case study against abortion

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Roe v. Wade and Supreme Court Abortion Cases

Reproductive rights in the United States, explained.

Is abortion a constitutional right?

Roe v. wade, what was the impact of the roe v. wade decision.

• The law after  Roe v. Wade

Supreme Court justices’ abortion views

Not under the U.S. Constitution, according to the current Supreme Court. In  Dobbs v. Jackson Women’s Health Organization  (2022), the Supreme Court overturned  Roe v. Wade  (1973), which guaranteed a constitutional right to abortion. Some state constitutions, however, independently protect abortion rights.

In  Roe v. Wade , the Supreme Court decided that the right to privacy implied in the 14th Amendment protected abortion as a fundamental right. However, the government retained the power to regulate or restrict abortion access depending on the stage of pregnancy. And after fetal viability, outright bans on abortion were permitted if they contained exceptions to preserve life and health. 

For the following 49 years, states, health care providers, and citizens fought over what limits the government could place on abortion access, particularly during the second and third trimesters. But abortion was fundamentally legal in all 50 states during that period.

Writing for the majority in  Dobbs , Justice Samuel Alito said that the only legitimate unenumerated rights — that is, rights not explicitly stated in the Constitution — are those “deeply rooted in the Nation’s history and tradition” and “implicit in the concept of ordered liberty.” Abortion, the majority held, is not such a right. 

Following  Dobbs , reproductive rights are being decided state by state.  Constitutions in 10 states  — Alaska, Arizona, California, Florida, Kansas, Massachusetts, Minnesota, Montana, New Jersey, and New Mexico — have been interpreted by state high courts to guarantee the right to abortion or protect access more strongly than the federal constitution. Other state legislatures have passed laws protecting abortion rights. Many states, however, have  made abortion illegal .

The road to  Roe

Abortion was illegal in most states in the 1960s, often with no exceptions for cases of rape or threat to life. A pair of high-profile crises, however, shined a spotlight on the impact of these restrictions.

Beginning in the late 1950s, thousands of babies were born with severe birth defects after their mothers took the morning sickness drug thalidomide while pregnant. The most well-known case was that of Sherri Finkbine, a host of the children’s television program  Romper Room , who was forced to travel to Sweden to obtain an abortion. A Gallup poll showed, perhaps surprisingly given the legal backdrop, that a majority of Americans  supported  Finkbine’s decision.

Shortly after the thalidomide scandal, an epidemic of rubella, or German measles, swept across the country. Babies that survived rubella in utero were often born with a  wide range of disabilities  such as deafness, heart defects, and liver damage. (A  rubella vaccine  didn’t become available until 1971.)

It was in this environment of maternal risk that high-profile doctors like  Alan Guttmacher  began to argue publicly that abortion should be treated like other medical procedures — as a decision to be made between physician and patient.

Griswold v. Connecticut  (1965)

While thalidomide and rubella impacted public perspectives on abortion, a series of cases built the foundation for the coming revolution in abortion law. The first involved the right to contraception, and the story begins in the 19th century.

In 1879, Connecticut senator P.T. Barnum (yes,  that  P.T. Barnum)  introduced a bill  barring not only contraceptives but also the distribution of information relating to them. The Barnum Act was still on the books in Connecticut in 1960, when the Food and Drug Administration approved the first oral contraceptive. Estelle Griswold, executive director of the Planned Parenthood League of Connecticut, was fined $100 for violating the law. Her appeal went all the way to the Supreme Court.

In  Griswold v. Connecticut , a seven-justice majority struck down the Barnum Act. Justice William O. Douglas explained that the Bill of Rights implies a right to privacy because when viewed as a coherent whole, it focuses on limiting government intrusions. The  Griswold  majority held that the government cannot prevent married couples from accessing contraception. (At the time, the justices did not extend the right to unmarried people.)  Griswold ’s contention that the Constitution creates a zone of privacy into which the government cannot enter paved the way for  Roe , among other landmark decisions.

Eisenstadt v. Baird  (1972)

The road from  Griswold  to  Roe  was not perfectly straight. Two years after  Griswold , reproductive rights activist  William Baird  offered contraceptives to an unmarried woman after a lecture on contraception to students at Boston University. He was sentenced to three months in prison.

Like Estelle Griswold, Baird appealed his conviction to the Supreme Court. In  Eisenstadt v. Baird , the Justices extended  Griswold . Justice William Brennan, writing for the six-justice majority, explained that the 14th Amendment guarantees equal protection under the law. There was no reason to treat married and unmarried people differently with regard to contraception.

United States v. Vuitch  (1971) 

Over the course of nine years, Washington, DC,–based physician Milan Vuitch was  arrested 16 times  for performing abortions, which had been illegal in the district since 1901 except “as necessary for the preservation of the mother’s life or health.”

Vuitch appealed his eventual conviction, arguing in part that the exception for “health” was unconstitutionally vague. The Supreme Court disagreed in  United States v. Vuitch . Taking a broad view of the word “health,” the justices ruled that abortion was legal in the district whenever necessary to protect mental or physical health.

The significance of  Vuitch , however, was to be short-lived.  Roe v. Wade  was already wending its way through the courts by the time of the decision. The day after they decided  Vuitch , the justices voted to hear  Roe . 

The parties to  Roe

Texan Norma McCorvey became pregnant for the third time in 1969. Struggling with drug and alcohol use, she previously relinquished responsibility for her first two children. She decided that she did not want to continue the pregnancy. 

Texas law, however, allowed abortion only to save the patient’s life. With McCorvey six months pregnant, Texas lawyers Linda Coffee and Sarah Weddington filed a suit on her behalf in federal court under the pseudonym Jane Roe.

Henry Wade was a legendary and  controversial  district attorney with an impressive conviction rate, most famous for prosecuting  Jack Ruby , who killed JFK’s assassin, Lee Harvey Oswald. Wade was, however, an odd foil for pro-choice activists. He did not aggressively prosecute illegal abortions and said little about them.

The lower court

A three-judge panel of the U.S. District Court for the Northern District of Texas  struck down  Texas’s abortion ban, finding it overbroad and locating the right to reproductive choice in the 9th and 14th Amendments. Citing  Griswold , the court noted that the Constitution guarantees “the right of choice over events which, by their character and consequences, bear in a fundamental manner on the privacy of individuals.” While the federal court declared the Texas law unconstitutional, it declined to immediately block its enforcement, putting  Roe v. Wade  on a fast track to the Supreme Court.

Norma McCorvey gave birth to a girl, Shelley Lynn, on June 2, 1970, fifteen days before the federal district court issued its ruling. The baby was adopted when she was three days old. Her identity was not known to the public until 2021. 

The  Roe v. Wade  oral argument

Sarah Weddington, who was just 26 years old when she stood before the justices of the Supreme Court on December 13, 1971, built her case for the constitutional right to abortion around the 9th and 14th Amendments, arguing that “meaningful” liberty must include the right to terminate an unwanted pregnancy.

Although the justices were largely receptive to Weddington’s points, Justice Byron White demanded to know whether the right to abortion extended right up to the moment of birth. After some hesitation, Weddington answered yes. Legal personhood began at birth, Weddington claimed. Until that moment, there should be an unfettered constitutional right to abortion.

After Weddington sat down, Texas Assistant Attorney General Jay Floyd stood to defend the state law. He began, inexplicably, with a sexist joke: “It’s an old joke, but when a man argues against two beautiful ladies like this, they are going to have the last word.” The bafflingly inappropriate comment was followed by three seconds of dead silence.

There was, however, one moment of wit in the argument. When Floyd argued that a woman who becomes pregnant has already made her choice, Justice Potter Stewart shot back, “Maybe she makes a choice when she decides to live in Texas!” The retort brought roars of laughter from the gallery.

Of particular note is how little the oral argument focused on the history of abortion laws during the founding or the post–Civil War era when the 14th Amendment was ratified. The justices focused instead on the biological realities of abortion and the text of the Constitution itself.

Also interesting: Justice Harry Blackmun, who would write the majority opinion in  Roe v. Wade , spoke only twice during the oral argument. By contrast, Justice Thurgood Marshall spoke more than 10 times, Justices White and William Brennan more than 20 times, and Justice Stewart more than 30. (Perhaps this was because Blackmun was initially inclined to  write a much more restrained opinion  than he ultimately did.)

The  Roe v. Wade  opinion

The Supreme Court handed down its decision on January 22, 1973. Seven of the nine justices agreed that the Due Process Clause of the 14th Amendment — which says that no state shall “deprive any person of life, liberty, or property, without due process of law” — implies a right to privacy. The majority seized upon Weddington’s definition of liberty, citing a series of prior cases indicating that the term “liberty” must be interpreted broadly in a free society.

The justices did, however, recognize that the state could place some limits on abortion if necessary to further a compelling state interest. The state’s ability to regulate increased as a pregnancy progressed. And after a fetus reached viability, the state could prohibit abortion, except when necessary to protect health or life.

Justices William Rehnquist and White dissented. Rehnquist argued that privacy, in the constitutional sense of illegal search and seizure, has nothing to do with abortion. In his view, since abortion bans implicate no fundamental rights, they must only have some rational basis, such as protecting a fetus. Foreshadowing the  Dobbs  decision in 2022, Rehnquist also declared that the only recognizable rights not explicitly listed in the Constitution are those with deep roots in the American legal tradition.

Doe v. Bolton  (1973)

On the same day the Supreme Court decided  Roe , it decided  Doe v. Bolton , which challenged Georgia’s abortion ban. The Georgia law limited abortion to cases of documented rape, a severely disabled fetus, or a threat to life. Before the procedure, it was necessary to obtain the approval of a doctor, two additional consulting physicians, and a hospital committee. The law also permitted relatives to challenge the abortion decision. It was, in short, a burdensome process.

In another 7–2 vote, with Blackmun again writing for the majority, the Court ruled that although the rights identified in  Roe  are not absolute, Georgia’s restrictions violated the constitutional right to abortion. He noted that the law established hurdles that were far higher than those that had to be overcome for other surgical procedures.

White and Rehnquist again dissented.

Roe  significantly reduced maternal mortality. A total of 39 women are known to have  died from unsafe abortions  in 1972, and this was almost certainly a drastic undercount. In 1975, there were only three such deaths. In 1965, eight years before  Roe  was decided, illegal abortion  caused 17 percent of pregnancy-related deaths . In modern times, just 0.2 percent of people who undergo abortions even require hospitalization for complications.

It’s not entirely clear what effect  Roe  had on public attitudes toward abortion because public opinion was already in flux before the case was decided. In 1965, just  5 percent  of Americans thought abortion should be legal for married people who simply didn’t want any more children. That number had risen to 36 percent by 1972, the year before  Roe  was decided. After  Roe  came down, pollsters began asking about abortion “for any reason,” and the polls show  relative stability  in the responses to that question since the mid-1970s.

The law after Roe v. Wade

Lingering resistance to abortion, particularly strong in certain parts of the country, led legislatures to test the decision’s boundaries. The Supreme Court issued many major abortion rulings up to the overturning of  Roe v. Wade  in the 2022 case  Dobbs v. Jackson Women’s Health Organization .

• In  Planned Parenthood v. Danforth   (1976), the justices blocked a law requiring spousal consent for abortion.
• Maher v. Roe   (1979) permitted states to exclude abortion services from Medicaid coverage.
• Colautti v. Franklin   (1979) struck down an unconstitutionally vague Pennsylvania law that required physicians to try to save the life of a fetus that might have been viable.
• In  Harris v. McRae   (1980), the Court upheld the  Hyde Amendment , a federal law that proscribed federal funding for abortions except when necessary to preserve life or as a result of rape or incest.
• In  L. v. Matheson   (1981), the Court upheld a law requiring parental notification when the patient is a minor living with parents.
• In  City of Akron v. Akron Center for Reproductive Health   (1983), the justices invalidated a wide range of limitations on abortion, such as a waiting period, parental consent without judicial bypass, and a ban on abortions outside of hospitals after the first trimester.
• Thornburgh v. American College of Obstetricians and Gynecologists   (1986) struck down a law that required informed consent to include information about fetal development and alternatives to abortion.
• In  Webster v. Reproductive Health Services   (1989), Justice Rehnquist upheld rules requiring doctors to test for viability after 20 weeks and blocking state funding and state employee participation in abortion services.
• Rust v. Sullivan   (1991) upheld a ban on certain federal funds being used for abortion referrals or counseling.
• Hill v. Colorado   (2000) upheld a law limiting protest and leafletting close to an abortion clinic.
• Stenberg v. Carhart   (2000) struck down Nebraska’s ban on the  dilation and extraction  abortion procedure.
• In  Gonzales v. Carhart   (2007), a slightly changed Court upheld a federal ban on the dilation and extraction procedure.

Planned Parenthood of Southeastern Pennsylvania v. Casey  (1992)

One case in the period between  Roe  and  Dobbs  deserves special attention. Through the 1980s, abortion opponents demanded the appointment of Supreme Court justices who would overturn  Roe . With the confirmation of Justices Anthony Kennedy, Sandra Day O’Connor, and David Souter, anti-abortion activists were confident they had the votes.

In 1988 and 1989, the Pennsylvania legislature adopted new abortion restrictions, including parental consent requirements, spousal notification, a waiting period, and an expanded informed consent process. Planned Parenthood of Southeastern Pennsylvania challenged the law, and many viewed the case as  Roe ’s last stand — an opportunity for the Court to do away with the constitutional right to abortion.

In  Planned Parenthood of Southeastern Pennsylvania v. Casey , however, the new members of the Court disappointed anti-abortion advocates. While the Court replaced  Roe ’s trimester-by-trimester doctrine with a weaker level of protection and upheld elements of the Pennsylvania law that did not unduly burden the right to abortion, the justices declined to overrule  Roe . A plurality opinion authored by O’Connor, Kennedy, and Souter explained that, while Supreme Court precedents are not eternal, there must be a compelling reason to abandon  stare decisis  — the notion that precedents should be upheld. The Court decided there was no adequate justification for overturning  Roe , especially since Americans had arranged their lives around an expectation of control over their reproductive health, including having access to abortion.  Casey  also acknowledged the strong equality concerns that justify abortion rights, arguing that women cannot participate fully in the social and economic life of the nation if they are forced to continue unwanted pregnancies. 

Dobbs v. Jackson Women’s Health Organization  (2022)

In 2018, the Mississippi legislature  banned abortions  after 15 weeks of gestation, except in cases of narrowly defined medical emergency or severe fetal abnormality. The law was a challenge to both  Roe  and  Casey . Jackson Woman’s Health Organization, the sole abortion provider in the state, contested the ban.

Long before  Dobbs  was decided, signs pointed to the Supreme Court’s intention to rescind the constitutional right to abortion. First, in a separate case that first appeared on the Court’s  shadow docket , the justices  allowed a Texas abortion ban  that contravened  Roe  and  Casey  to remain in force. Then, in the weeks before  Dobbs  came down, a draft decision overturning  Roe  and  Casey  leaked out of the Court in an unprecedented breach of Court protocol. 

The final  decision  was little changed from the leaked draft. Writing for the five-justice majority (with Chief Justice Roberts concurring only in the judgment), Justice Samuel Alito argued that the right to privacy is not specifically guaranteed anywhere in the Constitution. When unenumerated liberty rights exist — the right to raise your child as you see fit, for example — those rights must be “deeply rooted in the Nation’s history and tradition.” Reviewing the history of abortion restrictions in the early United States, Alito concluded that the right to abortion is not.

The opinion ignited a firestorm of controversy. Predictably so:  Dobbs  is arguably the first case to formally rescind a fundamental constitutional right. The opinion also  failed to explain  how its logic would not also result in the overturning of  Griswold ’s right to contraception or a series of other cases that rely on the same logic as  Roe . These include  Lawrence v. Texas  (2003), which invalidated laws criminalizing same-sex intimate sexual conduct, and  Obergefell v. Hodges  (2015), which recognized the right to marriage for same-sex couples. 

Also, for many Americans, Alito’s insistence that rights be “deeply rooted” in U.S. history revealed a broad discounting of historically marginalized communities, including women, people of color, and gay Americans. The only rights “deeply rooted” in our history are the ones that served the white, heterosexual men who dominated government at the time of the founding. While  Casey  had begun to address the equality dimensions of abortion rights,  Dobbs  moved in precisely the opposite direction, suggesting that non-majority groups must overcome special hurdles to have their rights recognized.

Abortion rights will now be defined on a state-by-state basis. Several state courts have ruled that their constitutions  guarantee the right to abortion , whether because of explicit references to “privacy” or by relying on language that broadly protects personal autonomy. The  Kansas Supreme Court , for example, has ruled that the constitution’s guarantee of “equal and inalienable natural rights” protects personal decision-making, self-determination, and bodily integrity. Other states have adopted an approach consistent with  Roe , in which the right to privacy, including reproductive freedom, has been recognized as implied in the state constitution.

Following the  Dobbs  case, anti-abortion activists have proposed state constitutional amendments stating that nothing in the constitution protects abortion rights. In some cases, these measures seek to overrule their state courts’ interpretations of the constitution. In others, there has been no court decision regarding the constitutional right to abortion. Other states have, in contrast, moved to expand or cement abortion rights, including through constitutional amendments.

Dobbs  also leaves a long list of unanswered practical questions. Can states ban women from traveling to obtain an abortion? How will they police the importation and use of abortion drugs? How will state courts handle the slew of “trigger laws” — state anti-abortion statutes designed to come into effect upon the overturning of  Roe ? Just as  Roe  set off years of legal uncertainty over the precise boundaries of abortion rights,  Dobbs  has launched a long period of uncertainty over states’ power to restrict abortion in the absence of those rights.

The current Court

• Chief Justice John   Roberts , during his time as a lawyer for the George W. Bush administration, wrote that  Roe  has “ no support  in the text, structure, or history of the Constitution.” In his  Dobbs  concurrence, however, Roberts favored preserving a more limited constitutional right to abortion, without specifying how far it would extend. “Surely we should adhere closely to principles of judicial restraint here, where the broader path the Court chooses entails repudiating a constitutional right we have not only previously recognized, but also expressly reaffirmed applying the doctrine of  stare decisis .”
• Justice Clarence Thomas , who was in the  Dobbs  majority, has written that  Roe  was “grievously wrong for many reasons, but the most fundamental is that its core holding — that the Constitution protects a woman’s right to abort her unborn child —  finds no support  in the text of the Fourteenth Amendment.”
• Justice Samuel Alito  complained as a young lawyer in the Reagan administration about “the courts’ refusal to  allow breathing room  for reasonable state regulation” of abortion. In a job application, he wrote, “I personally believe very strongly that the Constitution  does not protect  a right to an abortion.” As the authority of the majority opinion in  Dobbs , he wrote that “ Roe  was . . . egregiously wrong and on a collision course with the Constitution from the day it was decided.”
• Justice Neil Gorsuch , who was in the  Dobbs  majority, has said and written less on abortion than many other justices, but during his confirmation hearing, he noted that  Roe  was “a precedent of the U.S. Supreme Court” and added, “once a case is settled, that  adds to the determinacy  of the law.”
• Justice Amy Coney Barrett  added her name to a 2006 ad  calling for  Roe  to be overturned  and suggested that the possibility of adoption might  obviate the need for abortion rights .
• Justice Brett Kavanaugh , in 2017, proclaimed his admiration of former justice Rehnquist’s  Roe  dissent, noting that his views about unenumerated rights were “successful in  stemming the general tide  of freewheeling judicial creation of unenumerated rights that were not rooted in the nation’s history and tradition.”
• Justice Ketanji Brown Jackson  repeatedly described  Roe  as “settled law” in her confirmation hearings. In the same hearings, when asked when human life begins, she replied simply, “ I don’t know .”
• Justice Sonia Sotomayor  has focused much of her writing about abortion on the cost that bans impose on those who are economically disadvantaged. Objecting to the Court’s decision to allow a Texas abortion ban to stand, Sotomayor wrote, “Those without the ability to make this journey [to a state allowing abortion], whether due to lack of money or childcare or employment flexibility or the myriad other constraints that shape people’s day-to-day lives, may be forced to carry to term against their wishes or  resort to dangerous methods of self-help .” The  Dobbs  dissent, authored by Justice Breyer and joined by Justices Sotomayor and Kagan, continued that theme of disempowerment, lamenting the end of an era in which “respecting a woman as an autonomous being, and granting her full equality, meant giving her substantial choice over this most personal and most consequential of all life decisions.”
• Justice Elena Kagan  has a significant and slightly complicated record on abortion. As a lawyer in the Clinton administration, she wrote a  memo recommending  that the president sign a ban on “partial birth abortion” if it contained an exception in cases of serious risk to health. As a justice, however, Kagan has voted consistently against restrictions on abortion. She called a recent Texas abortion ban “patently unconstitutional” and dissented forcefully in  Dobbs . 

Notable past justices

• Justice Stephen Breyer : “Millions of Americans  believe that life begins at conception  and consequently that an abortion is akin to causing the death of an innocent child . . . Other millions fear that a law that forbids abortion would condemn many American women to lives that lack dignity, depriving them of equal liberty and leading those with least resources to undergo illegal abortions with the attendant risks of death and suffering.”
• Chief Justice Warren Burger : “The Constitution  does not compel a state to fine-tune its statutes  so as to encourage or facilitate abortions. To the contrary, state action ‘encouraging childbirth except in the most urgent circumstances’ is ‘rationally related to the legitimate governmental objective of protecting potential life.’”
• Justice Ruth Bader Ginsburg : “ Roe v. Wade  sparked public opposition and academic criticism, in part, I believe, because the Court  ventured too far in the change it ordered  and presented an incomplete justification for its action.”
• Justice Sandra Day O’Connor : “The  Roe  framework . . . is  clearly on a collision course  with itself.”
• Chief Justice William Rehnquist : “We do not see why the state’s interest in protecting human life should  come into existence only at the point of viability .”
• Justice Antonin Scalia : “We should get out of this area [abortion law], where we have no right to be, and where we  do neither ourselves nor the country  any good by remaining.”
• Justice Byron White : “The Court apparently  values the convenience of the pregnant mother  more than the continued existence of the life or potential life that she carries.”
• Justice William J. Brennan Jr. : “If the right to privacy means anything, it is the right of the individual, married or single, to be  free from unwanted government intrusion  into matters so fundamentally affecting a person as the decision to bear or beget a child.”
• Justice Anthony Kennedy : “Where it has a rational basis to act, and it does not impose an undue burden, the State may  use its regulatory power  to bar certain procedures and substitute others, all in furtherance of its legitimate interests in regulating the medical profession in order to promote respect for life, including life of the unborn.”
• Justice David Souter : “I have not got any agenda on  what should be done with  Roe v. Wade , if that case is brought before me.”

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The Most Important Study in the Abortion Debate

Researchers rigorously tested the persistent notion that abortion wounds the women who seek it.

The demographer Diana Greene Foster was in Orlando last month, preparing for the end of Roe v. Wade , when Politico published a leaked draft of a majority Supreme Court opinion striking down the landmark ruling. The opinion, written by Justice Samuel Alito, would revoke the constitutional right to abortion and thus give states the ability to ban the medical procedure.

Foster, the director of the Bixby Population Sciences Research Unit at UC San Francisco, was at a meeting of abortion providers, seeking their help recruiting people for a new study . And she was racing against time. She wanted to look, she told me, “at the last person served in, say, Nebraska, compared to the first person turned away in Nebraska.” Nearly two dozen red and purple states are expected to enact stringent limits or even bans on abortion as soon as the Supreme Court strikes down Roe v. Wade , as it is poised to do. Foster intends to study women with unwanted pregnancies just before and just after the right to an abortion vanishes.

Read: When a right becomes a privilege

When Alito’s draft surfaced, Foster told me, “I was struck by how little it considered the people who would be affected. The experience of someone who’s pregnant when they do not want to be and what happens to their life is absolutely not considered in that document.” Foster’s earlier work provides detailed insight into what does happen. The landmark Turnaway Study , which she led, is a crystal ball into our post- Roe future and, I would argue, the single most important piece of academic research in American life at this moment.

The legal and political debate about abortion in recent decades has tended to focus more on the rights and experience of embryos and fetuses than the people who gestate them. And some commentators—including ones seated on the Supreme Court—have speculated that termination is not just a cruel convenience, but one that harms women too . Foster and her colleagues rigorously tested that notion. Their research demonstrates that, in general, abortion does not wound women physically, psychologically, or financially. Carrying an unwanted pregnancy to term does.

In a 2007 decision , Gonzales v. Carhart , the Supreme Court upheld a ban on one specific, uncommon abortion procedure. In his majority opinion , Justice Anthony Kennedy ventured a guess about abortion’s effect on women’s lives: “While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort the infant life they once created and sustained,” he wrote. “Severe depression and loss of esteem can follow.”

Was that really true? Activists insisted so, but social scientists were not sure . Indeed, they were not sure about a lot of things when it came to the effect of the termination of a pregnancy on a person’s life. Many papers compared individuals who had an abortion with people who carried a pregnancy to term. The problem is that those are two different groups of people; to state the obvious, most people seeking an abortion are experiencing an unplanned pregnancy, while a majority of people carrying to term intended to get pregnant.

Foster and her co-authors figured out a way to isolate the impact of abortion itself. Nearly all states bar the procedure after a certain gestational age or after the point that a fetus is considered viable outside the womb . The researchers could compare people who were “turned away” by a provider because they were too far along with people who had an abortion at the same clinics. (They did not include people who ended a pregnancy for medical reasons.) The women who got an abortion would be similar, in terms of demographics and socioeconomics, to those who were turned away; what would separate the two groups was only that some women got to the clinic on time, and some didn’t.

In time, 30 abortion providers—ones that had the latest gestational limit of any clinic within 150 miles, meaning that a person could not easily access an abortion if they were turned away—agreed to work with the researchers. They recruited nearly 1,000 women to be interviewed every six months for five years. The findings were voluminous, resulting in 50 publications and counting. They were also clear. Kennedy’s speculation was wrong: Women, as a general point, do not regret having an abortion at all.

Researchers found, among other things, that women who were denied abortions were more likely to end up living in poverty. They had worse credit scores and, even years later, were more likely to not have enough money for the basics, such as food and gas. They were more likely to be unemployed. They were more likely to go through bankruptcy or eviction. “The two groups were economically the same when they sought an abortion,” Foster told me. “One became poorer.”

Read: The calamity of unwanted motherhood

In addition, those denied a termination were more likely to be with a partner who abused them. They were more likely to end up as a single parent. They had more trouble bonding with their infants, were less likely to agree with the statement “I feel happy when my child laughs or smiles,” and were more likely to say they “feel trapped as a mother.” They experienced more anxiety and had lower self-esteem, though those effects faded in time. They were half as likely to be in a “very good” romantic relationship at two years. They were less likely to have “aspirational” life plans.

Their bodies were different too. The ones denied an abortion were in worse health, experiencing more hypertension and chronic pain. None of the women who had an abortion died from it. This is unsurprising; other research shows that the procedure has extremely low complication rates , as well as no known negative health or fertility effects . Yet in the Turnaway sample, pregnancy ended up killing two of the women who wanted a termination and did not get one.

The Turnaway Study also showed that abortion is a choice that women often make in order to take care of their family. Most of the women seeking an abortion were already mothers. In the years after they terminated a pregnancy, their kids were better off; they were more likely to hit their developmental milestones and less likely to live in poverty. Moreover, many women who had an abortion went on to have more children. Those pregnancies were much more likely to be planned, and those kids had better outcomes too.

The interviews made clear that women, far from taking a casual view of abortion, took the decision seriously. Most reported using contraception when they got pregnant, and most of the people who sought an abortion after their state’s limit simply did not realize they were pregnant until it was too late. (Many women have irregular periods, do not experience morning sickness, and do not feel fetal movement until late in the second trimester.) The women gave nuanced, compelling reasons for wanting to end their pregnancies.

Afterward, nearly all said that termination had been the right decision. At five years, only 14 percent felt any sadness about having an abortion; two in three ended up having no or very few emotions about it at all. “Relief” was the most common feeling, and an abiding one.

From the May 2022 issue: The future of abortion in a post- Roe America

The policy impact of the Turnaway research has been significant, even though it was published during a period when states have been restricting abortion access. In 2018, the Iowa Supreme Court struck down a law requiring a 72-hour waiting period between when a person seeks and has an abortion, noting that “the vast majority of abortion patients do not regret the procedure, even years later, and instead feel relief and acceptance”—a Turnaway finding. That same finding was cited by members of Chile’s constitutional court  as they allowed for the decriminalization of abortion in certain circumstances.

Yet the research has not swayed many people who advocate for abortion bans, believing that life begins at conception and that the law must prioritize the needs of the fetus. Other activists have argued that Turnaway is methodologically flawed; some women approached in the clinic waiting room declined to participate, and not all participating women completed all interviews . “The women who anticipate and experience the most negative reactions to abortion are the least likely to want to participate in interviews,” the activist David Reardon argued in a 2018 article in a Catholic Medical Association journal.

Still, four dozen papers analyzing the Turnaway Study’s findings have been published in peer-reviewed journals; the research is “the gold standard,” Emily M. Johnston, an Urban Institute health-policy expert who wasn’t involved with the project, told me. In the trajectories of women who received an abortion and those who were denied one, “we can understand the impact of abortion on women’s lives,” Foster told me. “They don’t have to represent all women seeking abortion for the findings to be valid.” And her work has been buttressed by other surveys, showing that women fear the repercussions of unplanned pregnancies for good reason and do not tend to regret having a termination. “Among the women we spoke with, they did not regret either choice,” whether that was having an abortion or carrying to term, Johnston told me. “These women were thinking about their desires for themselves, but also were thinking very thoughtfully about what kind of life they could provide for a child.”

The Turnaway study , for Foster, underscored that nobody needs the government to decide whether they need an abortion. If and when America’s highest court overturns Roe , though, an estimated 34 million women of reproductive age will lose some or all access to the procedure in the state where they live. Some people will travel to an out-of-state clinic to terminate a pregnancy; some will get pills by mail to manage their abortions at home; some will “try and do things that are less safe,” as Foster put it. Many will carry to term: The Guttmacher Institute has estimated that there will be roughly 100,000 fewer legal abortions per year post- Roe . “The question now is who is able to circumvent the law, what that costs, and who suffers from these bans,” Foster told me. “The burden of this will be disproportionately put on people who are least able to support a pregnancy and to support a child.”

Ellen Gruber Garvey: I helped women get abortions in pre- Roe America

Foster said that there is a lot we still do not know about how the end of Roe might alter the course of people’s lives—the topic of her new research. “In the Turnaway Study, people were too late to get an abortion, but they didn’t have to feel like the police were going to knock on their door,” she told me. “Now, if you’re able to find an abortion somewhere and you have a complication, do you get health care? Do you seek health care out if you’re having a miscarriage, or are you too scared? If you’re going to travel across state lines, can you tell your mother or your boss what you’re doing?”

In addition, she said that she was uncertain about the role that abortion funds —local, on-the-ground organizations that help people find, travel to, and pay for terminations—might play. “We really don’t know who is calling these hotlines,” she said. “When people call, what support do they need? What is enough, and who falls through the cracks?” She added that many people are unaware that such services exist, and might have trouble accessing them.

People are resourceful when seeking a termination and resilient when denied an abortion, Foster told me. But looking into the post- Roe future, she predicted, “There’s going to be some widespread and scary consequences just from the fact that we’ve made this common health-care practice against the law.” Foster, to her dismay, is about to have a lot more research to do.

• Case report
• Open access
• Published: 14 June 2019

“Regardless, you are not the first woman”: an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua

• Samantha M. Luffy 1 ,
• Dabney P. Evans   ORCID: orcid.org/0000-0002-2201-5655 1 &
• Roger W. Rochat 1  

BMC Women's Health volume  19 , Article number:  76 ( 2019 ) Cite this article

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Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, public health practicioners and human rights advocates have made great strides to advance our understanding of sexual and reproductive rights and how they should be protected. The overall aim of the study was to understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua, from June to July 2014.

Case presentation

This case study focuses on the story of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her case, detailed under the pseudonym Ana Maria, presents unique challenges related to the fulfillment of sexual and reproductive rights due to the restrictive social norms related to sexual health, ubiquitous violence against women (VAW) and the total ban on abortion in Nicaragua. The case also provides a useful lens through which to examine individual sexual and reproductive health (SRH) experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; this in-depth analysis identifies the contextual risk factors that contributed to Ana Maria’s experience.

Conclusions

Far too many women experience their sexuality in the context of individual and structural violence. Ana Maria’s case provides several important lessons for the realization of sexual and reproductive health and rights in countries with restrictive legal policies and conservative cultural norms around sexuality. Ana Maria’s experience demonstrates that an individual’s health decisions are not made in isolation, free from the influence of social norms and national laws. We present an overview of the key risk and contextual factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion.

Peer Review reports

Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, however, the international community, States, and advocates have made great strides to advance our understanding of sexual and reproductive rights and how they can be protected at the national and international levels. The 1994 Cairo Declaration began this process by including sexual health under the umbrella of reproductive health and recognized the impact of violence on an individual’s sexual and reproductive health (SRH) decision-making. [ 1 ] One year later, the 1995 Beijing Platform for Action specifically addressed the issues of unintended pregnancy and abortion by emphasizing that improved family planning services should be the main method by which unintended pregnancies and unsafe abortions are prevented. [ 2 ]

A recent World Health Organization (WHO) report on the relationships between sexual health, human rights, and State’s laws sets the foundation for our contemporary understanding of these issues. The 2015 report describes sexual health as, “a state of physical, emotional, mental and social well-being in relation to sexuality.” [ 3 ] That state includes control over one’s fertility via access to health services such as abortion; it also includes the right to enjoy sexual experiences free from coercion, discrimination, and violence. [ 3 ] Whether experienced alone or in combination, rape, unintended pregnancy, and abortion are important SRH issues on which public health can and should intervene.

In the public health field, case studies provide a useful lens through which to examine individual women’s sexual and reproductive health experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; an in-depth analysis of these personal experiences can identify contextual risk factors and missed opportunities for public health rights-based  intervention. This type of analysis is especially cogent when legal policies and social factors, such as gender inequality, may influence one’s SRH decision-making process. On an individual level, bearing witness to women’s stories through in-depth interviews helps document their lived experience; surveying these experiences within the context of laws related to SRH provides important evidence for the impact of such policies on women’s well-being.

We present the case of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her complex experience of violence, unintended pregnancy, and unsafe abortion represent a series of contextual factors and missed opportunities for public health and human rights intervention. Ana Maria’s story, told through the use of a pseudonym, takes place in a city located in North Central Nicaragua – a country that presents unique challenges related to its citizens’ fulfillment of their sexual and reproductive health and rights.

Violence against women in Nicaragua

Along with 189 States, Nicaragua is a party to the United Nations (UN) Convention on the Elimination of All Forms of Discrimination against Women, which includes State obligations to protect and promote the health and well-being of Nicaraguan women. [ 4 ] As defined by human rights documents, the right to health includes access to health care services, as well as provisions for the underlying social determinants of health, such as personal experiences of structural violence. [ 5 ]

In the Nicaraguan context, political and sociocultural institutions support unequal power relations between genders. [ 6 ] Machismo is one such form of structural violence that perpetuates gender inequality and has been identified as a barrier to SRH promotion in Nicaragua. [ 7 , 8 ] The term ‘ machismo ’ is most commonly used to describe male behaviors that are sexist, hyper masculine, chauvinistic, or violent towards women. [ 9 ] These behaviors often legitimize the patriarchy, reinforce traditional gender roles, and are used to limit or control the actions of women, who are often perceived as inferior. [ 10 ]

The vast majority (89.7%) of Nicaraguan women have experienced some form of gender-based violence  during their lifetime, which poses a serious public health problem. The latest population-based Demographic and Health Survey showed that at least 50% of Nicaraguan women surveyed had experienced either verbal/psychological, physical, or sexual violenceduring their lifetime. An additional 29.3% of women reported having experienced both physical and sexual violence at least once, while another 10.4% reported having experienced all three types of violence. [ 11 ]

In 2012, Nicaragua joined a host of other Central and South American countries that have implemented laws to eliminate all forms of violence against women VAW, including rape and femicide. [ 12 ] Nicaragua’s federal law against VAW, Law 779, intends to eradicate such violence in both public and private spheres. [ 13 ] On paper, Law 779 guarantees women freedom from violence and discrimination, but it is unclear if the law is being adequately enforced; it has been reported that some women believe VAW has increased since the law’s implementation. [ 14 ]

Before Law 779, violent acts like rape, particularly of young women ages 15–24, were endemic in Nicaragua. Approximately two-thirds of rapes reported in Nicaragua between 1998 and 2008 were committed against girls under 17 years of age; most of these acts were committed by a known acquaintance. [ 15 ] Due to a lack of reporting and to culturally propagated stigma regarding rape, no reliable data suggest that Law 779 has been effective in reducing the incidence of rape in Nicaragua. For women who wish to terminate a pregnancy that resulted from rape, access to abortion services is vital, yet completely illegal. [ 16 ] In contrast, technical guidance from the WHO recommends that health systems include access to safe abortion services for women who experience unintended pregnancy or become pregnant as a result of rape. [ 17 ]

Family planning and unintended pregnancy in Nicaragua

Like violence, unintended pregnancies -- not only those that result from rape -- pose a widespread public health problem in Nicaragua. National data suggest that 65% of pregnancies among women ages 15–29 were unintended. [ 11 ] Oftentimes, unintended pregnancy results from a complex combination of social determinants of health including: low socioeconomic status (SES), low education level, lack of access to adequate reproductive health care, and restrictive reproductive rights laws. [ 18 , 19 , 20 ] Nicaraguan women of low SES with limited access to family planning services are at an increased risk of depression, violence, and unemployment due to an unintended pregnancy. [ 19 , 20 ]

The UN Committee on the Elimination of all forms of Discrimination Against Women (CEDAW) has expressed concern regarding the lack of comprehensive sexual education programs, as well as inadequate family planning services, and high rates of unintended pregnancy throughout Nicaragua. [ 21 ] Due to a lack of sexual education, Nicaraguan adolescents, if they use contraceptives like male condoms or oral contraceptive pills, often do so inconsistently or incorrectly. [ 22 ]

Deeply rooted cultural stigma surrounding unmarried women’s sexual behavior contributes to the harsh criticism of young women in Nicaragua that use a method of family planning or engage in sexual relationships outside of a committed union. [ 18 , 22 ] Also, young women who are not in a formal union may experience unplanned sex (consensual or nonconsensual) and are unlikely to be using contraception, which further increases the risk of unintended pregnancy. [ 22 ] These social and cultural factors, in conjunction with restrictive reproductive rights laws, may contribute to a high incidence of unintended pregnancy among young Nicaraguan women.

The total ban on abortion in Nicaragua

Compounding the economic, social, and emotional burden of unintended pregnancy on women’s lives is the current prohibition of abortion in Nicaragua. In 2006, the National Assembly unanimously passed a law to criminalize abortion, which had been legal in Nicaragua since the late 1800s. [ 20 ] Researchers often refer to this law as the “total ban” on abortion. [ 20 , 23 ] The total ban prohibits the termination of a pregnancy in all cases, including incest, rape, fetal anomaly, and danger to the life of the woman. Laws that prohibit medical procedures are, by definition, barriers to access; equitable access to safe medical services is a critical element of the right to health. [ 3 , 5 ] The UN Committee on Civil and Political Rights (CCPR) has also recognized the discriminatory and harmful nature of criminalizing medical procedures that only women undergo. [ 24 ]

Nicaragua is one of the few countries in the world to completely ban abortion in all circumstances. In States where illegal, abortion does not stop. Instead, women are forced to obtain abortions from unskilled providers in conditions that are often unsafe and unhygienic. [ 25 ] Unsafe abortions are among the main preventable causes of maternal morbidity and mortality worldwide and can be avoided through decriminalization of such services. [ 26 ]

The Nicaraguan ban includes serious legal penalties for women who obtain illegal abortions, as well as for the medical professionals who perform them, which can have profound negative effects on women’s health. [ 20 , 23 ] Women who need or want an abortion face not only the health risks that accompany an unsafe procedure, but additional criminal penalties. The total ban on abortion violates the human rights of both health care providers and women nationwide, as well as the confidentiality inherent in the patient-provider relationship. [ 20 ] It also results in a ‘chilling effect’ where health care providers are unwilling to provide both abortion and postabortion care (PAC) services for fear of prosecution. [ 20 ]

In response to the negative impacts of the total ban on maternal morbidity and mortality in Nicaragua, as well as detrimental effects on women’s physical, mental, and emotional health, CEDAW has recommended that the Nicaraguan government review the total ban and remove the punitive measures imposed on women who have abortions. [ 21 ] While the Nicaraguan government may not view abortion as a human right per se, women should not face morbidity or mortality as a result of illegal or unsafe abortion. [ 27 ]

Criminalizing abortion also increases stigma around this issue and significantly reduces people’s willingness to speak openly about abortion and related SRH services. Qualitative research conducted in Nicaragua suggests that women who have had unsafe abortions rarely discuss their experiences openly due to the illegal and highly stigmatized nature of such procedures. [ 18 ] Therefore, the overall aim of the study was to better understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua from June to July 2014. This private method of data collection allowed for the detailed exploration of each young woman’s personal experience with an unintended pregnancy, including the decision-making process she went through regarding how to respond to the pregnancy. Given the personal nature of this experience – including the criminalization and stigmatization of women who obtain abortions – IDIs allowed the participants to share intimate details and information that would be inappropriate or dangerous to share in a group setting. One case, presented here, emerged as salient for understanding the intersections of violence, unintended pregnancy, and abortion – and the missed opportunities for rights-based public health intervention.

Emory University’s Institutional Review Board ruled the study exempt from review because it did not meet the definition of “research” with human subjects as set forth in Emory policies and procedures and federal rules. Nevertheless, procedural steps were taken to protect the rights of participants and ensure confidentiality throughout data collection, management, and analysis. The first author reviewed the informed consent form in Spanish with each participant and then acquired each participant’s signature and verbal informed consent before the IDIs were conducted. The investigators developed a semi-structured interview guide with open-ended questions and piloted the guide twice to improve the cultural appropriateness of the script (Additional file 1 ). The investigators also collaborated with local partners to design and implement the research according to local cultural and social norms. Due to the contentious topics discussed in this study, these collaborators prefer to not be mentioned by name. Interviews were conducted in Spanish in a private location and audio taped to protect the participants’ privacy. Recordings were transcribed verbatim and transcripts were coded and analyzed using MAXQDA11 software (VERBI GmbH, Berlin, Germany).

Initially, participants were recruited for interviews through purposive sampling of individuals who had disclosed a personal experience with unintended pregnancy during focus group discussions (FGDs) conducted in a larger parent study. At the end of each interview, participants were asked to refer other young women they knew who may have experienced an unintended pregnancy to participate in an interview. This form of respondent-driven sampling created a network of participants with a wide variety of experiences with unintended pregnancy. Of the ten interviewees, two had experienced unintended pregnancy as a result of rape, though both used the phrase “ sexo no consensual ” or “nonconsensual sex” in lieu of “ violación, ” the Spanish word for rape. One of these women shared her personal experience receiving an unsafe abortion to terminate an unintended pregnancy that had resulted from rape. Her story, shared under the use of the pseudonym Ana Maria, is presented here in order to:

Illustrate the harmful impact of restrictive abortion laws on the health and well-being of women – especially those who do not have access to abortion in the case of rape; and

Exemplify the nexus of contextual risk factors that impact women’s SRH decision-making, such as conservative social norms and restrictive legal policies.

Through thorough analysis, we examine the impact of these contextual factors that impacted Ana Maria’s experience.

When she was 19, Ana Maria was raped by her godfather, a close friend of her family.

In an in-depth interview, Ana Maria described enduring incessant verbal harassment from her godfather – her elder brother’s best friend – in the months before the assault. He constantly called and texted her cell phone in order to interrogate her about platonic relationships with other men in town and to convince her to spend time alone with him. Even though he was married with children and she repeatedly dismissed his advances, he continued to engage in this form of psychological violence with his goddaughter. Ana Maria described eventually “giving in” and meeting him – not knowing that this encounter would result in her forcible rape.

The disclosure of Ana Maria’s rape during her interview was spontaneous and unexpected. Ana Maria was unwilling to disclose explicit details of the sexual assault. Instead, she stated multiple times that the sexual contact was nonconsensual and she did not want to have sex with him. When asked if she told anyone about this experience, she said no because she did not want others to judge her for what had happened.

Approximately a month of scared silence after she was raped, Ana Maria noticed that her period had not come. Nervous, she bought a pregnancy test from a local pharmacy. To her dismay, the test was positive. In order to confirm the pregnancy, she traveled alone to the nearby health center in her town to obtain a blood test. Again, the test was positive. She had never been pregnant before and she was terrified. In the midst of her fear, she shared the results with her rapist, her godfather.

His response: get an abortion. He did not want to lose his wife and children if they found out about the pregnancy.

Other than their illegal nature, Ana Maria knew nothing about abortions – where to get one, how it was done, what it felt like. She asked her neighbors to explain it to her. They said “it was worse than having a baby and [experiencing] childbirth.”

Though Ana Maria did not want to get the abortion, her godfather continued to pressure her to get the procedure saying, “Regardless, you must get the abortion… you are not the first woman to have ever had one.” Similar to the emotional violence before he raped her, he called and texted Ana Maria every day telling her to, “do it as fast as you can.” He forbade her from telling anyone about the pregnancy and Ana Maria didn’t feel like she had anyone to confide in about the situation. She worried about people judging her for getting pregnant outside of a committed relationship – even though she was raped. Ana Maria described this difficult time:

“When he started to pressure me [to get the abortion], I felt alone. I did not have enough trust in anyone to tell them [what had happened] because… if I had had enough trust in someone, I know that they would not have let me do it. If I had been given advice, they would have said, ‘No, do not do it,’ but I did not have anyone and I felt so depressed. What made it worse, I couldn’t sleep; I could not sleep [because I was] thinking of everything he had told me. At night, I would remember how it all started and I do not know what he did to find that money, but he gave me the money to get the abortion.”

Her godfather gave her 3000 Córdobas (approximately USD112 at the time) and put her on a public bus, alone. He had arranged for her to receive the abortion from an older woman that practiced “natural medicine” in a nearby city. When Ana Maria arrived at the woman’s home, she was instructed to remove her pants and underwear and lie on a bed. Ana Maria did not receive any medication before the woman inserted a “device like the one used for a Papanicolau… and then another device like an iron rod” into her vagina.

After describing these devices, Ana Maria made a jerking motion back and forth with her arm to imitate the movement the woman used to perform the abortion.

Once it was over, the woman gave Ana Maria an injection of an unknown substance and told her that she would pass a few blood clots over the next few days. That night, however, Ana Maria’s condition worsened; she became feverish, felt disoriented, and began to pass dark, fetid clots of blood. She described the pain she experienced throughout the ordeal:

“I felt so much pain when they took her out of me. I felt pain when the blood was leaving my body and when I had the fever. I felt a terrible pain that only I suffered. I am [a] different [person] now because of those pains.”

Ana Maria was too afraid to tell her family about the assault or the abortion because she was uncertain how they would react. She was even more terrified of the potential legal repercussions that she could face for violating the total ban on abortion. Within a few days of the abortion, though, Ana Maria’s brother heard rumors of his sister’s situation from neighbors “in the street” and confronted her about what had happened. At first, Ana Maria denied that she had had an abortion, but her brother continued to ask for the truth. Though she was nervous, Ana Maria eventually told her brother everything that had happened – from her godfather’s incessant verbal harassment, to the rape, to the unsafe abortion she was forced to get.

Afraid for his sister’s life, Ana Maria’s brother contacted a local nurse who discreetly provides postabortion care (PAC) to women experiencing complications from unsafe abortion and other obstetric emergencies. This nurse is locally known to be one of the few health care providers who provide PAC despite many other providers’ fear of prosecution under the total ban. The nurse recommended that Ana Maria come to the hospital immediately.

Ana Maria spent almost two weeks as an inpatient at the only hospital in the region. She had become septic as a result of what she described as a “perforated uterus,” a common complication from unsafe abortion. [ 28 ] Upon her initial examination, the nurse was afraid that her uterus could not be repaired because the infection was so severe. Fortunately, the medical team administered an ultrasound, removed infected blood clots, and completed uterine surgery to repair the damage from the unsafe abortion. At the request of the gynecologist taking care of her, Ana Maria received the one-month contraceptive hormonal injection before being discharged. At the time of the interview, Ana Maria had not received the next month’s injection because she “didn’t have any use for a man.”

As a result of this experience, Ana Maria reported feelings of depression, isolation, and recurring dreams about a little girl, which she described in this way:

“After I was discharged, I always dreamt of a little girl and that she was mine, standing in my doorway and when I awoke, I couldn’t find her. I looked for her in my bed but she wasn’t there. And this has tormented me because, it’s true: I am the girl that committed this error, but the little girl was not at fault. He pressured me so strongly to get the abortion, so I did.”

Ana Maria had the same recurring dream every night for more than two weeks and she continued to feel depressed weeks after leaving the hospital. One of the sources of her depression was the isolation she felt because there was no one with whom she could share this experience.

According to Ana Maria, she longs to have other people to talk to about her experience – particularly those who may have had similar experiences. She also expressed a desire to pursue a law degree so that she can have a career in local government.

Discussion and conclusions

Ana Maria’s case provides insight into the contextual factors effecting her ability to realize her sexual and reproductive health and rights in Nicaragua where restrictive legal policies and conservative cultural norms around sexuality abound. These contextual risk factors include social norms related to sexual health, laws targeting VAW, and the criminalization of abortion.

Social norms related to sexual health

The fundamental relationship between structural inequality and sexual and reproductive rights has been duly noted; gender inequality, in particular, must be addressed in order to fulfill sexual rights for women. [ 29 ] As in many cases in Nicaragua, the fact that Ana Maria’s first sexual experience was nonconsensual and was initiated by an older male and trusted family friend highlights the uneven power relations between men and women in Nicaraguan culture, which propagate high instances of VAW and sexual assault. In a patriarchal society where machismo and gender inequality run rampant, women’s sexuality is further constrained by the stigmatization of sexual health and a culture of violence that limits women’s autonomy. The compound stigma surrounding sexual health in general, and rape in particular, negatively impacted Ana Maria’s knowledge and ability to access mental health and SRH services, including emergency contraception and post-rape care, which may have assisted her immediately following her assault. Before her brother intervened, Ana Maria’s fear of judgment and legal repercussions also prevented her from seeking PAC, which was necessary to save her life.

Comprehensive sexual education is a primary way to challenge these social norms and widespread stigma surrounding sexuality and SRH services, such as contraception and PAC, at the population level. Such education might have mitigated Ana Maria’s experience of unintended pregnancy through the provision of advance knowledge of emergency contraception and medical options in the event of pregnancy. CEDAW has recognized this missed opportunity for public health intervention in Nicaragua, and recommends sexual education as a means of addressing stigma related to sexuality, decreasing unintended pregnancy, and increasing the acceptability and use of family planning services throughout the country. [ 21 ] Furthermore, the lack of adolescent-friendly sexual education and SRH services symbolizes a social reluctance to acknowledge the reality that young people have sex. [ 30 ] Such ignorance results in a lack of information on healthy relationships and human reproduction, as well as experiences of unintended pregnancy, early motherhood, and unsafe abortion. Exposure to this type of information may have improved Ana Maria’s ability to protect herself, mitigated the impact of Nicaragua’s pervasive misogyny on her decision making, and lessened the influence of her godfather’s coercion before her experiences of rape and unsafe abortion.

Individual and structural violence against women

Though we do not know explicit details of Ana Maria’s rape, the act of rape is inherently violent. The assault violated her right to enjoy sexual experiences free from coercion and violence. [ 3 ] To further constrain her sexual and reproductive rights, Ana Maria’s experience of rape resulted in an unintended pregnancy and an unsafe abortion that she was pressured into undergoing. Along with physical sequelae as a result of the procedure, she also expressed feelings of depression and isolation, which are common symptoms of post-traumatic stress disorder (PTSD). [ 31 ] These mental health consequences are forms of emotional violence that Ana Maria continued to experience long after the initial insult of physical violence. We can’t distinguish whether her mental health symptoms were a pre-existing condition or a result of the traumatic experience presented here. It is likely, however, that all parts of this experience impacted her mental and physical health. As reported elsewhere, perceived social criticism and a lack of social support are barriers to the fulfillment of sexual and reproductive health among young Nicaraguan women. [ 18 ] These contextual risk factors undoubtedly played a role in Ana Maria’s ability to navigate the circumstances surrounding her assault and its aftermath.

What legal recourse was feasibly available to Ana Maria for the crime of her sexual assault? To our knowledge, Ana Maria did not report the rape to authorities nor did her godfather ever face criminal charges for his actions. Yet Ana Maria’s own fear of prosecution for undergoing the unsafe abortion, as well as shame and fear of being stigmatized by others in her community, strongly influenced her decision not to report the rape -- even though Law 779 contains sanctions specific to those who commit rape.

In the event she had reported the crime, however, it is unclear if Law 779 would have provided justice. There are no data to suggest that Law 779 has led to an increase in the reporting or prosecution of rape at the national level. To the contrary, qualitative work in Nicaragua found a perceived increase in VAW following the passage of the law. [ 14 ] In Nicaragua, the inconsistent or ineffective enforcement of Law 779 is another factor worthy of consideration in cases like Ana Maria’s where individuals do not report such crimes. Documents like the UN Women Model Protocol have recently been released to improve the enforcement of laws like Law 779 in Latin American countries, presenting an opportunity for the effective operationalization of the law in Nicaragua. [ 32 ] If Law 779 is not adequately enforced, women like Ana Maria face the potential for re-victimization through the structural violence of impuity and continued exposure to VAW. To our knowledge, Ana Maria’s perpetrator faced no consequences for his perpetration of harassment, coercion and rape of Ana Maria. Moreover, in countries where abortion is criminalized, such as El Salvador, it is most often women who face criminal sanctions. [ 33 ] Indeed, it was Ana Maria herself who bore the physical and mental burden that resulted from her assault, unintended pregnancy, and unsafe abortion.

The criminalization of abortion

The criminalization of health services is a strategy that governments use to regulate people’s sexuality and sexual activity. [ 34 ] The criminalization of services such as abortion limits women’s ability to make autonomous decisions about their SRH. By definition, laws that restrict access to health services exclude people from receiving the information and services necessary to realize the highest level of SRH possible. [ 5 ] The criminalization of abortion puts the health and well-being of individuals and communities at risk. Beyond the individual level, complications from unsafe abortion often put unnecessary and immeasurable financial burdens on health systems that are already stretched [ 28 ].

Ana Maria did not have a choice when it came to her abortion; the man who raped her coerced her to undergo an unsafe and illegal procedure. The criminalization of abortion in Nicaragua put Ana Maria’s health at risk in two ways: first, it prevented her from obtaining a safe abortion and second, it limited her access to comprehensive sexual health information that could have helped her address her unintended pregnancy, through emergency contraception. After the unsafe abortion procedure, her access to PAC was likely constrained by her own fear of the possible legal repercussions of undergoing an abortion, and was compounded by her inability to trust that a health care provider would maintain patient confidentiality and provide adequate PAC.

In Nicaragua, the total ban on abortion directly contradicts strategic objectives outlined in the Beijing Declaration, which guarantees women’s rights to comprehensive SRH care, including family planning and PAC services. Though providing PAC is not considered illegal under the total ban, many Nicaraguan health care providers refuse to treat women who have had unsafe abortions, which results in a ‘chilling effect’; providers do not want to be accused of being complicit in providing abortions so they refuse to provide PAC services. The ‘chilling effect’ put Ana Maria at risk of morbidity or mortality as a result of the complications that resulted from her unsafe abortion.

Equally troubling is the use of criminal law against individuals like Ana Maria as well as health care professionals that provide PAC. By requiring health care providers to report to the police women who have had abortions, the total ban violates the privacy inherent in the patient-provider relationship. Health care providers are faced with a dual loyalty to both the State’s laws and the confidentiality of their patients, which makes it difficult for providers to fulfill their professional obligations. It also makes health care professionals complicit in a discriminatory practice, one where women face legal sanctions in ways that men do not. The criminalization of abortion in Nicaragua therefore resulted in the fear, stigma, discrimination, and negative health outcomes observed in Ana Maria’s case.

The contextual risk factors that contributed to Ana Maria’s experience of rape, unintended pregnancy, and unsafe abortion are as follows: sexual assault, impunity for violence, gender inequality, restrictive social norms around SRH, stigma resulting from unintended pregnancy and abortion, harmful health impacts from an unsafe abortion, and fear of prosecution due to the total ban. Her first sexual experience was forced and nonconsensual and preceded by months of harassment. Social norms made taboo any discussion of the harassment and sexual violence she experienced at the hands of her godfather; without social support, she was coerced into undergoing an unsafe abortion that resulted in serious mental and physical health sequelae. The illegal nature of abortion in Nicaragua placed Ana Maria at risk for social stigma as well as criminal prosecution. Her subsequent underutilization of family planning services at the time of the interview also placed Ana Maria at risk for an unintended pregnancy in the future; other long-term physical and mental health effects of her experience remain unknown.

The realization of one’s sexual and reproductive rights guarantees autonomous decision-making over one’s fertility and sexual experiences. However, Ana Maria’s story demonstrates that an individual’s SRH decisions are not made in isolation, free from the influence of social norms and national laws. Far too many women experience their sexuality in the context of individual and structural violence, such as VAW and gender inequality. This case highlights the contextual risk factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion; we must continue to critically investigate these factors to ensure that experiences like Ana Maria’s do not become further normalized in Nicaragua. Due to restrictive social norms around SRH, Ana Maria grew up experiencing stigma and taboo associated with sex, sexuality, contraceptive use and abortion. She also lacked access to information regarding SRH, healthy relationships, and how to respond to VAW before she was assaulted. After her assault, she did not have access to post-rape care, emergency contraception, safe abortion services, or mental health services to help her process this trauma. Shame and fear of stigma also prevented Ana Maria from reaching out for social support from family, friends, or the health or legal system. From the legal perspective, inadequate enforcement of VAW laws and the criminalization of abortion further exacerbated the trauma Ana Maria experienced.

It would require active engagement from the Nicaraguan government to address the contextual risk factors identified herein to protect their citizens’ right to health and prevent future experiences like Ana Maria’s. These efforts are particularly relevant given recent political unrest throughout Nicaragua including anti-government protests demanding the president’s resignation. [ 35 ] Nicaraguans’ right to health is at risk not only due to the widespread violence, but also because health care workers are being dismissed and persecuted nationwide. [ 36 ] Sexual and reproductive health researchers, advocates, and the public will continue to monitor Nicaragua’s response to the immediate demands and needs of its citizens -- including the demand that Nicaraguan women like Ana Maria are able to fully exercise their sexual and reproductive rights in times of both conflict and peace.

Availability of data and materials

Deidentified data are available upon reasonable request.

Abbreviations

Committee on Civil and Political Rights

Committee on the Elimination of all forms of Discrimination Against Women

In-Depth Interviews

Postabortion Care

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Socioeconomic Status

Sexual and Reproductive Health

United Nations

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Acknowledgements

The authors thank the research team and in-country collaborators from Proyecto Paz y Amistad, as well as the Emory University Global Field Experience (GFE) Fund and the Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund for financially supporting this project. We are also grateful to Ellen Chiang for her editorial support.

This study was funded with support from the Emory University Global Field Experience (GFE) Fund and the Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund. The funders did not play any direct role in the design of the study; the collection, analysis, and interpretation of data; or the writing of the manuscript.

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All authors contributed extensively to the work presented in this manuscript. SML, DPE, and RWR jointly designed the study. SML performed data collection and data analysis. SML and DPE wrote the manuscript with significant input from RWR. DPE and RWR also provided support and supervision throughout the study. All authors read and approved the final manuscript.

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Emory University’s Institutional Review Board found the study exempt from review because it did not meet the definition of “research” with human subjects as set forth in Emory policies and procedures and federal rules. The authors partnered with Proyecto Paz y Amistad, a local organization to design and implement this study. Proyecto Paz y Amistad deferred to the Emory University IRB’s determination. Nicaragua is notably absent from the US Department of Health and Human Services, International Compilation of Human Research Standards ( https://www.hhs.gov/ohrp/sites/default/files/2018-International-Compilation-of-Human-Research-Standards.pdf ). To our knowledge, there were no existing national level human subjects requirements or exemptions at the time of data collection.

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Luffy, S.M., Evans, D.P. & Rochat, R.W. “Regardless, you are not the first woman”: an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua. BMC Women's Health 19 , 76 (2019). https://doi.org/10.1186/s12905-019-0771-9

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The public health case for abortion rights

Joanne rosen from the johns hopkins center for law and the public's health discusses dobbs v. jackson women's health organization, which heads to the supreme court dec. 1.

By Annalies Winny, Alissa Zhu, and Lindsay Smith Rogers

This article is adapted from a special episode of the Public Health On Call podcast called Public Health in the Field. Hear the full episode online .

Editor's note: The terms "woman" and "women" are used throughout this article because that is how the CDC and other sources record related data.

A potentially landmark battle is in play over abortion rights, and it's headed to the U.S. Supreme Court on Dec. 1.

In 2018, the Mississippi legislature passed and the governor signed House Bill 1510, known as the Gestational Age Act, which bans abortions after 15 weeks. There are exceptions if the life of the fetus or parent is at risk—but not in cases of rape or incest. The law violated Roe v. Wade, the 1973 Supreme Court decision that legalized abortion nationwide and protects the right to abortion prior to "viability" of the fetus, which is at around 24 weeks. House Bill 1510 was quickly blocked by lower federal courts but now the law's fate is up to the Supreme Court.

The outcome of this case—Dobbs v. Jackson Women's Health Organization—has implications for abortion rights far beyond Mississippi: A decision that previability bans are not unconstitutional could upend longstanding protections established by Roe v. Wade.

The conversation about abortion rights in the U.S. is a noisy one involving politics, precedents, and personal beliefs. What often gets short shrift, however, is the public health reality that restricting access to abortion frequently results in erosion of the health of women, especially low-income women and women of color. This is why abortion is so much more than a legal battle.

According to The Turnaway Study , a 10-year study that followed nearly 1,000 women who either had or were denied abortions, any women who were denied wanted abortions had higher levels of household poverty, debt, evictions, and other economic hardships and instabilities, says Joanne Rosen , associate director of the Johns Hopkins Center for Law and the Public's Health.

"The study also found that women who were seeking but unable to obtain abortions endured higher levels of physical violence from the men who had fathered these children," Rosen says. "And people who were turned away when seeking abortions endured more health problems than women who were able to obtain [them], as well as more serious health problems. That gives you a sense of the ways in which being unable to obtain abortions had really long lasting impacts on these peoples' lives."

A 2020 study in the American Journal of Preventive Medicine found that women living in states with less restrictive reproductive health policies were less likely to give birth to low-weight babies. Other research published in The Lancet found that restrictive abortion laws actually mean a higher rate of abortion-related maternal deaths.

Restrictive abortion laws affect more than just the health of individuals and families—they affect the economy, too. Research from The Lancet found that "ensuring women's access to safe abortion services does lower medical costs for health systems."

The Institute for Women's Policy Research has a host of data around how reproductive health restrictions impact women's earning potential, including an interactive map tool, Total Economic Losses Due to State-level Abortion Restrictions. In Mississippi, for example, the data indicate that removing restrictions to abortion would translate to a 1.8% increase of Black women in the labor force, over 2% for Hispanic women, and a leap of more than 2.6% for women who identify as Asian-Pacific Islander. This same tool calculates that removing restrictions on abortion access would translate to an estimated $13.4 million in increased earnings at the state level for Black women alone.

Abortion restrictions disproportionately affect people of color and those with low-incomes. According to data from the CDC, Black women are five times more likely to have an abortion than white women, and Latinx women are two times as likely as whites. Seventy-five percent of people who have abortions are low-income or poor.

Mississippi, Texas, and the Supreme Court

On Dec. 1, the Supreme Court will hear Dobbs v. Jackson Women's Health Organization and Rosen thinks it's unlikely the court would agree to hear the case if they were just going to affirm the status quo.

The case isn't the only one on the docket, however. Texas' Senate Bill 8, which bans abortion after six weeks of pregnancy, made headlines earlier this month and may impact the court's ultimate decision on the Mississippi case. The high-profile law came before the Supreme Court in November 2021 and Rosen said the important thing to note is that the justices didn't actually address whether the six-week ban is constitutional. Rather, they examined the unusual enforcement scheme of the law—where, when, and by whom the Texas law could be challenged.

Rosen says that the justices may compare the Texas law with the Mississippi law and, when considering a six-week abortion ban, a 15-week ban may seem less extreme. In this way, the Texas case could give the court some cover to uphold Mississippi's 15-week ban.

It's likely to be months before an opinion is released; Rosen says the court typically releases its decisions on high-stakes or controversial cases in June. And high stakes this is: for the future of abortion, for reproductive health rights, and for public health.

Posted in Health , Politics+Society

Tagged supreme court , reproductive health , abortion

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• 26 October 2021

Why hundreds of scientists are weighing in on a high-stakes US abortion case

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An upcoming case in the US Supreme Court might hasten the end of abortion across roughly half of the United States — a right that the country has defended for nearly 50 years. More than 800 scientists and several scientific organizations have provided evidence to the court showing that abortion access is an important component of reproductive health care.

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doi: https://doi.org/10.1038/d41586-021-02834-7

Editor’s note: Nature recognizes that transgender men and non-binary people might become pregnant and seek abortion care. We use ‘women’ in this story to reflect how participants are reported in the studies we cite, and how people are referred to in court briefs.

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Four pro-life philosophers make the case against abortion

To put it mildly, the American Philosophical Association is not a bastion of pro-life sentiment. Hence, I was surprised to discover that the A.P.A. had organized a pro-life symposium, “New Pro-Life Bioethics,” at our annual conference this month in Philadelphia. Hosted by Jorge Garcia (Boston College), the panel featured the philosophers Celia Wolf-Devine (Stonehill College), Anthony McCarthy (Bios Centre in London) and Francis Beckwith (Baylor University), all of whom presented the case against abortion in terms of current political and academic values.

Recognizing the omnipresent call for a “welcoming” society, Ms. Wolf-Devine explored contemporary society’s emphasis on the virtue of inclusion and the vice of exclusion. The call for inclusion emphasizes the need to pay special attention to the more vulnerable members of society, who can easily be treated as non-persons in society’s commerce. She argued that our national practice of abortion, comparatively one of the most extreme in terms of legal permissiveness, contradicts the good of inclusion by condemning an entire category of human beings to death, often on the slightest of grounds. There is something contradictory in a society that claims to be welcoming and protective of the vulnerable but that shows a callous indifference to the fate of human beings before the moment of birth.

There is something contradictory in a society that claims to be protective of the vulnerable but shows a callous indifference to the fate of human beings before the moment of birth.

Mr. McCarthy’s paper tackled the question of abortion from the perspective of equality. A common egalitarian argument in favor of abortion and the funding thereof goes something like this: If a woman has an unwanted pregnancy and is denied access to abortion, she might be required to sacrifice educational and work opportunities. Since men do not become pregnant, they face no such obstacles to pursuing their professional goals. Restrictions to abortion access thus places women in a position of inequality with men.

Mr. McCarthy counter-argued that, in fact, the practice of abortion creates a certain inequality between men and women since it does not respect the experiences, such as pregnancy, which are unique to women. Some proponents of abortion deride pregnancy as a malign condition. A disgruntled audience member referred to pregnant women as “incubators.” Mr. McCarthy argued that authentic gender equality involves respect for what makes women different, including support for the well-being of both women and children through pregnancy, childbirth and beyond. He pointed out that in his native England, pregnant women acting as surrogates are given a certain amount of time after birth to decide whether to keep the child they bore and not fulfill the conditions of the surrogacy contract. This is done out of acknowledgment of the gender-specific biological and emotional changes undergone by a woman who has nurtured a child in the womb.

The most compelling argument against abortion remains what it has been for decades: Directly killing innocent human beings is gravely unjust.

Mr. Beckwith explored the question of abortion in light of the longstanding philosophical dispute concerning the “criteria of personhood.” The question of which human beings count as persons is closely yoked to the political question of which human beings will receive civil protection and which can be killed without legal penalty. The personhood criteria range from the most inclusive (genetic identity as a member of the species Homo sapiens ) to the more restrictive (evidence of consciousness) to the most exclusionary (evidence of rationality and self-motivating behavior).

Mr. Beckwith has long used the argument from personal identity (the continuity between my mature, conscious self and my embryonic, fetal and childhood self and my future older, possibly demented self) to make the case against abortion, infanticide and euthanasia. To draw the line between personhood and non-personhood after conception or before natural death is to make an arbitrary distinction—and a lethal one at that. Mr. Beckwith noted, however, that none of the usual candidates for a criterion of personhood is completely satisfying. Even the common pro-life argument from species membership could, unamended, smack of a certain materialism.

The most compelling argument against abortion remains what it has been for decades: Directly killing innocent human beings is gravely unjust. Abortion is the direct killing of innocent human beings. But political debate rarely proceeds by such crystalline syllogisms. The aim of the A.P.A.’s pro-life symposium was to amplify the argument by showing how our practice of abortion brutally violates the values of inclusion, equality and personhood that contemporary society claims to cherish. In the very month we grimly commemorate Roe v. Wade, such new philosophical directions are welcome winter light.

John J. Conley, S.J., is a Jesuit of the Maryland Province and a regular columnist for America . He is the current Francis J. Knott Chair of Philosophy and Theology at Loyola University, Maryland.

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Recent Case Highlights

The center for reproductive rights is litigating dozens of cases in state, national and regional courts against harmful laws that restrict access to abortion and other reproductive rights..

Below are updates on some of the Center’s current and recent cases.

Lawsuit Challenges Kansas Law Seeking Patients’ Reasons for Their Abortions

The Center and Planned Parenthood filed a legal challenge on May 20 to a new Kansas law that would force providers to report to the state patients’ reasons for seeking abortion care. The lawsuit asserts that the law, due to take effect July 1, directly interferes with Kansans’ bodily autonomy and their fundamental right to make their own decisions about health care, and that it violates patient privacy and jeopardizes provider-patient relationships. The lawsuit is asking the court to add this challenge to an ongoing case challenging other Kansas abortion restrictions.

Read more here.

U.S. Supreme Court Hears Its Second Major Abortion Case of the Term

The  U.S. Supreme Court  heard oral arguments on April 24 in a case that could deny pregnant patients access to emergency medical care and further upend abortion access across the country. The dispute concerns the State of Idaho’s near-total abortion ban, which conflicts with the Emergency Medical Treatment and Labor Act (EMTALA)—a federal law that requires hospitals to provide “stabilizing treatment” to patients seeking care in emergency rooms. The Center for Reproductive Rights submitted an  amicus brief   in the case on behalf of pregnant women in states with abortion bans who were denied or delayed stabilizing abortion care while experiencing obstetrical emergencies. 

Honduras’s Abortion Ban Being Challenged at the UN Human Rights Committee

The Center and the Centro de Derechos de Mujeres (CDM) are challenging Honduras’s total abortion ban in a case involving an indigenous Honduran woman who became pregnant as a result of rape—then was forced to give birth after being denied emergency contraception and abortion care. The case marks the first time Honduras has been brought before the UN for its total abortion ban.

Hearing Held in Tennessee “Medical Exceptions” Case

A hearing in Blackmon v. State of Tennessee , which challenges the state’s total abortion ban as applied to pregnant people with emergent medical conditions, was held April 4 at the Tennessee Twelfth Judicial District Court. 

View photos and media coverage here.

Read about the Center’s medical exceptions cases.

Medical Exceptions to U.S. State Abortion Bans

Representing women denied abortion care despite facing severe and dangerous pregnancy complications, the Center seeks to clarify medical exceptions to U.S. state laws that have outlawed abortion and put health, lives and fertility at risk.

Florida Supreme Court Allows State to Ban Abortion

The Florida Supreme Court on April 1 overturned decades of precedent and ruled that the Florida constitution’s explicit right to privacy no longer protects abortion rights. By upholding the state’s 15-week abortion ban, the Court also cleared the way for its six-week ban to take effect. 

U.S. Supreme Court Hears Case That Threatens Access to Abortion Medication

The U.S. Supreme Court heard arguments March 26 in Alliance for Hippocratic Medicine v. FDA , a case filed by anti-abortion advocates challenging the FDA’s approval of the abortion drug mifepristone and seeking to remove it from the market nationwide.

Kenya Court of Appeal Affirms Right to Respectful Maternal Health Care

In a significant victory for all Kenyans, the Court of Appeal of Kenya affirmed the right to respectful maternal health care in the case of Josephine Majani—a pregnant woman who was physically and verbally abused by hospital staff, and left to deliver her baby on a concrete hospital floor. The  Court’s decision , issued February 23, upheld a landmark 2018 judgment by the Kenyan High Court defending the human rights of Majani in the case, which was brought by the Center.

Center Sues Hawaiʻi to Protect Midwifery Care

To restore access to safe, respectful, and culturally informed maternal care in Hawaiʻi communities, the Center and its partners filed a lawsuit on February 27 asking a state court to block a midwifery restriction law. The law is preventing pregnant people from receiving pregnancy and birth care from trusted, skilled midwives and has been particularly devastating for Native Hawaiian midwifery practitioners and families of color. 

Center Sues Michigan to Align Abortion Laws with State’s Reproductive Freedom Amendment

To help ensure that Michigan’s abortion laws align with the amendment approved by voters in 2022 to enshrine reproductive freedom in the state’s constitution, the Center filed a lawsuit on February 6 challenging three burdensome state abortion restrictions still on the books.  “ With this lawsuit, we hope to eliminate archaic and harmful restrictions that are outright contrary to the RFFA and help ensure the state’s laws reflect the will of Michigan voters,” said Rabia Muqaddam, senior staff attorney at the Center.

Center and Partners Warn SCOTUS About “Junk Science” in Medication Abortion Case

An amicus brief submitted January 30 to the U.S. Supreme Court by the Center, the American Civil Liberties Union, and The Lawyering Project in support of the FDA’s 2016 and 2021 actions on mifepristone outlines how the lower courts, in rejecting the robust scientific basis for the FDA’s actions, relied on “patently unreliable witnesses” and “ideologically tainted junk science” in their rulings. The brief was filed January 30 in Alliance for Hippocratic Medicine v. FDA . The case—which threatens access to the abortion medication nationwide—will be argued at the Supreme Court on March 26. 

Read more on the brief and the case .

North Dakota Court Denies Request to Block Abortion Ban While Case Proceeds

In a preliminary ruling on January 23, a North Dakota state court  denied the Center’s request to block the state’s abortion ban in situations where an abortion is necessary to preserve the life or health of a pregnant person. The court did not address the constitutional questions that are the focus of the case and will issue a final ruling after a hearing on the merits of the case. In March 2023, the North Dakota Supreme Court blocked the state’s “trigger ban” as a violation of the state’s constitution. The following month, state lawmakers passed another total abortion ban, which is the law now at issue in the case.

Read more about the case here.

More Women Denied Abortion Care Join Case Against Tennessee

On January 8, 2024, four more women joined the Center’s lawsuit against Tennessee, Blackmon v. State of Tennessee , after being denied medically necessary abortion care for their severe and dangerous pregnancy complications. There are now nine plaintiffs in the case, which challenges Tennessee’s total abortion ban as applied to pregnant people with emergent medical conditions. The Center also asked the court for a temporary injunction, which would immediately block Tennessee’s abortion ban as it applies to dangerous pregnancy complications while the case proceeds.

Idaho “Medical Exceptions” Case to Continue After Court Rejects State’s Motion to Dismiss

An Idaho Court on December 29, 2023 rejected the state’s motion to dismiss Adkins v. State of Idaho , a case challenging the limited scope of the medical exceptions to Idaho’s two abortion bans: a total trigger ban and a “vigilante”-style six-week ban. The court’s ruling allows the case to proceed. The case was brought on behalf of four women who were denied abortion care despite facing severe pregnancy complications; two Idaho physicians who provide obstetrical care; and a professional membership organization consisting of Idaho physicians, medical residents and medical students.

Supreme Court Will Hear Case That Could Undermine Abortion Pill Access Nationwide

The U.S. Supreme Court agreed on December 13, 2023 to take up Alliance for Hippocratic Medicine v. FDA , a case filed by anti-abortion advocates challenging the FDA’s approval of the abortion drug mifepristone and seeking to remove it from the market nationwide. Arguments have been scheduled for March 26. The case reaches the Supreme Court after an appellate court partially upheld a lower court ruling attempting to reinstate burdensome pre-2016 restrictions on mifepristone that make it much harder to access. That order is currently blocked and will remain blocked until the Supreme Court rules, likely in June 2024.

Texas Supreme Court Denies Woman’s Request for Emergency Abortion Care

The Texas Supreme Court ruled on December 11, 2023 to deny a pregnant woman’s request for emergency abortion care in the state. The plaintiff, Kate Cox, recently received confirmation that her pregnancy had Trisomy 18 and had no chance of survival. She was warned by her OB-GYN and MFN specialist that continuing to carry the pregnancy to term could jeopardize her health and future fertility. The Center for Reproductive Rights filed the case, Cox v. Texas , on December 5, asking a state court to temporarily block Texas’s abortion bans so Cox was able to obtain the urgent care she needed to avoid the dangerous risks of being forced to stay pregnant.

Center Argues “Medical Exceptions” Case at the Texas Supreme Court

On November 28, 2023, the Center argued at the Texas Supreme Court to urge the court to uphold an  injunction issued  in August by a Texas district judge that the state’s abortion bans as they apply to patients with dangerous pregnancy complications. The ruling, which was appealed by Texas, also clarified that doctors can use their good-faith medical judgment to determine when to provide abortion care in those situations. The case, Zurawski v. State of Te xas , was brought on behalf of Texas physicians and women denied abortion care despite facing dangerous pregnancy complications.

Kansas State Court Blocks Abortion Restrictions

Although Kansas voters overwhelmingly rejected efforts to eliminate the fundamental right to abortion from the state constitution in 2022, state lawmakers enacted several onerous, harmful abortion restrictions that diminished access to care. On October 30, 2023, a Kansas state court judge blocked those restrictions, which were challenged by the Center and its partners in a lawsuit brought in June on behalf of Kansas abortion providers. The case argued that the restrictions violated the state constitution, including the rights to abortion and free speech.

Learn about cases with global impact.

Landmark Cases

Find out about court rulings secured by the Center that have transformed the landscape of reproductive health and rights for people around the world.

Georgia Supreme Court Allows Six-Week Abortion Ban to Remain in Effect

On October 24, 2023, the Georgia Supreme Court ruled to allow the state’s law banning abortion after approximately six weeks of pregnancy to remain in effect, reversing a lower court decision that struck down the law.

The lower court had ruled that since the Georgia Constitution prohibits the legislature from passing laws that violate either the state or federal constitution, the abortion ban was void since it violated Roe v. Wade when it was enacted in 2019.

The case, SisterSong v. Georgia , will return to the trial court, which has not yet ruled on the remaining claims brought by the plaintiffs that the ban violates Georgians’ rights to privacy and equal protection under the state Constitution.

Court Blocks Montana Clinic Licensing Law

On September 27, 2023, a court blocked a Montana law challenged by the Center that requires abortion clinics to be licensed and the state to issue regulations detailing licensure requirements. Although the law was set to take effect October 1, in the three months since the law was enacted, the state has yet to even propose regulations, making it impossible for clinics to comply by the effective date.

Kenyan Court Exonerates Mother and Health Care Provider From Abortion Charges

After a five-year court battle, a health care provider and the mother of an adolescent girl—represented by the Center and the Reproductive Health Network of Kenya (RHNK)—were cleared of charges of procuring an abortion by a court in Makadara, Kenya. The September 25, 2023 dismissal of the case, Republic v. Samson Mwita & Grace Wanjiku , aligns with earlier court rulings in Kenya declaring that it is illegal to arrest and prosecute abortion patients and providers, and it sends a clear message affirming abortion as a health care right.

Another Challenge to South Carolina Abortion Ban

The Center and its partners, on behalf of abortion providers in the state, filed a new challenge to South Carolina’s six-week abortion ban . The lawsuit, filed September 14, 2023, asks the South Carolina Supreme Court to resolve ambiguity raised in its August decision that upheld the ban.

Explore our cases in depth.

Case Archive

Index of the Center’s court cases by year, region and issue.

“Medical Emergency” Exceptions Complaints Filed in Three More States

Expanding its work on behalf of patients denied abortion care despite severe and dangerous pregnancy complications, on September 12, 2023, the Center filed complaints in Idaho, Tennessee and Oklahoma. The complaints seek to ensure that pregnant people in such dire situations can access abortion care and that doctors have clarity on “medical emergency” exceptions in their state’s abortion bans.

Read about the complaints here.

South Carolina Supreme Court Upholds Abortion Ban Almost Identical to One it Threw Out in January

After the makeup of the court changed, the South Carolina Supreme Court on August 23, 2023, upheld a law banning abortion at approximately six weeks of pregnancy. The ban is almost identical to the one it struck down in January and the ruling that will devastate abortion access in the state and throughout the region.

Read about the ruling here.

Court Denies Center’s Request to Ensure Access to Abortion Drug in Three States

On August 21, 2023, a federal court in Virginia denied the Center’s request for a preliminary injunction that would have protected access to the abortion pill mifepristone in Virginia, Montana, and Kansas.  The Center filed the request in Whole Woman’s Health Alliance v. FDA (WWH v. FDA) in May seeking to buttress the current access to mifepristone in line with a decision issued by a Washington court applicable to 17 states and D.C. In its ruling in WWH v. FDA , the court acknowledged the safety and importance of mifepristone, and the case will proceed in the trial court.

Access to mifepristone is threatened by an April 7 ruling by a Texas federal court in a separate case, Alliance for Hippocratic Medicine v. FDA , that attempted to block the FDA’s long-standing approval  of the drug. The ruling in WWH v. FDA came days after the Fifth Circuit Court of Appeals upheld in large part the Texas court’s ruling. (The Fifth Circuit ruling has not taken effect due to a U.S. Supreme Court stay, and the Government has asserted that it will appeal.)

Read about the WWH v. FDA case here.

Texas Ruling to Allow Abortions for Severe Pregnancy Complications is Blocked While Appeals Proceed

In a ruling August 4, 2023, on Zurawski v. State of Texas , a Texas district judge issued an injunction blocking Texas’s abortion bans as they apply to dangerous pregnancy complications, clarifying that doctors can use their own medical judgment to determine when to provide abortion care in emergency situations. The ruling also denied the state’s request to throw out the case, and it found S.B. 8—Texas’s citizen-enforced abortion ban—unconstitutional. The judge recognized in her ruling that the women who brought this case should have been given abortions.

The state immediately appealed the ruling directly to the Texas Supreme Court, putting the injunction on hold while appeals proceed. The Texas Supreme Court has set oral argument for November 28. 

Read more about the ruling here.

Search case news.

In the Courts

Hearing in zurawski v. state of texas.

A Texas state court will hear testimony and arguments July 19-20, 2023, in  Zurawski v. State of Texas , a lawsuit filed by the Center on behalf of Texas women denied abortion care despite facing severe pregnancy complications and risks to their health, fertility and lives. 

The hearing is scheduled for Wednesday, July 19 and Thursday, July 20 starting at 9 a.m. CT/10:00 a.m. ET at the Travis County Civil & Family Courts Facility in Austin. The Center will hold a press briefing, which will be  streamed live on Facebook , immediately after the hearing Wednesday.

Five plaintiffs in the case—four women denied abortions and an OB-GYN—and two experts in obstetrics and emergency medicine are scheduled to testify.  

Read more about the hearing here.

Center Challenges Kansas Restrictions on Abortion Access

Even though abortion is protected as a fundamental right under the Kansas constitution, state lawmakers have singled out abortion providers and patients with medically unnecessary and harmful restrictions to make access to care more difficult. On behalf of Kansas abortion providers, on June 6, 2023, the Center and its partner filed a lawsuit in state court challenging several restrictions scheduled to take effect as early as July 1.

The restrictions include measures requiring providers to relay to patients at least five times that a medication abortion can be “reversed”—a false, and potentially dangerous, claim unsupported by scientific evidence; a requirement that patients receive inaccurate state-mandated information, including medically unfounded statements that abortion poses a “risk of premature birth in future pregnancies” and “risk of breast cancer;” and other rules to delay care.

Read more about the lawsuit here.

Oklahoma Supreme Court Ruling Affirms Right to Life-Saving Abortion Care

On May 31, 2023, the Oklahoma Supreme Court  struck down  two citizen-enforced abortion bans mirroring Texas’ S.B. 8., affirming the court’s recent decision that the state constitution  protects the right to abortion in life-threatening situations . The high court confirmed that doctors must be able to use their medical judgement to determine whether to provide an abortion when a patient’s life is at risk. While abortion remains largely unavailable in Oklahoma and the state’s pre- Roe ban remains in effect, the ruling ensures that Oklahoma’s vigilante bans cannot hold doctors back from providing life-saving care.

Montana Supreme Court Strikes Down Law Prohibiting APRNs from Providing Abortion Care

On May 12, 2023, the Montana Supreme Court permanently struck down a law that prohibited advanced practice registered nurses (APRNs) from providing abortion care. In its unanimous decision, the Montana Supreme Court reaffirmed that the state constitution guarantees the right of Montanans to seek abortion care from a qualified healthcare provider of their choice. “Abortions remain one of the safest procedures when performed collectively by health care providers, including APRNs,” the justices wrote. The ruling expands the eligible pool of abortion providers in the state.

Read about the case here.

Medicaid Rule Limiting Abortion Access in Montana Is Blocked After Lawsuit by the Center and Partners

A Montana administrative rule that would have effectively eliminated abortion access for most Montanans insured through Medicaid was blocked May 1, 2023, in response to a  lawsuit filed April 28  by the Center and its partners. The lawsuit argues that the rule, which introduces restrictive new requirements for Medicaid-eligible Montanans seeking abortion care, violates the Montana Constitution. A Lewis and Clark County District Court judge issued a temporary restraining order   blocking the rule, which was to be enforced starting May 8.

Oklahoma Supreme Court Rules the Right to Abortion is Protected in Life-Threatening Situations

On March 21, 2023, the Oklahoma Supreme Court ruled that the state constitution protects the right to abortion in life-threatening situations, but declined to rule whether its constitution protects a broader right to abortion outside of those circumstances. In its ruling in  Oklahoma Call for Reproductive Justice v. Drummond , the court wrote that “the Oklahoma Constitution creates an inherent right of a pregnant woman to terminate a pregnancy when necessary to preserve her life” and struck down one of two total criminal abortion bans. The other ban remains in force, leaving abortion care unavailable for most Oklahomans.

Abortion Remains Legal in North Dakota as Court Blocks Total Ban

On March 16, 2023, the North Dakota Supreme Court ruled that the state’s total abortion ban will remain blocked, allowing abortion care to continue while the case proceeds in a lower court. The ruling came in a case filed in July by the Center and its partners on behalf of abortion providers, which argues that the ban is unconstitutional under the state’s constitution. In its ruling in Wrigley v. Romanick et al ., the North Dakota Supreme Court found that the challenge to the ban is likely to succeed.

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How Florida’s abortion law is affecting East Coast abortion clinics

A survey offers the first-of-its-kind look at the practical impact of a Florida law that banned most abortions on May 1.

Key takeaways

Summary is AI-generated, newsroom-reviewed.

• The clinics have seen a surge in patients since Florida banned most abortions, a survey found.
• Wait times for appointments rose at about 30 percent of clinics in some nearby states.
• Telemedicine and abortion pills may be mitigating the impact of the law somewhat.

Did our AI help? Share your thoughts.

Clinics up the East Coast have seen a surge in patient traffic since a law banning most abortion s in Florida went into effect on May 1 — but so far they have not experienced the collapse in care that many providers had feared before the new restrictions began in the country’s third most populous state, according to new data collected by a research team at Middlebury College.

Wait times for abortion appointments have increased at approximately 30 percent of clinics across North Carolina, Virginia, Maryland and Washington, D.C., the areas closest to Florida where abortion remains legal after six weeks of pregnancy, according to the data, which is based on a survey of clinics before and after the law went into effect. North Carolina experienced the sharpest increases, with wait times rising in half of the state’s 16 clinics.

Residents in Florida and across the South face far longer wait times since new law

Counties in red depict where residents who are further than six weeks into their pregnancies will struggle the most to get an abortion appointment.

Percent of facilities with no appointments available within two weeks

Less availability

Ban on all or most abortions

Ban on abortions after 12 weeks

Before Florida’s ban

After Florida’s ban

Note: Only clinics in D.C., Florida, Georgia, North Carolina, Maryland, South Carolina and Virginia were surveyed in May. Some counties outside the states surveyed are shown because the nearest abortion clinic is located in one of the seven jurisdictions included in the study.

Percent of facilities at nearest urban area with no appointments available within two weeks

Percent of facilities at nearest urban area

with no available appointments within two weeks

The average Florida resident now lives about 590 miles from the nearest clinic that offers abortions after six weeks and will need to wait nearly 14 days to end her pregnancy past that point — up from an average 20-mile drive and five-day wait before the ban, the data shows.

The study is a first-of-its-kind look at the practical impact of the new law in a state where 80,000 abortions had taken place each year. The survey was conducted by Caitlin Myers, a professor of economics at Middlebury College in Vermont and a team of undergraduate students, who systematically collected data from 130 clinics in six states and D.C. for the date of their next available appointment for an abortion after the six-week mark.

Although the survey offers only one window into the effect of the law, clinic directors and staff said it matched their own observations in the weeks since Florida banned most abortions on May 1.

Many said fewer Florida women appeared to be leaving the state for abortion care than was widely expected — a finding they largely attributed to increasing availability of telemedicine and abortion pills, in addition to long driving distances that may leave some women feeling they have no choice but to carry their unwanted pregnancy. At least 8,000 women every month are now obtaining abortion pills through the mail in states with strict abortion bans or significant restrictions in place, according to a recent study by the Society of Family Planning.

“Driving distance and appointment availability remain salient components of abortion access, but less so than they were three years ago,” said Myers, who has spent years quantifying the changing landscape of abortion access.

“Telehealth is really a game changer for abortion access,” she said. “But it might be a fragile one.”

Abortion pills have become a major target for many antiabortion advocates frustrated that studies show abortion numbers have continued to rise since Roe v. Wade was overturned. A court challenge seeking to restrict access to the pills, brought by a major antiabortion group, is pending before the Supreme Court, with a decision expected by late June.

Eileen Diamond, who runs an abortion clinic in Florida in the Fort Lauderdale area, said patients she has seen since the ban took effect have been extremely reluctant to leave the state if they are still within the 10-week window for taking abortion pills recommended by the U.S. Food and Drug Administration. Especially relatively early in pregnancy, she said, many experience “this feeling of disbelief” when they’re told they have to travel at least three states away to get an abortion.

“It’s very daunting for them,” Diamond said. “We are seeing a lot of patients turning to finding alternate ways to get pills by mail.”

Myers began conducting surveys of wait times at regular intervals at over 700 clinics across the United States in March 2022, anticipating that Roe would fall that summer. The results have helped illustrate the changing landscape of abortion access in the two years since.

As soon as Texas enacted its six-week “heartbeat ban” in the fall of 2021 — outlawing most abortions nine months before the fall of Roe — Texas patients quickly overwhelmed clinics in Oklahoma, Kansas and New Mexico, many of which had wait times of several weeks or ran out of appointments altogether, Myers said.

Before the Texas law, approximately 50,000 abortions occurred in the state every year — significantly fewer than had been performed annually in Florida. Despite those numbers, Myers said, “we’re not seeing that level of shock to access with the Florida ban.”

The reason, she said: “a general awareness” of medication and telehealth abortion.

“There are many more options to obtain the pills quickly and cheaply than there used to be,” Myers said.

Since last summer, U.S.-based doctors have been mailing thousands of pills into antiabortion states under “shield laws” recently enacted in a handful of blue states , designed to protect doctors from prosecution. Women in antiabortion states are also accessing pills through at least 25 nonmedical websites and several community-based networks that distribute the pills free.

Amy Hagstrom Miller, who leads Whole Woman’s Health, a national network of abortion clinics, opened a clinic in New Mexico after she was forced to shutter several clinics in Texas when Roe was overturned. The deluge of patients she expected from antiabortion states at that clinic, along with other clinics elsewhere, has yet to materialize, she said.

“We prepared for more of a surge than we’ve seen in any of our clinics,” she said. At her new clinic in New Mexico, which borders Texas, she said, “we’re not even close to capacity.”

With the help of state and national abortion funds, which provide financial support to people seeking abortions, advocates have been able to book flights for patients who want to leave the state for an abortion, Diamond said. Some have been able to fly to D.C. in the morning, have their procedure and return home that night.

For others, travel is more difficult. Several patients she has seen since the ban took effect have not been able to fly because they don’t have valid identification, Diamond said. Others can’t leave because they can’t miss work or don’t have anyone to help with child care.

A Washington Post analysis found that, in total, about 7 million women of reproductive age in Florida and surrounding states will now have to travel longer to receive abortions after six weeks of pregnancy. The average affected woman saw a drive-time increase of more than seven hours, analysis using data from OpenStreetMap shows. The group includes an outsize number of Black women and poor women, compared with the United States as a whole.

Diamond recounted that one of her patients recently arrived in Fort Lauderdale after driving 18 hours from Houston. She had not heard about the new six-week ban, Diamond said, and was already nine weeks pregnant.

“This woman was desperate,” Diamond said. “She had used everything she had to come to us.”

In the end, she drove on for at least 12 hours from Fort Lauderdale to Virginia, Diamond said — and was planning to drive 17 hours home after the procedure.

Before the Florida ban, a Houston resident would have driven 18 hours to get an abortion.

Fort Lauderdale

In May, a woman drove from Houston to Fort Lauderdale to get an abortion, having not heard about the ban. She drove on for at least 12 hours to a clinic in Virginia for the procedure.

The total drive time was at least 47 hours.

Note: The nearest abortion clinic to Fort Lauderdale is located in Danville, Va. The exact clinic where this patient received the procedure is unknown. Route is based on a Google Maps estimate of driving directions.

North Carolina, where abortion is legal until 12 weeks of pregnancy, is the closest state that offers abortions beyond Florida’s six-week limit. But another law, which requires patients to wait at least 72 hours between an initial in-person consultation with a doctor and the procedure, can make traveling there logistically difficult.

One Florida patient recently traveled 23 hours on a Greyhound bus for a consultation appointment at A Woman’s Choice in Charlotte, according to Lakeynn Huffman, the clinic manager — returning home that night because she could not find child care to cover the full 72 hours she had to wait between appointments.

The woman made the same trip two days later, Huffman said — traveling for a total of 92 hours to get an abortion.

Before the ban, a Jacksonville-area resident would have been able to remain in the city for an abortion procedure.

Jacksonville

The patient instead traveled this route to Charlotte twice — first for a consultation appointment, then for the abortion procedure two days later.

NORTH CAROLINA

She traveled for a total of 92 hours by bus.

Note: Route based on a Google Maps estimate of driving directions.

SOUTH CAROLINA

Ordering pills online can be a nerve-racking experience for some patients, Diamond said.

“They’re worried the pills won’t get there, worried they don’t have a clinic to back them up,” she said.

Nearly three weeks after the new ban took effect, Diamond said she had started hearing from far fewer patients in the second trimester, which begins at 13 weeks of pregnancy, beyond the FDA’s 10-week limit for taking abortion pills.

“They’re not coming to clinic. They’re not calling about travel,” she said.

Many, she said, may now assume there is nothing they can do in the face of a six-week ban.

“I think they are carrying these pregnancies,” she said.

Clara Ence Morse contributed to this report.

Methodology The Post used the most recent survey data collected by Caitlin Myers, a professor of economics at Middlebury College, and a team of undergraduate students. The survey collected data from 130 clinics representing all providers in six states – Florida, Georgia, South Carolina, North Carolina, Virginia, and Maryland – as well as Washington, D.C. These locations were surveyed in April 2024, prior to the Florida ban, and then again on May 13, 2024. The survey involved calling each facility to ask (1) about the availability of medication and procedural (surgical) abortions, and (2) for the date of the next available appointment for each type of abortion. The analysis for this story relied on comparisons between the April and May survey data. If appointments were available at a facility, the team calculated the “wait time” as the minimum number of weekdays until the next available appointment for an abortion, of any type. Students conducting the May 13 survey were Isabelle Cone, Georgia Crosby, Emma Dobson, Avery Goldstein, Kate Goodman, Angel Gurung, Sarah Holmes, Julia Joy, Emily Kuperstein, Sascha Leidecker, Awa-Victoria Morel, Grace Mumford, Audrey Peiker, Emily Ribeiro, Grace Sokolow, Shay Soodak and Claire Vermillion.

U.S. abortion access, reproductive rights

Tracking abortion access in the United States: Since the Supreme Court struck down Roe v. Wade , the legality of abortion has been left to individual states. The Washington Post is tracking states where abortion is legal, banned or under threat.

Abortion and the election: Voters in about a dozen states could decide the fate of abortion rights with constitutional amendments on the ballot in a pivotal election year. Biden supports legal access to abortion , and he has encouraged Congress to pass a law that would codify abortion rights nationwide. After months of mixed signals about his position, Trump said the issue should be left to states . Here’s how Biden and Trump’s abortion stances have shifted over the years.

New study: The number of women using abortion pills to end their pregnancies on their own without the direct involvement of a U.S.-based medical provider rose sharply in the months after the Supreme Court eliminated a constitutional right to abortion , according to new research.

Abortion pills: The Supreme Court seemed unlikely to limit access to the abortion pill mifepristone . Here’s what’s at stake in the case and some key moments from oral arguments . For now, full access to mifepristone will remain in place . Here’s how mifepristone is used and where you can legally access the abortion pill .

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Reproductive rights in America

Abortion pills that patients got via telehealth and the mail are safe, study finds.

Selena Simmons-Duffin

Access to the abortion drug mifepristone could soon be limited by the Supreme Court for the whole country. Here, a nurse practitioner works at an Illinois clinic that offers telehealth abortion. Jeff Roberson/AP hide caption

Access to the abortion drug mifepristone could soon be limited by the Supreme Court for the whole country. Here, a nurse practitioner works at an Illinois clinic that offers telehealth abortion.

In March, the Supreme Court will hear a case about mifepristone, one of two drugs used in medication abortions. A key question in that case is: Was the Food and Drug Administration correct when it deemed the drug safe to prescribe to patients in a virtual appointment?

A study published Thursday in Nature Medicine looks at abortion pills prescribed via telehealth and provides more support for the FDA's assessment that medication abortion is safe and effective.

Researchers examined the electronic medical records for more than 6,000 patients from three providers of abortion via telehealth. They also conducted an opt-in survey of 1,600 patients.

Some abortion patients talked to a provider over video, others used a secure chat platform, similar to texting. If patients were less than 10 weeks pregnant and otherwise found to be eligible, the providers prescribed two medications: mifepristone, which blocks a pregnancy hormone called progesterone, and misoprostol, which causes uterine contractions. Patients got both medicines via mail-order pharmacy.

Shots - Health News

Research at the heart of a federal case against the abortion pill has been retracted.

"Then 3 to 7 days later, there was a clinical follow up," explains the study's lead author, Ushma Upadhyay of the University of California – San Francisco. "The provider checked in with the patient. 'Did you receive the medications? Did you take the medications?' They asked about symptoms. And then there was a clinical follow-up four weeks after the original intake."

The researchers found that the medication was effective – it ended the pregnancy without any additional follow-up care for 97.7% of patients. It was also found to be safe – 99.7% of abortions were not followed by any serious adverse events. The safety and efficacy was similar whether the patients talked to a provider over video or through secure chat.

"These results shouldn't be surprising," Upadhyay says. "It's consistent with the over 100 studies on mifepristone that have affirmed the safety and effectiveness of this medication."

The results also echo international research on telehealth abortion and studies of medication abortion dispensed in a clinic with an in-person appointment, she notes.

Rishi Desai of Harvard Medical School is a medication safety expert who was not involved in the study. He says it was "well-conducted," especially considering it can be difficult to track patients who only connect with providers remotely.

"I would say that this study provides reassuring data regarding safety of the medications, and this is very much in line with what we have seen in many previous studies," he says. "So it's good to see that safety findings hold up in this setting as well."

Still, whether mifepristone is safe and whether FDA has appropriately regulated how it is prescribed is a live legal question right now.

An anti-abortion rights group sued FDA in 2022, arguing that mifepristone is not safe and was improperly approved in 2000. Judge Matthew Kacsmaryk, a district court judge appointed to the federal bench by President Trump, ruled that mifepristone should be pulled from the market nationwide. Although his decision didn't take effect pending appeals, the appeals court ruled against the FDA in part, specifically rolling back telehealth abortion access. That is also on hold for now.

The Supreme Court hears arguments in the case on March 26. The decision could affect access to medication abortion nationwide and set a new precedent on challenges to the FDA's authority.

Recently, there's been a flurry of mifepristone research news. Last week, a paper that raised safety concerns about mifepristone was retracted . This study, released Thursday, affirms the FDA's position that the medicine can be safely prescribed remotely.

Upadhyay says she's been working on this research for years and that the timing of its publication weeks before the Supreme Court arguments is coincidental.

"I don't know if they can enter new evidence into the case at this point," she says. "But I do hope it impacts the perception of how safe this medication is."

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• mifepristone
• Abortion rights
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An ethical issue: nurses’ conscientious objection regarding induced abortion in South Korea

Chung mee ko.

1 College of Nursing, Sungshin Women’s University, 55, Dobong-ro 76ga-gil, Gangbuk-gu, Seoul, 01133 Republic of Korea

Chin Kang Koh

2 College of Nursing, The Research Institute of Nursing Science, Seoul National University, 103 Daehakro, Jongrogu, Seoul, 03080 Republic of Korea

3 College of Nursing, Seoul National University, 103 Daehakro, Jongrogu, Seoul, 03080 Republic of Korea

Associated Data

The dataset supporting the conclusions is available from the corresponding author on reasonable request.

The Constitutional Court of South Korea declared that an abortion ban was unconstitutional on April 11, 2019. The National Health Care System will provide abortion care across the country as a formal medical service. Conscientious objection is an issue raised during the construction of legal reforms.

One hundred sixty-seven perioperative nurses responded to the survey questionnaire. Nurses’ perception about conscientious objection, support of legislation regarding conscientious objection, and intention to object were measured. Logistic regression was used to explore the factors associated with support of the legislation and the intention to conscientiously object.

Only 28.8% of the responding nurses were aware of health care professionals’ conscientious objection. The majority (68.7%) felt that patients’ rights should be prioritized over health care professionals’ conscientious objection. On the other hand, 45.8% supported the legislation on conscientious objection to abortion, and 42.5% indicated a willingness to refuse to participate in an abortion case if conscientious objection was permitted. Religion, awareness of conscientious objection, and prioritizing of nurses’ right to conscientious objection were significantly associated with supporting the legislation. Moreover, religion and prioritizing nurses' rights were significantly associated with the intention to conscientiously object.

Conclusions

This study provides information necessary for further discussion of nurses’ conscientious objection. Nursing leaders, researchers, and educators should appeal to nurses and involve them in making policies that balance a women's right to non-discrimination and to receiving appropriate care with nurses' rights to maintain their moral integrity without compromising their professional obligation.

On April 11, 2019, the Constitutional Court of South Korea ruled that the criminalization of abortion is unconstitutional [ 1 ]. The Constitutional Court ruled that women’s self-determination would take priority during the first 22 weeks of pregnancy [ 2 ]. According to Articles 269 and 270 of Chapter XXVII, “Crimes of Abortion” in the Criminal Act, a woman who procures her own miscarriage or a healthcare provider such as an obstetrician or midwife who performs an abortion for a woman shall be punished by a fine or imprisonment [ 3 ]. The Constitutional Court ruled these two articles as constitutional discordance and gave the National Assembly until the end of December 2020 to revise the law [ 2 ]. Therefore, the National Assembly is working on reforming related provisions of the Criminal Law and the Mother and Child Health Act. The Government is also working to support law making and to align policies and regulations implementing the new ruling while researching public opinions. Throughout this process, the National Health Care System will provide abortion care across the country as a formal medical service. This indicates that many health care providers in hospitals and clinics who have never been involved with abortion because it was performed covertly in a limited number of clinics will face abortion cases for the first time in their workplaces. Nationally, the number of annual abortions covertly performed is estimated at 50,000 cases, 90% of which are surgical abortions [ 4 ].

Conscientious objection (CO) is an issue raised during the construction of legal reforms. Currently, Paragraph 1 of Article 15 (Prohibition against Refusal to Provide Medical Services) under the Medical Service Act states: “Medical personnel or the founder of a medical institution shall not upon receiving a request for medical treatment or assistance in childbirth refuse such a request without good cause” [ 5 ]. Under this legislation, health care providers’ refusal to perform an abortion is banned [ 6 ]. The Ministry of Health and Welfare virtually stated its opposition to healthcare providers’ CO considering health care access at an official meeting held at the National Assembly [ 7 ]. However, physician groups such as the Korean Society of Obstetrics and Gynecology and Korean Association of Obstetrics and Gynecology have announced their position in support of physicians’ right to CO and have asked for new abortion laws that include provisions ensuring the right of healthcare workers to refuse abortions [ 8 ]. On the other hand, nurses and other health professional groups have not provided their official position about CO.

In some countries, the law contains provisions for the right of CO to abortion. For example, " Discussion " section of the Abortion Act in the UK states that health care providers may refuse to participate in any treatment based on his or her CO [ 9 ]. The Act recognizes the right to CO status related to abortion of which provision is ethically controversial and on which many people have strong views [ 10 ]. On the other hand, other countries do not legally grant the CO of health care providers [ 11 ]. For example, Sweden does not have legislation for CO under its Abortion Act, and the Swedish Parliament has rejected including a clause for CO [ 12 ]. Moreover, the World Health Organization has expressed reservations about CO because it may delay the delivery of health care services and place a woman’s health at risk [ 13 ].

There have been arguments for and against nurses’ CO. An argument for CO is that it is a human being’s fundamental moral right. Article 9 of the European Convention on Human Rights states that everyone has the right to freedom of thought, conscience, and religion [ 14 ]. Permitting CO avoids moral distress, which might occur when a nurse performs certain acts inconsistent with his or her beliefs [ 15 ]. Nurses who declared a CO in their practice stated that this was “based on one’s conscience-based perception of morality” [ 16 , p.1343]. Moreover, CO protects health care providers by crediting the individual’s conviction, and it supports health care providers in following their religious beliefs or religious law against providing abortion-related care [ 17 ]. An argument against CO in nursing is that it might negatively influence access-of-care or appropriate health care services [ 18 ]. Patients may have fewer options, and there is concern about the possible widespread practice of CO [ 17 ]. In addition, co-workers may see objectors as leaving unpleasant tasks to their colleagues [ 15 ].

Fleming et al. conducted a systematic review and identified 23 broad reasons and 116 narrow reasons in 4 categories, namely moral, practical, religious, and legal reasons [ 17 ]. Of the narrow reasons, 70% were for and 30% against CO in abortion care by midwives and nurses. Considering these reasons, balancing nurses’ right to CO and the patient’s right to receive appropriate care is a challenge in nursing [ 18 ]. We need to carefully evaluate what treatment boundaries we allow conscience to determine when considering social and health care environments [ 10 ]. However, in South Korea, no studies have focused on nurses’ CO to abortion care, although they now face an era of legal abortion as a formal medical service. Moreover, CO policy will have great impact on perioperative nurses [ 19 ].

Perioperative nurses have the duty of providing care relating to the surgical terminations of pregnancy, which is one ethical dilemma they may face in an operation [ 19 ]. Perioperative nurses prepare the theatre for procedures and assist in termination [ 19 ]. They also provide psychosocial care for women needing an abortion and for their significant others [ 20 , 21 ]. In terms of CO, according to the American Nurses Association guidelines, scrub and circulating nurses may object to providing instruments for the termination of a pregnancy when it causes moral distress [ 22 ]. The Association for Perioperative Practice in the UK also supports nurses’ right for CO regarding surgical abortion based on the Human Fertilization and Embryology Act of 1990 [ 19 ].

The purpose of this study was to explore perioperative nurses’ attitudes towards CO regarding abortion. The specific aims were (1) to examine whether they were aware of CO and how they prioritize between nurses’ right to CO and patients’ right to get an abortion, (2) to describe agreement with legislation of nurses’ CO, and (3) to explore nurses’ intention to assert CO.

Study design

This was a cross-sectional descriptive study utilizing a self-report survey method. The data was collected in October and November 2019 .

Measurements

Prior to inquiring about the nurses’ perceptions of and ideas about CO, we provided information about CO regarding abortion care because this was unfamiliar to the majority of the nurses. We provided a brief description based on the previous literature [ 9 – 11 ]. Each concept was measured using one question we developed based on the literature. Prior to the survey, we verified face validity by having ten nurses review the questions to assess their clarity, comprehensibility, and appropriateness.

• Support of legislation on conscientious objection to abortion

We asked nurses about whether they support the legislation ensuring nurses’ rights to CO: “Do you support that nurses’ right to CO should be ensured under the law?” The answer options were “support,” “oppose,” and “neither support nor oppose.”

• 2. Intentions to assert conscientious objection

The question regarding intention to assert CO was: “Would you object to participating in abortion care if CO for nurses were to be allowed by law?” Moreover, three situations were given [ 11 ], namely “abortion because of foetal problems within 22 weeks,” “abortion because of rape within 22 weeks,” and “abortion because of unwanted pregnancy within 22 weeks.” We posited a 22-week duration in which to allow abortions, which is in accordance with the judgement of the Constitutional Court on April 11, 2019. The answer choices were “I will object,” “I will not object,” and “I do not know.”

• 3. Awareness of CO and opinions about the conflict over nurses’ CO

The question used to assess nurses’ awareness of CO was “Prior to this survey, were you aware of health care workers’ CO?” The answers were measured on a five-point Likert Scale with the following options: 1 = “fully unaware,” 2 = “unaware,” 3 = “neither aware nor unaware,” 4 = “aware,” and 5 = “fully aware.” Furthermore, to ascertain their opinion about the conflict between the rights of nurses and those of patients, we asked: "If there is a conflict between nurses’ right to CO and patients’ right to have an abortion, which do you think should take priority?" [ 10 ]. The answers allowed were “nurses’ right to CO,” “patients’ right to have an abortion,” and “I do not know.”

Data analysis

We performed logistic regression to explore related factors and their odds ratios regarding nurses’ support of legislation to ensure CO and their intention to assert CO. For the logistic regression model of the nurses’ support of the legislation, we coded the nurses’ support as a dichotomous variable. We coded “oppose” and “neither support nor oppose” as 0, and “support” as 1.

In addition, for the logistic regression model, we coded nurses’ intention to assert CO as a dichotomous variable. We assigned “0′ in all cases where they did not choose “will reject” to all three items. These three items were “abortion because of foetal anomaly within 22 weeks,” “abortion because of rape within 22 weeks,” and “abortion because of unwanted pregnancy within 22 weeks.” We assigned “1” to all cases in which the respondent choose “will reject” to at least one of the three items. We utilized crude odds ratios and confidence intervals to show the association. The significance level was 0.05.

Study participants

This study included 167 perioperative nurses who were working in an operating department, including the preoperative area, operating theatres, and post-anaesthesia care unit, in a large tertiary care university hospital in the Seoul metropolitan area of South Korea. The total number of perioperative nurses was 203. Thus, the response rate was 82%. The mean age was 34.4 years, ranging between 22 and 57 years (Table ​ (Table1). 1 ). Among the 167 perioperative nurses, 152 were female, and 15 were male. Less than half (47.3%) reported being religious. The types of religion were Protestant, Catholic, and Buddhist. No other religions were reported. The average clinical experience was 11.03 years. In terms of clinical roles, the majority (62.9%) were operating room nurses. Other roles were recovery room nurses (15.6%), anaesthesia nurses (14.4%), and physician assistants or surgical assistants (7.2%).

Characteristics of study participants (N = 167)

CO conscientious objection

In terms of CO, the mean score of awareness of CO was 2.68 (SD = 1.10). Just 48 nurses (28.8%) reported being “fully aware” or “aware” of the CO of nurses and physicians. The majority (68.7%) felt that patients’ rights should be prioritized over CO.

Legislation on conscientious objection to abortion

Among the perioperative nurses, 45.8% supported the legislation on CO to abortion, 22.9% opposed it, and 31.3% neither supported nor opposed it. In the logistic regression, age, gender, marital status, clinical experience, and clinical role were not significantly associated with the nurses’ support of the legislation on CO to abortion (Table ​ (Table2). 2 ). On the other hand, the Protestant religion was significantly associated with support. Nurses who were Protestants were more likely to support the legislation than those who had no religion (OR = 2.471; 95% CI 1.189–5.133, p  = 0.015). Moreover, the perceived importance of religion was also associated with their support of the legislation on CO to abortion (OR = 0.400, 95% CI 0.207–0.773, p  = 0.006).

Support of legislation confirming health care professionals’ right to assert conscientious objection to abortion (N = 167)

CO: conscientious objection

On the other hand, the odds ratio of the awareness of CO was 2.042, with a 95% confidence interval of 1.033–4.035 ( p  = 0.040) (Table ​ (Table2). 2 ). In addition, the odds ratio of the nurses who answered “nurses’ rights take priority” in the case of a conflict between nurses’ rights to CO and patients’ right to receive nursing care for abortion was 6.750 with a 95% confidence interval of 1.762–25.893 ( p  = 0.005) where the reference group was the nurses who answered “I do not know.”

Nurses’ intentions to assert conscientious objection.

There were three items about the intention to assert CO based on the different reasons for having an abortion (Table ​ (Table3). 3 ). In case of abortion because of foetal problems, the percentage answering that they would object was 21.6%; it was 22.8% in cases of abortion because of rape; and it was 31.3% in cases of abortion because of unwanted pregnancy.

Intentions to assert conscientious objection (N = 167)

The number of those reporting a willingness to refuse being involved in the care of those receiving abortions for at least one of the three following reasons—foetal anomaly, rape, or unwanted pregnancy—was 71 (42.5%). From the logistic regression, protestant perioperative nurses were more likely to report that they would assert CO relative to those having no religious preference as the reference group (Table ​ (Table4). 4 ). The odds ratio was 2.209 with a 95% confidence interval of 1.073–4.549. The perceived importance of religion was also a significant factor related to the intention to assert CO, and nurses who stated that nurses’ rights should be prioritized were more likely to report that they would assert CO in cases of abortion where the reference group was those answering “I do not know.” No other factor was significantly associated with the nurses’ intention to assert CO.

Factors relating to the intention to assert conscientious objection (N = 167)

This study explored perioperative nurses’ attitudes towards the legalization of CO to induced abortion, as well as their intentions to assert objector status. Prior to the legalization of abortion in the formal health care system, this study investigated nurses’ views on CO.

In this study, 45.8% supported legislation granting healthcare professionals CO status, while 22.9% opposed it. In fact, prior to this survey, most nurses (71.3%) were unaware of healthcare professionals’ CO. Logistic regression analysis showed that awareness about CO prior to this survey was significantly associated with support for the legislation. Most of the nurses in this study were unfamiliar with the issue of CO. More generally, South Koreans in the nursing profession have not actively discussed this issue. Within the nursing profession, discussions about issues regarding nurses’ CO and other related matters such as practice, policy, education, and management, are needed.

This study also asked about nurses’ view on the conflict between nurses’ right to CO and patients’ right to health care service for an abortion. The majority (68.7%) answered that patients’ rights to health care take priority, whereas 21.1% answered that nurses’ CO takes priority. In a previous study, 75.7% of nurses answered that patients’ rights to health care choices took precedence, while 24.3% answered that nurses’ CO should take precedence [ 23 ]. This is a similar trend to that in our study, which demonstrated that nurses were more than three times as likely to report that patients’ rights take priority. In our study, this was significantly associated with support for this legislation, as well as the nurses’ willingness to refuse to participate in providing abortion care. Respondents who reported that the nurses’ rights should take priority were more likely to support this legislation and to be willing to refuse to participate in providing abortion care than were those who answered “I do not know.”

There have been debates about whose rights should take precedence. Some insist that health care professionals’ right to CO should take precedence to protect their basic human rights and freedom of conscience and to prevent compromising their moral integrity and ethical well-being [ 16 ]. In addition, whether abortion is even medically beneficial to women’s health in the majority of cases is fiercely contended [ 24 ]. In contrast, others insist that health care providers’ right of conscience should not take precedence over patients’ conscience, health, and life [ 12 ]. Because it is not prima facie obvious, balance between these two competing perspectives is important in policy making. Some countries allowing CO have policies in place to reduce difficulties that women face in seeking abortion care services [ 9 ]. In other countries that prohibit CO, almost all health care providers who object to abortion choose to work in areas that are not involved in this procedure so that they can avoid moral distress while fulfilling the requirements of their professional role [ 12 ]. In South Korea, the effects of CO to abortion on health care professionals, the health care system, and women’s health needs active social discussion.

Regarding the refusal to provide abortion care, 42.5% of the nurses showed a willingness to refuse to participate in an abortion case if CO was permitted. In Davis et al., 66.4% of nurses reported they were likely to assert CO in cases that went against their religious or moral beliefs [ 23 ]. Other research has shown comparatively lower percentages. In a study by Nieminen et al., 3.5–14.1% of Finnish nursing and medical students, nurses, and physicians intended to assert CO to induced abortion [ 25 ]. Moreover, Nordstrand et al. reported that 14.7–18.5% of Norwegian medical students would be willing to refuse abortions in situations based on the length of the pregnancy and the motivation for seeking an abortion [ 26 ]. One reason for the varying rates in these studies might be that they were performed in the context of differing social reasons and health care systems. Another reason could be a measurement issue, as how the questions were asked differed between studies. Thus, it is difficult to compare the numbers directly.

Nurses’ assertion of CO to protect their moral integrity could cause problems such as discrimination against patients, limitations to patients’ access to care, difficulties in nursing staff management, and an increased workload for colleagues [ 15 ]. The number of nurses per 1,000 people in South Korea was 6.9 in 2017, which was lower than the average of 8.8 for all OECD countries and much lower than those of the top three countries (Norway, Switzerland, and Iceland with 17.7, 17.2, and 14.5, respectively) [ 27 ]. Nursing shortages and high turnover rates are issues in South Korea [ 28 ]. The Nursing shortage itself negatively affects patients’ access to care. Within the context of a national nursing shortage, nurses’ CO may have more of an effect on Korean women’s ability to receive appropriate care and may place a greater burden on managers and colleagues than it does on women in other countries that have more nurses per capita. Given nursing shortage, nurses’ ethical decision may impact patients’ access to beneficent care and nurses’ level of stress differently [ 29 ].

Although a national nursing shortage may affect the negative outcomes of nurses’ CO, certain strategies may reduce these negative outcomes. If a health care institution has a sufficient number of nurses who are non-objectors, those who object may more easily refuse when experiencing moral distress without burdening their colleagues or limiting patients’ access to care. Nurses’ CO is closely related to the issue of staffing in each institution. To protect nurses’ ethical beliefs without affecting patients’ access to care, hospital administrators and nurse managers need to make efforts to maintain a sufficient number staff and have an effective nursing staffing system in place. Moreover, ethical climates in the workplace play an important role in preventing negative outcomes from nurses’ behaviour based on their conscience [ 30 ].

On the other hand, prohibiting CO may also negatively affect patients’ health. In this study, four out of ten nurses reported their intention to CO. If CO is prohibited, nurse objectors may leave their job to avoid abortion, which would worsen the nursing shortage in abortion care. Furthermore, if they do not leave their job, they may experience negative feelings such as burnout, fatigue, anxiety, and frustration with moral distress, which could affect patients’ health and safety [ 15 ]. Therefore, considering nurses’ CO requires a more judicious approach for providing beneficial care to patients.

Of the respondents, 47.3% stated that they had a religion. Having a religion was a significant predictor of nurses’ intention to assert CO in this study. This is consistent with the findings of previous studies. In the Strickland study of medical students in the UK, Muslim and non-Muslim students had differing rates of intention to assert CO [ 31 ]. In Nordstrand et al., both perceiving religion to be important and having a religion were significantly related to medical students’ willingness to assert CO to abortion [ 26 ]. In this study, nurses who perceived religion as important were more likely to refuse to provide abortion care. Moreover, in Italy, where the Catholic Church has a greater influence on society, 68.4% of gynaecologists are conscientious objectors [ 32 ].

Regarding the type of religion, protestantism was statistically associated with nurses’ intention to assert CO, and the odds ratio for nurses who were Protestants was 2.209 (1.073–4.549; p  = 0.032) compared with those who had no religious affiliation. On the other hand, Catholicism and Buddhism were not statistically significant factors. Among the nurses, 28.1% were Protestants, 15.0% were Roman Catholic, and 4.2% were Buddhist. In the Census Data, 43.9% of the South Korean population has a religion, and Korea’s three major religions—Protestantism, Buddhism, and Roman Catholicism—account for 19.7%, 15.5%, and 7.9% of the population, respectively [ 33 ]. In this study, the percentage of Buddhists is lower than in the general population because Buddhism is most popular among the elderly population.

Prior to the Constitutional Court ruling, the Protestant and Catholic churches of South Korea strongly expressed their official positions in favour of continuing the law banning abortion, while the Buddhists remained neutral. Specifically, the legislation of the Catholic Church is strongly against abortion [ 17 ], and the Catholic Church of South Korea demonstrated its strong opposition to abortion with a cardinal announcement and a signature-gathering campaign that reached more than one million people. Also reflecting the Catholic Church’s position, previous studies have revealed Catholic health care providers’ refusal to provide abortion care [ 17 , 32 ]. However, in this study, there was no significant difference between the willingness to assert CO of Catholic nurses and nurses without a religion. The small sample size collected in the hospital could be one reason that this study does not show the influence of Catholicism. Another reason could be that Catholic nurses may have a somewhat different attitude than that of the general Catholic population because of other factors, such as professional duty. This study did not include specific questions to gather information on how the legislative framework of Catholicism impacted nurses’ intention to CO. Further research is needed to explore how nurses’ belief as Catholics increases their potential to become conscientious objectors.

This study has some limitations. First, this study used the reference of pregnancy at 22 weeks’ duration when asking about ethical dilemmas and CO; therefore, thoughts about various pregnancy durations could not be examined. Further research is needed to explore nurses’ perceptions about other pregnancy durations such as 12 and 16 weeks. Second, this study included perioperative nurses in a large hospital. However, medical abortions are more frequently provided internationally, and nurses involved in that procedure may experience a different type of stress to those involved in surgical abortions [ 34 ]. In South Korea, as abortion is legalized, the number of medical abortions will increase. Therefore, further research needs to include the perceptions of nurses in obstetrics and genecology clinics where most medical abortions are performed. Finally, this study was performed at one hospital. This limits the ability to generalize the results thereof.

This study provides information for further discussions of nurses’ CO. Four out of ten nurses reported their intention to refuse to provide abortion care. The number of nurses who supported a CO clause in the abortion law was double those who opposed it. Furthermore, the majority answered that patients’ rights to health care take priority over nurses’ right to refuse it. Nursing leaders, researchers, and educators should appeal to nurses and involve them in formulating national health care policies that balance nurses' right to maintain their moral integrity with women’s rights to nondiscrimination and appropriate care. The nursing profession should seriously consider whether insisting on nurses’ right to CO is needed and should be actively involved in the process of determining the new abortion law and related policies.

As shown in this study, a considerable number of nurses want to refuse their involvement in an abortion. If CO is prohibited as per the current position of the Ministry of Health and Welfare, strategies need to be prepared to reduce these nurses’ moral distress in providing abortion care and for preventing a nursing shortage in this field. On the other hand, even if CO is legally protected, some nurses at health care institutions with insufficient nurse manpower may have difficulty in asserting their CO. Countermeasures for this issue should be prepared. Nurses’ ethical well-being is necessary in terms of providing high-quality nursing care and in ensuring patients’ safety.

This study furthers our understanding of nurses’ CO, as it is the first empirical study on this issue in South Korea. This study is especially timely and needed as we are entering a new era of legalized abortion in South Korea. More research should be performed to provide knowledge for nursing practice. In addition, because abortion has been banned for a long time, nursing education has rarely dealt with ethical issues including CO, which is why many nurses in this study were unaware of CO to abortion. Nursing education including the undergraduate curriculum and continuing education should include material dealing with the ethical issues of abortion and related CO.

Acknowledgements

Not applicable.

Abbreviations

Authors’ contributions.

All authors, CMK, CKK, and YSL, made substantial contributions to conception and design and drafting the article. Analysis and interpretation of data were performed by CMK and CKK. All authors have read and approved the manuscript.

This work was supported by the Sungshin Women's University Research Grant of 2017. This funding source had no role in study design, execution, analyses, interpretation of the data, or decision to submit results.

Availability of data and materials

Ethics approval and consent to participate.

This study was approved by the institutional review board of the university hospital where the research was performed. Signed consent was waived, and verbal consent for participation was obtained. Nurses were fully informed and voluntarily decided to participate in the study. Data were collected and managed to protect the privacy and confidentiality of the participants.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Chung Mee Ko, Email: rk.ca.nihsgnus@eelkmc .

Chin Kang Koh, Email: rk.ca.uns@hokc .

Ye Sol Lee, Email: rk.ca.uns@ayodgna .

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Journal Retracts Studies Cited in Federal Court Ruling Against Abortion Pill

The journal found that the studies, which had suggested that medication abortion is unsafe, included incorrect factual assumptions and misleading presentation of the data.

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By Pam Belluck

An academic journal publisher this week retracted two studies that were cited by a federal judge in Texas last year when he ruled that the abortion pill mifepristone should be taken off the market .

Most of the authors of the studies are doctors and researchers affiliated with anti-abortion groups, and their reports suggested that medication abortion causes dangerous complications, contradicting the widespread evidence that abortion pills are safe .

The lawsuit in which the studies were cited will be heard by the Supreme Court in March. The high court’s ruling could have major implications for access to medication abortion, which is now the most common method of pregnancy termination.

The publisher, Sage Journals, said it had asked two independent experts to evaluate the studies, published in 2021 and 2022 in the journal Health Services Research and Managerial Epidemiology, after a reader raised concerns.

Sage said both experts had “identified fundamental problems with the study design and methodology, unjustified or incorrect factual assumptions, material errors in the authors’ analysis of the data, and misleading presentations of the data that, in their opinions, demonstrate a lack of scientific rigor and invalidate the authors’ conclusions in whole or in part.”

The publisher also retracted a third study by many of the same authors that was published in 2019 in the same journal, which did not figure in the mifepristone lawsuit.

Sage said that when it had begun examining the 2021 study, it confirmed that most of the authors had listed affiliations with “pro-life advocacy organizations” but had “declared they had no conflicts of interest when they submitted the article for publication or in the article itself.”

Sage said it had also learned that one of the reviewers who evaluated the article for publication was affiliated with the Charlotte Lozier Institute, the research arm of Susan B. Anthony Pro-Life America.

The institute denied that the studies were flawed, as did the lead author, James Studnicki, who is vice president and director of data analytics at the institute.

“Sage is targeting us,” Dr. Studnicki, who has a doctor of science degree and a master’s degree in public health, said in a video defending the team’s work.

Noting that the studies had been used in legal actions, he said: “We have become visible, people are quoting us, and for that reason we are dangerous, and for that reason they want to cancel our work. What happened to us has little or nothing to do with real science and has everything to do with political assassination.”

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The lawsuit seeking to bar mifepristone — the first pill in the two-drug medication abortion regimen — was filed against the Food and Drug Administration by a consortium of groups and doctors who oppose abortion. In fighting the lawsuit, the federal government has defended its approval and regulation of mifepristone, provided years of evidence that the pill is safe and effective and argued that the plaintiffs have no legal standing to sue because they are not abortion providers and have not been harmed by mifepristone’s availability.

In his opinion last April, Judge Matthew J. Kacsmaryk cited the 2021 study to support his conclusion that the plaintiffs had legal standing to sue. That study reported a higher rate of emergency room visits after medication abortions than after procedural abortions. Citing it, Judge Kacsmaryk wrote that the plaintiffs “have standing because they allege adverse events from chemical abortion drugs can overwhelm the medical system and place ‘enormous pressure and stress’ on doctors during emergencies and complications.”

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Judge Kacsmaryk’s opinion was criticized by many legal experts, and an appeals court struck parts of it but said significant restrictions should be placed on mifepristone that would prevent it from being mailed or prescribed by telemedicine.

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Similarly, she said, some justices would already have concluded that the vast majority of studies show mifepristone is safe, so if a justice was “prepared to say that, notwithstanding the weight of the evidence, mifepristone is really dangerous, you could easily do that again if you lose a couple of studies.”

Pam Belluck is a health and science reporter, covering a range of subjects, including reproductive health, long Covid, brain science, neurological disorders, mental health and genetics. More about Pam Belluck

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Texas Is Letting a Maternal-Mortality Skeptic Investigate Maternal Mortality

Dr. ingrid skop thinks 9-year-olds can have safe pregnancies and “abortion regret” is deadlier than abortion bans., nina martin.

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Mother Jones; Jose Luis Magana/AP

Just a few years ago, maternal mortality was the rare reproductive justice issue that seemed to transcend partisan politics. In late 2018, Republicans and Democrats in Congress even came together to approve $60 million for state maternal mortality review committees (MMRCs) to study why so many American women die from causes related to pregnancy and childbirth. Donald Trump—not exactly famous for his respect toward pregnant women and new mothers in his personal life—signed the bill.

But some Republicans’ enthusiasm for these committees began to wane at around the same time abortion rights advocates began warning that draconian restrictions on reproductive care would only push the shamefully high US maternal mortality rate— the worst among affluent countries—even higher. Nor did conservatives, like Idaho lawmakers , appreciate the policy recommendations that came out of many MMRCs.

Texas, whose record on maternal mortality (and maternal health more broadly ) has been an embarrassment since long before Dobbs , has a history of controversial attempts to play down potentially unwelcome findings from its MMRC . After the Dobbs decision, when the state committee was working on its report examining maternal deaths in 2019, Texas officials decided to slow-roll its release until mid-2023—too late for lawmakers to act on its recommendations. “When we bury data, we are dishonorably burying each and every woman that we lost,” one furious committee member told the Texas Tribune . Ultimately, officials released the report three months late, in December 2022. Soon afterward, the Legislature reconfigured the MMRC, increasing its size—but also ejected one of its most outspoken members. 

Now Texas officials have stirred up the biggest furor yet, appointing a leading anti-abortion activist to the panel. Dr. Ingrid Skop, an OB-GYN who practiced in San Antonio for 25 years , will join the MMRC as a community member representing rural areas (even though she is from the seventh-largest city in the US). But she also represents a largely overlooked segment of the anti-abortion movement: researchers who seek to discredit the idea that abortion restrictions are putting women’s lives in danger. To the contrary, Skop and her allies argue that abortions are the real, hidden cause of many maternal deaths—and that abortion restrictions actually save mothers’ lives.

Skop and her allies argue that abortions are the real, hidden cause of many maternal deaths—and that abortion restrictions actually save mother’s lives .

One of several doctors suing to revoke the Food and Drug Administration’s approval of mifepristone, the medication abortion drug at the center of one of this term’s blockbuster Supreme Court cases, Skop has been a familiar face on the anti-abortion expert-witness circuit for more than a decade. She has frequently testified in favor of strict abortion bans in court cases, state legislatures, and before Congress. In a high-profile case this winter, she submitted an affidavit stating that a Dallas woman named Kate Cox — who was seeking a judge’s permission to terminate a nonviable pregnancy—did not qualify for an abortion under Texas’s medical exception. The Texas Supreme Court rejected Cox’s petition, and to get medical care, the 31-year-old mother of two had to flee the state. Apparently, Skop’s hard-line stance against abortion-ban exemptions extends to children. At a 2021 congressional hearing, she testified that rape or incest victims as young as 9 or 10 could potentially carry pregnancies to term. “If she is developed enough to be menstruating and become pregnant, and reached sexual maturity,” Skop said , “she can safely give birth to a baby.”

Skop’s relatively new role as vice president and director of medical affairs for the Charlotte Lozier Institute, the research arm of Susan B. Anthony Pro-Life America, has solidified her standing in the anti-abortion firmament. Lozier, which has positioned itself as the anti-abortion alternative to the Guttmacher Institute , described Skop’s role as “coordinat[ing] the work of Lozier’s network of physicians and medical researchers who counter the abortion industry’s blizzard of misinformation with science and statistics for life.” Elsewhere on its website, Lozier notes that Skop’s “research on maternal mortality, abortion, and women’s health has been published in multiple peer-reviewed journals.”

What her Lozier bio doesn’t mention is that three of the studies  Skop co-authored about the purported risks of abortion were retracted by their publisher this February. Attorneys representing Skop and her fellow anti-abortion doctors had cited the studies in the FDA-mifepristone case. As my colleague Madison Pauly reported , an independent review of the papers found “fundamental problems,” “incorrect factual assumptions,” “material errors,” “misleading presentations,” and undisclosed conflicts of interest between the studies’ authors (including Skop) and anti-abortion advocacy groups (including Lozier). In a rebuttal on its website, Lozier called the publisher’s move “meritless,” adding, “There is no legitimate reason for [the] retractions.”

Skop’s work on maternal mortality hasn’t received the same attention as those papers—yet. But her reflections on maternal deaths in the US have raised plenty of eyebrows.

Skop has argued repeatedly that abortions are directly and indirectly behind the rise in maternal mortality in the US. In a 53-page “Handbook of Maternal Mortality ” she wrote for Lozier last year, she says that CDC maternal mortality data can’t be trusted in part because “there is much unreported maternal mortality and morbidity associated with legal, induced abortion, often obscured due to the political nature of the issue.” She claims that a history of abortions puts women at risk in pregnancy, childbirth, or during the postpartum period—whether from maternal complications she contends are linked to prior abortions, or from mental health problems, such as drug addiction and suicide, purportedly caused by abortion regret. 

In another paper co-written with some of the same co-authors as in her retracted studies, Skop and her colleagues call for an overhaul of how states and the CDC collect maternal mortality data, urging the inclusion of “mandatory certification of all fetal losses,” including abortions.

And whereas the vast majority of public health experts predict that maternal deaths and near-deaths will increase in states with abortion bans, Skop takes the opposite view. In yet another Lozier paper, she lists 12 reasons why states with abortion bans will have fewer maternal deaths. For instance, she argues, because of abortion restrictions, women will have fewer later-term abortions, which tend to be more dangerous to women than first-trimester procedures. (In fact, researchers report , that state bans have led to an increase in second-trimester abortions.) She claims that since women who don’t have abortions won’t have mental health problems supposedly associated with pregnancy loss, their alleged risk of postpartum suicide would be reduced. (In fact, the idea that abortion regret is widespread and dangerous has been thoroughly debunked .) Skop makes a similar argument about abortion’s purported (and disproven) link to breast cancer, arguing that fewer abortions will mean fewer women dying of malignant tumors.

Much of Skop’s advocacy work has been done in collaboration with colleagues who share her strong ideological views. MMRCs, by contrast, have a public health role that is supposed to transcend politics—their focus is on analyzing the deaths of expectant and new mothers that occur within a year of the end of the pregnancy. Typically, committee members come from a wide range of professional backgrounds: In Texas, these include OB-GYNs, high-risk pregnancy specialists, nurses, mental health providers, public health researchers, and community advocates. Panels also aim to be racially and geographically diverse, the better to understand the communities—Black, Indigenous, rural, poor—where mothers are at disproportionate risk of dying. In a country that hasn’t prioritized maternal health, MMRCs are uniquely positioned to identify system failures and guide policy changes that can save lives.

Texas’s most recent maternal mortality report found that 90 percent of maternal deaths were preventable, racial disparities in maternal outcomes weren’t improving, and severe childbirth complications were up 23 percent—all before the state’s abortion bans took effect.

It remains to be seen how someone with Skop’s background and agenda will fit in with her new colleagues, especially at this dire moment for women in the state. Maternal health advocates aren’t optimistic: “This appointment speaks volumes about how seriously certain state leaders are taking the issue of maternal mortality,” Kamyon Conner, executive director of the Texas Equal Access Fund, told the Guardian . “It is another sign that the state is more interested in furthering their anti-abortion agenda than protecting the lives of pregnant Texans.”

Skop, contacted through Lozier, didn’t respond to a request for comment. In a statement to the Texas Tribune , Skop said she was joining the Texas MMRC because questions about maternal mortality data deserve “rigorous discourse.” “There are complex reasons for these statistics, including chronic illnesses, poverty, and difficulty obtaining prenatal care, and I have long been motivated to identify ways women’s care can be improved,” she said. “For over 30 years, I have advocated for both of my patients, a pregnant woman and her unborn child, and excellent medicine shouldn’t require I pit one against the other.”

Meanwhile, the American College of Obstetricians and Gynecologists criticized Skop’s appointment, asserting that members of any maternal mortality review committee should be “unbiased, free of conflicts of interest and focused on the appropriate standards of care.”

“The importance of the work done by MMRCs to inform how we respond to the maternal mortality crisis cannot be overstated,” the group said in a statement. “It is crucial that MMRC members be clinical experts whose work is informed by data, not ideology and bias.”

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