POV: Overturning Roe v. Wade Will Worsen Health Inequities in All Reproductive Care
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POV: Overturning Roe v. Wade Will Worsen Health Inequities in All Reproductive Care
The burden of impact will be borne disproportionately by people of color
On Friday, the US Supreme Court released its decision on Dobbs v. Jackson Women’s Health Organization. In one of its most consequential decisions of the past 50 years, the Court’s 6-3 decision reversed Roe v. Wade, the landmark 1973 decision certifying a constitutional right to an abortion. The reversal of Roe leaves the legality of abortion care in the hands of state governments. While some states have recently reaffirmed the right to an abortion, 26 states are likely or certain to ban abortion in most or all circumstances.
The recent national conversation has appropriately focused on the devastating impact of limiting or banning access to abortion care. Conservative estimates show that in the year following the overturning of Roe, at least 75,000 people who want, but cannot get, abortions will give birth instead. And these people are facing higher than ever—and rising—pregnancy-related mortality rates. Despite our world-class healthcare facilities, at least 700 women already die of pregnancy-related complications each year in the United States (use of the gender-specific term throughout reflects limitations in research). But not all pregnant people are at equal risk. Black and American Indian or Alaskan Native (AIAN) women have pregnancy-related mortality rates that are over three times (American Indian) and two times (Alaskan Native) higher compared to the rate for white women (40.8 and 29.7 vs. 12.7 per 100,000 live births). Women of color are more likely to enter prenatal care late or not at all, which is a risk factor for preterm birth and low birth weight. This is one of the reasons that infants born to Black and native Hawaiian and other Pacific Islander women are over twice as likely to die relative to those born to white women (10.8 and 9.4 vs. 4.6 per 1,000), and the mortality rate for infants born to AIAN women (8.2 per 1,000) is nearly twice as high.
Yet the impact of the fall of Roe will go well beyond people who are denied wanted and needed abortions. There are four other areas of reproductive health that will be affected by lack of abortion care. And as with abortion care, the burden of impact will be borne disproportionately by people of color.
Ectopic pregnancy
Ectopic pregnancy occurs when a fertilized egg implants outside the uterine cavity, most often in the fallopian tube. Ectopics occur in 2 percent of pregnancies, but are the leading cause of death in the first trimester, when the pregnancy ruptures. People of color are at an increased risk of ectopic pregnancy, as much as 50 percent higher than white women.
Many state laws banning abortion have written legislation that refers to a pregnancy at any point after fertilization. And many do not carve out an exception for pregnancies that are not viable (meaning healthy enough to continue to term). The vast majority of ectopic pregnancies (those that do not self-resolve) can be treated only with medication or surgery that terminates the pregnancy. Already, a patient in Texas with an ectopic pregnancy has been turned away for care because the clinicians were afraid that treating her pregnancy would violate S.B.8, the state law banning most abortions. And at least one Texas pharmacy has let area physicians know that they would no longer dispense methotrexate, the medication used to treat ectopic pregnancy, citing the law. Restrictive abortion laws in more states are likely to lead to more cases of patients with ectopic pregnancy being unable to secure timely, and life-saving, care.
Miscarriage
Black women are more likely to experience a loss of pregnancy after 10 weeks of gestation, including stillbirth, compared to white and Hispanic women. Stillbirth is often managed with induction of labor, but earlier pregnancy loss is managed with the same procedures and medications used for abortion. As the number of centers and doctors who can provide abortion care decreases, pregnant people experiencing pregnancy loss may have fewer options for care without traveling great distances.
Moreover, in states that have banned abortion, clinicians and pharmacists may be hesitant to prescribe mifepristone and misoprostol, the evidence-based regimen of medications to treat early pregnancy loss. As these are the same medications used for induced abortion, they fear criminal prosecution or civil action (under “bounty hunter” laws) if someone questions their intent—if they are caring for a patient with miscarriage or aiding and abetting an abortion. Pharmacists in Texas have already refused to dispense these medications to patients having a miscarriage. Thus, abortion bans can directly impact the care of people experiencing complications of very wanted pregnancies.
Contraception
Outlawing abortion may have additional consequences, including banning some of the most popular types of birth control. Bills that define the life of an “unborn child” as starting at fertilization or conception could be used to ban emergency contraception, oral contraceptives (“the pill”), or intrauterine devices. These methods of birth control do not stop a pregnancy after fertilization; hormonal methods delay ovulation and thicken the mucus in the cervix, making it harder for sperm to reach an egg if ovulation does occur. And the copper IUD makes sperm less likely to fertilize an egg. But some abortion rights opponents consider these methods of contraception “life-ending” because of the possibility that implantation may be disrupted. Even though these claims are not based on evidence, all scientists know that it’s impossible to prove a negative. And women of color are already less likely to use contraception overall, use different contraceptive methods, and have higher rates of contraceptive failure than white women.
In addition to the abortion laws with this widespread impact, legal scholars have raised the possibility that the overturning of Roe sets the stage for the overturning of Griswold v. Connecticut, the 1965 Supreme Court decision permitting the provision of contraception to married people. (Single people didn’t get this right until 1972.) As Griswold established a right to privacy and legalized birth control (for married couples only at the time), the Court could use its ruling in Dobbs and other recent cases to overturn Griswold altogether.
Assisted reproductive technologies
Black women are twice as likely to report experiencing infertility, but are only half as likely to be evaluated and treated for infertility as white women. Furthermore, people of color have a lower rate of achieving pregnancy and live birth after the use of assisted reproductive technology, such as in vitro fertilization (IVF). IVF often requires the fertilization of multiple eggs to maximize the chance of a successful pregnancy. Any healthy embryos created that are not implanted in the uterus are often frozen and stored for possible further implantation; embryos that are not healthy are often discarded.
Legislation banning abortion after fertilization may have a profound impact on IVF. It is possible that clinics may have to limit the number of embryos created, which reduces the likelihood of a successful pregnancy. Doctors may even need to implant more embryos than is healthy for the patient, to reduce the number of embryos remaining. And if a fertilized egg is considered a life, clinicians could conceivably be charged with manslaughter for discarding them. Any of these limitations would make IVF more expensive and more difficult to gain access to.
Make no mistake about it: the overturning of Roe v. Wade will have immediate and far-reaching impacts on the reproductive health of all pregnancy-capable people. And as with all healthcare delivery in the United States, the impact will be felt most acutely by people of color, worsening already tragic health inequities.
“POV” is an opinion page that provides timely commentaries from students, faculty, and staff on a variety of issues: on-campus, local, state, national, or international. Anyone interested in submitting a piece, which should be about 700 words long, should contact John O’Rourke at orourkej@bu.edu. BU Today reserves the right to reject or edit submissions. The views expressed are solely those of the author and are not intended to represent the views of Boston University.
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