The US Supreme Court’s June 2022 Dobbs v Jackson Women’s Health Organization decision dismantled the 50-year precedent protecting the right to abortion care, leaving the United States as one of a handful of high-income countries where that right is no longer secure. As the World Health Organization has noted, “Inaccessibility of quality abortion care risks violating a range of human rights of women and girls.”1 Restrictions on abortion care violate rights to “decisional and bodily autonomy in a way that rejects the agency, dignity, and equality of people who can become pregnant.”2 They also undermine rights to health, privacy, and freedom from cruel, inhuman, and degrading treatment.3 Since the Dobbs decision, 24 states have banned or significantly restricted access to abortion care,4 whereas 21 states have enacted further protections for abortion access.5
Protective states have increasingly sought to provide substantial funding to expand access to abortion services. They also aim to offer protections for health workers who provide abortions, including to residents of other states. But the legal landscape is complex, which engenders fear in providers and people who might want to access services. Traveling to a state where abortion is legally protected is a privilege that many cannot afford.
Although there are currently no federal restrictions, a new presidential administration will be able to further restrict access to abortion care even if Congress does not enact any nationwide restrictions. The articles in this issue of AJPH present recent evidence from across the United States on the impact of the Dobbs decision over the past two years. The articles review the litigation, legislative, and policy quagmire that Dobbs has spawned as well as the turmoil it has caused for those seeking or providing care. They also present local and global examples of how to build a movement to regain abortion care rights and reproductive justice.
Even before the Dobbs ruling, the confusion caused by state-level decisions and challenges to these decisions had a chilling effect on abortion care access. This was most evident in Texas, where various waves of executive orders and abortion restrictions have curtailed abortion care. As Whitfield et al. (p. 1013) note, Governor Greg Abbott’s 2020 executive order prohibiting abortion care under the premise that it is a nonessential procedure that would divert protective personal equipment from other medical procedures reduced access to timely abortion care. By 2021, the executive order was replaced by a more restrictive policy—Senate Bill 8 (SB8)—which banned abortion care for pregnancies in which a fetal heartbeat had been detected. SB8 threatened anyone with a civil lawsuit if they provided an abortion or aided someone seeking an abortion. Following the Dobbs decision, all facility-based abortion care providers in Texas were shut down, effectively prohibiting abortion care in the state.
An insightful geospatial analysis by Sauter et al. (p. 1024) reveals that after the passage of SB8 and the Dobbs decision, the distance to the nearest abortion care provider significantly increased for some Texas residents, particularly those living in neighborhoods with concentrated disadvantage and severe income inequality. New Mexico is one state that experienced a surge in people traveling from other states for abortion care. McQuade et al. (p. 1008) provide a powerful picture of the lived realities of people who went to New Mexico for abortion care between 2020 and 2023. The authors present journal entries that capture the complex emotions and medical dilemmas that surrounded the decision to seek abortion care. For those coming from Texas, the desire for autonomy and to overcome the political barriers that restricted abortion care access were powerful themes.
In Ohio, one of several states where referenda have succeeded in rolling back post-Dobbs restrictions, a state ban on abortion care was overturned by a ballot initiative. Smith et al. (p. 1034) examined unique data from monthly abortion care provider surveys. They sought to ascertain changes in the number of abortions provided, determine which states patients seeking abortion care were traveling from, and gather qualitative information on the clinical and socioeconomic burdens placed on out-of-state patients seeking abortion care in Ohio.
A natural next question is what happens to women, children, and families in states that have enacted strict abortion care regulations since the Dobbs decision. Not surprisingly, the cumulative burden of abortion bans and restrictions as well as curtailed access to timely and appropriate medical care are heaviest on women who are the most socially, economically, and geographically vulnerable. In their analytic essay, Madden et al. (p. 1043) report that states with the most stringent post-Dobbs abortion care restrictions are home to, on average, a greater proportion of persons of reproductive age who identify as non-Hispanic Black and are of low socioeconomic status. These states are more likely to have rejected Medicaid expansion and have less supportive medical and social safety net services for children and families.
Nationwide, determining Dobbs’s full impact is difficult because of the increasingly complex and uncertain legal and political landscape. As Ziegler (p. 997) cogently explains, after the Dobbs decision, litigation on abortion care has “multiplied” in both state and federal courts, deepening the uncertainty of patients and providers alike. Some of this litigation features relatively novel challenges to state abortion care bans; other cases threaten to further limit abortion care access at either the state or federal level.
Two recent Supreme Court decisions in cases that Ziegler anticipated highlight the uncertainty. In Food and Drug Administration v Alliance for Hippocratic Medicine (June 13, 2024), the Supreme Court, as Ziegler predicted, ruled that the plaintiffs lacked standing to challenge the US Food and Drug Administration’s decision to expand access to mifepristone. Because that decision rests on standing, it leaves the door open to other challenges to mifepristone. These appear even more viable following the court’s June 2024 decision in Loper Bright Enterprises v Raimondo to override the 40-year-old Chevron deference, which required lower courts to defer to regulatory agencies when they offered plausible interpretations of their statutory authority.
The Supreme Court also punted on a set of cases that Ziegler discusses concerning whether Idaho’s abortion care ban conflicts with federal protections for patients in emergency departments. The court’s decision to return those cases to lower courts without review means that litigation and uncertainty will persist. In the meantime, the rights and health of pregnant persons will continue to be contested politically and legally across the country.
Although more than 60 countries have moved to broaden access in the past 50 years, the United States is one of four countries—along with El Salvador, Nicaragua, and Poland—where legal protection of abortion rights has been reversed (https://bit.ly/4bLKa3O). However, strategies from activists across several Latin American countries may serve as a blueprint for fostering a national movement in support of reproductive justice. Roth and Jones (p. 1003) argue that a successful public health movement in the United States ought to draw inspiration and lessons learned from the Marea Verde (the Green Wave), which spread across Latin America and successfully overturned restrictive abortion care bans. Their argument calls for forging a movement that (1) prioritizes access to abortion care as central to any future legalization efforts; (2) advocates legal reform at both state and federal levels and in multiple legal contexts (e.g., legislative, judicial); and (3) supports grassroots organizations, including those that provide funds to guarantee safe, legal, and accessible abortion care. To this end, Rice et al. (p. 1000) provide examples of how local policymaking along with the establishment of a network of community-based clinics and direct-aid organizations has played a vital role in sustaining access to abortion care across the Southern US, including Texas. Their examples provide a powerful reminder that even in the face of continued attacks, the actions of committed public health advocates can help to grow a movement for reproductive justice.
As this period of uncertainty continues, people face significant barriers to reproductive health services, with the most vulnerable communities oftentimes the most affected. Now more than ever, public health researchers must study and report on the impact of these barriers and the complex policy landscape, and the public health community must champion the rights, dignity, and health of individuals who are, may become, or want to become pregnant.
See also Abortion Access 2 Years After Dobbs v Jackson Ruling, pp.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to disclose.
