We already know what a post-Roe v. Wade nation will look like. Here’s the data.
Limits on abortion mean people will have to travel farther to get the procedure. Those denied are at higher risk of physical and financial harm.
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When Maleeha Aziz of Dallas needed an abortion at age 20, she accidentally made an appointment with one of the state’s crisis pregnancy centers, which seek to dissuade people from abortion. In what she calls “the most traumatic experience of my life,” the staff were “almost harassing” her to not undergo an abortion, ticking off harms they alleged were associated with the procedure.
Aziz wanted a medication abortion, which requires taking prescribed pills in a set time frame, often at a cost of hundreds of dollars, and can be done at home. The crisis pregnancy center staff told her that medication abortions were banned in Texas, which was not true at the time. That’s when Aziz, a Pakistani immigrant who didn’t know the law, “completely panicked.” She spent thousands of dollars to fly to Colorado Springs, Colorado, to start a medication abortion, completing the second stage in her bathroom back home in Texas.
In the eight years since, Texas has adopted some of the most draconian abortion laws in the country, including Senate Bill 8, which took effect in September and bans abortions after about six weeks of pregnancy. By this summer, the Supreme Court is expected to overturn Roe v. Wade, the 1973 decision that legalized abortion nationwide. Strict limits like those in Texas or even outright bans could become commonplace in dozens of states.
That would likely have profound negative effects on the physical and mental health and economic status of millions of people who seek abortions going forward, according to extensive scientific research on the effects of abortion limits. Those from marginalized populations — including people of color, immigrants and people already under financial strain — would sustain the greatest impacts, studies suggest, including insurmountable expenses, increased risk of domestic violence and preterm birth when they can’t access abortion services.
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The case before the Supreme Court concerns a 2018 Mississippi law that bans abortions after 15 weeks of pregnancy — well before the 22- to 24-week threshold set by Roe and upheld by the court’s 1992 decision in Planned Parenthood of Southeastern Pennsylvania v. Casey, which prohibited limiting abortions before fetal viability outside the uterus. The conservative 6-3 majority on the court is expected to back the Mississippi statute, in a seismic overhaul of a half-century of reproductive-health law.
A dozen states including Texas have pending “trigger” laws to ban abortion if Roe falls, and even more are likely to implement similar laws. As the nation awaits the Supreme Court ruling, which is expected by the end of June, the effects of abortion denial and limited access under existing state-level limitations offer a window into what the future could bring.
The risks of domestic violence and preterm birth increase when abortion is denied
The typical person seeking an abortion is a young woman, age 18 to late 20s, who already has at least one child and is poor or low-income, said Caitlin Knowles Myers, an economist at Middlebury College in Vermont. About 75 percent of people who seek abortion live below 200 percent of the poverty line, she has found.
The price of being denied an abortion is steep. The Turnaway Study, which tracked 1,000 women who sought abortions at 30 U.S. facilities from 2008 to 2010 and followed them for up to five years, found that those who were not able to undergo the procedure suffered “serious physical health consequences,” both immediate and longer-term, lasting years. “There is an increased likelihood of poverty and a lower likelihood of setting aspirational plans, including having an intended pregnancy later,” said Diana Greene Foster, a demographer at the University of California, San Francisco (UCSF), who leads the project.
It and other peer-reviewed studies have shown that those who are denied abortions also are likelier to have anxiety, to experience near-term pregnancy complications that include death and to stay in violent relationships. The risks climb for people of color, people with low incomes and immigrants. Those findings, backed by solid data, stand in stark contrast to claims made by abortion opponents who claim without credible evidence that the procedure causes lasting physical and mental harm.
Perhaps most sobering among studies of denied abortions are findings related to intimate partner violence. Supporters of the Mississippi law argued to the Supreme Court that society now allows for an almost ideal life balance for pregnant people today, making the need for abortion obsolete. But as 14 anti-domestic violence groups noted in an amicus brief, forced pregnancy from rape is more common among survivors of intimate partner violence. In addition, an analysis of the Turnaway study and other data shows that access to abortion is linked to lower risk of violence from an intimate partner.
The ripple effects of limiting abortion can also vary by race or national origin. One study of the relationship between restrictive state abortion policies and negative birth outcomes from 2005 to 2015 found that the risk of the worst outcomes was higher for Black people. Using a “restrictiveness index,” reproductive health researcher Sara Redd of Emory University’s Rollins School of Public Health and her colleagues showed that Black people in states with more limits on abortion are at increased risk for preterm birth. The gap in outcomes between people with fewer versus more years of education also widened as the restrictiveness index values increased.
Legal risks stemming from immigration status, or from being a person of color, can also dissuade people from seeking abortion, especially when they must travel far to reach a provider. “I am concerned about undocumented people who fear that traveling long distances puts them at risk for deportation, just being out and interacting with healthcare providers in other states,” said Ushma Upadhyay, a public health social scientist at UCSF. Furthermore, “people who are low-income live in fear that accessing abortion services could put their eligibility for other services at risk.”
Recent changes in federal policy make it easier for people to access abortion care from their own homes — in theory. In late 2021, the Food and Drug Administration lifted restrictions on doctors’ ability to dispense medication abortion drugs. Until then, the agency had required that mifepristone, the first of the two drugs used for the procedure, be given in person by a clinician, not a pharmacist. The new policy does away with that requirement, allowing telehealth consults to prescribe the pills with delivery by mail. (Some groups outside the United States, including Women on Web, have long offered both telehealth consults and the pills by mail.)
But not all states allow abortion medications to be mailed, rendering moot the FDA’s changed stance.
In those places, a potential legal threat arises if complications occur with a self-managed, at-home medication abortion, said Abigail Aiken, a reproductive health policy researcher in the LBJ School of Public Affairs at the University of Texas at Austin. People who are already marginalized might find it hard to seek care if one of these rare complications occurs, anxious that someone will report them. Some prosecutors will “throw spaghetti at the wall to find ways to prosecute people, and that disproportionately happens to people of low income and to people of color,” Aiken said.
Even as self-managed abortion becomes increasingly important “as a form of reproductive autonomy when your state is trying to take it away from you,” she said, “the main risks are not medical ones but legal ones.”
Access limits come at a high price
The blow of a denied abortion is heavier to people experiencing poverty.
Researchers have looked at credit report data for participants in the Turnaway Study, comparing outcomes between people denied abortion just past the gestation limit and those who obtained an abortion just under that limit and later became pregnant again and delivered. Being denied abortion was associated with “large and persistent” pregnancy-related negative effects on financial well-being, the study found.
Those who could not obtain a wanted abortion had a 78 percent increase in overdue unpaid debt and an 81 percent increase in rates of tax liens, evictions and bankruptcies. These effects lasted years after the denial of abortion; those denied abortions were less likely to have a prime credit score at two years after giving birth, for instance. Foster and her co-authors concluded that being denied abortion was a financial blow equivalent to being evicted or losing health insurance.
Limits on abortion access also mean that people seeking abortion will have to travel increasingly long distances to obtain one. The twin factors of distance and denial hit already marginalized people the hardest.
The United States is already a land of abortion deserts, said Upadhyay. She and her colleagues looked at access in U.S. cities with 50,000 or more residents and found 27 such deserts, where a person would have to travel either 100 miles or one hour to obtain an abortion. The Midwest and the South are littered with them: Someone living in Rapid City, South Dakota, for example, would have to travel 318 miles to reach an abortion facility.
Texas is home to 10 abortion deserts, including Midland and Odessa in West Texas and Amarillo in the Panhandle. Studies show that after S.B. 8 took effect, someone in Austin would have to drive at least 335 miles to the nearest abortion provider, in Shreveport, Louisiana. The vast majority of travel distances in Texas are several hundred miles, according to an analysis from researchers at the University of Texas at Austin.
When Texas passed a law in 2013 requiring abortion providers to have hospital admitting privileges — a policy that has since been overturned — almost half of the state’s abortion clinics closed, most of them permanently. The distance a state resident had to travel for an abortion doubled. Research indicates that where travel distance increases by 25 miles, there is a 10 percent reduction in abortions. That is reinforced by data from Texas that shows abortions dropped by 13 percent while the 2013 bill was in effect.
The September 2021 enactment of S.B. 8 has led to even steeper declines. Abortions plummeted by 49.8 percent during that first month compared with September 2020, from 4,313 to 2,164. These declines likely represent many abortions denied.
Economics also plays a role in the effects of distance on abortion access. In a recent modeling analysis, Myers found that increasing the distance people must travel for the procedure from zero to 100 miles would keep 20.5 percent of people seeking abortion from accessing a provider. And that would prompt a 2.4 percent overall increase in births.
Any furthering in travel requirements beyond the local region presents a difficult obstacle. “Even an increase in distance to 25 miles can prevent a substantial number of people seeking abortions from reaching providers,” Myers said. Although people of all ages and ethnicities are affected, the resulting increase in births is most weighty for women ages 15 to 24 years and for non-Hispanic Black women.
People seeking abortion are often already in tough circumstances, experiencing disruptive life events such as job loss. The price of travel, child care, lost wages and lodging in addition to the cost of the abortion on average tops $1,000, a daunting sum for many.
Yet most abortions, especially medication abortions, are not specialized care, notes Upadhyay: “This is primary care. People shouldn’t expect to have to travel an hour or more to reach an abortion provider for primary care.”
Texas’ restrictive laws are emboldening other states
Texas is not alone in setting strict limits on abortion access. According to the Guttmacher Institute, a research group that supports abortion rights, 33 states enacted 479 new abortion restrictions during 2011 to 2019 — accounting for almost half of such restrictions put into place in the 49 years since Roe. Forty-three states have gestational limits, banning abortions at a specific point in a pregnancy. Some states, such as California and Washington, set the limit at viability outside the uterus, or roughly 24 weeks. Ohio and Georgia have passed laws similar to Texas’s six-week rule, although a court order has prevented them from taking effect.
Meanwhile, lawmakers across the country have proposed hundreds more restrictive laws since early 2021, shortly after the Supreme Court’s conservative majority grew to six justices. This acceleration in restrictions is taking place alongside a growing number of laws targeting those who perform abortions. These tactics, such as the 2013 Texas law requiring abortion providers to have hospital admitting privileges, have led to double-digit declines in abortion center numbers in the Midwest and South.
Indeed, the trick of Texas S.B. 8 is that it is designed to be enforced by private citizens, rather than state officials — making legal challenges difficult. The law allows any Texas citizen to sue anyone in or out of the state who helps, or intends to help, a person obtain an abortion in Texas after six weeks — to the tune of at least $10,000. One year after Mississippi’s governor signed the law at the center of the Supreme Court case, he approved a stricter six-week-limit law. The Mississippi version does not allow enforcement by private citizens, but it does allow for the medical license of any physician performing an abortion after the six-week mark to be suspended or revoked.
Texans who do make it to a clinic before the cutoff have to pay for their abortion out of pocket, even if they are on Medicare or Medicaid. The Hyde Amendment, tacked onto Medicaid appropriation bills since 1976, bars use of federal funds to pay for this care. Many states have co-opted this tactic, with at least 35 states prohibiting state Medicaid coverage for abortion except to save a pregnant person’s life or in cases of rape or incest. Some, including Texas, even limit abortion coverage by private insurers.
These restrictions inordinately affect people who are already struggling financially. Myers said that one of the many things that troubles her in the Dobbs case is the argument that abortion has “become this obsolete medical service” and that “women now effortlessly balance work and motherhood.” She noted that many states that probably will ban abortion if Roe falls are the same states “where the social net for working mothers is frayed. No expansion of Medicaid, welfare benefits are laughably low.”
Autumn Keiser, spokesperson for Planned Parenthood of Greater Texas, said that the current situation in the state is, “in a word, heartbreaking.” Since S.B. 8 went into effect, the primary safety net for people who are low-income or poor is the nonprofit abortion funds that help people travel out of state for the procedure. Aziz, who made her own journey out of state for an abortion eight years ago, is now a community organizer for one of these groups, the Texas Equal Access Fund. Patients today can turn to Planned Parenthood patient navigators to learn more about these services. But it’s not always an easy solution.
“You’re talking about people who may never have traveled before, never been on an airplane, have small kids at home, and they’ve got to get to California or Colorado,” Keiser said.
And an overturned Roe could immediately trigger similarly severe limitations in states where Texans currently seek abortions, leading to an impassable cul-de-sac of care. Abortion providers in neighboring states already are oversubscribed with clients from Texas, which is expected to worsen with the intensification of the national divide on abortion.
The combined number of abortion facilities in the four states neighboring Texas is less than the 22 facilities Texas still has; there are just two in Arkansas, three in Louisiana, four in Oklahoma and six in New Mexico. In a post-Roe nation, even if these states weren’t poised to enact more restrictive laws against abortion (and most are), they would likely be unable to meet surging demand.
The effect of Texas S.B. 8 hints at this: Wait times for abortion appointments in the four neighboring states have lengthened since the Texas law took effect. They sometimes extend longer than two weeks. Longer wait times can extend pregnancies past the 10-week frame for medication abortion and into the second trimester, a riskier period for abortion.
In a post-Roe nation, many abortion-seekers will have to journey even farther for the procedure as the number of states that offer it shrinks. Right now, a strip of land running north to south, from Montana to west Texas, is the nation’s largest abortion desert. People living in this region must travel more than 200 miles to reach an abortion facility. If Roe is overturned, this swath of abortion desert will stretch eastward to encompass most of the central Southern states, according to an analysis Myers and co-authors published in the health journal Contraception in 2019. Another two north-south corridors of access deserts also are predicted to arise, from Idaho to Arizona and Michigan to Alabama.
Several of these states are among the 19 that prohibit telemedicine for abortion, overriding the FDA’s recent decision to relax requirements for medication abortion, Aiken said. “They either require the person to be in the presence of the dispensing physician or ban mailing the abortion pill, or both,” she added. The FDA’s decision doesn’t automatically supersede state law.
The disparate rules for access to abortion drugs have already created a patchwork of care — one that could get more complex if Roe falls.
“Access to medical abortion and all abortion is a ZIP code lottery,” said Aiken. Things will continue to get worse if the “blatantly unconstitutional” S.B. 8 bill is allowed to stand, she said. “We could see Roe be diminished or overturned, and other states will enact Texas-like legislation.”
Estimates suggest that if the Supreme Court strikes down Roe, states such as Louisiana and the Dakotas with trigger bans poised to take effect would see a steep decline in abortions — more than 40 percent in some areas. In states that don’t have trigger bans but are classified as high-risk for making abortion illegal, the pattern is similar but much more widespread. With a reversal of Roe, rates of abortion in these high-risk areas are predicted to drop by almost 33 percent. Nationally, the rates are predicted to decline by 12.8 percent, representing 93,546 to 143,561 pregnant people not getting abortion care.
Upadhyay, a co-author of the study reporting these findings, noted the research showed negative consequences for people denied abortion, including “economic hardship for years to come” and worse developmental and economic outcomes for children born from these pregnancies. These experiences can be expected to only intensify with increases in denied abortions.
“The overall picture is that abortion access was already bad and whatever the Supreme Court decides is going to make it much worse,” Foster said. “All of the Turnaway findings are relevant here.”
But Upadhyay doesn’t see a total return to a pre-Roe landscape: “Things have changed somewhat with medication abortion, and there will be many more who have safer means to end pregnancies on their own.” The catch, she said, is “that they would still be at great legal risk.”
It’s not all hopeless. Myers said that although abortion providers may face dramatic increases in demand in the immediate aftermath of an overturned Roe, capacity will grow in the long run. Places where abortion remains legal will likely become destinations for people in the Deep South and Midwest who need abortions, and more providers begin offering the procedure, she predicted.
In the meantime, studies in regions of the world where abortion is outlawed or severely restricted suggest that pregnant people will continue to seek abortions, safe or otherwise. If Roe is overturned, “this will become everybody’s issue,” Aiken said. After all, she added, “abortions have been happening in North America since people came to North America.”
An earlier version of this story misspelled Autumn Keiser's name. It also attributed a quote from Abigail Aiken to Ushma Upadhyay. This version has been corrected.