers to say they are absolutely 100% certain there won’t be off-target changes in the genome. Proceeding without that full knowledge could be risky. </p>
<p>But that’s where bioethicists need to come into play. Researchers don’t know what the full risk is, so how do you make that risk-benefit calculation?</p>
<p><strong>Mary Faith</strong></p>
<p>There’s the option of a voluntary global moratorium on using these technologies on human embryos. But somebody somewhere is <a href="https://theconversation.com/did-he-jiankui-make-people-better-documentary-spurs-a-new-look-at-the-case-of-the-first-gene-edited-babies-196714">still going to do it</a>, because the technology is just sitting there, waiting to be moved forward.</p>
<h2>How will the legal landscape affect the development and implementation of assisted reproductive technologies?</h2>
<p><strong>Mary Faith</strong></p>
<p>Any research that involves human embryos is in some ways politicized. Not only because the <a href="https://doi.org/10.1038/d41586-020-00127-z">government provides funding</a> to the basic science labs that conduct this research, but because of the wide array of beliefs that members of the public at large have about <a href="https://theconversation.com/defining-when-human-life-begins-is-not-a-question-science-can-answer-its-a-question-of-politics-and-ethical-values-165514">when life begins</a> or <a href="https://theconversation.com/what-is-personhood-the-ethics-question-that-needs-a-closer-look-in-abortion-debates-182745">what personhood means</a>.</p>
<p>The <a href="https://theconversation.com/roe-overturned-what-you-need-to-know-about-the-supreme-court-abortion-decision-184692">Dobbs decision</a>, which overturned the constitutional right to an abortion, has implications for assisted reproduction and beyond. Most people who are pregnant don’t even know they’re pregnant at the earliest stages, and somewhere around <a href="https://theconversation.com/most-human-embryos-naturally-die-after-conception-restrictive-abortion-laws-fail-to-take-this-embryo-loss-into-account-187904">60% of those pregnancies end naturally</a> because of genetic aberrations. Between 1973 and 2005, <a href="https://doi.org/10.1215/03616878-1966324">over 400 women were arrested for miscarriage in the U.S.</a>, and I think that number is going to grow. The implications for reproductive health care, and for assisted reproduction in the future, are challenging and frightening.</p>
<p>What will abortion restrictions mean for people who have <a href="https://www.cdc.gov/art/key-findings/multiple-births.html">multiple-gestation pregnancies</a>, in which they carry more than one embryo at the same time? In order to have one healthy child born from that process, the other embryos often need to be removed so they don’t all die. In the past 40 years, the number of twin births doubled and triplet and higher-order births quadrupled, primarily because of fertility treatments. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/534477/original/file-20230628-27-v0r0uc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Needle touching eggs in petri dish under microscope in IVF" src="https://images.theconversation.com/files/534477/original/file-20230628-27-v0r0uc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534477/original/file-20230628-27-v0r0uc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534477/original/file-20230628-27-v0r0uc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534477/original/file-20230628-27-v0r0uc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534477/original/file-20230628-27-v0r0uc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534477/original/file-20230628-27-v0r0uc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534477/original/file-20230628-27-v0r0uc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">IVF may involve transferring more than one embryo at a time.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/in-vitro-fertilization-royalty-free-image/1272954210">Antonio Marquez lanza/Moment via Getty Images</a></span>
</figcaption>
</figure>
<p><strong>Keith</strong> </p>
<p>IVF may transfer one, two, or sometimes three embryos at a time. The <a href="https://doi.org/10.1016/j.jpeds.2022.11.038">cost of care for preterm birth</a>, which is one possible outcome of multiple-gestation pregnancies, can be high. That’s in addition to the <a href="https://doi.org/10.1016/j.ajog.2013.10.005">cost of delivery</a>. IVF clinics are increasingly transferring just one embryo to mitigate such concerns.</p>
<p>The life-at-conception bills that have been put forth in some U.S. state legislatures and Congress may contain language claiming they are not meant to prevent IVF. But the language of the bills could be extended to affect procedures such as IVF with pre-implantation genetic testing to detect chromosomal abnormalities, particularly when single-embryo transfer is the goal. Pre-implantation genetic testing has been increasing, with one study estimating that <a href="https://doi.org/10.1001/jama.2022.1892">over 40% of all IVF cycles</a> in the U.S. in 2018 involved genetic screening. </p>
<p>Could life-at-conception bills criminalize clinics that don’t transfer embryos known to be genetically abnormal? Freezing genetically abnormal embryos could avoid destroying them, but that raises questions of, to what end? Who would pay for the storage, and who would be responsible for those embryos?</p>
<h2>How can we determine whether the risks outweigh the benefits when so much is unknown?</h2>
<p><strong>Keith</strong></p>
<p>Conducting studies in animal models is an important first step. In some cases, it either hasn’t been done or hasn’t been done extensively. Even with animal studies, you have to recognize that mice, rabbits and monkeys are not human. Animal models may reduce some risks before a technology is used in people, but they won’t eliminate all risks, because of biological differences between species.</p>
<p><strong>Mary Faith</strong> </p>
<p>We could look to the example of <a href="https://www.genome.gov/25520302/online-education-kit-1972-first-recombinant-dna">early recombinant DNA research in the U.S.</a> The federal government created the <a href="https://doi.org/10.1089%2Fhum.2013.2524">Recombinant DNA Advisory Committee at the National Institutes of Health</a> to oversee animal and early-phase human research involving synthetic or hybrid genetic material. </p>
<p>The <a href="https://doi.org/10.1126/science.307.5712.1028b">death of Jesse Gelsinger</a>, who was a participant in a gene therapy clinical trial in 1999, led to a halt in all gene therapy clinical trials in the U.S. for a time. When the Food and Drug Administration investigated what went wrong, they found huge numbers of adverse events in both humans and animals that should have been reported to the advisory committee but weren’t. Notably, the principal investigator of the trial was also the <a href="https://sciencehistory.org/stories/magazine/the-death-of-jesse-gelsinger-20-years-later/">primary shareholder</a> of the biotech company that made the drug being tested. That raises questions about the reality of oversight.</p>
<p>I think something like that earlier NIH advisory committee but for reproductive technologies would still be advisable. But researchers, policymakers and regulators need to learn from the lessons of the past to try to ensure that – especially in early-phase research – we’re very thoughtful about the potential risks and that research participants really understand what the implications are for participation in research. That would be one model for translating research from the animal into the human.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/534481/original/file-20230628-30590-2nwhy8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Child looking into a slip lamp microscope for an eye exam with a doctor" src="https://images.theconversation.com/files/534481/original/file-20230628-30590-2nwhy8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534481/original/file-20230628-30590-2nwhy8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534481/original/file-20230628-30590-2nwhy8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534481/original/file-20230628-30590-2nwhy8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534481/original/file-20230628-30590-2nwhy8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534481/original/file-20230628-30590-2nwhy8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534481/original/file-20230628-30590-2nwhy8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The FDA approved a gene therapy for a form of congenital vision loss in 2017. The child in this photo, then 8, first received gene therapy at age 4.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/BlindnessTreatmentPrice/c567cc3a2b244cac8afc2b5ae2c62ca3">Bill West/AP Photo</a></span>
</figcaption>
</figure>
<p><strong>Keith</strong></p>
<p>A process to make sure that the people conducting studies don’t have a conflict of interest, like having the potential to commercially profit from the technology, would be useful. </p>
<p>Caution, consensus and cooperation should not take second place to profit motives. Altering the human genome in a way that allows human-made genetic changes to be <a href="https://doi.org/10.1089/crispr.2020.0096">propagated throughout the population</a> has a potential to alter the genetics of the human species as a whole. </p>
<p><strong>Mary Faith</strong></p>
<p>That raises the question of how long it will take for long-term effects to show. It’s one thing for an implanted egg not to survive. But how long will it take to know whether there are effects that aren’t obvious at birth?</p>
<p><strong>Keith</strong> </p>
<p>We’re still collecting long-term outcome data for people born using different reproductive technologies. So far there have been no obviously horrible consequences. But some abnormalities could take decades to manifest, and there are many variables to contend with. </p>
<p>One can arguably say that there’s substantial good in helping couples have babies. There can be a benefit to their emotional well-being, and reproduction is a natural part of human health and biology. And a lot of really smart, dedicated people are putting a lot of energy into making sure that the risks are minimized. We can also look to some of the practices and approaches to oversight that have been used over the past several decades.</p>
<p><strong>Mary Faith</strong></p>
<p>And thinking about international guidelines, such as from the <a href="https://cioms.ch">Council for International Medical Science</a> and other groups, could provide guidance on protecting human research subjects.</p>
<p><strong>Keith</strong></p>
<p>You hate to advocate for a world where the automatic response to anything new is “no, don’t do that.” My response is, “Show me it’s safe before you do it.” I don’t think that’s unreasonable.</p>
<p>Some people have a view that scientists don’t think about the ethics of research and what’s right and wrong, advisable or inadvisable. But we do think about it. I co-direct a research training program that includes teaching scientists how to responsibly and ethically conduct research, including speakers who specifically address the ethics of reproductive technologies. It is valuable to have a dialogue between scientists and ethicists, because ethicists will often think about things from a different perspective. </p>
<p>As people go through their scientific careers and see new technologies unfold over time, these discussions can help them develop a deeper appreciation and understanding of the broader impact of their research. It becomes our job to make sure that each generation of scientists is motivated to think about these things. </p>
<p><strong>Mary Faith</strong></p>
<p>It’s also really important to include stakeholders – people who are nonscientists, people who experience barriers to reproduction and people who are opposed to the idea – so they have a voice at the table as well. That’s how you get good policies, right? You have everyone who should be at the table, at the table.</p><img src="https://counter.theconversation.com/content/208276/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Scientists can create viable eggs from two male mice. In the wake of CRISPR controversies and restrictive abortion laws, two experts start a dialogue on ethical research in reproductive biology.Keith Latham, Professor of Animal Science, Adjunct Professor of Obstetrics, Gynecology and Reproductive Biology, Michigan State UniversityMary Faith Marshall, Professor of Biomedical Ethics, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2073902023-06-21T12:30:58Z2023-06-21T12:30:58ZOne year after the fall of Roe v. Wade, abortion care has become a patchwork of confusing state laws that deepen existing inequalities<figure><img src="https://images.theconversation.com/files/532284/original/file-20230615-17-u98cyj.jpg?ixlib=rb-1.1.0&rect=22%2C0%2C4914%2C1638&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The range of reproductive health care available to women depends significantly on the state they live in.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/sad-young-woman-sitting-looking-out-window-and-royalty-free-image/1132941100?phrase=abortion&adppopup=true">fizkes/iStock via Getty Images Plus</a></span></figcaption></figure><p>In the year since the <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">U.S. Supreme Court’s Dobbs v. Jackson ruling</a> <a href="https://theconversation.com/supreme-court-overturns-roe-upends-50-years-of-abortion-rights-5-essential-reads-on-what-happens-next-184697">struck down the constitutional right to abortion</a>, society has been seeing the results of a post-Roe world. </p>
<p>While there is no law in the U.S. that regulates what a man can do with his body, the reproductive health of women is now more regulated than it has been in 50 years. And the scope of reproductive health care that women can receive is highly dependent on where they live. </p>
<p>This creates a <a href="https://doi.org/10.1177/10901981221125430">system of inequalities</a> and further exacerbates health disparities.</p>
<p>I am a <a href="https://www.uml.edu/health-sciences/nursing/faculty/collins-fantasia-heidi.aspx">nurse practitioner</a> who <a href="https://scholar.google.com/citations?user=6rrHhmUAAAAJ&hl=en">studies women’s reproductive health across the lifespan</a>. </p>
<p>My research found that college women are concerned about pregnancy, but they lack knowledge and skills about <a href="https://doi.org/10.1097/JFN.0000000000000046">navigating sexual consent</a> and often participate in <a href="https://doi.org/10.1111/j.1939-3938.2011.01108.x">sexual activity without explicit consent</a>, leaving them at risk for not using contraception and exposure to sexually transmitted infections. </p>
<p>These findings indicate that women are at risk of pregnancy at a historic time when women’s reproductive rights in the U.S. are restricted and not guaranteed. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/z4nHG4_Sqhw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A retrospective on Roe v. Wade – and a look ahead.</span></figcaption>
</figure>
<h2>Current state of abortion in the US</h2>
<p>The <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">Dobbs v. Jackson ruling</a> returned decisions regarding abortion to individual states. This has led to a <a href="https://theconversation.com/in-the-year-since-the-supreme-court-overturned-roe-v-wade-and-ruled-states-should-decide-the-legality-of-abortion-voters-at-the-state-level-have-been-doing-just-that-4-essential-reads-207299">patchwork of laws</a> that <a href="https://states.guttmacher.org/policies/">span the entire range</a> from complete bans and tight restrictions to full state protection for abortion.</p>
<p>In some states, such as Texas, Louisiana and Mississippi, <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">abortion is banned</a> beginning at six weeks gestational age, when very few women even know they are pregnant. Other states, such as Massachusetts, Vermont, New York and Oregon, have enacted state-level protections for abortion. </p>
<p>The patchwork of state laws also results in a great deal of confusion. In the past year, women’s rights organizations and women’s health advocates have brought numerous <a href="https://www.kff.org/womens-health-policy/issue-brief/legal-challenges-to-state-abortion-bans-since-the-dobbs-decision/#">legal challenges to restrictive abortion laws</a>. These cases have halted the implementation of some of the strictest abortion regulations until additional court rulings are finalized. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Protesters gather in a small crowd holding signs including " src="https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533009/original/file-20230620-27-mj0m9l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Protesters against a stricter abortion ban stand in the State House lobby on May 23, 2023, in Columbia, S.C.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AbortionSouthCarolina/a08c0479d51341e493cf4850cb1df634/photo?Query=abortion%20bans&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=2705&currentItemNo=12">AP Photo/Jeffrey Collins</a></span>
</figcaption>
</figure>
<h2>Downstream effects for health care professionals</h2>
<p>Abortion training is considered <a href="https://doi.org/10.1097/ACM.0000000000005154">essential health care and a core competency</a> for physicians in obstetrics and gynecology, or OB-GYN, residency programs. Approximately 50% of OB-GYN residency programs are located in states <a href="https://doi.org/10.1097/AOG.0000000000004832">with restricted or highly restricted access to abortion</a>. This will logically result in not only fewer health care providers being trained to perform gynecologic procedures for abortion, but also other conditions such as miscarriage, fetal death and nonviable pregnancies. </p>
<p>In states with changing abortion laws and legal challenges to new laws, <a href="https://www.ama-assn.org/delivering-care/population-care/ambiguous-anti-abortion-laws-are-putting-patients-risk">physicians are uncertain</a> of what procedures can be legally done. <a href="https://www.politico.com/news/2022/05/06/potential-abortion-bans-and-penalties-by-state-00030572">Penalties for violating abortion laws</a> may include arrest, loss of medical license, fines and discipline by state boards of medicine. </p>
<p>As a result, physicians are <a href="https://www.axios.com/2023/04/18/abortion-ban-states-drop-student-residents">choosing to leave states</a> with the <a href="https://www.npr.org/sections/health-shots/2023/05/23/1177542605/abortion-bans-drive-off-doctors-and-put-other-health-care-at-risk">most restrictive abortion laws, and clinics are closing</a>, which is contributing to the current <a href="https://www.cnn.com/2023/04/19/health/abortion-ban-affects-physician-training/index.html">shortage of health care providers</a>.</p>
<h2>Inequalities in health care access</h2>
<p>The unequal access to abortion procedures across the country is most directly affecting the poorest women in the U.S.</p>
<p>Currently, 12 states restrict abortion coverage by private insurance, and more than 30 states <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">prohibit public Medicaid payment</a> for abortion. Women who qualify for Medicaid are among the poorest in the U.S. Lack of access to abortion limits education and wage earning and <a href="https://www.npr.org/2022/08/18/1111344810/abortion-ban-states-social-safety-net-health-outcomes">contributes to poverty</a>. States with the most restrictive abortion laws also have <a href="https://www.axios.com/2022/05/20/abortion-roe-supreme-court-babies-mothers">limited access to pregnancy care</a> and <a href="https://www.usnews.com/news/politics/articles/2022-04-07/social-programs-weak-in-many-states-with-tough-abortion-laws">supportive programs</a> for pregnant and parenting women. </p>
<p>In addition, traveling to a different state to obtain an abortion is often not possible for poor women. Lack of transportation and limited financial resources reduce or eliminate options to obtain an abortion in a different geographic location. </p>
<p>What’s more, states with the most abortion restrictions have some of the <a href="https://worldpopulationreview.com/state-rankings/maternal-mortality-rate-by-state">worst pregnancy and maternal health outcomes</a> for women, especially women of color. Pregnancy itself is associated with a <a href="https://doi.org/10.1097%2FAOG.0000000000003762">risk of dying</a>. </p>
<p>Maternal morbidity is the term used to describe short- or long-term <a href="https://www.nichd.nih.gov/health/topics/maternal-morbidity-mortality">health problems that result from pregnancy</a>. Maternal mortality refers to the <a href="https://www.who.int/news-room/fact-sheets/detail/maternal-mortality">death of women during pregnancy</a> or within the first six weeks after birth. </p>
<p>For example, Mississippi and Louisiana have the highest rates of maternal mortality in the U.S. and also <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">have the most restrictive abortion laws</a>. Black women have the <a href="https://www.ama-assn.org/print/pdf/node/66881">highest maternal mortality of all races</a> and ethnicities. Women in these states who are unable to terminate a pregnancy have a higher risk of dying as a result of the pregnancy than women in other states. </p>
<p>Additionally, research shows that a <a href="https://doi.org/10.1097/aog.0b013e31823fe923">woman’s risk of dying</a> related to pregnancy or childbirth is about 14 times higher than the risk of death from an abortion. </p>
<p>In addition to the increased risks of death, there are other <a href="https://www.ansirh.org/research/ongoing/turnaway-study">physical and mental health implications</a> associated with carrying an undesired pregnancy to term. Being denied access to abortion is associated with increased anxiety and <a href="https://www.ansirh.org/research/ongoing/turnaway-study">fewer future plans</a> for the next year. Research also shows that not being able to obtain an abortion makes women more likely to <a href="https://doi.org/10.2105/AJPH.2017.304247">live below the federal poverty level</a> and to <a href="https://doi.org/10.1363/psrh.12216">lack partner support</a>. </p>
<p>Conversely, research has shown that there are <a href="https://doi.org/10.1016/j.contraception.2008.07.005">few if any significant negative mental health outcomes</a> among women who have abortions. </p>
<h2>Unsafe abortions</h2>
<p>Restricting legal abortion increases the risk that women will seek out <a href="https://doi.org/10.1016/j.bpobgyn.2010.02.012">pregnancy termination from unskilled people</a> in unsafe settings. Or they may not seek care quickly for pregnancy complications due to fear of being accused of a crime.</p>
<p>In Texas, physicians are <a href="https://www.newyorker.com/news/dispatch/in-the-post-roe-era-letting-pregnant-patients-get-sicker-by-design">reporting an increase in sepsis</a>, or an <a href="https://theconversation.com/sepsis-still-kills-1-in-5-people-worldwide-two-icu-physicians-offer-a-new-approach-to-stopping-it-175650">overwhelming response to infection</a>, from incomplete abortions. These physicians predict that sepsis will become the leading cause of maternal death in Texas. </p>
<p>Prior to 1973, when Roe v. Wade established constitutional protection for abortion in the U.S., women often resorted to unsafe methods to induce abortion that resulted in a high death toll. <a href="https://doi.org/10.2307/3419941">Septic abortion wards</a> – or designated areas of hospitals where women were treated for sepsis as a result of illegal abortions – were common. In 1965, 17% of all deaths related to pregnancy were <a href="https://www.guttmacher.org/sites/default/files/article_files/gr060108.pdf">attributed to illegal abortion</a>. </p>
<p>Now that the constitutional right to abortion has been eliminated, more women will inevitably <a href="https://doi.org/10.1016/j.ajog.2022.07.033">die or become seriously ill</a> due to lack of safe access to abortion services. In states with the most restrictions on abortion, whether a woman meets the criteria for an exemption to save the life of the mother may be <a href="https://publichealth.jhu.edu/2023/a-year-without-roe">decided by a hospital committee</a>. This can delay necessary care and increase the risk to the mother.</p>
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<figcaption><span class="caption">Said one: “I didn’t know I was important enough to draw boundaries around what people could and couldn’t do with my body.”</span></figcaption>
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<h2>Women affected by violence</h2>
<p>In the U.S., more than 25% of women will <a href="https://ncadv.org/STATISTICS">experience physical or sexual violence</a> in their lifetime. Violence from an intimate partner is a <a href="https://www.ansirh.org/research/ongoing/turnaway-study">leading reason for abortion</a>. My research shows that women affected by violence have a <a href="https://doi.org/10.1016/j.contraception.2012.03.005">higher risk of pregnancy</a> and that college women are at increased risk of <a href="https://doi.org/10.1097/jfn.0000000000000086">nonconsensual and forced sexual encounters</a>.</p>
<p>Currently, there are 14 states with abortion bans that contain <a href="https://www.kff.org/womens-health-policy/issue-brief/a-review-of-exceptions-in-state-abortions-bans-implications-for-the-provision-of-abortion-services/">no exception for rape or incest</a> or require that the sexual assault be reported to law enforcement to qualify for exception. </p>
<p>Research has shown that women often <a href="https://doi.org/10.3200/JACH.55.3.157-162">don’t report sexual assault</a> due to stigma, embarrassment or fear of not being believed. Even if women qualify for an abortion as a result of sexual violence, those who have not filed a formal police report lack “proof” that their pregnancy resulted from assault. </p>
<p>While the changes that have occurred since the fall of Roe one year ago are already deeply concerning, the full effect of eliminating the constitutional right to an abortion won’t be known for years. And as laws are enacted and subsequently challenged, uncertainty and confusion regarding women’s reproductive health care will undoubtedly continue for years to come.</p><img src="https://counter.theconversation.com/content/207390/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Heidi Collins Fantasia has received funding from the National Institutes of Health, National Institute of Child Health and Human Development and Heart, Lung, and Blood Institute. Dr. Fantasia is the editor of Nursing for Women's Health. </span></em></p>Abortion bans and restrictions have numerous downstream effects on health care. For instance, medical students in states where those laws exist will not receive training for some standard procedures.Heidi Collins Fantasia, Associate Professor of Nursing, UMass LowellLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2075782023-06-14T10:56:57Z2023-06-14T10:56:57ZWoman jailed over abortion – an expert on what UK law actually says and what needs to change<figure><img src="https://images.theconversation.com/files/531693/original/file-20230613-27-cae5hq.jpg?ixlib=rb-1.1.0&rect=70%2C50%2C6639%2C4416&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/crop-close-young-african-american-woman-1863927673">fizkes/Shutterstock</a></span></figcaption></figure><p>Many people assume that because abortion is relatively accessible in England, it is not a crime. The fact that a woman has now received a <a href="https://www.theguardian.com/world/2023/jun/12/woman-in-uk-jailed-for-28-months-over-taking-abortion-pills-after-legal-time-limit">28-month prison sentence</a> for taking abortion pills past the legal time limit shows that this assumption is wrong. </p>
<p>Abortion remains within the criminal law to some extent in almost every country globally, despite the fact that it is a safe and relatively common procedure. Laws can criminalise women and pregnant people, healthcare providers or anyone who helps a woman get an abortion. The sentencing in Poland of activist <a href="https://www.amnesty.org/en/latest/news/2023/03/poland-conviction-of-activist-prosecuted-for-aiding-an-abortion-offers-chilling-snapshot-of-future/">Justyna Wydrzyńska</a> is one example. In March 2023, she received eight months community service for aiding an abortion seeker. </p>
<p>The 28-month sentence for the 44-year-old mother of three in England reflects the desperate need for a change to the law, in the form of decriminalisation. </p>
<p>In England and Wales, abortion is considered legal when it is performed by a registered medical practitioner, authorised by two doctors and meets certain conditions, such as risk to physical or mental health or risk of fetal anomaly. Abortion can only be performed after 24 weeks gestation in very limited circumstances. </p>
<p>The <a href="https://www.bpas.org/get-involved/campaigns/briefings/abortion-law/">1967 Abortion Act</a> determines the situations in which an abortion is not a criminal act and the gestational time limits when one can be performed. The <a href="https://academic.oup.com/sp/article-abstract/21/1/26/1607984?login=false">act was written</a> in response to healthcare providers’ concerns about unsafe “backstreet” abortions, rather than out of concern for women’s bodily rights or autonomy. </p>
<p>Lawmakers did not want to make abortion available on request, therefore the sections of the <a href="https://www.legislation.gov.uk/ukpga/Vict/24-25/100/contents">1861 Offences Against the Person Act</a> which criminalise abortion were not repealed. Sections 58 and 59 make it a criminal offence to administer or supply drugs or use instruments to procure an abortion. The offences carry a maximum sentence of life imprisonment.</p>
<p>While the 1967 Abortion Act applies in Scotland, the Offences Against the Person Act does not. There, abortion is considered a crime in common law, developed by court precedent. </p>
<p>The recent prosecution is not an anomaly. In the past eight years, police in England and Wales <a href="https://www.theguardian.com/commentisfree/2022/aug/19/abortion-legal-great-britain-women-life-sentences-roe-v-wade">have investigated</a> at least 17 people for procuring their own abortion outside the law. The legacy of the 1861 act as a Victorian colonial era law continues to be felt globally, and still applies in countries such as the Gambia, Malawi and Jamaica. </p>
<h2>Decriminalising abortion</h2>
<p>Northern Ireland is the only region of the UK where abortion is <a href="https://www.tandfonline.com/doi/full/10.1080/14616742.2022.2053297">decriminalised</a>. The 1967 act was never extended to Northern Ireland. </p>
<p>After years of activist lobbying and an international inquiry by the UN committee for the elimination of discrimination against women, Westminster repealed sections 58 and 59 of the Offences Against the Person Act in 2019 – but only in Northern Ireland. The <a href="https://www.legislation.gov.uk/uksi/2020/345/contents/made">Abortion (Northern Ireland) Regulations 2020</a> now govern abortion access. </p>
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Read more:
<a href="https://theconversation.com/westminster-steps-in-after-northern-ireland-fails-to-comply-with-abortion-law-change-how-it-happened-158239">Westminster steps in after Northern Ireland fails to comply with abortion law change – how it happened</a>
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<p>But while the law in Northern Ireland is now more liberal, issues remain around <a href="https://theconversation.com/westminster-steps-in-after-northern-ireland-fails-to-comply-with-abortion-law-change-how-it-happened-158239">access</a> to abortion services. Healthcare providers have had to organise themselves to provide medical abortions, rather than receiving government support and people seeking surgical abortions still have to travel to England.</p>
<p>The <a href="https://policycommons.net/artifacts/2269625/abortion-care-guideline/3029443/">World Health Organization</a> (WHO) and <a href="https://gh.bmj.com/content/7/12/e010409">international human rights bodies</a> have recommended that, at minimum, abortion be removed from the criminal law and decriminalised around the world.</p>
<p>The WHO defines this as “the complete decriminalisation of abortion for all relevant actors: removing abortion from all penal/criminal laws, not applying other criminal offences (e.g., murder, manslaughter) to abortion, and ensuring there are no criminal penalties for having, assisting with, providing information about or providing abortion”. </p>
<p>This approach recognises that making abortion a crime does not prevent abortion, nor does it protect people from having unsafe abortions. What it does do is impede access and influence how people who have abortions are viewed. Higher levels of <a href="https://www.makeinroads.org/making-inroads/2021/September/how-abortion-stigma-and-criminalization-shape-each-other">stigma</a> are often seen in regions with stricter abortion laws.</p>
<p>Removing abortion from the criminal law does not mean that it is ungoverned, simply that is it governed in the same way as other health procedures. The case of Northern Ireland shows that there is nothing stopping Westminster from repealing sections 58 and 59 of the Offences Against the Person Act. This latest case should make it an issue of political urgency.</p><img src="https://counter.theconversation.com/content/207578/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Pierson receives funding from the British Academy and is a board member of Alliance for Choice Belfast. </span></em></p>In the past eight years, police in England and Wales have investigated at least 17 people for procuring their own abortion outside the law.Claire Pierson, Senior Lecturer in Politics, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2042632023-04-26T12:28:46Z2023-04-26T12:28:46ZChallenging the FDA’s authority isn’t new – the agency’s history shows what’s at stake when drug regulation is in limbo<figure><img src="https://images.theconversation.com/files/522817/original/file-20230425-28-sxmbmf.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2048%2C1370&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In addition to evaluating new drug applications, the FDA also inspects drug manufacturing facilities.</span> <span class="attribution"><a class="source" href="https://flic.kr/p/bCZpCD">The U.S. Food and Drug Administration/Flickr</a></span></figcaption></figure><p>Political pressure is nothing new for the U.S. Food and Drug Administration. The agency has <a href="https://theconversation.com/the-fdas-big-gamble-on-the-new-alzheimers-drug-162396">frequently come under fire</a> for its drug approval decisions, but attacks on its decision-making process and science itself have increased <a href="https://www.statnews.com/2020/08/27/trump-has-launched-an-all-out-attack-on-the-fda-will-its-scientific-integrity-survive/">during the COVID-19 pandemic</a>.</p>
<p>Recent challenges to the FDA’s authority have emerged in the context of reproductive rights.</p>
<p>On Nov. 18, 2022, a group of anti-abortion doctors and medical groups <a href="https://adflegal.org/sites/default/files/2022-11/Alliance-for-Hippocratic-Medicine-v-FDA-2022-11-18-Complaint.pdf">filed a lawsuit</a> against the FDA, challenging its approval from more than 20 years ago of <a href="https://theconversation.com/mifepristone-is-under-scrutiny-in-the-courts-but-it-has-been-used-safely-and-effectively-around-the-world-for-decades-204163">mifepristone</a>, a drug taken in combination with another medication, misoprostol, to <a href="https://theconversation.com/how-will-the-supreme-courts-decision-on-mifepristone-affect-abortion-access-4-questions-answered-204172">treat miscarriages</a> and used to induce <a href="https://www.guttmacher.org/article/2022/02/medication-abortion-now-accounts-more-half-all-us-abortions">more than 50% of abortions</a> in early-stage pregnancies in the U.S.</p>
<p>It is widely believed that the plaintiffs filed the lawsuit in the Northern District of Texas so District Judge Matthew J. Kacsmaryk, a <a href="https://www.nytimes.com/2023/04/07/us/politics/texas-judge-matthew-kacsmaryk-abortion-pill.html">well-known abortion opponent</a>, could oversee the litigation. While Kacsmaryk did issue a preliminary injunction ruling that the FDA lacked the authority to approve mifepristone, an appeal <a href="https://storage.courtlistener.com/recap/gov.uscourts.ca5.213145/gov.uscourts.ca5.213145.183.2_1.pdf">partially reversed</a> the decision and the Supreme Court <a href="https://www.supremecourt.gov/opinions/22pdf/22a901_3d9g.pdf">stayed Kacsmaryk’s order</a>. The case now sits at the 5th U.S. Circuit Court of Appeals and will likely return to the Supreme Court.</p>
<p>The FDA is the government’s oldest consumer protection agency. The effects of this lawsuit could reach far beyond mifepristone – undermining the agency’s authority could threaten its entire drug approval process and change access to commonly used drugs, ranging from amoxycillin and Ambien to prednisone and Paxlovid.</p>
<p>I am a <a href="https://scholar.google.com/citations?user=Yeg0EUgAAAAJ&hl=en">legal scholar</a> whose research focuses in part on the law and ethics of the FDA’s drug approval process. Examining the FDA’s history reveals the unprecedented nature of the current challenges to the agency’s authority.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Chart titled 'Data for Decisions' depicting sources the FDA considers in its decision-making" src="https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=381&fit=crop&dpr=1 600w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=381&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=381&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=479&fit=crop&dpr=1 754w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=479&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=479&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Then FDA Commissioner George Larrick used this chart during 1964 Senate testimony to illustrate the range of sources the agency uses in evaluating proposals.</span>
<span class="attribution"><a class="source" href="https://flic.kr/p/dv6CFV">The U.S. Food and Drug Administration/Flickr</a></span>
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</figure>
<h2>Events shaping FDA’s focus on safety</h2>
<p>In its early years, the FDA focused primarily on balancing the competing goals of consumer safety with access to experimental treatments. The priority was strengthening consumer protection to prevent tragedy from recurring. </p>
<p>For instance, at the turn of the 20th century, Congress passed the <a href="https://ncjolt.org/articles/volume-23/volume-23-issue-4/fdas-accelerated-approval-emergency-use-authorization-and-pre-approval-access-considerations-for-use-in-public-health-emergencies-and-beyond/">Biologics Control Act of 1902</a>, providing the federal government the authority to regulate vaccines. This law was introduced after 13 children died from inadvertently contaminated diphtheria antitoxin, which was made from the blood of a horse infected with tetanus. </p>
<p>A few years later, after investigative journalists publicized the unsanitary conditions and food-handling practices in meatpacking plants, Congress passed the <a href="https://ssrn.com/abstract=3237889">Pure Food and Drug Act of 1906</a>, which prohibited the marketing and sale of misbranded and contaminated foods, drinks and drugs.</p>
<p>Similarly, in 1937, approximately 71 adults and 34 children died from ingesting <a href="https://doi.org/10.7326/0003-4819-122-6-199503150-00009">S.E. Massengill’s antibacterial elixir</a>, which contained a poisonous raspberry flavoring added to sweeten the taste. In response, Congress passed the <a href="https://www.fda.gov/about-fda/fda-history/milestones-us-food-and-drug-law">Federal Food, Drug and Cosmetic Act of 1938</a>, requiring manufacturers to show that drugs are safe before they go on the market. This act marked the beginning of modern drug regulations and the birth of the FDA as a regulatory agency. </p>
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<figcaption><span class="caption">FDA scientist Frances Oldham Kelsey’s decision to not approve thalidomide for use in the U.S. protected Americans from the birth defects that swept newborns in other countries.</span></figcaption>
</figure>
<p>Then, in 1962, Dr. Frances Oldham Kelsey, a pharmacologist, physician and medical officer working at the FDA, <a href="https://www.fda.gov/about-fda/fda-history/milestones-us-food-and-drug-law">refused to approve thalidomide</a>, a drug marketed in Europe, Canada, Japan and other countries to alleviate morning sickness in pregnant women but later found to cause severe birth defects. Shocking revelations of children born without limbs or suffering from other debilitating conditions motivated Congress to pass the <a href="https://theconversation.com/could-thalidomide-happen-again-46813">Kefauver-Harris Drug Amendments of 1962</a>, which ushered in a more cautious approach to the drug approval process.</p>
<h2>FDA’s turn toward expanding access</h2>
<p>During the 1970s, questions about the limits of safety versus an individual’s right to access arose when cancer patients who wanted access to an unapproved drug derived from apricots, Laetrile, sued the FDA. The agency had blocked the drug’s shipment and sale because it was not approved for use in the U.S. At that time, the Supreme Court <a href="https://tile.loc.gov/storage-services/service/ll/usrep/usrep442/usrep442544/usrep442544.pdf">upheld the FDA’s protective authority</a>, holding that an unproven therapy is unsafe for all patients, including the terminally ill.</p>
<p>The 1980s, however, marks the FDA’s shift toward increasing access following reports of an emerging disease – AIDS – which primarily affected gay men. In the first nine years of the AIDS epidemic, <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/00001880.htm">over 100,000 Americans died</a>. AIDS patients and their advocates became <a href="https://dx.doi.org/10.2139/ssrn.2739121">vocal critics of the FDA</a>, arguing that the agency was too paternalistic and restrictive following events like the thalidomide scare.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="ACT UP protestors lying on the ground with tombstone-shaped signs demanding the FDA allow access to experimental HIV/AIDS drugs" src="https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=412&fit=crop&dpr=1 600w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=412&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=412&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=518&fit=crop&dpr=1 754w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=518&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=518&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Protests from HIV/AIDS activists like ACT UP spurred the FDA to develop expedited drug approval tracks to meet urgent public health needs.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/protesters-close-the-federal-drug-administration-building-news-photo/1213566352">Mikki Ansin/Peter Ansin via Getty Images</a></span>
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<p>After massive protests, Dr. Anthony Fauci, then director of the National Institute of Allergy and Infectious Diseases, proposed a <a href="https://www.washingtonpost.com/outlook/2020/04/29/fight-against-aids-has-shaped-how-potential-covid-19-drugs-will-reach-patients/">parallel track program</a> allowing eligible patients access to unapproved experimental treatments. This, along with other existing FDA mechanisms, helped lay the path for other alternative approval pathways, such as <a href="https://theconversation.com/what-are-emergency-use-authorizations-and-do-they-guarantee-that-a-vaccine-or-drug-is-safe-151178">Emergency Use Authorization</a>, which played a large role in permitting use of vaccines and medications pending full FDA approval during the COVID-19 pandemic.</p>
<h2>Future of the FDA</h2>
<p>Despite the FDA’s shift toward increased access, the <a href="https://www.statnews.com/2018/05/31/right-to-try-ron-johnson/">political right has in recent years argued</a> that the agency remains too bureaucratic and paternalistic and should be deregulated – an argument seemingly contrary to the reasoning underlying Kacsmaryk’s recent order that the FDA did not sufficiently evaluate the safety of mifepristone in its approval.</p>
<p>Mifepristone, which has <a href="https://www.ama-assn.org/delivering-care/public-health/ama-court-don-t-overturn-fda-approval-mifepristone">overwhelming data supporting its safety</a>, could remain available to some people in some states regardless of the outcome of this lawsuit. While the FDA approves drugs for consumer use, it does not regulate the general practice of medicine. Doctors can <a href="https://www.fda.gov/patients/learn-about-expanded-access-and-other-treatment-options/understanding-unapproved-use-approved-drugs-label">prescribe FDA-approved drugs off-label</a>, meaning they could prescribe a drug with a different dose, in a different way or for a different use than what the FDA has approved it for.</p>
<p>The mifepristone case has broad implications for the FDA’s future and could have devastating effects on health in the U.S. Due in part to FDA involvement, public health interventions have led to a <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm#">62% increase in life expectancy</a> in the 20th century. These include vaccines and medications for childhood illnesses and infectious diseases such as HIV, increased regulation of tobacco, and <a href="https://theconversation.com/fda-approval-of-over-the-counter-narcan-is-an-important-step-in-the-effort-to-combat-the-us-opioid-crisis-198497">over-the-counter Narcan</a> to combat the opioid crisis, among others.</p>
<p>The FDA needs to be able to use its scientific expertise to make data-driven decisions that balance safety and access, without the ability of a single judge to potentially gut the system. The agency’s history is an important reminder of the need for strong administrative agencies and ongoing vigilance to protect everyone’s health.</p><img src="https://counter.theconversation.com/content/204263/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christine Coughlin is affiliated with the Foundation for Prosecutorial Accountability.</span></em></p>As the government’s oldest consumer protection agency, the FDA has long butted up against drugmakers, activists and politicians. But undermining its work could be harmful to patient health and safety.Christine Coughlin, Professor of Law, Wake Forest UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2041632023-04-26T12:28:33Z2023-04-26T12:28:33ZMifepristone is under scrutiny in the courts, but it has been used safely and effectively around the world for decades<figure><img src="https://images.theconversation.com/files/522668/original/file-20230424-26-v5rdtr.jpg?ixlib=rb-1.1.0&rect=0%2C170%2C2915%2C1755&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Mifepristone is used together with another pill, misoprostol, in medication abortions.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AbortionPill/513c7c2f6d0346b9b9ddaa2c7344be46/photo?Query=mifepristone%20supreme%20court&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=39&currentItemNo=32">AP Photo/Allen G. Breed</a></span></figcaption></figure><p><em>A <a href="https://theconversation.com/the-supreme-court-rules-mifepristone-can-remain-available-heres-how-2-conflicting-federal-court-decisions-led-to-this-point-203623">flurry of court rulings</a> in April 2023 has left the <a href="https://www.reuters.com/world/us/us-abortion-providers-relieved-wary-supreme-court-preserves-pill-access-2023-04-22/">future of the abortion pill mifepristone in question</a>. For now, a U.S. Supreme Court decision on April 21 <a href="https://theconversation.com/how-will-the-supreme-courts-decision-on-mifepristone-affect-abortion-access-4-questions-answered-204172">allows the drug to remain accessible</a> <a href="https://www.nbcnews.com/health/womens-health/abortion-pill-lawsuit-mifepristone-questions-future-access-rcna79455">without additional restrictions</a> as the merits of the case are <a href="https://www.washingtonpost.com/politics/2023/04/21/mifepristone-abortion-pill-access-supreme-court/">weighed in lower court proceedings</a>.</em> </p>
<p><em>Depending on the outcome, the pill <a href="https://www.reuters.com/legal/government/us-supreme-court-preserves-access-abortion-pill-now-whats-next-2023-04-22/">could face a ban or tightened restrictions</a> on its usage, a possibility that has many health care providers concerned.</em></p>
<p><em>The Conversation asked Grace Shih, a family physician practicing in Washington state, to explain the science behind mifepristone as well as its safety and efficacy in medication abortions.</em></p>
<h2>What is mifepristone, and how does it work?</h2>
<p>Mifepristone is a pill that is <a href="https://theconversation.com/what-is-a-medication-or-medical-abortion-5-questions-answered-by-3-doctors-182646">used in medication abortion</a> during early pregnancy. It was initially <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation">approved by the Food and Drug Administration in 2000</a> and is approved by the FDA for medication abortion up to 10 weeks after the first day of the last menstrual period. </p>
<p>It can be taken as one part of a two-part pill regimen for medication abortion. Mifepristone is prescribed as a 200-milligram dose taken orally, followed by an 800-microgram dose of misoprostol, which is placed in the vagina or between the teeth and cheek, where it dissolves and is absorbed, usually 24 to 48 hours later. </p>
<p>Mifepristone acts by blocking the hormone progesterone, which is necessary for a pregnancy to develop. This stops the pregnancy growth and softens and dilates the cervix. It also prepares the uterus for contractions, increasing its sensitivity to medications such as misoprostol. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/GknDlnjVPFM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Mifepristone blocks the action of progesterone, a hormone that is needed for a pregnancy to develop.</span></figcaption>
</figure>
<p>Misoprostol is a synthetic <a href="https://www.yourhormones.info/hormones/prostaglandins/">prostaglandin</a>. Prostaglandin is a hormonelike substance that has multiple effects, including the stimulation of uterine contractions, which helps expel pregnancy tissue such as the thickened uterine lining and the tissues that are the precursor to the placenta. </p>
<p>Misoprostol is <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2002/19268slr037.pdf">currently FDA-approved</a> for reducing the risk of gastric ulcers in patients who are at high risk of complications from ulcers. But it is commonly used off-label for things like cervical ripening, or softening, to induce or help with labor. Mifepristone and misoprostol are also both used in the <a href="https://doi.org/10.1056/NEJMoa1715726">medical management of miscarriage</a>.</p>
<p>Medication abortion can also be done with misoprostol alone, an approach known as the misoprostol-only regimen. This <a href="https://doi.org/10.1097/aog.0000000000003017">regimen is safe</a> and has been <a href="https://www.washingtonpost.com/world/2023/04/19/abortion-pill-mifepristone-global-approved/">used widely by people around the world</a>. In the misoprostol-only regimen, an 800-microgram dose is placed in the vagina or between the teeth and cheek every three hours for up to three doses. </p>
<p>Both protocols are very effective, with the two-drug regimen <a href="https://doi.org/10.1097/AOG.0000000000000910">up to 99.6% effective</a> and the <a href="https://doi.org/10.1097%2FAOG.0000000000003017">misoprostol-alone regimen between 84% to 96%</a> in medication abortions.</p>
<h2>Why would a person opt for one regimen or the other?</h2>
<p>People usually don’t choose the type of medication abortion they receive. Because the availability of mifepristone and misoprostol is highly variable, whichever method is available to you is medically safe. Patients should feel assured that guidelines for medication abortion support the <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">safety and efficacy of both medication regimens</a>.</p>
<p>The <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">American College of Obstetricians and Gynecologists</a>, the <a href="https://doi.org/10.1016/j.contraception.2020.08.004">Society for Family Planning</a> and the <a href="https://www.who.int/publications/i/item/9789240039483">World Health Organization</a> all support both types of medication abortion. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/kzd4ABInBio?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Mifepristone and misoprostol work in tandem to terminate a pregnancy.</span></figcaption>
</figure>
<h2>How widely accessible is mifepristone?</h2>
<p>In January 2023, the <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answers-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation#">FDA updated its guidelines</a> to allow mifepristone to be dispensed through pharmacies with a prescription.</p>
<p>The change means that the drug is available both by mail or at brick-and-mortar pharmacies, as long as that retail pharmacy has been certified. In other words, people who live in states where abortion is not banned can take their mifepristone prescription and get it the way they pick up other medications. </p>
<p>For someone able to pick up mifepristone from a local pharmacy, the process is no different from picking up birth control pills or blood pressure medications. This allows mifepristone and its applications for abortion care and miscarriage management to be treated as typical health care. </p>
<p>While the January 2023 FDA ruling theoretically increases the ways that a person can get mifepristone, so far it has not been widely available at retail pharmacies.</p>
<h2>Can I still get mifepristone?</h2>
<p>The short answer is yes, mifepristone is still FDA-approved. The Supreme Court’s April 21, 2023, ruling means that there will be <a href="https://theconversation.com/how-will-the-supreme-courts-decision-on-mifepristone-affect-abortion-access-4-questions-answered-204172">no changes to mifepristone access for now</a>. However, for use in abortion care, mifepristone still faces restrictions depending on your state’s legislation.</p>
<p>As of April 2023, 27 states have <a href="https://www.guttmacher.org/state-policy/explore/medication-abortion">some restriction on medication abortion</a> according to the <a href="https://www.guttmacher.org/">Guttmacher Institute</a>, a reproductive health policy organization. This includes 12 states that have a near-total ban on abortion and one state that has stopped offering abortion care because of legal uncertainty. </p>
<p>Of the 15 states with restrictions specific to medication abortion, all of them require that medication be provided by a physician and not an advanced practitioner like a nurse practitioner. Six of the states require an in-person visit with a physician, one state requires that mifepristone be taken in the presence of a physician, and one state bans mailing medication abortion pills.</p>
<h2>Evidence-based health care</h2>
<p>As a practicing family physician, I follow the science and make medical decisions with my patients using the most up-to-date evidence. Medication abortion using mifepristone and misoprostol is <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">exceptionally safe and highly effective</a>, as is <a href="https://doi.org/10.1097%2FAOG.0000000000003017">medication abortion using misoprostol alone</a>. Side effects of the misoprostol-only regimen are similar to the combined regimen, though they may last longer because of the need for multiple doses of misoprostol.</p>
<p>Some news coverage has focused on comparing the efficacy of the two regimens. But percentage points mean very little to an individual’s health – what matters is that people get the care they need.</p>
<p>I will continue working, providing and advancing care that is based on science. Leading health professional organizations including the <a href="https://www.acog.org/clinical-information/policy-and-position-statements/position-statements/2018/improving-access-to-mifepristone-for-reproductive-health-indications">American College of Obstetricians and Gynecologists</a>, the <a href="https://policysearch.ama-assn.org/policyfinder/detail/mifepristone?uri=%2FAMADoc%2FHOD.xml-H-100.948.xml">American Medical Association</a> and the <a href="https://www.aafp.org/dam/AAFP/documents/events/nc/congress/nc18-ncfmr-actions-referrals.pdf">American Academy of Family Physicians</a> have all issued statements that call for removing all restrictions around mifepristone and/or support the safety of misoprostol-only medication abortion.</p>
<p><em>This is an updated version of an <a href="https://theconversation.com/what-the-fdas-rule-changes-allowing-the-abortion-pill-mifepristone-to-be-dispensed-by-pharmacies-mean-in-practice-5-questions-answered-197339">article originally published</a> on Jan. 11, 2023.</em></p><img src="https://counter.theconversation.com/content/204163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grace Shih does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Mifepristone’s safety in medication abortions has been well established over more than two decades, but legal wrangling leaves the future of the drug hanging in the balance.Grace Shih, Associate Professor of Family Medicine, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2036232023-04-22T01:19:01Z2023-04-22T01:19:01ZThe Supreme Court rules mifepristone can remain available – here’s how 2 conflicting federal court decisions led to this point<figure><img src="https://images.theconversation.com/files/522351/original/file-20230421-1599-guspc1.jpg?ixlib=rb-1.1.0&rect=35%2C53%2C5955%2C3934&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Supreme Court is the latest court to take up the question of regulating a medication used for abortions.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/the-supreme-court-of-the-united-states-on-wednesday-april-news-photo/1252000986">Kent Nishimura/Los Angeles Times via Getty Images</a></span></figcaption></figure><p>The U.S. Supreme Court issued an emergency ruling on April 21, 2023, that allows continued access to the abortion pill <a href="https://www.supremecourt.gov/opinions/22pdf/22a901_3d9g.pdf">mifepristone in states where abortion is legal</a>.</p>
<p>The court’s decision, <a href="https://www.nytimes.com/interactive/2023/04/21/us/23-supreme-court-order.html">which included few details</a> and only indicated that Justices Clarence Thomas and Samuel Alito did not concur, follows a whirlwind legal process about whether people should be able to purchase mifepristone, one of two drugs used in a two-dose series for inducing a medical abortion.</p>
<p>On April 7, <a href="https://storage.courtlistener.com/recap/gov.uscourts.txnd.370067/gov.uscourts.txnd.370067.137.0_11.pdf">two federal district court judges</a> <a href="https://int.nyt.com/data/documenttools/court-decision-keeping-mifepristone-available/1d2b761e9ab275f7/full.pdf">halfway across the country</a> from each other issued conflicting rulings about the validity of the Food and Drug Administration’s approval of mifepristone. </p>
<p>Within a week, <a href="https://www.nytimes.com/interactive/2023/04/13/us/abortion-pill-fifth-court-of-appeals.html">yet another court</a> issued a third opinion, which allowed mifepristone to continue to be prescribed, but under more limited circumstances. Two days after that, on April 14, the U.S. <a href="https://www.supremecourt.gov/orders/courtorders/041423zr2_c9dh.pdf">Supreme Court issued</a> yet a fourth divergent opinion, albeit a temporary one, maintaining that the drug should be kept available while the court considered the most recent emergency ruling.</p>
<p>As <a href="https://www.law.gwu.edu/sonia-m-suter">scholars of reproductive</a> justice, <a href="https://www.law.virginia.edu/faculty/profile/nrc8g/2915359">we have</a> been carefully following these cases to make sense of what they mean for the FDA’s authority to approve drugs – and where that leaves access to medication abortion, which is used in <a href="https://theconversation.com/medication-abortion-could-get-harder-to-obtain-or-easier-theres-a-new-wave-of-post-dobbs-lawsuits-on-abortion-pills-198978">more than half of all</a> abortions today. </p>
<p>One issue that confuses many people is how different courts can rule in contradictory ways. </p>
<p>But in fact, there are many instances when federal courts in one part of the country hand down decisions that conflict with those of other jurisdictions. </p>
<h2>The federal system</h2>
<p>It’s first useful to understand how the federal court system in the U.S. works. State-run court systems are entirely separate from the federal judicial system, which is where the mifepristone rulings are playing out.</p>
<p><a href="https://www.uscourts.gov/about-federal-courts/federal-courts-public#:%7E:text=Federal%20courts%20have%20jurisdiction%20over,U.S.%20government%20and%20foreign%20governments">Federal courts handle a variety of issues</a>, including those relating to the United States government, the Constitution or federal laws, or controversies between states or between the U.S. government and foreign governments.</p>
<p>There are <a href="https://www.uscourts.gov/about-federal-courts/court-role-and-structure">94 federal district courts, organized into 12 regional circuits</a>. The district courts are trial courts, where cases are presented to a judge or jury. Their decisions are bound by the legal doctrine established by their respective circuit courts, which handle appeals of cases from their constituent district courts. All of these courts are bound by Supreme Court decisions. </p>
<p>If there is no prior ruling to establish a precedent on the matter, federal district court judges can issue rulings based on their independent legal judgment. Consequently, district courts in different circuits can end up issuing separate rulings that contradict each other.</p>
<p>It’s relatively common for <a href="https://californialawreview.org/print/irons-procedure-circuit-splits/#clr-toc-heading-2">differences to arise between district courts</a> – or even for <a href="https://www.scotusblog.com/2022/06/vaccine-requirements-cancer-claims-and-circuit-splits/">different circuit courts to rule differently</a> on appeals in similar cases.</p>
<p>Only the Supreme Court can issue an opinion that binds all circuits. So when there are disagreements between circuit courts, the <a href="https://www.vox.com/2015/6/26/17937558/supreme-court-same-sex-gay-marriage-sixth-circuit-ruling">Supreme Court can step in</a> and make a decision for the whole country.</p>
<p>For example, the 6th Circuit, which serves Kentucky, Ohio, Michigan and Tennessee, upheld same-sex marriage bans in all four states in 2014. By then, <a href="https://www.scotusblog.com/2014/11/sixth-circuit-the-split-on-same-sex-marriage/">four other circuits</a> had reached the opposite result and struck down same-sex marriage bans. This set up, as <a href="https://www.scotusblog.com/2014/11/sixth-circuit-the-split-on-same-sex-marriage/">one commentator explained</a>, an “<a href="https://www.scotusblog.com/2014/11/sixth-circuit-the-split-on-same-sex-marriage/">almost certain review by the Supreme Court</a>,” particularly because this was “<a href="https://www.scotusblog.com/2014/11/sixth-circuit-the-split-on-same-sex-marriage/">an issue of fundamental constitutional significance</a>.” </p>
<p>Until the <a href="https://www.oyez.org/cases/2014/14-556">Supreme Court decided the issue in 2015</a>, however, same-sex marriage was legal in some states, but not in others. </p>
<h2>Other examples</h2>
<p>There are many other examples where federal circuit courts disagree.</p>
<p>In 2018, the <a href="https://www.aclu-in.org/sites/default/files/7thcirdecision.pdf">7th Circuit Court of Appeals</a>, which serves Illinois, Indiana and Wisconsin, ruled that an Indiana state law that banned abortions based on genetic anomalies was not constitutional. The Supreme Court <a href="https://www.supremecourt.gov/opinions/18pdf/18-483_3d9g.pdf">decided not to take Indiana’s appeal of that ruling</a>.<br>
But in 2021, the <a href="https://www.opn.ca6.uscourts.gov/opinions.pdf/21a0083p-06.pdf">6th Circuit Court of Appeals</a> upheld an Ohio law banning abortions based on one kind of genetic anomaly, Down syndrome. That created a circuit-court split of a sort usually resolved by the Supreme Court. </p>
<p>However, the Dobbs decision, which resolved a different abortion case, essentially dissolved the conflict by holding that the U.S. Constitution does not prevent states from banning abortions for any reason: They simply must show a <a href="https://www.oyez.org/cases/2021/19-1392">“rational basis” that “would serve legitimate state interests</a>.” </p>
<p>One other thing that confuses many people is how district courts can issue orders that go beyond the borders of their districts, and even their circuits, sometimes applying nationally. There is <a href="https://www.law.cornell.edu/uscode/text/5/706">some scholarly dispute about this</a>. Nevertheless, many judges have issued nationwide rulings on a wide range of issues, <a href="https://crsreports.congress.gov/product/pdf/LSB/LSB10664/1">including migrant protection protocols, loan foregiveness</a> and <a href="https://www.cnn.com/2022/04/18/politics/cdc-mask-mandate-ruling/index.html">mask-wearing mandates</a>.</p>
<h2>The case of mifepristone</h2>
<p>With this latest example of courts butting heads, Federal District Judge <a href="https://storage.courtlistener.com/recap/gov.uscourts.txnd.370067/gov.uscourts.txnd.370067.137.0_11.pdf">Matthew Kacsmaryk in Texas ruled first</a>, on April 7. His decision took the form of a <a href="https://pro.bloomberglaw.com/brief/how-to-file-a-preliminary-injunction">preliminary injunction</a>, which is essentially a temporary ruling, until the court has a chance to go through a full trial. Kacsmaryk concluded that the FDA had exceeded its authority in approving mifepristone in 2000 and in loosening the prescribing restrictions over the years. As a result, he ruled that the <a href="https://www.nytimes.com/2023/04/10/health/abortion-pill-fda.html">drug’s approval should be revoked entirely</a>. </p>
<p>Within an hour of Kacsmaryk’s ruling, <a href="https://int.nyt.com/data/documenttools/court-decision-keeping-mifepristone-available/1d2b761e9ab275f7/full.pdf">Federal District Judge Thomas Rice</a> in Washington state issued a contradictory ruling, which was also a preliminary injunction, declaring that the FDA’s approval of the drug and its uses should not be revoked.</p>
<p>While Kacsmarkyk’s ruling applied nationwide, Rice’s ruling applied only to the 17 states and the District of Columbia that were the plaintiffs in the suit he was handling. He noted that he had authority to make his ruling nationwide, but he also had discretion to limit the reach of the ruling to the parties that brought suit. </p>
<h2>Where the issues stand</h2>
<p>The Supreme Court’s ruling means mifepristone will remain as widely available as it was before. Fifteen states <a href="https://www.guttmacher.org/state-policy/explore/medication-abortion">already restrict access to medication abortions</a>. </p>
<p>“As a result of the Supreme Court’s stay, <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2023/04/21/statement-from-president-joe-biden-on-the-supreme-courts-decision-in-alliance-for-hippocratic-medicine-v-fda/">mifepristone remains available</a> and approved for safe and effective use while we continue this fight in the courts,” President Joe Biden said in a White House statement. </p>
<p>But that decision is only in effect while the case is being decided by the 5th Circuit. Undoubtedly, that decision will be appealed to the Supreme Court again. </p>
<p>So far, no one has appealed the Washington district court opinion, although a potential future Supreme Court ruling after the 5th Circuit decision would also affect that case’s outcome. And the situation gets even more complicated, <a href="https://storage.courtlistener.com/recap/gov.uscourts.mdd.535091/gov.uscourts.mdd.535091.1.0.pdf">with a third lawsuit filed in a federal court in Maryland</a> on April 19. That case was brought by GenBioPro, the manufacturer of a generic version of mifepristone, which the FDA approved in 2019. GenBioPro is seeking to preserve the approval of its drug, despite all the conflicting and confusing court rulings.</p>
<p>Although the Supreme Court majority said that it had hoped that the Dobbs opinion would <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">end federal battles over abortion rights</a>, there is more confusion and conflict than ever, in every corner of the country. And the confusion may continue for a while.</p><img src="https://counter.theconversation.com/content/203623/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many people wonder how courts can rule in contradictory ways. But it happens relatively frequently.Naomi Cahn, Professor of Law, University of VirginiaSonia Suter, Professor of Law, George Washington UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1913102023-04-19T12:44:30Z2023-04-19T12:44:30ZEmergency contraception is often confused with abortion pills – here’s how Plan B and other generic versions work to prevent pregnancy<figure><img src="https://images.theconversation.com/files/520092/original/file-20230410-26-r8dpzm.jpg?ixlib=rb-1.1.0&rect=46%2C0%2C5200%2C3440&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Morning-after pills are most effective when taken within three days after sex.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/woman-taking-contraceptive-pill-royalty-free-image/91558808?phrase=Morning%20after%20pill&adppopup=true">Ian Hooton/Science Photo Library via Getty Images</a></span></figcaption></figure><p>Since the overturning of Roe v. Wade in June 2022 and the <a href="https://theconversation.com/supreme-court-overturns-roe-upends-50-years-of-abortion-rights-5-essential-reads-on-what-happens-next-184697">end of constitutional protection for abortion</a>, emergency contraception has become more difficult to obtain and – more than ever – shrouded in misinformation. </p>
<p>Attempting to control inventory, Amazon, Rite Aid and Walmart have <a href="https://www.theguardian.com/society/2022/jun/28/emergency-contraception-pills-pharmacies">imposed purchase limits on the emergency contraception known as Plan B</a> since the Supreme Court’s ruling. Panicked buyers have been trying to stock up on the drug in case it becomes unavailable. </p>
<p>Several legislators and proposed bills have <a href="https://nwlc.org/resource/dont-be-fooled-birth-control-is-already-at-risk/">conflated emergency contraception with abortion</a> and are trying to limit access to it. The <a href="https://theconversation.com/anti-mifepristone-court-decisions-rely-on-medical-misinformation-about-abortion-and-questionable-legal-reasoning-203742">recent court ruling</a> <a href="https://www.washingtonpost.com/politics/2023/04/07/texas-abortion-pill-ruling-mifepristone/">blocking access to mifepristone</a> – which has been approved by the FDA since 2000 – is an ominous sign to many that emergency contraception could be the next target. </p>
<p>Regardless of one’s stance on abortion, it is important to understand why emergency contraception should be a basic component of women’s reproductive health care and family planning services. As a researcher of <a href="https://www.researchgate.net/profile/Amie-Ashcraft">women’s sexual and reproductive health and decision-making</a>, I have extensively researched access to emergency contraception.</p>
<h2>What is emergency contraception?</h2>
<p>Emergency contraception is the only way to prevent pregnancy after sex has already occurred. It can be used when no contraception was used or it was used incorrectly, such as with missed birth control pills or broken condoms. Emergency contraception is also used to prevent pregnancy after sexual assault or rape. </p>
<p>Emergency contraception can take the form of pills – sometimes called the morning-after pill – or <a href="https://www.acog.org/womens-health/faqs/long-acting-reversible-contraception-iud-and-implant">an intrauterine device, or IUD</a> that delays ovulation. </p>
<p>There are two types of emergency contraception pills. The most widely known is <a href="https://medlineplus.gov/druginfo/meds/a610021.html">levonorgestrel</a>, which is sold in the U.S. under the brand name <a href="https://www.planbonestep.com/">Plan B</a>, along with numerous generic versions. </p>
<p>Levonorgestrel was <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/plan-b-one-step-15-mg-levonorgestrel-information#:%7E">first approved for over-the-counter sale</a> to women 18 and older in 2006, and in 2013 age restrictions were removed. </p>
<p>The second type of emergency contraception pill is ulipristal acetate, which is sold under the brand name ella. Both Plan B and ella work by delaying ovulation. In addition, ella <a href="https://doi.org/10.3109/09513590.2014.950648">also thins the uterus lining</a> so that even if an egg were fertilized, it is harder for it to implant in the uterus to start a pregnancy. </p>
<p>Both types of pills are effective at preventing pregnancy. Plan B is most effective if taken within three days of sex, with some declining effectiveness on days four and five. Ella is effective if taken within five days of sex and, unlike Plan B, is equally effective all five days.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/7Vozr9vHeMo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Studies show emergency contraception prevents pregnancy only before the egg is fertilized, not after.</span></figcaption>
</figure>
<p>The most effective types of emergency contraception are IUDs that are inserted by a health care provider. Copper IUDs – also referred to as nonhormonal IUDs – are sold under the brand name Paragard. They release into the uterus copper ions that are <a href="https://www.mayoclinic.org/tests-procedures/paragard/about/pac-20391270">toxic to both eggs and sperm</a>. This allows them to be used as emergency contraception if inserted within five days after sex, and as ongoing contraception for up to 10 years. </p>
<p>Levonorgestrel IUDs – referred to as hormonal IUDs – are sold under the brand names Mirena, Liletta, Kyleena and Skyla. The levonorgestrel released into the uterus makes the mucus around the cervix thicker so that a sperm cannot penetrate to fertilize the egg, and it is as effective as the copper IUD when inserted as emergency contraception <a href="https://doi.org/10.1056/NEJMoa2022141">for up to five days after sex</a>. Both Paragard and Mirena IUDs have been approved by the FDA for use as contraception, but they are <a href="https://www.contemporaryobgyn.net/view/updates-on-emergency-contraception">not yet approved specifically for use as emergency contraception</a>.</p>
<h2>How is emergency contraception different from the abortion pill?</h2>
<p>For many years, the way that emergency contraception works has been misunderstood. There has been confusion about whether emergency contraception is an abortifacient – that is, a medication that triggers an abortion. The key difference is that the abortion pill works only when a woman is pregnant, and emergency contraception works only when she is not.</p>
<p>The so-called abortion pill is used for a medication abortion and actually consists of <a href="https://www.bedsider.org/abortion/abortion-pill">two separate pills that do different things</a>. </p>
<p>The <a href="https://theconversation.com/what-the-fdas-rule-changes-allowing-the-abortion-pill-mifepristone-to-be-dispensed-by-pharmacies-mean-in-practice-5-questions-answered-197339">first of these pills is mifepristone</a>, which functions to block production of the pregnancy hormone progesterone so that the uterus lining thins and the embryo detaches from it. This is the pill that is receiving national attention because of clashing court rulings over access, a battle that is headed to <a href="https://www.statnews.com/2023/04/13/abortion-mifepristone-texas-appeals-court-restores-access-access/">the Supreme Court</a>.</p>
<p>The second pill, misoprostol, stimulates contractions in the uterus to eject the embryo and gestational sac. Emergency contraception prevents a pregnancy before it occurs, whereas the abortion pill ends a pregnancy once it’s begun.</p>
<figure>
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<figcaption><span class="caption">Some observers say there’s a possibility of an eventual ban on Plan B and other contraceptives.</span></figcaption>
</figure>
<h2>How do abortion restrictions jeopardize emergency contraception?</h2>
<p>With the increase in abortion restrictions, access to a full range of contraceptive options – including emergency contraception – is more critical than ever. </p>
<p>There are already numerous barriers to obtaining emergency contraception in a timely manner. The most effective types of emergency contraception, ulipristal acetate and both hormonal and nonhormonal IUDs, must be obtained from a health care provider. This means a woman needs an appointment – usually available only on a weekday during business hours – as well as transportation and the means to pay for the appointment, either through health insurance or self-pay. She may need to take time off of work to attend the appointment, or she may need to obtain child care.</p>
<p>For many women in poor, rural or geographically isolated neighborhoods, these barriers are difficult to surmount. This is particularly true given the short window of time in which emergency contraception is effective.</p>
<p>Levonorgestrel emergency contraception pills are available over the counter and should be easily accessible, but individuals trying to purchase them run into numerous obstacles. These include <a href="https://doi.org/10.1016/j.japh.2020.07.027">low stocks in pharmacies</a> – especially independent pharmacies – and <a href="https://doi.org/10.1016/j.srhc.2022.100765">point-of-sale restrictions</a>, such as requirements that purchasers be a certain age, show identification or have parental consent. People also encounter high rates of misinformation about when to take levonorgestrel for maximum effectiveness and about sales restrictions. Finally, they encounter pharmacy staff who object to selling it because they <a href="https://doi.org/10.1177/0969733020918926">misunderstand how it works</a>.</p>
<p>The surge in demand for emergency contraception since the reversal of Roe v. Wade and the <a href="https://www.theguardian.com/society/2022/jun/28/emergency-contraception-pills-pharmacies">purchase limits put on it by retailers</a> have exacerbated these access challenges. </p>
<h2>What are the benefits of emergency contraception?</h2>
<p>Access to emergency contraception promotes women’s health in several ways. <a href="https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/index.htm">Nearly half of pregnancies in the U.S. are unintended</a>, and emergency contraception can prevent about <a href="https://www.who.int/news-room/fact-sheets/detail/emergency-contraception">95% of unwanted or mistimed pregnancies</a> when used within five days of sex. It can also be used as a backup option when another form of contraception fails. And it can be given to survivors of sexual assault. Emergency contraception also <a href="https://www.guttmacher.org/news-release/2005/emergency-contraception-ec-played-key-role-abortion-rate-declines">reduces the need for abortions</a>.</p>
<p>Overall, access to a full range of contraceptive options – including emergency contraception – gives women greater control over their reproductive choices. The ability to control the number and spacing of their pregnancies improves the health, social and <a href="https://iwpr.org/iwpr-issues/reproductive-health/the-economic-effects-of-contraceptive-access-a-review-of-the-evidence/">economic outcomes</a> of both women and their families.</p><img src="https://counter.theconversation.com/content/191310/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amie Ashcraft does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The increase in abortion restrictions may also lead to a decline in access to emergency contraceptives.Amie Ashcraft, Service Assistant Professor in Family Medicine, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1989782023-02-09T13:35:35Z2023-02-09T13:35:35ZMedication abortion could get harder to obtain – or easier: There’s a new wave of post-Dobbs lawsuits on abortion pills<figure><img src="https://images.theconversation.com/files/508726/original/file-20230207-28-4ztdo9.jpg?ixlib=rb-1.1.0&rect=287%2C23%2C3706%2C2502&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Legal battles are being waged over mifepristone, one of two drugs used in medication abortion.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/mifepristone-and-misoprostol-the-two-drugs-used-in-a-news-photo/1241524154?adppopup=true">Robyn Beck/AFP via Getty Images</a></span></figcaption></figure><p>Medication abortion now accounts for <a href="https://www.cdc.gov/reproductivehealth/data_stats/abortion.htm">more than half of all abortions</a> in the United States.</p>
<p>Typically, patients take a <a href="https://theconversation.com/what-is-a-medication-or-medical-abortion-5-questions-answered-by-3-doctors-182646">two different pills</a>: first mifepristone, then misoprostol. </p>
<p>Even though this option has been legally available for more than two decades, two recent events have raised legal questions about it. First, the Supreme Court’s <a href="https://www.oyez.org/cases/2021/19-1392">Dobbs v. Jackson Women’s Health</a> ruling overturned the constitutional right to abortion recognized in 1973 in <a href="https://www.oyez.org/cases/1971/70-18">Roe v. Wade</a>. Second, in January 2023, the Food and Drug Administration decided that <a href="https://theconversation.com/what-the-fdas-rule-changes-allowing-the-abortion-pill-mifepristone-to-be-dispensed-by-pharmacies-mean-in-practice-5-questions-answered-197339">certified U.S. pharmacies could sell mifepristone</a> <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answers-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation">by prescription</a>.</p>
<p>The result is a raft of new legal battles over access to medication abortion.</p>
<p>Some <a href="https://www.smith.senate.gov/u-s-senator-tina-smith-and-rep-cori-bush-re-introduce-legislation-to-protect-access-to-medication-abortion/">congressional lawmakers seek</a> to protect the right to access the pills through pharmacies and telehealth in states where abortion remains legal. At least <a href="https://www.nytimes.com/2023/01/25/health/abortion-pills-ban-genbiopro.html">three lawsuits are pending</a>, and some states that have banned abortion altogether or have restricted access to it are vowing to block the new federal rules. South Dakota Governor Kristi Noem, for example, has <a href="https://apnews.com/article/abortion-health-sd-state-wire-south-dakota-medication-21146e96236c67244331a8cfe64e84d3">threatened to prosecute any pharmacist</a> who sells the pills in her state.</p>
<p><a href="https://www.law.virginia.edu/faculty/profile/nrc8g/2915359">As experts</a> on <a href="https://www.law.gwu.edu/sonia-m-suter">reproductive health and justice</a>, we’re trying to untangle when and where mifepristone might be available and what these contradictory trends signal.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/kzd4ABInBio?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Mifepristone and misoprostol work in tandem to terminate a pregnancy.</span></figcaption>
</figure>
<h2>Prescribing abortion drugs</h2>
<p>Who has the authority to determine when, how or whether abortion medication can be prescribed and sold?</p>
<p>Under its long-held, congressionally granted authority to regulate pharmaceutical products, <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation">the FDA approved mifepristone in 2000</a> after an extensive review demonstrated that the drug was safe and effective for early pregnancy termination.</p>
<p>From the beginning, the sale of mifepristone was tied to several safety requirements known as a risk evaluation and mitigation strategy. Initially, the drug had to be dispensed by <a href="https://www.acog.org/news/news-articles/2022/03/understanding-the-practical-implications-of-the-fdas-december-2021-mifepristone-rems-decision">certified medical providers in person</a>.</p>
<p>But in late 2021, the FDA concluded that was no longer necessary for patient safety. Today, the pill, in its original or generic form, is approved for use up to 10 weeks’ gestation and can be <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation">dispensed by a certified prescriber or pharmacy</a>.</p>
<p>Recent lawsuits challenge the scope of the FDA’s authority to regulate the sale of mifepristone.</p>
<p>In one, GenBioPro, a drug company that makes generic mifepristone, <a href="https://www.courtlistener.com/docket/66756764/genbiopro-inc-v-sorsaia/">sued officials in West Virginia</a>, claiming that the state’s abortion ban impedes its sales. GenBioPro argues that the ban contradicts FDA’s approval of and safety requirements for mifepristone, setting up a conflict between federal and state law.</p>
<p>In short, the drugmaker argues that the federal regulations override West Virginia’s abortion restrictions. West Virginia Attorney General Patrick Morrisey, however, <a href="https://www.nytimes.com/2023/01/25/health/abortion-pills-ban-genbiopro.html">plans to defend the abortion ban vigorously because</a> “the U.S. Supreme Court has made it clear that regulating abortion is a state issue.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/508729/original/file-20230207-28-3c0zky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Young women protest restrictions on access to abortion." src="https://images.theconversation.com/files/508729/original/file-20230207-28-3c0zky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508729/original/file-20230207-28-3c0zky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=423&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508729/original/file-20230207-28-3c0zky.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=423&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508729/original/file-20230207-28-3c0zky.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=423&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508729/original/file-20230207-28-3c0zky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=532&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508729/original/file-20230207-28-3c0zky.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=532&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508729/original/file-20230207-28-3c0zky.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=532&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Protesters in Raleigh, N.C., object to the Supreme Court’s Dobbs ruling on June 25, 2022.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/abortion-rights-demonstrators-gather-to-protest-against-the-news-photo/1241513344?phrase=north%20carolina%20abortion&adppopup=true">Peter Zay/Anadolu Agency via Getty Images</a></span>
</figcaption>
</figure>
<p>In another pending lawsuit, <a href="https://www.courtlistener.com/docket/66756666/bryant-v-stein/">Bryant v. Stein</a>, obstetrician-gynecologist Amy Bryant sued officials in North Carolina on similar grounds. Although North Carolina has not banned abortion, it imposes a number of restrictions, including a 72-hour waiting period before accessing medical or surgical abortions. </p>
<p>Bryant argues that the restrictions exceed the FDA requirements for dispensing mifepristone and are therefore preempted by federal law.</p>
<p>There is limited precedent in this area.</p>
<p>In one case, the manufacturer of an opioid – Zohydro – challenged a Massachusetts ban of the drug, even though the FDA had approved it. The federal court ruled for the manufacturer because the ban would “<a href="https://casetext.com/case/zogenix-inc-v-patrick">obstruct the FDA’s Congressionally-given charge</a>.”</p>
<p>That 2014 opinion might suggest that GenBioPro will succeed. On the other hand, a court might distinguish the two cases: Massachusetts banned Zohydro on public health grounds, which is squarely within the FDA’s authority, while West Virginia bans abortions on moral grounds – to protect fetal life – which is outside the FDA’s purview.</p>
<p>In the North Carolina case, the state does not ban mifepristone; it just imposes more restrictions than the FDA requires. Therefore, it is uncertain whether the Zohydro reasoning would be adopted. </p>
<p>A 2008 Supreme Court case, however, might be relevant.</p>
<p>In <a href="https://www.oyez.org/cases/2008/06-1249">Wyeth v. Levine</a>, a drugmaker claimed that FDA labeling requirements for a drug made by Wyeth, which was used to prevent allergies and motion sickness, preempted Vermont’s stricter labeling requirements. The Supreme Court rejected that argument. It concluded instead that allowing states to require stronger warnings didn’t interfere with Congress’ purpose in entrusting the FDA with drug labeling decisions.</p>
<p>Wyeth is not precisely like Bryant, however.</p>
<p>Whereas Wyeth dealt with labeling requirements, Bryant deals with regulations that affect access to a drug. Nevertheless, the Wyeth precedent could allow a court to permit states to impose stronger restrictions on access to mifepristone – as long as they fall short of banning the drug outright.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/509026/original/file-20230208-31-4ocqoh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman in scrubs gives a pill to a woman in black leggings and pink Crocs" src="https://images.theconversation.com/files/509026/original/file-20230208-31-4ocqoh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509026/original/file-20230208-31-4ocqoh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509026/original/file-20230208-31-4ocqoh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509026/original/file-20230208-31-4ocqoh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509026/original/file-20230208-31-4ocqoh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509026/original/file-20230208-31-4ocqoh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509026/original/file-20230208-31-4ocqoh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Until now, most abortion drugs have been dispensed in person at clinics.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/resident-gives-a-25-year-old-woman-medication-to-terminate-news-photo/1241513931">Gina Ferazzi / Los Angeles Times via Getty Images</a></span>
</figcaption>
</figure>
<h2>Banning mifepristone</h2>
<p>Another pending lawsuit may threaten the FDA’s authority to authorize any sales of mifepristone in the United States. </p>
<p>In <a href="https://adflegal.org/sites/default/files/2022-11/Alliance-for-Hippocratic-Medicine-v-FDA-2022-11-18-Complaint.pdf">Alliance for Hippocratic Medicine v. FDA</a>, a <a href="https://www.nytimes.com/2023/02/05/opinion/republicans-judges-biden.html">group of abortion opponents</a> asked a U.S. district court in November 2022 to force the FDA to stop allowing mifepristone sales anywhere in the United States. The lawsuit argues that the FDA “chose politics over science” and “exceeded its regulatory authority” in various ways, including allegedly disregarding “substantial evidence” that medication abortion is riskier than surgical abortions.</p>
<p>The <a href="https://www.guttmacher.org/2023/02/10-us-states-would-be-hit-especially-hard-nationwide-ban-medication-abortion-using?utm_source=substack&utm_medium=email">consequences could be quite significant</a>, and the issue <a href="https://www.washingtonpost.com/politics/2023/02/05/abortion-pills-texas-lawsuit">could even end up on the Supreme Court’s docket</a> in the future. Nevertheless, there are compelling legal reasons why this lawsuit should fail. </p>
<p><a href="https://www.bloomberglaw.com/public/desktop/document/AllianceforHippocraticMedicineetalvUSFoodandDrugAdministrationeta/1?doc_id=X5HTS5K5059AJ9KRB669CPR0KQ">Some of the same organizations have tried</a> to challenge the FDA’s approval of mifepristone before – without success. And in 2008, <a href="https://www.gao.gov/assets/gao-08-751.pdf">the Government Accountability Office found no irregularities</a> in the FDA’s approval and oversight of mifepristone. </p>
<p>In contradiction to the plaintiffs’ safety argument, <a href="https://doi.org/10.1016/j.contraception.2015.01.005">numerous studies have shown</a> <a href="https://nap.nationalacademies.org/read/24950/chapter/4#53">mifepristone</a> to <a href="https://www.ipas.org/clinical-update/english/recommendations-for-abortion-before-13-weeks-gestation/medical-abortion/safety-and-effectiveness/">be a safe</a> <a href="https://doi.org/10.1097/aog.0000000000000897">and effective</a> <a href="https://doi.org/10.1016/j.jogc.2020.04.006">drug</a>.</p>
<p>Nevertheless, <a href="https://www.vox.com/policy-and-politics/2022/12/17/23512766/supreme-court-matthew-kacsmaryk-judge-trump-abortion-immigration-birth-control">U.S. District Court Judge Matthew Kacsmaryk</a>, who sits in Amarillo, Texas, and is hearing this case regarding whether the FDA should rescind its approval of mifepristone, has not been supportive of reproductive rights in the past. Thus, it is possible that the court could try to stop the FDA from allowing mifepristone to be sold in that part of Texas or even, possibly, across the entire nation.</p>
<p>If the court prevents the sale of mifepristone nationwide, medication abortions would only be possible with the other pill, misoprostol, which is also <a href="https://www.ncbi.nlm.nih.gov/books/NBK539873/#:%7E:text=Currently%2C%20misoprostol%20is%20FDA%20approved,at%20high%20risk%20for%20ulceration">approved for other purposes</a>. Recent data suggests that this one-drug approach to medication abortions may <a href="https://www.theatlantic.com/health/archive/2022/09/abortion-pill-misoprostol-effectiveness/671465/">safely and effectively induce abortion</a>. </p>
<h2>Pills in interstate commerce</h2>
<p>In addition to questions of whether the FDA’s authority can override state-imposed abortion restrictions, there’s a second issue concerning the ability to sell the pills through interstate commerce. </p>
<p>As the <a href="https://perma.cc/M6BA-2ZFZ">Supreme Court has explained</a>, the Constitution <a href="https://www.oyez.org/cases/2011/11-393">grants Congress the authority to regulate</a> “things in interstate commerce,” as well as “those activities that substantially affect interstate commerce.”</p>
<p>Thus, in the GenBioPrio lawsuit pending in West Virginia, the company argues that <a href="https://www.documentcloud.org/documents/23586762-genbiopro-wv-lawsuit">state efforts to restrict sale of the pill are unconstitutional</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/508731/original/file-20230207-16-u1jg3u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Large beige building with a bright green lawn" src="https://images.theconversation.com/files/508731/original/file-20230207-16-u1jg3u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508731/original/file-20230207-16-u1jg3u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508731/original/file-20230207-16-u1jg3u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508731/original/file-20230207-16-u1jg3u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508731/original/file-20230207-16-u1jg3u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508731/original/file-20230207-16-u1jg3u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508731/original/file-20230207-16-u1jg3u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An organization that opposes abortion filed a lawsuit in a court located in Amarillo, Texas, that seeks to revoke the FDA’s approval of mifepristone.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/potter-county-courthouse-in-downtown-amarillo-texas-news-photo/1178112126?phrase=amarillo%20district%20court&adppopup=true">Don & Melinda Crawford/Education Images/Universal Images Group via Getty Images</a></span>
</figcaption>
</figure>
<h2>Mailing abortion pills</h2>
<p>Many people are also taking <a href="https://www.plancpills.org/guide-how-to-get-abortion-pills">abortion pills they get through the mail</a>. In response to that trend, <a href="https://www.axios.com/2023/02/01/attorney-general-letter-cvs-walgreens-abortion">20 Republican state attorneys general recently threatened</a>
pharmacies with “legal consequences” if they mail and distribute mifepristone. </p>
<p>An 1873 law, the <a href="https://www.law.cornell.edu/uscode/text/18/1461">Comstock Act</a>, is central to the issue of whether it is legal to mail abortion pills. That law makes it a crime to use the mail for any “lewd, lascivious, indecent, filthy or vile article” as well as any “article, instrument, substance, drug, medicine or thing which is advertised or described in a manner calculated to lead another to use of apply it for producing abortion.”</p>
<p>When the <a href="https://theconversation.com/proposed-federal-abortion-ban-evokes-19th-century-comstock-act-a-law-so-unpopular-it-triggered-the-centurylong-backlash-that-led-to-roe-188681">Comstock Act</a> was enacted, of course, modern delivery services like FedEx and UPS did not exist. But the law also prohibits any “express company” from engaging in the same acts. </p>
<p>The U.S. Postal Service asked the Justice Department whether abortion pills can be mailed under the Comstock Act, and it responded with a <a href="https://www.justice.gov/olc/opinion/file/1560596/download">carefully worded 21-page opinion</a> in late December 2022. The opinion concludes that mailing the abortion pills is not illegal so long as the sender “lacks the intent that the recipient of the drugs will use them unlawfully.” </p>
<p>As the opinion pointed out, recipients could use the drugs for a variety of reasons that would be legal in every state. For example, the combination can “treat a miscarriage,” and misoprostol can prevent and treat <a href="https://www.mayoclinic.org/drugs-supplements/misoprostol-oral-route/side-effects/drg-20064805">gastric ulcers</a>.</p>
<p>Regardless of how Judge Kacsmaryk rules, we expect to see medication abortion remain available in states that don’t have abortion bans. But we also are certain that legal challenges over abortion access will continue.</p><img src="https://counter.theconversation.com/content/198978/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A rash of pending lawsuits raises questions about the FDA’s approval of mifepristone two decades ago, whether the drug can be legally mailed and the constitutional right to interstate commerce.Naomi Cahn, Professor of Law, University of VirginiaSonia Suter, Professor of Law, George Washington UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1973392023-01-11T13:26:42Z2023-01-11T13:26:42ZWhat the FDA’s rule changes allowing the abortion pill mifepristone to be dispensed by pharmacies mean in practice – 5 questions answered<figure><img src="https://images.theconversation.com/files/503684/original/file-20230109-13-cophlz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7348%2C4407&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The rule change has little to no effect in states where abortion is banned or restricted.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/simplifying-the-dispensing-process-with-smart-apps-royalty-free-image/1138202173?phrase=pharmacist%20dispensing%20pills&adppopup=true">LaylaBird/E+ via Getty Images</a></span></figcaption></figure><p><em>In early January 2023, the U.S. Food and Drug Administration <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answers-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation#">modified its rules for mifepristone</a>, a drug used for medication abortion, allowing it to be offered with a prescription by certified pharmacies. Before this rule change, mifepristone could be dispensed only in person by providers at hospitals, clinics and medical offices, as well as by some mail-order pharmacies.</em></p>
<p><em>The Conversation asked Grace Shih, a family physician practicing in Washington, to explain the significance of this change for health care providers and their patients.</em></p>
<h2>What is mifepristone, and how does it work?</h2>
<p>Mifepristone is a pill that is <a href="https://theconversation.com/what-is-a-medication-or-medical-abortion-5-questions-answered-by-3-doctors-182646">used in medication abortion</a> during early pregnancy. It was initially <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation">approved by the FDA in 2000</a> and is FDA-approved for medication abortion up to 10 weeks after the first day of last menstrual period.</p>
<p>It can be taken as one part of a two-part pill regimen for medication abortion. Mifepristone is prescribed as a 200-milligram dose taken orally followed by an 800-microgram dose of misoprostol, which is placed in the vagina or between the teeth and cheek, where it dissolves and is absorbed, usually 24 to 48 hours later. </p>
<p>Mifepristone acts by blocking the hormone progesterone, which is necessary for a pregnancy to develop. This stops the pregnancy growth and softens and dilates the cervix. It also prepares the uterus for contractions, increasing its sensitivity to medications such as misoprostol. </p>
<p>Misoprostol is a synthetic <a href="https://www.yourhormones.info/hormones/prostaglandins/">prostaglandin</a>. Prostaglandin is a hormonelike substance that has multiple effects, including the stimulation of uterine contractions, which helps expel pregnancy tissue such as the thickened uterine lining and the tissues that are the precursor to the placenta. Mifepristone and misoprostol are also both used in the <a href="https://doi.org/10.1056/NEJMoa1715726">medical management of miscarriage</a>. </p>
<p>Medication abortion can also be done with misoprostol alone, known as the misoprostol-only regimen. In the misoprostol-only regimen, an 800-microgram dose of misoprostol is placed in the vagina or between the teeth and cheek every three hours for up to three doses. </p>
<h2>Why would a person opt for one regimen or the other?</h2>
<p>People usually don’t choose the type of medication abortion they receive. Either mifepristone is available where they are seeking care or it is not. </p>
<p>The American College of Obstetricians and Gynecologists <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">states that</a> “combined mifepristone-misoprostol regimens are recommended as the preferred therapy for medication abortion because they are significantly more effective than misoprostol-only regimens.” </p>
<p>The efficacy <a href="https://doi.org/10.1097/AOG.0000000000000897">of the two-pill regimen is approximately 95% to 98%</a>. However, because mifepristone is under the FDA’s <a href="https://www.fda.gov/drugs/drug-safety-and-availability/risk-evaluation-and-mitigation-strategies-rems">risk evaluation and mitigation strategy program</a>, which places <a href="https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm?event=RemsDetails.page&REMS=390">specific restrictions on mifepristone</a>, it can be difficult to obtain. </p>
<p>When mifepristone is not available, the American College of Obstetricians and Gynecologists considers the misoprostol-only regimen, which has an efficacy of 76% to 88%, to be an “<a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">acceptable alternative</a>.” Thus, the FDA’s permission to dispense mifepristone at retail pharmacies will help broaden access to the more effective combined mifepristone-misoprostol regimen of medication abortion. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/kzd4ABInBio?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Mifepristone and misoprostol work in tandem to terminate a pregnancy.</span></figcaption>
</figure>
<h2>What will the FDA’s rule change mean in practice?</h2>
<p>The recent FDA change means that retail pharmacies may dispense mifepristone by mail or at brick-and-mortar pharmacies, as long as that retail pharmacy has been certified. In other words, people who live in states where abortion is not banned can take their mifepristone prescription and get it the way they pick up other medications. </p>
<p>For someone able to pick up mifepristone from a local pharmacy, the process will be no different from picking up birth control pills or blood pressure medications. In this way, mifepristone and its uses for abortion care and miscarriage management will be treated as typical health care. </p>
<p>It is unclear whether or how the FDA’s rule will affect state restrictions on abortion care. If medication abortion is not permitted in a specific state, retail pharmacies in that state may or may not be able to dispense mifepristone for abortion care. However, mifepristone could be dispensed from certified pharmacies for reasons unrelated to abortion care, such as miscarriage management.</p>
<h2>What brought about the change?</h2>
<p>On Jan. 3, 2023, the FDA formally modified its <a href="https://www.acog.org/news/news-releases/2020/05/acog-suit-petitions-the-fda-to-remove-burdensome-barriers-to-reproductive-care-during-covid-19">regulations and guidelines around mifepristone use</a>, which were initially proposed during the COVID-19 pandemic. Previous guidelines required that mifepristone be dispensed in person.</p>
<p>These changes were brought about by a <a href="https://www.acog.org/-/media/project/acog/acogorg/files/advocacy/acog-v-fda-complaint-mifepristone-covid19.pdf?">civil complaint</a> that was sponsored by obstetrician-gynecologists, family physicians and reproductive justice advocates. It noted that “of the 20,000 drugs regulated by the FDA, mifepristone is the only one that patients must receive in person at a hospital, clinic or medical office,” even though the medication itself can be taken orally by a person unsupervised, at any location. </p>
<p>The in-person requirement meant that those seeking medication abortion or miscarriage care were required to face increased risk of COVID-19 exposure simply to obtain mifepristone. There has been <a href="https://www.acog.org/news/news-releases/2020/05/acog-suit-petitions-the-fda-to-remove-burdensome-barriers-to-reproductive-care-during-covid-19">no documented benefit</a> from this in-person dispensing requirement. </p>
<p>As a result of this complaint, the FDA placed a temporary pause on enforcement of the in-person dispensing requirement and subsequently <a href="https://www.fda.gov/files/drugs/published/Risk-Evaluation-and-Mitigation-Strategies--Modifications-and-Revisions-Guidance-for-Industry.pdf">conducted a formal review</a> of its regulations around the dispensing of mifepristone. The Jan. 3 decision is the FDA’s final decision.</p>
<p>Misoprostol has never been subject to the same restrictions. In addition to its use in the medication abortion regimen, misoprostol is FDA approved for management of gastric ulcers. And it is used, off-label, for cervical dilation and softening when doctors induce labor. People may continue to get their misoprostol at retail or mail-order pharmacies.</p>
<h2>How might this rule change affect medication abortion access?</h2>
<p>While this change is an important step in <a href="https://www.acog.org/news/news-releases/2023/01/statement-fda-announcement-regarding-changes-to-restrictions-on-provision-of-mifepristone">securing access to medication abortion</a>, it does not have a clear benefit for people who live in states where <a href="https://reproductiverights.org/maps/abortion-laws-by-state/">abortion is banned</a>. And it has limited benefit in states that have restrictions on medication abortion. </p>
<p>According to the <a href="https://www.guttmacher.org/">Guttmacher Institute</a>, a reproductive health policy organization, 29 states have <a href="https://www.guttmacher.org/state-policy/explore/medication-abortion">some restriction on medication abortion</a>, including 18 states that require that the clinician providing a medication abortion be physically present with the patient. Those restrictions therefore prohibit the use of telemedicine to prescribe medications for abortion.</p>
<p>It is unclear how many pharmacies will pursue certification and how quickly that certification can happen. Pharmacies that want to dispense mifepristone must comply with <a href="https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm?event=RemsDetails.page&REMS=390">FDA pharmacy agreements to achieve certification</a>. </p>
<p>This includes having systems in place to track and verify mifepristone prescribers, using a tracked shipping service and having the ability to report patient deaths to prescribers, <a href="https://www.accessdata.fda.gov/drugsatfda_docs/rems/Mifepristone_2023_01_03_Pharmacy_Agreement_Form_Danco_Laboratories.pdf">among other requirements</a>. CVS and Walgreens have already <a href="https://www.nytimes.com/2023/01/05/health/abortion-pills-cvs-walgreens.html">announced plans to become certified pharmacies</a>.</p>
<p>As a practicing family physician, I see the permanent removal of the in-person dispensing requirement as essential for normalizing abortion care and improving access to medication abortion. However, many obstacles remain, including specific patient consent forms, unique and required prescriber certification and the aforementioned pharmacy certification. </p>
<p>Leading health professional organizations including the <a href="https://www.acog.org/clinical-information/policy-and-position-statements/position-statements/2018/improving-access-to-mifepristone-for-reproductive-health-indications">American College of Obstetricians and Gynecologists</a>, the <a href="https://policysearch.ama-assn.org/policyfinder/detail/mifepristone?uri=%2FAMADoc%2FHOD.xml-H-100.948.xml">American Medical Association</a> and the <a href="https://www.aafp.org/dam/AAFP/documents/events/nc/congress/nc18-ncfmr-actions-referrals.pdf">American Academy of Family Physicians</a> have all issued statements that call for removing all restrictions around mifepristone, since there is no evidence that these restrictions improve patient care or safety.</p><img src="https://counter.theconversation.com/content/197339/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grace Shih does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The FDA’s allowance for pharmacies to dispense mifepristone will broaden access to the two-pill mifepristone-misoprostol regimen of medication abortion, which is 95% to 98% effective.Grace Shih, Associate Professor of Family Medicine, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1952792022-12-04T12:36:31Z2022-12-04T12:36:31ZPro-choice crowdfunding has surged in the U.S. — but donating that way has risks<figure><img src="https://images.theconversation.com/files/498049/original/file-20221129-13745-wc1ghw.jpg?ixlib=rb-1.1.0&rect=0%2C97%2C5912%2C3221&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Abortion rights protesters attend a rally outside the Michigan capitol building on June 24, 2022, following the United States Supreme Court's decision to overturn Roe v. Wade. </span> <span class="attribution"><span class="source">(AP Photo/Paul Sancya)</span></span></figcaption></figure><p>The <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf"><em>Dobbs v. Jackson Women’s Health Organization</em></a> decision by the United States Supreme Court earlier this year overturned constitutional protections of reproductive choice for Americans.</p>
<p>The ruling sparked protests, political action and outreach to women affected by the decision, including <a href="https://www.reuters.com/world/us/donations-us-abortion-rights-groups-clinics-surge-after-supreme-court-leak-2022-05-04/">a flood</a> of financial contributions to pro-choice organizations and causes.</p>
<p>Crowdfunding campaigns have been part of the story of financial support for reproductive justice in the aftermath of the Supreme Court decision. But while these campaigns have been massively successful by the standards of crowdfunding, they also raise significant concerns.</p>
<h2>Repercussions</h2>
<p>Financial needs arising from the <em>Dobbs</em> decision are acute. In addition to money for political and legal activism at the federal and state levels, women in states with newly restrictive abortion laws have been forced to cross state lines to access reproductive services. </p>
<p>These needs require support that may not be available from employers and insurance companies, particularly against a backdrop of policy change and legal uncertainty. </p>
<p>Women travelling to seek reproductive care as a result of <em>Dobbs</em> <a href="https://sites.utexas.edu/txpep/files/2022/03/TxPEP-out-of-state-SB8.pdf">have reported</a> being forced to take out loans or dip into their savings, and are struggling to pay rent and other bills. </p>
<p>In the two months after the <em>Dobbs</em> decision, approximately <a href="https://fivethirtyeight.com/features/overturning-roe-has-meant-at-least-10000-fewer-legal-abortions/">10,000 fewer</a> legal abortions took place in the U.S. By the end of October 2022, at least <a href="https://www.guttmacher.org/2022/10/100-days-post-roe-least-66-clinics-across-15-us-states-have-stopped-offering-abortion-care">66 U.S. abortion providers had closed</a>. </p>
<p>Clinics in states with newly restrictive laws must now seek legal advice about whether they can remain open while also exploring relocating to more permissive states. </p>
<p>Given these new realities, many people have been moved to donate to women in need of abortions, funds and organizations that provide access to abortion, and political and legal advocacy groups that work to protect reproductive choice. </p>
<h2>Influx of funds</h2>
<p>The National Network of Abortion Funds, for example, <a href="https://www.nytimes.com/2022/06/24/us/abortion-funds-donations-roe.html">says it received</a> US$1.5 million the week the <em>Dobbs</em> decision was leaked in May 2022, and more than US$3 million from 33,000 donors on June 24, 2022, the day of the Supreme Court ruling.</p>
<p>Social media has been key to organizing online giving as well — activist Olivia Julianna <a href="https://www.businessinsider.com/olivia-julianna-abortion-fundraiser-trolled-matt-gaetz-2-million-dollars-2022-8">helped raise</a> more than $2.3 million for the <a href="https://secure.actblue.com/donate/genzforchoice">Gen-Z for Choice Abortion Fund</a> after being body-shamed by Republican representative Matt Gaetz.</p>
<p>While the majority of this fundraising activity has taken the form of direct donations to individuals and organizations, others have used crowdfunding to facilitate giving. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1553832229255761922"}"></div></p>
<h2>A surge in donations</h2>
<p>My preliminary research has found that between May 2, 2022 — when the <em>Dobbs</em> decision was <a href="https://www.politico.com/news/2022/05/02/supreme-court-abortion-draft-opinion-00029473">first leaked</a> — and the Nov. 8, 2022 midterm elections in the U.S., 308 American crowdfunding campaigns on the GoFundMe platform raised almost US$3.2 million from more than 41,000 donations.</p>
<p>This included money for campaigns for abortion access funds like the National Network of Abortion Funds, organizations and protest movements seeking to protect and expand reproductive rights and women seeking abortion access.</p>
<p>Recent giving through crowdfunding is markedly different than abortion-related crowdfunding prior to <em>Dobbs</em>. When a colleague and I looked at these fundraisers <a href="https://doi.org/10.1186/s12905-020-00938-2">in 2018</a>, we only identified five campaigns for abortion funds compared to 226 following the <em>Dobbs</em> ruling. The 2018 fundraisers were also much more focused on individuals.</p>
<p>In addition to being more focused on pro-choice organizations, the recent abortion rights fundraisers are also much more successful than earlier abortion access campaigns. In 2018, campaigns seeking to provide abortion access averaged four donors with US$138.82 pledged per campaign, whereas the post-<em>Dobbs</em> campaigns attracted an average of 135 donors with US$10,300 pledged per campaign. </p>
<p>And while only 25 per cent of earlier campaigns received a donation, every one of the post-<em>Dobbs</em> campaigns received support.</p>
<figure class="align-center ">
<img alt="A woman wearing a mask that says bans off our bodies carries a sign that reads Keep Your Religion Out of my Uterus." src="https://images.theconversation.com/files/498043/original/file-20221129-24-bkkrts.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498043/original/file-20221129-24-bkkrts.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498043/original/file-20221129-24-bkkrts.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498043/original/file-20221129-24-bkkrts.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498043/original/file-20221129-24-bkkrts.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498043/original/file-20221129-24-bkkrts.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498043/original/file-20221129-24-bkkrts.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A protester outside the Kentucky Supreme Court chambers rallies in favour of abortion rights. Crowdfunding donations to abortion rights campaigns have dramatically increased since 2018.</span>
<span class="attribution"><span class="source">(AP Photo/Timothy D. Easley)</span></span>
</figcaption>
</figure>
<h2>Campaign organizers at risk?</h2>
<p>On the face of it, this is good news for proponents of reproductive choice, as it shows that crowdfunding can be part of a larger effort to support this cause. </p>
<p>But crowdfunding is an imperfect means of organizing this support. </p>
<p>Being successful in crowdfunding typically requires putting personal details online. This can include who is doing the fundraising, why it’s needed and where the money will go. In the case of women seeking an abortion, this means giving the public access to deeply personal information at an emotionally vulnerable moment. </p>
<p>Even for those fundraising on behalf of an organization or abortion access fund, crowdfunding can mean putting a public target on their backs to people who view abortion as the moral equivalent of murder.</p>
<p>Crowdfunding platforms also act as intermediaries between campaigners and donors, shaping how money is paid out — or whether campaigns are allowed at all. Platforms could decide not to host abortion-related campaigns if they’re opposed to abortion rights or fear that supporting those rights will draw unwanted attention. </p>
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<strong>
Read more:
<a href="https://theconversation.com/is-gofundme-violating-its-own-terms-of-service-on-the-freedom-convoy-176147">Is GoFundMe violating its own terms of service on the 'freedom convoy?'</a>
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<h2>Crowdfunding restrictions</h2>
<p>This isn’t a hypothetical concern.</p>
<p>GoFundMe <a href="https://www.salon.com/2014/09/10/gofundme_bans_all_content_relating_to_abortion_but_leaves_antiabortion_campaigns_active/">temporarily banned</a> campaigns to pay for abortion in 2014, and the right-wing Christian crowdfunding platform GiveSendGo currently <a href="https://www.thenation.com/article/society/givesendgo-crowdfunding-extremism/">restricts campaigns for abortion access</a>. </p>
<p>While GoFundMe is currently home to a wide range of abortion rights campaigns, many American states <a href="https://www.cnn.com/2022/07/03/us/abortion-help-travel-out-of-state-online-offers/index.html">are exploring</a> <a href="https://thehill.com/opinion/judiciary/3536720-the-right-to-travel-to-seek-an-abortion-in-a-post-dobbs-world/">legal</a> <a href="https://www.washingtonpost.com/politics/2022/06/29/abortion-state-lines/">action</a> to prevent and potentially prosecute people facilitating abortions. </p>
<p>These actions create legal exposure for crowdfunding platforms like GoFundMe and, as a for-profit company, it could easily choose to restrict these campaigns in its own self-interest.</p>
<p>In short, crowdfunding encourages giving but also adds new barriers. Giving directly to abortion rights groups and pro-choice organizations helps avoid some of these problems while still making giving easy. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/498056/original/file-20221129-7082-y1xnou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A protester holds up a sign that reads We Will Not Go Back." src="https://images.theconversation.com/files/498056/original/file-20221129-7082-y1xnou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/498056/original/file-20221129-7082-y1xnou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498056/original/file-20221129-7082-y1xnou.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498056/original/file-20221129-7082-y1xnou.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498056/original/file-20221129-7082-y1xnou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498056/original/file-20221129-7082-y1xnou.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498056/original/file-20221129-7082-y1xnou.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An abortion rights supporter protests at the Mississippi Capitol. Crowdfunding can encourage donations but also poses new obstacles.</span>
<span class="attribution"><span class="source">(AP Photo/Rogelio V. Solis)</span></span>
</figcaption>
</figure>
<p>Direct giving can also allow these organizations to develop relationships with donors that may be sustained beyond the initial outrage of the <em>Dobbs</em> decision. Online crowdfunding uses social media to increase the visibility of giving and encourage others to help, but people who want to make their support public and encourage giving online can still choose to do so. </p>
<p>While crowdfunding campaigns are well-intentioned and have done a great deal of good, there are thankfully less compromised venues for support available.</p><img src="https://counter.theconversation.com/content/195279/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeremy Snyder does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Crowdfunding campaigns are well-intentioned and have done a great deal of good on the abortion rights front, but there are less compromised venues for support available.Jeremy Snyder, Professor, Health Sciences, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1941402022-11-09T22:33:15Z2022-11-09T22:33:15ZIn first nationwide election since Roe was overturned, voters opt to protect abortion access<figure><img src="https://images.theconversation.com/files/494537/original/file-20221109-21-3148v1.jpg?ixlib=rb-1.1.0&rect=49%2C444%2C8194%2C5042&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Voters in Michigan said 'yes' to Prop 3, a ballot protecting abortion rights.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/proposal-3-stickers-are-displayed-for-volunteers-at-the-news-photo/1439552294?phrase=abortion%20midterm&adppopup=true">Brandon Bell/Getty Images</a></span></figcaption></figure><p>The first major election since the <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">Supreme Court overturned Roe v. Wade</a> saw abortion rights on the ballot <a href="https://www.nytimes.com/interactive/2022/11/08/us/elections/results-abortion.html">in a record number of states</a>. The <a href="https://www.npr.org/sections/2022-live-primary-election-race-results/2022/08/02/1115317596/kansas-voters-abortion-legal-reject-constitutional-amendment">outcomes of these initiatives suggest</a> that when Kansas voters in August 2022 rejected a proposed constitutional amendment declaring there is no state right to abortion, it was not a fluke.</p>
<p>Indeed, results following the close of polls on Nov. 8 revealed that voters in Kentucky had followed suit and rejected a similar constitutional amendment. And in three other states — California, Michigan and Vermont — voters approved constitutional amendments to safeguard abortion access as part of a broader protection of personal reproductive autonomy, including contraception. In Vermont, the <a href="https://www.nytimes.com/interactive/2022/11/08/us/elections/results-abortion.html">margin of victory was sweeping</a>: 77.2% to 22.8%, with 95% of votes in.</p>
<p>In Montana, where restrictive abortion laws already prohibit post-viability abortions – that is, those after 24 weeks of pregnancy – voters <a href="https://npr.brightspotcdn.com/62/fd/c2a1150c481fb245d9e81585ada3/lr-131-ballot-statement-language-1.pdf">rejected a referendum</a> that threatened doctors with criminal penalties of up to 20 years in prison if they did not try to sustain the life of a fetus “born alive” after an abortion. </p>
<p>All told, the outcome of the initiatives underscores the crucial role of state law after the Supreme Court’s Dobbs ruling returned the issue of abortion access back to “the people” and the states.</p>
<h2>Abortion on the ballot and the campaign trail</h2>
<p>But abortion was also “on the ballot” indirectly – in key state and federal elections in which abortion appeared to have been a campaign issue.</p>
<p>In Pennsylvania, Democrat Josh Shapiro, the state’s Attorney General, <a href="https://www.nbcnews.com/politics/2022-election/josh-shapiro-declared-winner-2022-pennsylvania-governor-midterm-electi-rcna55169">won the race for governor over</a> Republican Doug Mastriano, and Democrat John Fetterman defeated Dr. Mehmet Oz for the available U.S. Senate seat. Access to abortion care and protecting abortion rights were key themes in Shapiro’s campaign, while Mastriano stressed culture war issues. <a href="https://www.inquirer.com/news/election-day-pennsylvania-abortion-reproductive-rights-voters-20221108.html">Commentary and exit polling suggest</a> that abortion was a motivating issue among Pennsylvania voters – especially younger voters. </p>
<p>In New York, where Governor Kathy Hochul defeated Republican challenger Lee Zeldin, the Democrat incumbent billed herself as “the reason why abortion is protected in New York” and <a href="https://spectrumlocalnews.com/nys/central-ny/ny-state-of-politics/2022/11/02/hochul-says-she-s-a-bulwark-for-abortion-rights-in-new-york">stressed a governor’s “immense” power</a> to affect abortion rights.</p>
<p>Exit polls indicate <a href="https://abcnews.go.com/Politics/live-updates/midterm-elections-exit-polls-live-updates/?id=92683687">60% of voters nationwide</a> – up 9% since 2020 – believe that abortion should be legal in all or most cases.</p>
<p>A majority – 60% – of voters <a href="https://abcnews.go.com/Politics/live-updates/midterm-elections-exit-polls-live-updates/?id=92683687">expressed anger</a> at the Supreme Court over the Dobbs ruling and indicated that they trusted the Democratic Party more than the Republican Party on the issue by a margin of 52% to 42%. These sentiments played out in the election results. For example, in New Hampshire, Democrat Maggie Hassan held onto her Senate seat against a Republican challenger, Don Bolduc, who called the Dobbs ruling <a href="https://www.wmur.com/article/hassan-bolduc-new-hampshire-us-senate-debate/41849758#">a reason to “rejoice</a>.” And 35% of New Hampshire voters <a href="https://abcnews.go.com/Politics/live-updates/midterm-elections-exit-polls-live-updates/?id=92683687">said abortion was their top issue</a>, behind only inflation at 36%. Polls also show a gender gap, with more women than men reporting abortion as their top issue.</p>
<h2>More state battles over abortion?</h2>
<p>Ballot initiatives are likely to <a href="https://www.washingtonpost.com/politics/2022/10/11/abortion-rights-advocates-eye-ballot-measures-2024/">continue into the 2024 presidential election</a> given voters’ response on Tuesday.</p>
<p>The midterm elections point toward protecting access to abortion, more so than preelection polls suggested they would.</p>
<p>As of this writing, the House and Senate hang in the balance, yet federal bills that would protect or restrict access to abortion were already unlikely to become laws given that the Supreme Court has <a href="https://theconversation.com/what-would-it-mean-to-codify-roe-into-law-and-is-there-any-chance-of-that-happening-182406">indicated states should decide their own laws</a>. This means state laws remain on the front line, and the midterm election was just a “hold the line” moment. </p>
<p>Most states have not yet had legislative sessions or elections, and most candidacies were declared before Dobbs was decided. The midterm elections didn’t make the landscape worse for access to care – indeed, the right to abortion care was expanded, or least protected in some places. But the <a href="https://www.kff.org/womens-health-policy/dashboard/abortion-in-the-u-s-dashboard/">high variability of state laws</a> will mean that <a href="https://www.justice.gov/opa/pr/justice-department-sues-idaho-protect-reproductive-rights">conflicts continue both among states, and between states and the federal government</a>.</p>
<p>Patient and provider confusion will likely continue, given the high degree of state law variability, which will <a href="https://www.smfm.org/repro">limit access to care and increase risks</a> in some states.</p><img src="https://counter.theconversation.com/content/194140/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Abortion rights were on the ballot in five states during the midterm elections – all broke in favor of abortion-rights advocates.Linda C. McClain, Professor of Law, Boston UniversityNicole Huberfeld, Edward R. Utley Professor of Health Law and Professor of Law, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1914312022-09-28T14:37:05Z2022-09-28T14:37:05ZAbortion pills are being widely used in Nigeria: women and suppliers talk about their experiences<figure><img src="https://images.theconversation.com/files/486801/original/file-20220927-12-2w6p1o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nigerian law forbids abortion unless a woman's life is in danger.</span> <span class="attribution"><span class="source">Photo by Universal Images Group via Getty Images</span></span></figcaption></figure><p>Unintended pregnancy is <a href="https://www.guttmacher.org/report/reducing-unintended-pregnancy-nigeria">common</a> among women of reproductive age in Nigeria and a substantial number end in abortion. <a href="http://paa2019.populationassociation.org/uploads/190710">Annually between 2015 and 2019</a>, almost three million pregnancies were unintended. Forty eight per cent ended in abortion. </p>
<p>Many of these <a href="https://www.pmadata.org/technical-areas/abortion">abortions are unsafe and some result in serious maternal morbidity or death</a>. The main reason for this is that <a href="https://reproductiverights.org/maps/worlds-abortion-laws/">termination is only allowed legally</a> in Nigeria if a woman’s life is in danger. This drives women to obtain abortions clandestinely through unqualified providers using inappropriate methods.</p>
<p>But abortions have become relatively safer since the emergence and increasing availability of medication abortion, especially misoprostol. <a href="https://srh.bmj.com/content/32/4/213">Misoprostol was approved</a> in Nigeria in January 2006 for the treatment of postpartum haemorrhage. Evidence suggests that Nigerian women are beginning to access and use it safely to induce their own abortions.</p>
<p><a href="https://bmjopen.bmj.com/content/10/5/e034670">A recent study</a> showed that 94% of women who used misoprostol – which they obtained from drug sellers (pharmacists and patent medicine vendors) in Lagos State – reportedly completed their abortions without further actions. </p>
<p>In Nigeria, patent and proprietary medicine vendors are outlets without formal training in pharmacy who sell orthodox pharmaceutical products on a retail basis for profit. Pharmacies are regulated in Nigeria.</p>
<p>Having uncomplicated abortions using misoprostol is a positive development for Nigerian women. It promotes their health and prevents unnecessary deaths due to unsafe abortion. Additionally, the privacy that the method provides protects women’s health and saves lives. It also has the ability to reduce social stigma and the financial cost of resolving an unintended pregnancy with an abortion.</p>
<p>In sum, in the context of restrictive abortion laws, promoting access to misoprostol as a harm reduction strategy is a life saver.</p>
<p>In <a href="https://pubmed.ncbi.nlm.nih.gov/36060610/">our study</a>, we assessed the quality of care provided to women who obtained misoprostol for abortion from drug sellers (patent medicine vendors and pharmacies) in 2018 across six local government areas in Lagos State, south west Nigeria. Our study emphasised the need to understand the knowledge of drug-sellers on provision of medication abortion and the extent of information they provided to their clients. This is important for ensuring the efficiency of medication abortion.</p>
<p>Drug sellers are not the only providers of misoprostol. But <a href="https://bmjopen.bmj.com/content/10/5/e034670">most women prefer to patronise them</a>. Understanding the quality of care provided during the abortion process is therefore critical to ensuring that women are able to self-manage abortions safely and effectively.</p>
<p>Our study therefore set out to determine if the quality of abortion care differed by drug seller type. Our research involved collecting insights from drug sellers as well as from women who had procured the drug. </p>
<p>Our findings show that women are more likely to obtain medication abortion at patent medicine vendors than at pharmacies. Also, there are differences in the socioeconomic characteristics of women who obtain care from patent medicine vendors compared with pharmacies. Medication abortion drugs are usually paid for out-of-pocket by women. Thus, we hypothesise that women who may have lower purchasing power or prefer to pay less are more likely to visit patent medicine vendors than pharmacies. Patent medicine vendors usually have lower prices and are easily accessible. </p>
<h2>Our research</h2>
<p>In assessing quality care we looked at three broad domains: the technical competence of the drug seller, information given to clients, and client experience of care. </p>
<p>We examined these domains from the perspective of drug sellers, as well as from those of the women.</p>
<p>We selected local government areas that had at least one higher-level educational institution. We hypothesised that areas with higher-level educational institutions would have a greater market for misoprostol due to the concentration of young females with a secondary education or higher, a population that has a relatively higher estimated <a href="https://www.pmadata.org/technical-areas/abortion">incidence of abortion in Nigeria</a>. </p>
<p>Field activities were organised into two major components.</p>
<p>The drug seller study included two categories of drug sellers – registered pharmacies and patent and proprietary medicine vendors. Those who reported selling misoprostol-containing medication were selected. </p>
<p>The second component was women who procured these drugs from the drug sellers to terminate a pregnancy.</p>
<p>We included 126 drug sellers while 386 women completed all three prospective interviews during the study.</p>
<p>We explored the consistency between the drug sellers’ and the women’s reporting on the quality of care received. This was to shed light on potential discordance between what and how information is given, intended, received and used. </p>
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Read more:
<a href="https://theconversation.com/restrictive-abortion-laws-put-nigerian-women-in-danger-183153">Restrictive abortion laws put Nigerian women in danger</a>
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<p>.</p>
<h2>Our findings</h2>
<p>Our findings suggest that, in general, more women seek safe abortion care from patent medicine vendors than from pharmacists. Additionally, we found that drug sellers’ knowledge about medication abortion was sub-optimal. And there was a gap in the knowledge and information they are expected to give to women who obtained medication abortion from them. </p>
<p>Anecdotally, pharmacy staff are regarded as better providers. But our results suggest there was no difference between the technical knowledge of patent medicine vendors and pharmacy staff related to prescribing medication abortion. </p>
<p>It is however important to note that a greater proportion of patent medicine vendors reported receiving on-the-job training in safe abortion and post abortion care than pharmacy staff. Regulatory agencies and other stakeholders should consider this as utmost priority.</p>
<p>We also found that women experienced better quality of care at patent medicine vendors compared with pharmacies. They reported receiving more accurate information on what kinds of medicines they were prescribed, how to use them, and what to expect after using the medicines. </p>
<h2>Next steps</h2>
<p>In an abortion-restrictive setting like Nigeria, local pharmacies and proprietary patent medicine vendors continue to play a major role in the provision of medication abortion, including misoprostol.</p>
<p>Drug sellers – particularly patent medicine vendors – <a href="https://www.researchgate.net/publication/281516911_Social_support_in_the_practices_of_informal_providers_The_case_of_patent_and_proprietary_medicine_vendors_in_Nigeria">are often the most accessible frontline health workers</a> in many communities in Nigeria. In some settings they may indeed be the only healthcare provider immediately accessible to patients. </p>
<p>Our findings confirmed that drug sellers are important providers within the healthcare system. That they are trusted by individuals within the community. And that they can provide essential sexual reproductive healthcare including medication abortion. </p>
<p>Our evidence suggests they are an important part of the health system and can provide the same quality of care as pharmacies, or better. Also, women trust them. But the strength of patent medicine vendors is <a href="https://www.frontiersin.org/articles/10.3389/fgwh.2022.899662/full">particularly underused in public health strategies</a> compared with formal pharmacies.</p>
<p>To expand access to sexual reproductive health care commodities and services Nigeria should systematically train and integrate them into programmes and interventions. This has already been done with community health workers and traditional birth attendants for maternity care. </p>
<p>There is also a need to strengthen the capacity and skills of patent medicine vendors in dispensing and administration of medical abortion drugs. This would serve as an important harm reduction strategy. Also, the skills of frontline providers must be improved.</p>
<p><em>Dr. Onikepe Owolabi was at the Guttmacher Institute during the time of this research and continues to collaborate on this data with them</em>.</p><img src="https://counter.theconversation.com/content/191431/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In the context of Nigeria’s restrictive abortion laws, promoting access to medication abortion drugs is a life saver.Akanni Ibukun Akinyemi, Professor, Obafemi Awolowo UniversityAkinrinola Bankole, Senior Fellow, Guttmacher InstituteMelissa Stillman, Research Associate, Guttmacher InstituteOnikepe Owolabi, Public Health Researcher, Guttmacher InstituteTemitope Erinfolami, PhD Candidate, Obafemi Awolowo UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1878172022-09-15T12:22:25Z2022-09-15T12:22:25ZIn states where abortion is banned, children and families already face an uphill battle<figure><img src="https://images.theconversation.com/files/482819/original/file-20220905-14-wr41ei.jpg?ixlib=rb-1.1.0&rect=21%2C26%2C3540%2C2344&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Of the 10 most child-friendly states, only one has attempted to ban abortion.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/katherine-merlos-a-pre-k-3-student-centron%C3%ADa-gives-a-thumbs-news-photo/1239430403">Sarah L. Voisin/The Washington Post via Getty Images</a></span></figcaption></figure><p>Some proponents of abortion bans and restrictions say they are concerned about “supporting not just life,” but what they call “<a href="https://missouriindependent.com/2022/07/06/states-with-strong-antiabortion-laws-have-high-maternal-and-infant-mortality-rates/">quality of life worth living</a>,” saying they want to <a href="https://www.theatlantic.com/politics/archive/2022/06/anti-abortion-movement-dobbs-roe-overturned/661393/">promote laws and policies that help families</a>. Three authors from Brigham Young University, for instance, have noted that the overturning of Roe v. Wade provides a “<a href="https://www.thepublicdiscourse.com/2022/06/82906/">genuine opportunity for pro-lifers to work with people of diverse political persuasions</a> to seek a more just and compassionate world. This world would be not only pro-life, but also pro-child, pro-parent and pro-family.”</p>
<p>U.S. Sen. Mitt Romney of Utah is one of three Republicans in the Senate who have sponsored a bill called the <a href="https://www.romney.senate.gov/romney-family-security-act-2-0-one-of-the-most-important-efforts-to-support-the-family-in-nearly-thirty-years/">Family Security Act</a>, billed as a “pro-family, pro-life and pro-marriage plan” that would provide a monthly cash benefit starting at pregnancy and continuing through the child turning 17.</p>
<p>But so far, these are <a href="https://www.theatlantic.com/politics/archive/2022/06/anti-abortion-movement-dobbs-roe-overturned/661393/">minority voices</a> in the anti-abortion movement. </p>
<p>As a law professor who <a href="https://scholar.google.com/citations?user=gCJEShUAAAAJ&hl=en&oi=ao">studies reproductive care</a>, policies that affect families and political partisanship, I have been following the relationship between <a href="https://www.urban.org/urban-wire/research-shows-access-legal-abortion-improves-womens-lives">abortion restrictions and family well-being</a> for decades. It turns out that states taking the strictest stands against abortion tend to have among the <a href="https://www.nytimes.com/2022/07/28/upshot/abortion-bans-states-social-services.html">worst statistics</a> on child and family well-being in the nation.</p>
<h2>Unintended pregnancy and infant mortality</h2>
<p>Take Mississippi, the state that enacted the abortion restriction law that was at the center of the Supreme Court’s June 2022 opinion in <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">Dobbs v. Jackson Women’s Health Organization</a>, which struck down federal protection for the right to get an abortion. </p>
<p>In 2019, Mississippi had the <a href="https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/unintended_pregnancy/state/U.S">highest rate of unintended pregnancy</a>, defined as the percentage of women who recently gave birth but whose pregnancies were either <a href="https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/index.htm">unwanted or happened at an unwanted time</a>. In Mississippi, 47% of women who recently had a child did not want to become pregnant or wanted to become pregnant later in life.</p>
<p>By contrast, Vermont had the nation’s lowest rate of unintended pregnancy in 2019, with <a href="https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/unintended_pregnancy/state/U.S">just 20% of women who recently had a child</a> saying they would have preferred not to get pregnant or wanted to do so at some point in the future. That state already protects abortion rights. If Vermont’s <a href="https://www.wcax.com/2022/06/23/will-vermont-become-abortion-haven-if-scotus-upends-roe-v-wade/">upcoming referendum on abortion</a> passes, the state’s constitution will protect “<a href="https://legislature.vermont.gov/Documents/2022/Docs/BILLS/PR0005/PR0005%20As%20adopted%20by%20the%20Senate%20Official.pdf">an individual’s right to personal reproductive autonomy</a>.”</p>
<p>Mississippi also has the <a href="https://www.cdc.gov/nchs/pressroom/sosmap/infant_mortality_rates/infant_mortality.htm">highest infant mortality rate</a> in the country. Five of the other nine states with the highest infant mortality <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">also have abortion bans</a>. At the other end of the spectrum, of the 10 states with the lowest infant mortality rates, <a href="https://www.cdc.gov/nchs/pressroom/sosmap/infant_mortality_rates/infant_mortality.htm">only one – Iowa</a> – has a law restricting abortions, <a href="https://www.kcci.com/article/governor-kim-reynolds-announces-legal-actions-regarding-abortion-in-iowa/40449729">although a court has prevented its enforcement</a>.</p>
<h2>Childhood poverty and teen birth rates</h2>
<p>Mississippi has the <a href="https://www.census.gov/acs/www/data/data-tables-and-tools/ranking-tables/">highest rate of child poverty in the country</a>. Six of the other 10 states with the country’s highest child poverty levels also have <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">abortion bans in effect</a>: Louisiana, Arkansas, Kentucky, Alabama, Oklahoma and Tennessee.</p>
<p>Mississippi also had the <a href="https://www.cdc.gov/nchs/pressroom/sosmap/teen-births/teenbirths.htm">highest teen birth rate in the country</a>, and eight of the other nine states with the highest teen birth rates also <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">ban abortions or have a ban blocked</a>.</p>
<p>In all 10 states with the lowest teen birth rates, <a href="https://www.washingtonpost.com/politics/2022/06/24/abortion-state-laws-criminalization-roe/">abortion is legal</a> and likely to be protected for the foreseeable future.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A pregnant person has a written message on the skin of her belly: 'My daughter deserves a choice'" src="https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A pregnant activist calls for abortion rights in Chicago on June 25, 2022.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/pregnant-woman-takes-part-in-a-protest-in-downtown-chicago-news-photo/1241562432?adppopup=true">Vincent D. Johnson/Xinhua via Getty Images)</a></span>
</figcaption>
</figure>
<h2>Supporting families</h2>
<p>The well-being of children also depends on the availability of support for their parents.</p>
<p>For instance, <a href="https://www.ncsl.org/research/labor-and-employment/state-family-and-medical-leave-laws.aspx">11 states plus the District of Columbia legally require employers</a> to offer workers paid time off after the birth or adoption of a child. None of those jurisdictions <a href="https://www.washingtonpost.com/politics/2022/06/24/abortion-state-laws-criminalization-roe/">bans abortions</a>.</p>
<p>Another federal effort to support families came in the Affordable Care Act, enacted in 2010, with <a href="https://www.healthcare.gov/glossary/affordable-care-act/">sweeping changes</a> to the nation’s health insurance marketplace. One provision allowed states to <a href="https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/">expand Medicaid eligibility</a> to more adults, with financial support from the federal government. If Medicaid were expanded, <a href="https://www.urban.org/research/publication/3-7-million-people-would-gain-health-coverage-2023-if-remaining-12-states-were">reproductive-aged women</a> would be among the groups to experience the largest coverage gains.</p>
<p>As of August 2022, <a href="https://www.urban.org/research/publication/3-7-million-people-would-gain-health-coverage-2023-if-remaining-12-states-were">12 states</a> had not adopted the expansion: Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin and Wyoming. <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">Eight of those states</a> have either a full ban on abortion or a ban after six weeks – before many people realize they are pregnant.</p>
<p>Two of those states, <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">South Carolina and Wyoming</a>, have abortion <a href="https://www.npr.org/2022/08/04/1115542013/wyomings-new-ban-on-abortions-has-been-temporarily-blocked">laws that are tied up in the courts</a>, and Florida bans abortions after 15 weeks. </p>
<p>In a June 2022 <a href="https://www.brookings.edu/blog/up-front/2022/06/30/the-end-of-roe-will-create-more-inequality-of-opportunity-for-children/">Brookings Institution study</a> of the states that are considered most child-friendly – measured by state expenditures per child and children’s overall well-being – the authors found that among the top 10, only Wyoming was <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">even trying to ban abortion</a>. For the 10 states Brookings rated least child-friendly, nine either had a trigger ban or other abortion restriction.</p>
<p>The overall pattern is clear: A strong social safety net and other anti-poverty programs <a href="https://www.nytimes.com/2022/07/13/opinion/abortion-romney-child-tax-credit.html">are more likely to be available</a> in states that also support abortion access, while actual measures of child and family well-being are often worse in states that restrict abortions.</p><img src="https://counter.theconversation.com/content/187817/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Naomi Cahn does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>States taking the strictest stands against abortion tend to have among the worst statistics in the nation on child and family well-being.Naomi Cahn, Professor of Law, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1879042022-09-01T12:24:52Z2022-09-01T12:24:52ZMost human embryos naturally die after conception – restrictive abortion laws fail to take this embryo loss into account<figure><img src="https://images.theconversation.com/files/482135/original/file-20220831-22-3h2hxf.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1298%2C1029&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The majority of fertilized eggs die and are resorbed into the body.</span> <span class="attribution"><a class="source" href="https://flic.kr/p/JsYKsc">ZEISS Microscopy/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Many state legislatures are seriously considering human embryos at the earliest stages of development for <a href="https://news.bloomberglaw.com/us-law-week/fetal-rights-laws-impact-extends-from-abortion-to-hov-lanes">legal personhood</a>. <a href="https://www.frc.org/blog/2021/07/state-round-total-abortion-bans">Total abortion bans</a> that consider humans to have full rights from the moment of conception have created a <a href="https://www.washingtonpost.com/health/2022/06/28/abortion-ban-roe-doctors-confusion/">confusing legal domain</a> that affects a <a href="https://time.com/6191886/fetal-personhood-laws-roe-abortion/">wide range of areas</a>, including assisted reproductive technologies, contraception, essential medical care and parental rights, among others. </p>
<p>However, an important biological feature of human embryos has been left out of a lot of ethical and even scientific discussion informing reproductive policy – <a href="https://doi.org/10.1007/s10815-020-01749-y">most human embryos die</a> before anyone, including doctors, even know they exist. This embryo loss typically occurs in the first two months after fertilization, before the clump of cells has developed into a <a href="https://bio.libretexts.org/Bookshelves/Human_Biology/Book%3A_Human_Biology_(Wakim_and_Grewal)/23%3A_Human_Growth_and_Development/23.4%3A_Fetal_Stage">fetus</a> with immature forms of the body’s major organs. Total abortion bans that define personhood at conception mean that full legal rights exist for a 5-day-old blastocyst, a hollow ball of cells roughly <a href="https://biologydictionary.net/blastocyst/">0.008 inches (0.2 millimeters)</a> across with a high likelihood of disintegrating within a few days.</p>
<p>As an <a href="https://scholar.google.com/citations?user=ijKRO44AAAAJ&hl=en">evolutionary biologist</a> whose career has focused on how embryos develop in a wide variety of species over the course of evolution, I was struck by the extraordinarily high likelihood that most human embryos die due to random genetic errors. Around <a href="https://doi.org/10.1186/1741-7015-11-154">60% of embryos disintegrate</a> before people may even be aware that they are pregnant. Another 10% of pregnancies end in miscarriage, after the person knows they’re pregnant. These losses make clear that the vast majority of human embryos don’t survive to birth.</p>
<p>The emerging scientific consensus is that high rate of early embryo loss is a common and normal occurrence in people. Research on the causes and evolutionary reasons for early embryo loss provides insight into this fundamental feature of human biology and its implications for reproductive health decisions.</p>
<h2>Intrinsic embryo loss is common in mammals</h2>
<p>Intrinsic embryo loss, or embryo death due to internal factors like genetics, is common in <a href="https://doi.org/10.1007/978-94-009-5038-2_2">many mammals</a>, such as <a href="https://doi.org/10.1095/biolreprod60.6.1273">cows</a> and <a href="https://doi.org/10.2527/1994.72suppl_316x">sheep</a>. This persistent “<a href="https://doi.org/10.1007/978-94-009-5038-2_1">reproductive wastage</a>” has <a href="https://doi.org/10.1093/jas/skaa288">frustrated breeders</a> attempting to increase livestock production but who are unable to eliminate high embryonic mortality. </p>
<p>In contrast, most embryo loss in animals that lay eggs like <a href="https://doi.org/10.1023/A:1011069126615">fish</a> and <a href="http://www.jstor.org/stable/25599224">frogs</a> is due to external factors, such as predators, disease or other environmental threats. These lost embryos are effectively “<a href="https://worldcat.org/en/title/752304487">recycled” in the ecosystem as food</a>. These egg-laying animals have <a href="https://doi.org/10.1016/j.aquaculture.2021.737352">little to</a> <a href="https://doi.org/10.1017/S0266467406003506">no</a> intrinsic embryo loss.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ETQTMtchAUc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Each square shows the first 24 hours of embryo development in a different animal species. From left to right: 1. zebrafish (<em>Danio rerio</em>), 2. sea urchin (<em>Lytechinus variegatus</em>), 3. black widow spider (<em>Latrodectus</em>), 4. tardigrade (<em>Hypsibius dujardini</em>), 5. sea squirt (<em>Ciona intestinalis</em>), 6. comb jelly (<em>Ctenophore</em>, <em>Mnemiopsis leidyi</em>), 7. parchment tube worm (<em>Chaetopterus variopedatus</em>), 8. roundworm (<em>Caenorhabditis elegans</em>), and 9. slipper snail (<em>Crepidula fornicata</em>).</span></figcaption>
</figure>
<p>In people, the <a href="https://doi.org/10.1007/s10815-020-01749-y">most common outcome</a> of reproduction by far is embryo loss due to random genetic errors. An estimated <a href="https://www.verywellfamily.com/making-sense-of-miscarriage-statistics-2371721">70% to 75%</a> of human conceptions fail to survive to birth. That number includes both embryos that are <a href="https://doi.org/10.1002/uog.21922">reabsorbed into the parent’s body</a> before anyone knows an egg has been fertilized and miscarriages that happen later in the pregnancy.</p>
<h2>An evolutionary drive for embryo loss</h2>
<p>In humans, an evolutionary force called <a href="https://doi.org/10.1371/journal.pbio.3001671">meiotic drive</a> plays a role in early embryo loss. Meiotic drive is a type of competition within the genome of unfertilized eggs, where variations of different genes can manipulate the cell division process to favor their own transmission to the offspring over other variations.</p>
<p><a href="https://doi.org/10.1073/pnas.95.5.2361">Statistical models</a> attempting to explain why most human embryos fail to develop usually start by observing that a massive number of random genetic errors occur in the mother’s eggs even before fertilization.</p>
<p>When sperm fertilize eggs, the resulting embryo’s DNA is packaged into 46 chromosomes – 23 from each parent. This genetic information guides the embryo through the <a href="https://doi.org/10.1016/j.cell.2020.11.003">development process</a> as its cells divide and grow. When <a href="https://doi.org/10.1038/ejhg.2011.272">random mistakes</a> occur during chromosome replication, fertilized eggs can inherit cells with these errors and result in a condition called <a href="https://www.nature.com/scitable/topicpage/chromosomal-abnormalities-aneuploidies-290/">aneuploidy</a>, which essentially means “the wrong number of chromosomes.” With the instructions for development now disorganized due to mixed-up chromosomes, embryos with aneuploidy are <a href="https://www.verywellfamily.com/aneuploidy-definition-2371596">usually doomed</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/482144/original/file-20220831-3577-zgrz7f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Microscopy image of four early human embryos" src="https://images.theconversation.com/files/482144/original/file-20220831-3577-zgrz7f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/482144/original/file-20220831-3577-zgrz7f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=477&fit=crop&dpr=1 600w, https://images.theconversation.com/files/482144/original/file-20220831-3577-zgrz7f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=477&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/482144/original/file-20220831-3577-zgrz7f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=477&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/482144/original/file-20220831-3577-zgrz7f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=600&fit=crop&dpr=1 754w, https://images.theconversation.com/files/482144/original/file-20220831-3577-zgrz7f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=600&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/482144/original/file-20220831-3577-zgrz7f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=600&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">As many as three out of four human embryos naturally die in the development process.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/human-egg-royalty-free-image/509171917">Red Hayabusa/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<p>Because human and other mammal embryos are highly protected from environmental threats – unlike animals that lay eggs outside their bodies – researchers have theorized that these early losses have <a href="https://doi.org/10.1371/journal.pbio.3001671">little effect</a> on the reproductive success of the parent. This may allow humans and other mammals to <a href="https://www.jstor.org/stable/2458433">tolerate meiotic drive</a> over evolutionary time.</p>
<p>Counterintuitively, there may even be benefits to the high rates of genetic errors that result in embryo loss. Early loss of aneuploid embryos can direct maternal resources to <a href="https://doi.org/10.1371/journal.pbio.3001671">healthier single newborns</a> rather than twins or multiples. Also, in the deeper evolutionary history of a species, having a huge pool of genetic variants could occasionally provide a beneficial <a href="https://doi.org/10.1038/s41467-019-13669-2">new adaptation</a> that could aid in human survival in changing environments.</p>
<h2>Spontaneous abortion is natural</h2>
<p>Biological data on human embryos brings new questions to consider for <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">abortion policies</a>.</p>
<p>Although <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">required in some states</a>, early embryo loss is typically not documented in the medical record. This is because it occurs before the person knows they are pregnant and often coincides with the next menstrual period. Until relatively recently, researchers were unaware of the extremely high rate of early embryo loss in people, and “conception” was an imagined moment <a href="https://doi.org/10.1017/9781107705647">estimated from last menstruation</a>.</p>
<p>How does naturally built-in, massive early embryo loss affect legal protections for human embryos?</p>
<p>Errors that occur during chromosomal replication are <a href="https://www.nature.com/scitable/topicpage/mitosis-meiosis-and-inheritance-476/">essentially random</a>, which means development can be disrupted in different ways in different embryos. However, while both early embryos and <a href="https://doi.org/10.1056/NEJMoa1201569">late fetuses</a> can become inviable due to genetic errors, early and late abortions are <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">regulated very differently</a>. Some states still require doctors to wait until the health of the pregnant person is endangered before allowing induced abortion of nonviable fetuses.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/72LogwxNSq4?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">In the wake of anti-abortion laws, doctors have refused to treat patients with miscarriages because it uses the same procedures as abortions.</span></figcaption>
</figure>
<p>Since so many pregnancies end naturally in their very earliest days, early embryo loss is exceedingly common, though most people won’t know they’ve experienced it. I believe that new laws ignoring this natural occurrence lead to a slippery slope that can put lives and livelihoods at risk.</p>
<p>Between 1973 and 2005, <a href="https://doi.org/10.1215/03616878-1966324">over 400 women were arrested</a> for miscarriage in the U.S. With the current shift toward restrictive abortion policies, the continued criminalization of pregnancies that don’t result in birth, despite how common they are, is a <a href="https://www.brennancenter.org/our-work/analysis-opinion/miscarriage-justice-danger-laws-criminalizing-pregnancy-outcomes">growing concern</a>.</p>
<p>I believe that acknowledging massive early embryo loss as a normal part of human life is one step forward in helping society make rational decisions about reproductive health policy.</p><img src="https://counter.theconversation.com/content/187904/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathryn Kavanagh does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Human embryos are far more likely to die than come to term, an evolutionary trait seen across species. Laws granting personhood at conception ignore built-in embryo loss, with potentially grave consequences.Kathryn Kavanagh, Associate Professor of Biology, UMass DartmouthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1870132022-08-31T12:26:45Z2022-08-31T12:26:45ZWhen abortion at a clinic is not available, 1 in 3 pregnant people say they will do something on their own to end the pregnancy<figure><img src="https://images.theconversation.com/files/478589/original/file-20220810-15-3oc00y.jpg?ixlib=rb-1.1.0&rect=60%2C0%2C6720%2C4325&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A self-managed abortion is the termination of pregnancy outside the formal health care system, often with self-sourced abortion pills.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-woman-with-abortion-pill-and-glass-of-water-royalty-free-image/1314748004?adppopup=true">Liudmila Chernetska/iStock via Getty Images Plus</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em> </p>
<h2>The big idea</h2>
<p>One in three people in need of abortion will consider doing something on their own to end the pregnancy if they are unable to get an abortion at a clinic. These are the findings of a <a href="https://doi.org/10.1186/s12978-022-01486-8">study I recently published</a> after surveying over 700 people seeking abortions in three states across the U.S.: Illinois, California and New Mexico.</p>
<p>The one-in-three figure is even higher among those who have a difficult time affording the cost of their abortion, have no health insurance or are seeking an abortion because of concerns about their own physical or mental health. </p>
<p>These findings offer a clear snapshot of what lies ahead as states move to ban abortion outright or severely restrict access. </p>
<h2>Why it matters</h2>
<p>Research over the past two decades has shown that pregnant people who <a href="https://doi.org/10.1016/j.contraception.2021.09.009">face obstacles</a> to getting to an abortion clinic <a href="https://doi.org/10.1016/j.ajog.2020.02.026">or who have a desire</a> for a more natural or private abortion experience will try to end a pregnancy on their own. This might include turning to <a href="https://doi.org/10.1016/j.bpobgyn.2019.08.002">self-sourced abortion pills</a>, alcohol or drugs, herbs or physical methods. </p>
<p>My own research in 2017 found that 7% of U.S. women of reproductive age <a href="https://doi.org/10.1001/jamanetworkopen.2020.29245">will use one of these methods</a> in their lifetime to try to end a pregnancy outside of the formal health care system. </p>
<p>What has changed recently – and dramatically – is access to clinic-based abortion. With the Supreme Court’s decision <a href="https://theconversation.com/supreme-court-overturns-roe-upends-50-years-of-abortion-rights-5-essential-reads-on-what-happens-next-184697">overturning federal protections on abortion access</a>, as of Aug. 30, 2022, 14 states have already <a href="https://reproductiverights.org/maps/abortion-laws-by-state/">implemented bans on abortion</a>; an additional 12 are projected to do so in the coming months. </p>
<p><iframe id="KZgzc" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/KZgzc/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>These restricted-abortion states are home to just over <a href="https://www.nytimes.com/interactive/2022/05/07/us/abortion-access-roe-v-wade.html">one-half of U.S. women of reproductive age</a>. Putting these numbers together with data on who seeks abortion in the U.S., researchers estimate that over 100,000 pregnant people per year will soon <a href="https://doi.org/10.1016/j.contraception.2019.07.139">face insurmountable travel distances</a> to their nearest abortion provider and be unable to get an abortion at a clinic. </p>
<p>If people do as they project in our study, around 33,000 pregnant people per year will consider doing something on their own to end a pregnancy.</p>
<h2>What still isn’t known</h2>
<p>One yet unanswered question is how many of those in need of abortion and unable to get to a clinic will be able to <a href="https://doi.org/10.1001/jamainternmed.2022.2893">end a pregnancy on their own</a> with a <a href="https://theconversation.com/abortion-pills-are-safe-to-prescribe-without-in-person-exams-new-research-finds-179622">safe and effective method</a> such as the <a href="https://theconversation.com/how-to-navigate-self-managed-abortion-issues-such-as-access-wait-times-and-complications-a-family-physician-explains-186186">FDA-approved medications mifepristone and misoprostol, or misoprostol alone</a> – versus how many will turn to other, likely less effective, methods with potentially harmful outcomes. </p>
<p>Researchers now have clear evidence that <a href="https://doi.org/10.1001/jamanetworkopen.2021.22320">telehealth</a> and <a href="https://doi.org/10.1016/j.lana.2022.100200">mail-order models</a> enabling access to medication abortion <a href="https://doi.org/10.1001/jamainternmed.2022.0217">without the need for an in-person visit</a> with a health care provider – <a href="https://theconversation.com/covid-19-mental-health-telemedicine-was-off-to-a-slow-start-then-the-pandemic-happened-177670">models accelerated in part by the COVID-19 pandemic</a> – are safe, effective and satisfactory to patients.</p>
<p>However, these models will remain out of reach for some. This is especially true for those who are further along in their pregnancy, <a href="https://doi.org/10.1016/j.ssmqr.2021.100003">cannot afford the cost</a>, live in one of the 19 states that <a href="https://www.kff.org/womens-health-policy/slide/state-restrictions-on-telehealth-abortion/">ban telehealth provision of medication abortion</a> or don’t have a safe place to receive and use the pills. </p>
<p>What is also unknown is how many pregnant people will face legal repercussions for doing something to try to end a pregnancy. Although public support <a href="https://doi.org/10.1007/s13178-021-00572-z">for criminalizing a pregnant person</a> for self-managing an abortion is low, state legislators are <a href="https://www.ifwhenhow.org/resources/making-abortion-a-crime-again/">actively proposing such policies</a>. Between 2000 and 2020, more than 61 people were <a href="https://www.ifwhenhow.org/resources/self-care-criminalized-preliminary-findings/">investigated or arrested for such attempts</a>.</p>
<h2>What’s next</h2>
<p>In the coming months, my colleagues and I will document the magnitude of any increase in self-managed abortion by <a href="https://www.ansirh.org/research/ongoing/self-managed-abortion-attitudes-study-smaash">repeating a nationally representative survey</a> that we fielded <a href="https://doi.org/10.1001/jamanetworkopen.2020.29245">in 2017</a> and 2021. </p>
<p>Our research underscores that even when abortion is restricted, people will move forward with abortion on their own. Having access to abortion pills is critical so that when people need to self-manage an abortion, the health, medical and advocacy community is supporting them to do so safely and effectively.</p><img src="https://counter.theconversation.com/content/187013/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lauren Ralph receives funding from the Society of Family Planning Research Fund and an anonymous foundation. </span></em></p>The fall of Roe v. Wade will result in more people deciding to privately end a pregnancy, a new study finds. But how often people will turn to safe versus unsafe options remains to be seen.Lauren Ralph, Associate Professor of Obstetrics, Gynecology and Reproductive Sciences, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1872662022-08-30T12:19:38Z2022-08-30T12:19:38ZWhat to know about the costs of traveling for abortion care in the US – here’s what I learned from talking to hundreds of women who’ve sought abortions<figure><img src="https://images.theconversation.com/files/480453/original/file-20220822-64771-176vis.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6299%2C4117&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A plane ticket and hotel stay are not the only costs to consider when traveling to get an abortion.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/delayed-flight-royalty-free-image/1217875309?adppopup=true">kieferpix/iStock via Getty Images Plus</a></span></figcaption></figure><p>Abortion travel isn’t new. People have been crossing national and state borders to get abortion care <a href="https://doi.org/10.1080/00497878.2012.663260">since the 1960s</a>, when air travel became more common and affordable. </p>
<p>The number of people who need to travel and the distances they must travel for care <a href="https://doi.org/10.1016/j.contraception.2019.07.139">will increase</a> following the U.S. Supreme Court’s ruling in <a href="https://www.scotusblog.com/case-files/cases/dobbs-v-jackson-womens-health-organization/">Dobbs v. Jackson Women’s Health Organization</a>, <a href="https://theconversation.com/supreme-court-overturns-roe-upends-50-years-of-abortion-rights-5-essential-reads-on-what-happens-next-184697">which overturned Roe v. Wade</a>.</p>
<p>As a <a href="https://www.ansirh.org/about/staff/katrina-kimport-phd">sociologist who studies gender, reproduction and health</a>, I have interviewed hundreds of women who have sought abortions, many of whom had to travel for care. My <a href="https://doi.org/10.1016/j.socscimed.2021.114667">recent study</a> on the experiences of people who had to travel across state lines for abortion care can help people better understand what costs abortion patients face when they have to travel.</p>
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<figcaption><span class="caption">For those living in states that have restricted abortion, traveling for a procedure can be expensive, daunting and lonely.</span></figcaption>
</figure>
<h2>1. Why do people travel for abortion care?</h2>
<p>People travel for medical care for many reasons. In the case of abortion travel, they are typically traveling because abortion is either legally restricted or unavailable in their home area. To get an abortion, they have no choice but to travel.</p>
<p>As of late August 2022, about half of the states in the U.S. <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">have already restricted or are expected to heavily restrict abortion</a>. Abortion seekers in those states may opt to travel to another state where abortion remains legal, <a href="https://sites.utexas.edu/txpep/files/2022/03/TxPEP-out-of-state-SB8.pdf">as many Texans did</a> following the implementation of their state’s highly restrictive law in 2021. </p>
<h2>2. What are the main costs of traveling for abortion care?</h2>
<p>Most people rightly anticipate that abortion travel entails expenses like gas money or plane tickets and hotel charges. As research shows that most abortion patients are <a href="https://www.guttmacher.org/report/characteristics-us-abortion-patients-2014">at or just above the federal poverty line</a>, it is easy to see that these costs alone could represent a substantial burden.</p>
<p>But traveling for an abortion often also includes numerous other costs. For instance, most abortion patients are <a href="https://www.guttmacher.org/report/characteristics-us-abortion-patients-2014">already parenting children</a>, so they must figure out child care logistics when they have to travel for abortion care. People who do not have access to a reliable vehicle may need to rent a car to make a long-distance drive across state borders. </p>
<p>Abortion funds – nonprofit organizations that provide practical and financial support to people seeking abortion care – <a href="https://theconversation.com/abortion-funds-are-in-the-spotlight-with-the-end-of-roe-v-wade-3-findings-about-what-they-do-182636">can help people</a> who are financially struggling navigate some of these costs. But often this aid isn’t sufficient to cover all costs. There are also real questions about <a href="https://theconversation.com/abortion-funds-may-not-be-able-to-keep-up-with-rising-demands-as-more-people-travel-out-of-state-for-the-procedure-185937">whether funds can meet the growing demand</a>.</p>
<p>And then there is the issue of lost wages during the time a patient must spend traveling. For many people engaged in hourly work, when you don’t work, you don’t get paid.</p>
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<figcaption><span class="caption">Some companies, like Starbucks and Dick’s Sporting Goods, are offering financial support to employees who travel for an abortion.</span></figcaption>
</figure>
<p>Abortion travel can also entail emotional costs. I’m currently working on a new study based on interviews with 30 women from around the U.S. about the emotional impacts of having to travel out of state for abortion care. Based on these interviews, I’ve learned that having to travel for abortion care can mean the stress of having to navigate a new place. For some people, this could be their first time in that city or even away from home. It also means being removed from their usual support systems and the physical and emotional comforts of home. This, too, can take an emotional toll. </p>
<p>And, of course, having to travel means having to explain to others – including co-workers and family members – why they are traveling, which can also come at a high personal and emotional cost.</p>
<h2>3. Are there any positives to traveling for abortion care?</h2>
<p>There is not much work on this question to date. Most research on abortion travel has focused on its negative aspects. But <a href="https://doi.org/10.1016/j.socscimed.2021.114667">in my research</a>, some of the women who had to travel for abortion care talked about how much they appreciated the emotional support they received in their destination clinic – especially after the hostility to abortion they had experienced in their home communities. </p>
<p>Seeking out nonjudgmental, compassionate care might motivate someone to prefer to travel for abortion care. But in the post-Roe landscape, few will have that luxury. Rather, travel will be a necessity, not a choice. Even with the possibility of emotional benefits, travel for abortion care exacts clear and substantial costs.</p><img src="https://counter.theconversation.com/content/187266/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katrina Kimport receives funding from the Society of Family Planning, the David and Lucile Packard Foundation, and an anonymous foundation. </span></em></p>For many who must travel to get an abortion, the financial burden of the trip can be overwhelming.Katrina Kimport, Professor of Sociology, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1870092022-08-25T12:26:30Z2022-08-25T12:26:30ZNew restrictions on abortion care will have psychological harms – here’s what research shows will happen in post-Roe America<figure><img src="https://images.theconversation.com/files/480125/original/file-20220819-3033-r16b6e.jpg?ixlib=rb-1.1.0&rect=87%2C35%2C5768%2C3863&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Without full access to reproductive health care, traumatic birth experiences will undoubtedly rise.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/mother-holding-her-newborn-baby-feeling-sleepy-royalty-free-image/1351160342?adppopup=true">urbazon/E+ via Getty Images</a></span></figcaption></figure><p>“I’m struggling a bit this morning,” a client of mine stated at the start of our session the morning of June 24, 2022. “I just heard on the news about the <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">decision to overturn</a> <a href="https://tile.loc.gov/storage-services/service/ll/usrep/usrep410/usrep410113/usrep410113.pdf">Roe v. Wade</a>. There was so much for me to process I had to turn it off.” </p>
<p>While this client did not have personal experience with elective abortion, she had a complicated reproductive history that included a recent pregnancy in which she was unsure if the baby would survive. In our session that day, she recognized how privileged she was to have had a medical team that communicated with her about all available options and potential outcomes for her and the baby. Most importantly, she acknowledged the significance of having a say in the decisions about her reproductive care. </p>
<p>Our session came hours after the <a href="https://theconversation.com/roe-overturned-what-you-need-to-know-about-the-supreme-court-abortion-decision-184692">fall of Roe</a>, which overturned 50 years of abortion rights. I spent time in that session, and many others that week, with clients talking through the “what-ifs.” </p>
<p><a href="https://scholar.google.com/citations?user=S3nu_Nese3gC&hl=en">As a therapist and scholar</a> specializing in the mental health of people during the perinatal period, the time frame during pregnancy and postpartum, I’ve witnessed firsthand the psychological impacts of reproductive traumas across pregnancy and after childbirth. This gives me insights into how new restrictions on reproductive health care from overturning Roe are inextricably linked to psychological well-being.</p>
<h2>Research supports the need for abortion access</h2>
<p>Before Roe was overturned, research already demonstrated the importance of access to safe abortions. The landmark <a href="https://www.ansirh.org/research/ongoing/turnaway-study">Turnaway Study</a>, conducted from 2008 to 2013, examined the effects of receiving versus being denied a wanted abortion by studying health outcomes of nearly 1,000 women seeking abortions at 30 facilities across the U.S. </p>
<p>Results from that study demonstrated that people were <a href="https://www.ansirh.org/sites/default/files/2022-07/turnawaystudyannotatedbibliography063022.pdf">more likely to experience elevated psychological issues</a>, such as anxiety and depression, when denied an abortion compared with people who received one. The study also demonstrated individuals who were denied an abortion were more likely to experience <a href="https://www.ansirh.org/sites/default/files/publications/files/the_harms_of_denying_a_woman_a_wanted_abortion_4-16-2020.pdf">long-term economic hardship and intimate partner violence</a>. </p>
<p>Other research has also shown an <a href="https://doi.org/10.1007/s00737-016-0646-0">increased risk of suicide</a> for individuals not able to legally terminate an unwanted pregnancy.</p>
<p>Additionally, research shows most women who have an abortion feel they made the right decision. Over 95% of women in a <a href="https://www.sciencedirect.com/science/article/pii/S0277953619306999?via%3Dihub#bib24">2020 study</a> reported that abortion was the right decision when looking back over five years, with <a href="https://doi.org/10.1371/journal.pone.0128832">previous research</a> also supporting these findings. Yet some states continue to put mandatory waiting periods and counseling into place based on unfounded assumptions that people will regret their decision and have negative psychological consequences. </p>
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<figcaption><span class="caption">The impact of the Supreme Court’s abortion ruling has been swift and widespread.</span></figcaption>
</figure>
<h2>How abortion bans affect mental health</h2>
<p>The perinatal period places people at an increased risk <a href="https://doi.org/10.1001/jamapsychiatry.2013.87">for the onset</a> and <a href="https://doi.org/10.1001/jama.295.5.499">relapse</a> of mental health disorders. The increased restrictions on receiving abortion care coupled with proven risk factors for perinatal mood and anxiety disorders could increase people’s risks for psychological suffering.</p>
<p>With the overturning of Roe, experts expect that half of U.S. states <a href="https://reproductiverights.org/maps/abortion-laws-by-state/">will ban abortion health care</a> in the coming months. While this is an ever-evolving landscape, as of late August 2022, 10 states have full abortion bans and five states have banned abortion after six weeks of pregnancy. </p>
<p>A 2019 study projected there would be an <a href="https://doi.org/10.1016/j.contraception.2019.07.139">approximately 13% reduction in U.S. abortions</a> in the immediate aftermath of a Roe reversal because of new state restrictions and increased travel distances to get to facilities in states permitting abortions. This equates to between 93,546 and 143,561 women being prevented from having a wanted abortion in the first year post-Roe.</p>
<p>Current statistics suggest that <a href="https://doi.org/10.1001/jamapsychiatry.2013.87">perinatal mental health disorders affect 1 in 5 women</a> throughout pregnancy and postpartum and upwards of <a href="https://doi.org/10.1097/nnr.0b013e3181e501fd">34% report a traumatic birth</a>. Risk factors such as negative emotions surrounding childbirth and a perceived lack of control <a href="https://doi.org/10.1017/S0033291715002706">increase the likelihood for experiencing birth trauma</a>. These risk factors are consistent with what a person would face when seeking a wanted abortion and being denied access to reproductive health care.</p>
<h2>More risk for those who are already vulnerable</h2>
<p>Some sectors of the U.S. population are disproportionately more vulnerable to developing perinatal mood and anxiety disorders than others. Roughly <a href="https://connectionswellnessgroup.com/diagnosis-and-treatment-of-perinatal-mood-and-anxiety-disorders-pmads-in-black-indigenous-and-people-of-color-populations-bipoc-and-gender-and-sexual-minority-populations/">1 in 3 women of color</a> and up to <a href="https://www.postpartum.net/wp-content/uploads/2014/11/PSI-PMD-FACT-SHEET-2015.pdf">60% of low-income women</a> experience mental health concerns during pregnancy or in the year after childbirth. Historically, <a href="https://www.guttmacher.org/gpr/2008/08/abortion-and-women-color-bigger-picture">Black and Hispanic women</a> also have disproportionately higher abortion rates than white women, as do <a href="https://www.guttmacher.org/fact-sheet/induced-abortion-united-states">low-income women</a>. </p>
<p>In a <a href="https://www.guttmacher.org/sites/default/files/article_files/3711005.pdf">survey of more than 1,000 abortion patients</a> who were asked about their reasons for having abortions, 48% of women indicated they did not want to be a single parent or that they were having relationship problems. These are <a href="https://www.postpartum.net/wp-content/uploads/2021/05/2021_05_21-Discussion-Tool-ENGLISH.pdf">two more proven factors</a> associated with risk for perinatal mood and anxiety disorders.</p>
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<figcaption><span class="caption">Ultimately, about half of U.S. states are expected to ban at least some access to abortions.</span></figcaption>
</figure>
<p>Not only are there increased mental health risks for parents of color and those who are economically disadvantaged, single or experiencing relationship distress, but there are also concerning disparities among these groups in rates for <a href="https://doi.org/10.1176%2Fappi.ps.62.6.619">starting and staying in treatment during the perinatal period</a>.</p>
<p>As abortion services become increasingly restricted across the U.S., there are <a href="https://19thnews.org/2022/08/abortion-bans-no-fetal-anomaly-exceptions/">lesser anticipated impacts on reproductive health care</a> that will also have immense psychological effects. For example, parents who would have otherwise terminated the pregnancy because of severe birth defects or fatal medical issues detected in the fetus will no longer have this option in some states. </p>
<p>There is already a dearth of resources and support for families of children with disabilities and complex developmental and medical needs, <a href="https://ftm.aamft.org/disabilities-and-the-family-where-are-the-marriage-couple-and-family-therapists/">despite the known higher risk</a> for parental stress and relational difficulties between partners. At this point it is not clear whether <a href="https://doi.org/10.1056/NEJMp2206246">necessary expansion for supports</a> will occur as the needs increase.</p>
<h2>Accessing supports post-Roe</h2>
<p>In states with abortion bans, there will be <a href="https://www.kff.org/racial-equity-and-health-policy/issue-brief/what-are-the-implications-of-the-overturning-of-roe-v-wade-for-racial-disparities/">dramatic disparities</a> in people’s ability to access abortions. For accurate and up-to-date information on safe and legal abortion care, the U.S. Department of Health and Human Services provides information about <a href="https://reproductiverights.gov/">Americans’ rights to reproductive health care and resources</a>. </p>
<p>With time, the short- and long-term psychological impacts of the post-Roe era will unfold. What is certain now is that mental health providers should be preparing themselves to respond to the mental health needs of individuals denied abortion care as a result of the Supreme Court’s decision to overturn Roe v. Wade.</p><img src="https://counter.theconversation.com/content/187009/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Diamond does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Escalating legal restrictions throughout the US might mean an increase in mental health disorders for those who are denied an abortion.Rachel Diamond, Clinical Training DIrector and Assistant Professor of Couple and Family Therapy, Adler UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1870402022-07-28T12:24:28Z2022-07-28T12:24:28ZAfter Roe’s overturning, Americans are demanding Supreme Court term limits<figure><img src="https://images.theconversation.com/files/474921/original/file-20220719-6821-znixn7.jpg?ixlib=rb-1.1.0&rect=1363%2C225%2C4428%2C3620&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The US Supreme Court in Washington, DC, on June 27, 2022. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/the-us-supreme-court-in-washington-dc-on-june-27-2022-the-news-photo/1241574008?adppopup=true">Stefani Reynolds/AFP via Getty Images</a></span></figcaption></figure><p>Following the Supreme Court’s landmark ruling in <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">Dobbs v. Jackson Women’s Health Organization</a>
overturning half a century of abortion rights under <a href="https://www.law.cornell.edu/supremecourt/text/410/113">Roe v. Wade</a>, nearly <a href="https://www.politico.com/newsletters/playbook-pm/2022/06/27/new-poll-voters-oppose-overturning-roe-back-court-reform-00042585">two-thirds of Americans</a> want fundamental court reform, specifically term limits for Supreme Court justices. </p>
<p>Indeed, on July 25, 2022, <a href="https://ocgnews.com/georgia-rep-hank-johnson-introduces-term-limit-measures-for-supreme-court-justices/">Democrats introduced a bill</a> that would allow a new justice to take the bench every two years and spend 18 years in active service. </p>
<p>The majority that overturned Roe was possible only because of the current system in which <a href="https://sunypress.edu/Books/D/Deciding-to-Leave">justices serve for life</a> and are therefore able to choose when and whether to step down. </p>
<p>Justice Amy Coney Barrett owes her seat to Justice Ruth Bader Ginsburg’s <a href="https://www.politico.com/news/magazine/2022/06/10/ruth-bader-ginsburg-retire-legacy-00038638">refusal to retire</a> under a Democratic president and her <a href="https://apnews.com/article/ruth-bader-ginsburg-voting-rights-politics-joe-biden-elections-bf6704fa6e900967a705054c801a5495">subsequent death</a> under a Republican. </p>
<p>Justice Brett Kavanaugh is on the court because of Reagan appointee Justice Anthony Kennedy’s <a href="https://www.latimes.com/opinion/op-ed/la-oe-ward-kennedy-retirement-20180629-story.html">decision to step down</a> under a GOP administration. Justice Neil Gorsuch was appointed after conservative Justice <a href="https://apnews.com/article/religion-elections-courts-presidential-elections-gun-politics-0a5453e54bb848fd8858124e7a80dfec">Antonin Scalia happened to die</a> and President Donald Trump took office. </p>
<p>The author of the opinion in Dobbs, Justice Samuel Alito, took his seat when Republican Justice Sandra Day O’Connor <a href="https://www.nytimes.com/2005/07/02/politics/politicsspecial1/oconnor-to-retire-touching-off-battle-over-court.html">chose to leave</a> under President George W. Bush. </p>
<p>Justice Clarence Thomas – the leader of <a href="https://www.theguardian.com/us-news/2022/jul/10/clarence-thomas-supreme-court-justice">the court’s conservative majority</a> – has served on the high court for over three decades and is there only because liberal icon <a href="https://apnews.com/article/f10d6e4172ccc67bb2fc4cb9070ab2b5">Justice Thurgood Marshall</a> refused to retire under a Democratic president and subsequently died with a Republican in office. </p>
<p>All federal judges in the U.S., including Supreme Court justices, enjoy life tenure. </p>
<p>Under <a href="https://constitutioncenter.org/interactive-constitution/interpretation/article-iii/clauses/45">Article 3 of the Constitution</a>, justices cannot be forced out of office against their will, barring impeachment. This provision, which followed <a href="https://www.nytimes.com/2022/06/30/briefing/supreme-court-us-democracy.html">the precedent of Great Britain</a>, is meant to ensure judicial independence that allows judges to render decisions based on their understandings of the law – free from political, social and electoral influences.</p>
<p><a href="https://polsci.umass.edu/people/paul-m-collins-jr">Our</a> extensive <a href="https://www.niu.edu/clas/polisci/about/faculty-staff/ward.shtml">research</a> on the Supreme Court shows life tenure, while well intended, has had unforeseen consequences. </p>
<p>It skews how the <a href="https://www.cambridge.org/core/books/supreme-court-confirmation-hearings-and-constitutional-change/5294A199815AA35235FD64AB04FC7E4D">confirmation process</a> and <a href="https://www.sup.org/books/title/?id=22199">judicial</a> <a href="https://oxford.universitypressscholarship.com/view/10.1093/acprof:oso/9780195372144.001.0001/acprof-9780195372144">decision-making</a> work and causes justices who want to retire to <a href="https://www.sunypress.edu/p-3721-deciding-to-leave.aspx">behave like political operatives</a>. </p>
<h2>Problems with lifetime tenure</h2>
<p>Life tenure has motivated presidents to pick <a href="https://qz.com/1324841/brett-kavanaughs-age-at-53-means-that-he-may-wield-influence-on-the-supreme-court-for-a-very-long-time/#:%7E:text=That's%20about%20where%20it%20was,the%20court%20was%20around%2053">younger and younger</a> justices. </p>
<p>In the post-World War II era, presidents generally forgo appointing jurists in their 60s, who would bring <a href="https://www.fjc.gov/history/exhibits/graphs-and-maps/age-and-experience-judges">a great deal of experience</a>, and instead nominate judges in their 40s or 50s, who could serve on the court for many decades. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/408271/original/file-20210624-19-rsfajf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Supreme Court Justice Ruth Bader Ginsburg in 2005." src="https://images.theconversation.com/files/408271/original/file-20210624-19-rsfajf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/408271/original/file-20210624-19-rsfajf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1003&fit=crop&dpr=1 600w, https://images.theconversation.com/files/408271/original/file-20210624-19-rsfajf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1003&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/408271/original/file-20210624-19-rsfajf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1003&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/408271/original/file-20210624-19-rsfajf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1260&fit=crop&dpr=1 754w, https://images.theconversation.com/files/408271/original/file-20210624-19-rsfajf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1260&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/408271/original/file-20210624-19-rsfajf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1260&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Justice Ruth Bader Ginsburg.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/supreme-court-justice-ruth-bader-ginsburg-watches-president-news-photo/525578128?adppopup=true">Brooks Kraft LLC/Corbis via Getty Images</a></span>
</figcaption>
</figure>
<p>And <a href="https://www.pewresearch.org/fact-tank/2017/02/08/younger-supreme-court-appointees-stay-on-the-bench-longer-but-there-are-plenty-of-exceptions/">they do</a>. </p>
<p>When <a href="https://www.washingtonpost.com/archive/politics/1991/07/02/bush-picks-thomas-for-supreme-court/943b9fda-e079-405e-974e-14c2d0cd999b/">Thomas was appointed</a> at age 43 by President George H.W. Bush in 1991, he <a href="https://www.nytimes.com/1993/11/27/us/2-years-after-his-bruising-hearing-justice-thomas-can-rarely-be-heard.html">famously said</a> he would serve for 43 years. There are another dozen years until his promise is met, should he choose to keep it at all. </p>
<h2>Partisanship problems</h2>
<p>Justices change during their decades on the bench, <a href="https://mqscores.lsa.umich.edu/">research shows</a>.</p>
<p>Justices who at the time of their confirmation espoused views that reflected the general public, the Senate and the president who appointed them tend to <a href="https://scholarlycommons.law.northwestern.edu/cgi/viewcontent.cgi?article=1113&context=nulr_online">move away</a> from those <a href="https://journals.sagepub.com/doi/abs/10.1177/106591290005300306">preferences over time</a>. They become <a href="https://doi.org/10.1017/s002238160808081x">more ideological</a>, focused on putting their own <a href="https://www.cambridge.org/core/books/supreme-court-and-the-attitudinal-model-revisited/5982FCCD061EB38DBB870DBC5E9A3197">policy preferences</a> into law.</p>
<p>Other Americans’ <a href="https://www.journals.uchicago.edu/doi/abs/10.1086/706889">political preferences</a> tend to be stable throughout their lives. </p>
<p>The consequence is that Supreme Court justices may no longer reflect the America they preside over. </p>
<p>This can be problematic. </p>
<p>If the court were to routinely stray too far from the public’s values, <a href="https://www.washingtonpost.com/politics/2020/10/23/why-americans-are-perfectly-willing-undermine-integrity-independence-supreme-court/">the public could reject</a> its dictates by refusing to follow the court’s decisions. The Supreme Court relies on public confidence to <a href="https://doi.org/10.2307/2111585">maintain its legitimacy</a>. In addition to public resistance to its decisions, if the court lost its legitimacy, lower court judges and legislative and executive branch actors might resist implementing the court’s rulings. </p>
<p>Life tenure has also turned staffing the Supreme Court into an increasingly <a href="https://www.pbs.org/newshour/nation/is-the-hyper-partisan-supreme-court-confirmation-process-the-new-normal">partisan process</a>, politicizing one of the <a href="https://www.jstor.org/stable/25791761">nation’s most powerful institutions</a>.</p>
<p>In the 1980s and 1990s, Supreme Court nominees could generally expect broad, bipartisan <a href="https://www.senate.gov/legislative/nominations/SupremeCourtNominations1789present.htm">support in the Senate</a>. Today, judicial confirmation votes are almost <a href="https://www.pewresearch.org/fact-tank/2018/03/07/federal-judicial-picks-have-become-more-contentious-and-trumps-are-no-exception/">strictly down party lines</a>. </p>
<p>Public support for judicial nominees is likewise shaped by <a href="https://news.gallup.com/poll/322232/amy-coney-barrett-seated-supreme-court.aspx">partisanship</a>. Simply put, Democrats are much more supportive of nominees appointed by Democratic presidents, and Republicans are much more supportive of nominees appointed by Republican presidents. </p>
<p>Life tenure can turn supposedly independent judges into <a href="https://www.latimes.com/opinion/op-ed/la-oe-ward-kennedy-retirement-20180629-story.html">political players</a> who <a href="https://www.tristatehomepage.com/news/justice-ginsburgs-fervent-last-wish-was-to-not-be-replaced-until-a-new-president-is-installed-report-says/">attempt to time their departures</a> to secure their <a href="https://www.nytimes.com/2020/09/21/magazine/ginsburg-successor-obama.html">preferred successors</a> – and this may have factored in to Justice Stephen Breyer’s decision this year under President Joe Biden, a Democrat. </p>
<p>Biden appointed Justice Ketanji Brown Jackson, one of Breyer’s <a href="https://apnews.com/article/Ketanji-Brown-Jackson-biden-supreme-court-nominee-32f77fe08d7cf64af95591668a0aaa41">former clerks</a>, to replace him.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/408268/original/file-20210624-25-1hygzzd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Supreme Court Justice Anthony Kennedy is presented a medal." src="https://images.theconversation.com/files/408268/original/file-20210624-25-1hygzzd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/408268/original/file-20210624-25-1hygzzd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=403&fit=crop&dpr=1 600w, https://images.theconversation.com/files/408268/original/file-20210624-25-1hygzzd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=403&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/408268/original/file-20210624-25-1hygzzd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=403&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/408268/original/file-20210624-25-1hygzzd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/408268/original/file-20210624-25-1hygzzd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/408268/original/file-20210624-25-1hygzzd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Justice Anthony Kennedy receiving the 2019 Liberty Medal from Justice Neil Gorsuch.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/retired-supreme-court-justice-anthony-kennedy-is-presented-news-photo/1178587667?adppopup=true">William Thomas Cain/Getty Images</a></span>
</figcaption>
</figure>
<h2>The proposed solution</h2>
<p>Many <a href="https://blogs.chicagotribune.com/files/supctlawcalabresi.pdf">Supreme Court</a> <a href="https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.scotusblog.com%2Fwp-content%2Fuploads%2F2009%2F02%2Fjudiciary-act-of-2009.do">experts</a> have coalesced around a <a href="https://www.amacad.org/sites/default/files/publication/downloads/2020-Democratic-Citizenship_Our-Common-Purpose_0.pdf">solution</a> to these problems: <a href="https://fixthecourt.com/fix/term-limits/">staggered 18-year terms</a> with a <a href="https://www.washingtonpost.com/news/monkey-cage/wp/2017/03/23/why-not-limit-neil-gorsuch-and-all-supreme-court-justices-to-18-year-terms/">vacancy automatically occurring</a> every two years <a href="https://www.theatlantic.com/politics/archive/2014/05/its-time-for-term-limits-for-the-supreme-court/371415/">in nonelection years</a>. </p>
<p>This system would promote <a href="https://www.brennancenter.org/our-work/analysis-opinion/saving-supreme-court">judicial legitimacy</a>, they argue, by taking departure decisions <a href="https://www.cnn.com/2019/03/20/politics/sandra-day-oconnor-supreme-court-evan-thomas-book">out of the justices’ hands</a>. </p>
<p>It would help insulate the court from becoming a <a href="https://www.nytimes.com/2016/05/19/us/politics/donald-trump-supreme-court-nominees.html">campaign issue</a> because <a href="https://www.npr.org/2018/06/29/624467256/what-happened-with-merrick-garland-in-2016-and-why-it-matters-now">vacancies would no longer arise</a> during election years. Indeed, even if a justice died during an election year, a lower court judge could be temporarily elevated as a replacement. Term limits would also <a href="https://www.reuters.com/article/us-usa-court-termlimits/democrats-prepare-bill-limiting-u-s-supreme-court-justice-terms-to-18-years-idUSKCN26F3L3">preserve judicial independence</a> by shielding the court from political calls to fundamentally alter the institution. </p>
<p>Partisanship would still tinge the selection and confirmation of judges by the president and Senate and ideological extremists could still reach the Supreme Court. But they would be limited to 18-year terms. </p>
<h2>Instituting life tenure</h2>
<p>The U.S. Supreme Court is one of the world’s few high courts whose members have life tenure. </p>
<p><a href="https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780198810230.001.0001/oxfordhb-9780198810230-e-39">Almost all democratic nations</a> have either <a href="https://blogs.chicagotribune.com/files/supctlawcalabresi.pdf">fixed terms or mandatory retirement ages</a> for their top judges, including the <a href="https://www.supremecourt.uk/docs/scotus-and-uksc-comparative-learning-tool.pdf">United Kingdom</a>. </p>
<p>Except for <a href="https://www.providencejournal.com/news/20200118/changes-ahead-for-ris-aging-supreme-court">Rhode Island</a>, all U.S. states either have <a href="https://www.ncsc.org/information-and-resources/trending-topics/trending-topics-landing-pg/mandatory-judicial-retirement">mandatory retirement ages</a> or let voters choose when judges leave the bench through <a href="https://www.routledge.com/Judicial-Elections-in-the-21st-Century/Bonneau-Hall/p/book/9781138185890">judicial elections</a>. </p>
<p>Even before Dobbs, polling consistently showed <a href="https://www.reuters.com/article/us-usa-court-poll/americans-favor-supreme-court-term-limits-reuters-ipsos-poll-idUSKCN0PU09820150720">a large bipartisan</a> <a href="https://www.reuters.com/business/legal/most-americans-want-end-lifetime-supreme-court-appointments-2021-04-18/">majority</a> of Americans supported ending life tenure for Supreme Court justices. </p>
<p>This view comes amid reports of <a href="https://fivethirtyeight.com/features/why-the-supreme-courts-reputation-is-at-stake/">eroding public confidence</a> as the court routinely issues <a href="https://slate.com/news-and-politics/2020/03/kansas-v-garcia-scotus-ideological-splits.html">decisions down partisan lines</a> on the day’s most controversial issues. </p>
<p>Although judges’ ideology has <a href="https://press.princeton.edu/books/hardcover/9780691175522/ideology-in-the-supreme-court">long influenced</a> Supreme Court decisions, today’s court is <a href="https://www.washingtonpost.com/news/monkey-cage/wp/2018/06/29/it-took-conservatives-50-years-to-get-a-reliable-majority-on-the-supreme-court-here-are-3-reasons-why/">unusual</a> because all the conservative justices are Republicans and all the liberal justices are Democrats. In the past, it was <a href="https://global.oup.com/academic/product/the-company-they-keep-9780190278052?cc=us&lang=en&">not uncommon</a> to have liberal-leaning justices who were appointed by Republican presidents, and conservative-leaning justices who were appointed by Democratic presidents. </p>
<p>In April 2021, President Biden <a href="https://www.nytimes.com/2021/04/15/us/politics/supreme-court-commission.html">formed a committee</a> to examine <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2021/04/09/president-biden-to-sign-executive-order-creating-the-presidential-commission-on-the-supreme-court-of-the-united-states/">reforming the Supreme Court</a>, including term-limiting justices. </p>
<p>Some argue that <a href="https://crsreports.congress.gov/product/pdf/R/R46731">to end the justices’ life tenure</a> would require a constitutional amendment necessitating approval from two-thirds of both houses of Congress and three-fourths of U.S. states. But there is a way to enact term limits short of amendment. </p>
<p>The Constitution does not speak of “life tenure” per se. It states only <a href="https://www.law.cornell.edu/constitution-conan/article-3/section-1/good-behavior-clause-overview">that justices serve</a> “during good behavior” and does not specify the type of work that justices will do. </p>
<p>As a result, ordinary legislation – such as that <a href="https://thehill.com/homenews/house/3575349-democrats-introduce-bill-to-enact-term-limits-for-supreme-court-justices/">introduced</a> this week – could be passed by a majority of both houses of Congress that would require justices to take “senior status” at the end of their 18-year terms. </p>
<p>Senior status is <a href="https://www.uscourts.gov/faqs-federal-judges#faq-What-is-a-senior-judge">already an option</a> for justices who qualify for it and wish to step down from their Supreme Court duties. Senior status allows them either to retire or to sit on a lower court with undiminished salary for the remainder of their careers. </p>
<p>All that is needed, <a href="https://www.amacad.org/ourcommonpurpose/recommendation-1-8">these proponents argue</a>, is a change in the existing retirement statute that requires senior status after 18 years on the court. </p>
<p>And while <a href="https://crsreports.congress.gov/product/pdf/R/R46731">there are questions</a> over whether term limits via statute are constitutional, or whether the Supreme Court justices who would be affected by them are the appropriate body to make such a determination, the larger question is whether there is or will be the political will in Congress to enact them. </p>
<p><em>This story has been updated from <a href="https://theconversation.com/should-the-supreme-court-have-term-limits-159620">the original version</a> published on July 6, 2021.</em></p><img src="https://counter.theconversation.com/content/187040/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Unlike in most countries, US Supreme Court justices enjoy life tenure. Some legal scholars believe that centuries-old custom, meant to protect judicial independence, no longer serves the public.Paul M. Collins Jr., Professor of Legal Studies and Political Science, UMass AmherstArtemus Ward, Professor of Political Science, Northern Illinois UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1861862022-07-22T12:29:58Z2022-07-22T12:29:58ZHow to navigate self-managed abortion issues such as access, wait times and complications – a family physician explains<figure><img src="https://images.theconversation.com/files/474177/original/file-20220714-32290-129v78.jpg?ixlib=rb-1.1.0&rect=31%2C31%2C5260%2C3364&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When abortion care is restricted, demand for abortion pills goes up.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/abortion-drug-pills-and-drinking-water-royalty-free-image/1163891983?adppopup=true">Peter Dazeley/The Image Bank via Getty Images</a></span></figcaption></figure><p>“Are these pills legit? If I send money, am I even going to get these pills?”</p>
<p>These are the kinds of questions people have when they are curious about ordering medication abortion pills online.</p>
<p>This process, often called “self-sourced <a href="https://theconversation.com/what-is-a-medication-or-medical-abortion-5-questions-answered-by-3-doctors-182646">medication abortion</a>,” refers to an individual finding or sourcing medications to induce an abortion on their own, without going through their primary care provider, OB-GYN or other clinic like Planned Parenthood. Globally, abortion pills <a href="https://doi.org/10.1016/S0020-7292(98)00195-7">might be found without prescriptions</a> at neighborhood pharmacies or by accessing local community networks. In the U.S., even prior to the fall of Roe v. Wade, someone could order abortion pills online. </p>
<p><a href="https://www.uwmedicine.org/bios/grace-shih">As a family physician</a> practicing in Washington, I expect that abortion care will remain legal in my state. Even so, in the setting of legal abortion, I have cared for people who are self-managing their abortion because they don’t have a nearby abortion provider, because they cannot get a timely appointment or because they want control of their abortion experience. </p>
<p>In a study done before Roe v. Wade was overturned, researchers estimated that 7% of U.S. women would attempt <a href="https://doi.org/10.1001/jamanetworkopen.2020.29245">self-managed abortion in their lifetime</a>. Research shows that when there are more restrictions around care, demand for online abortion pills increases. </p>
<p>For example, one study looked at <a href="https://doi.org/10.1001/jamanetworkopen.2022.1122">requests to a common online source of abortion pills</a> the week after enactment of <a href="https://doi.org/10.1056/NEJMp2207423">Texas’ Senate Bill 8</a> – legislation that banned abortion after the detection of embryonic cardiac activity. That study found a mean daily increase of 1,180% over the baseline before the legislation took effect. We can only expect a larger surge given the new legal landscape in the post-Roe world.</p>
<p>As more people look to the internet to find <a href="https://theconversation.com/abortion-pills-are-safe-to-prescribe-without-in-person-exams-new-research-finds-179622">abortion pills</a>, what can they do to avoid getting scammed and stay safe? Here are some resources and common questions people have about the process. </p>
<h2>How do you get abortion pills online?</h2>
<p>There are lots of places where you can get abortion pills online; however, not all sites have been vetted for legitimacy. One reliable “one-stop shop” is <a href="https://www.plancpills.org/">plancpills.org</a>. This is a private advocacy organization that provides information on how to get pills. It does not mail the pills itself, but identifies the options that are available depending on someone’s location as well as basic information like the cost, delivery time, age restrictions and financial assistance availability. It’s like <a href="https://www.goodrx.com/">GoodRx</a> for abortion pills. </p>
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<figcaption><span class="caption">Those considering abortion pills should plan to rest and remain at home on the day they take misoprostol.</span></figcaption>
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<h2>What are the abortion pills?</h2>
<p>There are two medications that are commonly used for medication abortion: <a href="https://www.webmd.com/drugs/2/drug-20222-325/mifepristone-oral/mifepristone-oral/details">mifepristone</a> and <a href="https://medlineplus.gov/druginfo/meds/a689009.html">misoprostol</a>. Mifepristone blocks the hormone progesterone and stops the pregnancy from continuing. Misoprostol is a prostaglandin – a compound that has hormone-like effects on the body – that helps soften and dilate the cervix to expel the pregnancy. </p>
<p>Some online abortion sites may offer the mifepristone pill with misoprostol pills, and others may only have misoprostol pills. Both options are <a href="https://theconversation.com/abortion-pills-are-safe-to-prescribe-without-in-person-exams-new-research-finds-179622">safe and highly effective</a>. </p>
<p>In the U.S., medication abortion is <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/020687s020lbl.pdf">approved by the Food and Drug Administration</a> as the combination of mifepristone with misoprostol. However, mifepristone can be difficult to obtain <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/mifeprex-mifepristone-information">because of prescribing restrictions</a>. </p>
<p>Misoprostol is more readily accessible and available over the counter in many countries. There are accepted protocols for both the <a href="https://www.reproductiveaccess.org/wp-content/uploads/2020/08/2022-06-How-to-Use-Abortion-Pills-Mife-and-Miso.pdf">mifepristone-plus-misoprostol abortion</a> and the <a href="https://www.reproductiveaccess.org/resource/mabfactsheet-miso/">misoprostol-only abortion</a> pills. </p>
<h2>What if I live in a state with restricted abortion access?</h2>
<p>You can still buy the pills in states with restricted abortion access, but it may take longer to get them and there may be some legal risks. There are several options for people living in states <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">that have total bans on abortion</a>, like Texas, Oklahoma, South Dakota, Missouri, Mississippi, Arkansas and Alabama. </p>
<p>One option is <a href="https://aidaccess.org/">Aid Access</a>, a private organization with clinicians inside and outside the United States. When requests are made by people living in states with abortion bans, prescriptions are written by non-U.S. physicians and pills are mailed from international sources. Because of this process, it takes longer – two to three weeks versus two to three days – to receive the abortion pills. </p>
<p>Another option is ordering directly from online pharmacies. This means no prescription is required since no clinicians are involved; the process can be quicker, but it also may cost more (say, $200 to $400 compared to $100). </p>
<p>Finally, <a href="https://www.plancpills.org/mail-forwarding">some people use mail forwarding</a> as a way to get abortion pills to restricted states. For legal questions, people can seek free, confidential help on the Repro Legal Helpline <a href="https://www.reprolegalhelpline.org/sma-contact-the-helpline/">either online</a> or at 844-868-2812. </p>
<h2>Are the online pills safe?</h2>
<p>For the most part, yes. A 2017 study <a href="https://doi.org/10.1016/j.contraception.2017.09.016">investigated the process</a> of buying abortion pills from online sources, including verifying the chemical quality of the pills received. Most of the sources contained within 8% of the labeled active ingredient. </p>
<p>This study was <a href="https://gynuity.org/">conducted by researchers from Gynuity and Plan C</a>, which are nonprofit organizations dedicated to abortion research and advocacy. <a href="https://www.plancpills.org/">Plan C Pills</a> continues to check its sources, and only those that have been vetted and verified are included on its website. </p>
<p>In general, medication abortion is very safe. In fact, medication abortion pills are so safe and easy to use that a label prototype for over-the-counter medication abortion <a href="https://doi.org/10.1097/AOG.0000000000004757">has been studied</a>. </p>
<h2>What happens if you have a question once you have the pills?</h2>
<p>Depending on where you order the pills, you may have access to a clinician who works with the organization that mails out the pills. If no clinician is available or if you ordered directly from an online pharmacy, people can contact the <a href="https://www.mahotline.org/">M+A Hotline</a>, which is a text/phone-based hotline staffed by volunteer licensed clinicians, or <a href="https://abortionpillinfo.org/">Self-Managed Abortion Safe & Supported</a>, a global nonprofit where trained counselors answer questions through a secure web portal. </p>
<p>The bottom line is that self-managed medication abortion <a href="https://doi.org/10.1016/j.lana.2022.100200">is medically safe</a>, and there are many reliable resources available to help people through the process. As abortion restrictions increase in the U.S., abortion pills may become like any other internet commodity – just a click away.</p><img src="https://counter.theconversation.com/content/186186/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grace Shih is part of a network of providers that supports people and providers with sexual and reproductive health questions.</span></em></p>Abortion pills are available online, and many of them are safe. But not all sites have been properly vetted for legitimacy.Grace Shih, Associate Professor of Family Medicine, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1859372022-07-18T12:26:32Z2022-07-18T12:26:32ZAbortion funds may not be able to keep up with rising demands, as more people travel out of state for the procedure<figure><img src="https://images.theconversation.com/files/474217/original/file-20220715-18-eopgdo.jpg?ixlib=rb-1.1.0&rect=136%2C12%2C3708%2C2377&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A sign reads 'I'm on your side' outside the Hope Medical Group for Women in Shreveport, La., in April 2022. </span> <span class="attribution"><a class="source" href="https://media.gettyimages.com/photos/sign-reading-im-on-your-side-is-planted-on-the-lawn-in-front-of-the-picture-id1240239954?s=2048x2048">Francois Picard/AFP via Getty Images</a></span></figcaption></figure><p>Abortion providers in places <a href="https://www.wesa.fm/health-science-tech/2022-07-11/as-people-travel-to-pittsburgh-from-out-of-state-for-abortions-black-patients-could-be-left-out">like Pennsylvania</a> and <a href="https://www.nytimes.com/2022/07/11/us/california-out-of-state-abortion-patients.html">California</a> are seeing an uptick in abortion patients traveling from other states, where the procedure is now banned or restricted.</p>
<p>The cost of getting an abortion is rising for many of these patients, as people may need to travel farther to one of the <a href="https://www.washingtonpost.com/politics/2022/06/24/abortion-state-laws-criminalization-roe/">28 states</a>, or to Washington, D.C., where abortion – at least for now – remains legal. </p>
<p>In the wake of the Supreme Court’s <a href="https://www.oyez.org/cases/2021/19-1392">decision allowing states</a> to decide whether and <a href="https://www.wpr.org/fight-fund-abortions-post-roe-america">in what circumstances to legalize</a> or ban abortions, <a href="https://theconversation.com/abortion-funds-are-in-the-spotlight-with-the-end-of-roe-v-wade-3-findings-about-what-they-do-182636">abortion funds</a> – charitable organizations that help people pay for <a href="https://abortionfunds.org/about/abortion-funds-101/">abortion procedures</a>, and sometimes other expenses like the <a href="https://abortionfunds.org/about/abortion-funds-101/">travel and lodging</a> they need to get an abortion – are facing new pressures.</p>
<p>Meanwhile, some <a href="https://theconversation.com/abortion-funds-are-in-the-spotlight-with-the-end-of-roe-v-wade-3-findings-about-what-they-do-182636">abortion funds</a> have closed over the last few weeks in states like <a href="https://www.texastribune.org/2022/06/29/texas-abortion-funds-legal/">Texas</a> and <a href="https://whnt.com/community/alabama-abortion-fund-will-temporarily-pause-services-for-safety-security-reasons/">Alabama</a>, and new ones have opened up in <a href="https://bronx.news12.com/new-fund-launched-to-help-pay-for-connecticut-abortion-care">states like Connecticut</a>. </p>
<p>As a <a href="https://scholar.google.com/citations?user=AsV2eNIAAAAJ&hl=en">social work professor</a> who studies access to reproductive health care, I think it’s important to understand that state abortion bans and restrictions will increase people’s need to travel out of state to get an abortion. This will prompt more <a href="https://abortionfunds.org/about/abortion-funds-101/">people seeking help</a> from abortion funds, which themselves are facing new kinds of legal and financial pressures. </p>
<h2>A funding boost</h2>
<p>Shortly after the draft Supreme Court <a href="https://apnews.com/article/roe-wade-supreme-court-leaked-draft-opinion-c6a923f6e370672f4a5ccfd3be325786">opinion leaked</a> in May 2022, foreshadowing the overturn of Roe v. Wade, donors gave US$1.5 million to abortion funds within a week. </p>
<p>When the actual ruling came down on June 24, the National Network of Abortion Funds, which reports having over 90 affiliate abortion fund members, <a href="https://www.nytimes.com/2022/06/24/us/abortion-funds-donations-roe.html">received over</a> $3 million from 33,000 new donors.</p>
<p>An increase in “<a href="https://www.pbs.org/newshour/nation/funding-increases-for-abortion-related-causes-as-rage-giving-continues">rage-giving</a>,” which refers to donations that are sparked by <a href="https://www.pbs.org/newshour/health/abortion-funds-feel-frustration-gratitude-at-rage-giving">anger</a>, has continued. But the jump in donations may not match people’s rising needs, <a href="https://www.pbs.org/newshour/nation/funding-increases-for-abortion-related-causes-as-rage-giving-continues">abortion fund experts say</a>. </p>
<h2>Still unable to meet demand</h2>
<p>Calls to abortion funds requesting help with out-of-state travel have <a href="https://fortune.com/2022/06/24/roe-v-wade-overturned-abortion-access-funds-restrictive-state-laws/">skyrocketed in Texas</a> since <a href="https://www.texastribune.org/2021/08/31/texas-abortion-law-supreme-court/">September 2021</a>, <a href="https://19thnews.org/2022/03/senate-bill-8-texas-abortion-ban-remains-enforced-supreme-court/">after the state</a> banned abortion beyond six weeks of pregnancy. </p>
<p>In response to the Dobbs ruling, abortion funds have been <a href="https://www.nytimes.com/2022/06/24/us/abortion-funds-donations-roe.html">expecting a continued nationwide increase</a> in requests for help. </p>
<p>This help is needed because an estimated 75% of abortion patients are <a href="https://www.guttmacher.org/infographic/2016/abortion-patients-are-disproportionately-poor-and-low-income">poor or low-income</a>, and <a href="https://doi.org/10.1016/j.whi.2014.01.003">research shows that</a> out-of-pocket abortion expenses can make up about one-third of an average patient’s monthly income. </p>
<p>But even with the new influx of cash, abortion funds’ <a href="https://fortune.com/2022/06/24/roe-v-wade-overturned-abortion-access-funds-restrictive-state-laws/">financial capacities</a> are limited. </p>
<p>The <a href="https://abortionfunds.org/about/">National Network of Abortion Funds</a> reports that its member organizations helped almost 82,000 people cover abortion expenses during the 2019-2020 fiscal year. But that was only one-third <a href="https://abortionfunds.org/about/abortion-funds-101/">of the almost 230,000 people</a> who requested money. Each person they helped received an <a href="https://media.abortionfunds.org/cms/assets/uploads/2021/07/29145901/NNAF-Annual-Report-%E2%80%93-FY-2019-FY-2020.pdf">average of $215</a>. </p>
<p>One reason there is a gap between demand and availability is the high cost of an abortion. First-trimester surgical abortions range from <a href="https://www.thecut.com/2018/11/how-much-does-an-abortion-cost.html">$455 to $955</a>. While some private health insurance companies cover abortion costs, most insurances, including Medicaid in most states, <a href="https://www.guttmacher.org/evidence-you-can-use/medicaid-coverage-abortion">will not pay for it</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/474208/original/file-20220714-16-ei6fgs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two women wearing masks stand over a crowded office desk with papers and answer a landline phone." src="https://images.theconversation.com/files/474208/original/file-20220714-16-ei6fgs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474208/original/file-20220714-16-ei6fgs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=355&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474208/original/file-20220714-16-ei6fgs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=355&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474208/original/file-20220714-16-ei6fgs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=355&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474208/original/file-20220714-16-ei6fgs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=447&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474208/original/file-20220714-16-ei6fgs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=447&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474208/original/file-20220714-16-ei6fgs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=447&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Employees answer phone calls at the Hope Medical Group for Women in Shreveport, La., which receives many abortion patients from Texas, in April 2022.</span>
<span class="attribution"><a class="source" href="https://media.gettyimages.com/photos/employees-answer-numerous-phone-calls-at-the-hope-medical-group-for-picture-id1240239743?s=2048x2048">Francois Picard/AFP via Getty Images</a></span>
</figcaption>
</figure>
<h2>High costs</h2>
<p>My colleagues and I <a href="https://doi.org/10.1080/00981389.2016.1263270">studied</a> cases, representing the years 2010 through 2015, of patients who got help from one national abortion fund that prioritized serving people who were close to the gestational limit on when they could get an abortion. We found that the average procedural cost for these patients was over $2,200. </p>
<p>In the study, the abortion fund was able to give these patients an average of almost $260 to help with the cost of the abortion procedure.</p>
<p>Patients in the same study also received almost $800, on average, in help from other sources, such as family, friends or other abortion funds. Even with this extra help, though, patients were still about $600 short of the procedure’s cost. </p>
<p>When patients have to scrape together money for abortions, the procedure is often delayed, resulting in <a href="https://www.guttmacher.org/gpr/2016/07/abortion-lives-women-struggling-financially-why-insurance-coverage-matters">cost increases</a> because an abortion becomes more medically complicated and expensive <a href="https://www.guttmacher.org/evidence-you-can-use/later-abortion">later</a> in pregnancy. </p>
<p>Our research on two different <a href="https://academic.oup.com/hsw/article-abstract/45/3/186/5849139">state</a> and <a href="https://www.tandfonline.com/doi/full/10.1080/00981389.2016.1263270">national</a> abortion funds found that these organizations most often assisted parents in their 20s, who were already parenting an average of two children. Over 50% of people who received money from these abortion funds identified as Black, while about 25% identified as white.</p>
<p>People in rural areas may especially need to seek help from abortion funds, since they often have to travel farther from home to get the procedure. <a href="https://www.mdpi.com/1660-4601/17/4/1198">Interviews I conducted with Appalachian residents</a> in 2019 revealed that people in the rural region had difficulty getting reproductive health care, including contraception or abortion, because of problems such as few regional health care providers. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/474207/original/file-20220714-16-3dpcur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Kathy Hochul stands at a podium, in front of a screen that says 'A safe harbor for all: Protecting abortion rights.'" src="https://images.theconversation.com/files/474207/original/file-20220714-16-3dpcur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474207/original/file-20220714-16-3dpcur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474207/original/file-20220714-16-3dpcur.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474207/original/file-20220714-16-3dpcur.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474207/original/file-20220714-16-3dpcur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474207/original/file-20220714-16-3dpcur.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474207/original/file-20220714-16-3dpcur.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">New York Governor Kathy Hochul spoke on July 12, 2022, to announce more funding for abortion and to invite businesses to relocate to the state.</span>
<span class="attribution"><a class="source" href="https://media.gettyimages.com/photos/governor-kathy-hochul-holds-media-availability-press-conference-and-picture-id1241871760?s=2048x2048">Lev Radin/Pacific Press/LightRocket via Getty Images</a></span>
</figcaption>
</figure>
<h2>What’s next</h2>
<p>Several major companies, including <a href="https://www.cnn.com/2022/06/24/tech/companies-abortion-reaction/index.html">Apple and Disney</a>, say they will pay some expenses for employees who need to travel to get an abortion. But most people who cannot afford to get an abortion are not full-time employees of a large company. </p>
<p>As less than <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">half of states</a> ban or plan to place new restrictions on abortion, staffers in abortion funds in places like in Texas may fear their work could result in <a href="https://www.texastribune.org/2022/06/29/texas-abortion-funds-legal/">jail time</a>, because it is <a href="https://www.texastribune.org/2022/06/29/texas-abortion-funds-legal/">currently unclear</a> whether it is a crime to help Texans pay for an abortion performed out of state.</p>
<p>Texas had <a href="https://theconversation.com/what-triggers-the-trigger-laws-that-could-ban-abortions-184361">an existing law</a> triggering a <a href="https://www.texastribune.org/2022/06/24/texas-abortion-law-answers/">near complete</a> abortion ban 30 days after Roe is overturned, which will also allow citizens to <a href="https://stateofreform.com/5-things/2022/07/5-things-texas-1925-abortion-ban-child-health-policy-recommendations-medical-debt-guidance/">sue anyone</a> who helps someone get an abortion. As of now, <a href="https://www.texastribune.org/2022/06/24/texas-abortion-law-answers/">Texas clinics</a> have stopped providing abortions. </p>
<p><a href="https://www.texastribune.org/2022/06/29/texas-abortion-funds-legal/">Texas reverted</a> to <a href="https://www.houstonpublicmedia.org/articles/news/politics/2022/06/28/427879/texas-judge-blocks-states-pre-roe-ban-allows-some-abortions-to-continue/">another pre-Roe law</a> that penalized abortion with a five-year prison term. For now, the <a href="https://www.texastribune.org/2022/07/02/texas-abortion-1925-ban-supreme-court/">Texas Supreme Court</a> has said this law can go back <a href="https://www.texastribune.org/2022/07/02/texas-abortion-1925-ban-supreme-court/">into effect</a>. </p>
<p>However, some experts have voiced concern that abortion fund employees or volunteers both <a href="https://www.texastribune.org/2022/06/29/texas-abortion-funds-legal/">in</a> and <a href="https://www.bloomberg.com/news/articles/2022-06-30/here-s-why-abortion-clinics-are-worried-about-out-of-state-prosecutions#xj4y7vzkg">outside</a> of Texas could face <a href="https://www.texastribune.org/2022/06/29/texas-abortion-funds-legal/">criminal penalties</a> for “<a href="https://stateofreform.com/5-things/2022/07/5-things-texas-1925-abortion-ban-child-health-policy-recommendations-medical-debt-guidance/">aiding and abetting</a>” abortion seekers as new state abortion bans are implemented. </p>
<p>Legal experts say that <a href="https://www.npr.org/sections/money/2022/07/05/1109080841/the-fight-to-fund-abortions-in-post-roe-america">states cannot stop residents</a> from traveling out of state to get an abortion – although lawmakers in Missouri did <a href="https://www.wbur.org/onpoint/2022/03/24/inside-missouris-push-to-ban-out-of-state-abortions">propose legislation</a> earlier this year that tried to do just that. </p>
<p>The <a href="https://www.cbsnews.com/dfw/news/shifting-abortion-laws-cause-confusion-for-patients-clinics/">murky legal landscape</a> is not expected to stop abortion funds from helping patients pay for abortions. But it can <a href="https://www.cbsnews.com/dfw/news/shifting-abortion-laws-cause-confusion-for-patients-clinics/">scare or confuse people who want abortions</a> and create uncertainty as they try to figure out where to go for help.</p><img src="https://counter.theconversation.com/content/185937/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gretchen E. Ely has previously received research funding from the Society of Family Planning, the National Network of Abortion Funds, and inroads:The International Network for the Reduction of Abortion Discrimination and Stigma. Dr. Ely is not affiliated with any abortion fund organizations. She is currently serving on the community board for the Planned Parenthood affiliate in Knoxville, TN. </span></em></p>Abortion funds, which help people who cannot afford the procedure, are facing new kinds of pressures, including potential legal risks and a rising client demand that exceeds their capabilities.Gretchen E. Ely, Professor of Social Work, University of TennesseeLicensed as Creative Commons – attribution, no derivatives.