Roe v. Wade and Public Health
June 30, 2022
By Dean Ana V. Diez Roux, MD, PhD, MPH
Although anticipated for weeks, the recent U.S. Supreme Court decision overturning Roe v. Wade came as a shock to many of us because of its many implications for health, for women’s rights, and for other constitutionally protected rights that have served as the foundation for Supreme Court rulings on same-sex relationships, same-sex marriage and access to contraception. It will take many months, even years, to understand the full impact of this ruling. We are only beginning to see all the complexities and consequences including the threat of criminalization of abortion providers and abortion seekers.
Legalization of abortion may not in itself suffice to reduce unsafe abortions in all settings (access to information and health care can also limit access to safe legal abortion), but the presence of abortion bans is linked to greater rates of unsafe abortions and more complications of abortion resulting in higher maternal morbidity and mortality. An illustrative “natural experiment” is Romania: under the communist government of Nicola Ceausescu abortion was made illegal in 1966 and maternal mortality quickly rose to levels much higher than what was observed in other countries of Eastern Europe. When Ceausescu was deposed December 1989, the new Government of Romania abolished the abortion ban, and maternal mortality immediately dropped.
The case of Romania is only one example. The WHO has identified unsafe abortions as a leading cause of maternal deaths and morbidity world-wide and includes comprehensive abortion services in its list of essential health care services. There is also substantial evidence that access to safe abortion is linked to women’s economic opportunities and well being, and women’s status generally, with its many other associated social benefits for children and families.
A recent article in The New York Times on the drug market for abortion drugs in Brazil highlights the perverse dynamics that can emerge when access to abortion is restricted. It is not surprising that in these settings those with money and connections can still secure access to safe abortions by travelling or otherwise securing abortions through their ability to pay. I know this from experience. As a medical student in Argentina in the late 80s my contraception failed and I got pregnant. It was of course unexpected and filled me with mixed emotions, as I am sure it does most women. Because I had connections and the ability to pay, I found an abortion provider recommended by a friend who had herself had an abortion. I knew it was not risk free but the fact that he had “trained in the United States” was some reassurance that he knew what he was doing. I am grateful that, because of my fortunate circumstances, I had the choice. There is no doubt in my mind that my life would have been radically different if I had not had it. Many women in Argentina, and across Latin America where abortion was for the most part severely restricted, were much less fortunate than I was. They were dying from unsafe abortions.
When I lived in Argentina, the progressive abortion laws in the United States were respected and admired. Feminist movements in Argentina have been fighting for many years to make abortion safe and legal. Only recently Argentina became one of the first countries in Latin America to legalize abortion: in December of 2020 the Argentinian congress passed a bill making abortion legal on demand during the first 14 weeks of pregnancy. At the time only three other countries in Latin America had legal access to abortion on request (Cuba since 1965, Guyana since 1995, and Uruguay since 2012). The trend seems to be continuing: in 2021 the Supreme Court of Mexico ruled that abortion is not a crime, although its legalization varies by state (Mexico City has had legal abortion upon request since 2007); in February 2022 the constitutional court in Colombia made abortion legal on demand and without restrictions up to the 24th week of pregnancy. Of course there have also been set backs: in Nicaragua, Daniel Ortega, transformed from revolutionary leader into totalitarian dictator, banned all abortions in 2009.
Laws and rulings protecting the reproductive rights of women are fundamental to gender equity, to women’s rights and to the advancement of women, which in turn have many other social benefits as has been repeatedly documented. But also and perhaps most importantly they are key to equity as they minimize (although may not completely eliminate) the inequities in access to safe abortions by social class and race or ethnicity that inevitably emerge when abortion is banned or severely restricted. As stated by Michele Bachelet, United Nations High Commissioner for Human Rights, in reference to the recent SCOTUS decision, “This decision strips such autonomy from millions of women in the U.S., in particular those with low incomes and those belonging to racial and ethnic minorities, to the detriment of their fundamental rights,” she warned. Notably over the past 25 years more than 50 countries with previously restrictive laws have liberalized their abortion legislation.
The recent SCOTUS decision on Roe v. Wade brought back emotional memories of the abortion that I had many years ago, and I have talked about it to friends and family as I never had before. It has made me reflect on my own history and how places and circumstances affected my life and how things could have been very different. Paradoxically, Argentina now has legal access to abortion on demand, whereas the U.S., a country that I am now a citizen of and have lived in for over 30 years, a country whose approach to abortion used to be an inspiration, now seems to be moving backwards in time, even following the path historically taken by reactionary and authoritarian governments across the world. But the women’s movement that I saw in Argentina and that I see sweeping across Latin America for reproductive and women’s rights gives me hope, even in the midst of the despair that many of us living in the United States now feel.