Racial/ethnic and educational inequities in restrictive abortion policy variation and adverse birth outcomes in the United States

"I Went Into This Field to Empower Other People, and I Feel Like I Failed": Residents Experience Moral Distress Post-Dobbs

Background The 2022 Supreme Court ruling in Dobbs v Jackson Women's Health Organization nullified the constitutional right to abortion, which led to effective bans in at least 14 US states and placed obstetrics and gynecology (OB/GYN) residents in dilemmas where they may have to withhold care, potentially causing moral distress-a health care workforce phenomenon less understood among resident physicians. Objective To identify and explore moral distress experienced by OB/GYN residents due to care restrictions post-Dobbs. Methods In 2023, we invited OB/GYN residents, identified by their program directors, training in states with restricted abortion access, to participate in one-on-one, semi-structured interviews via Zoom about their experiences caring for patients post-Dobbs. We used thematic analysis to analyze interview data. Results Twenty-one residents described their experiences of moral distress due to restrictions. We report on 3 themes in their accounts related to moral distress (and 4 subthemes): (1) challenges to their physician identity (inability to do the job, internalized distress, and reconsidering career choices); (2) participating in care that exacerbates inequities (and erodes patient trust); and (3) determination to advocate for and provide abortion care in the future. Conclusions OB/GYN residents grappled with moral distress and identified challenges from abortion restrictions.

Self-care interventions for women's health and well-being

The human right to health is universal and non-exclusionary, supporting health in full, and for all. Despite advances in health systems globally, 3.6 billion people lack access to essential health services. Women and girls are disadvantaged when it comes to benefiting from quality health services, owing to social norms, unequal power in relationships, lack of consideration beyond their reproductive roles and poverty. Self-care interventions, including medicines and diagnostics, which offer an additional option to facility-based care, can improve the autonomy and agency of women in managing their own health. However, tackling challenges such as stigma is essential to avoid scenarios in which self-care interventions provide more choice for those who already benefit from access to quality healthcare, and leave behind those with the greatest need. This Perspective explores the opportunities that self-care interventions offer to advance the health and well-being of women with an approach grounded in human rights, gender equality and equity.

Abortion training in U.S. obstetrics and gynecology residency programs in a post-Dobbs era

OBJECTIVES

The Accreditation Council for Graduate Medical Education requires all obstetrics and gynecology residents have access to abortion training. The impact of Dobbs on training remains unknown. We aimed to describe residency programs affected by abortion bans and those lacking abortion training despite permissive state policies. We considered demographic data to understand the impacts on residents under-represented in medicine.

STUDY DESIGN

We used residency databases and websites to abstract data. We identified programs offering routine abortion training as either those with Ryan Programs or those with website or email acknowledgment of training. We defined states with abortion bans as those with either complete or 6-week bans as of December 2022. We used χ2 and Student's t tests in descriptive analyses and performed a logistic regression to adjust for demographic and program-specific variables.

RESULTS

Of 286 residency programs included, 140 (49%) offered routine abortion training prior to Dobbs. As of December 2022, 19 of these (14%) had lost the ability to provide routine in-state abortion training. Of 223 residency programs in states with legal abortion, 102 (46%) programs lacked routine abortion training. These sites were more likely to be community or community-university programs, with graduates more likely to practice as generalists. Resident race/ethnicity did not differ between residents in states with legal abortion vs abortion bans.

CONCLUSIONS

Nearly half of obstetrics and gynecology residency programs in states with legal abortion do not appear to provide routine abortion training. Further work is needed to understand this paucity of training and maximize access in legislatively permissible environments.

IMPLICATIONS

Following Dobbs, 14% of residency programs lost in-state abortion training. Notably, in states with legal abortion, 46% of programs lack routine abortion training despite permissive legislation. This presents a window of opportunity for expansion of abortion training, particularly at community and community-university hybrid residency sites.

Association Between Restricted Abortion Access and Child Entries Into the Foster Care System

Importance

The 2022 US Supreme Court decision Dobbs v Jackson Women's Health Organization overturned federal protections to abortion care, allowing many states to severely restrict or ban access to abortion. Given the implications of the Dobbs ruling, there is a need to understand the full consequences of restricted abortion access. Before 2022, many states restricted access to safe and legal abortions through Targeted Regulation of Abortion Providers (TRAP) laws, which provide a historical mode for estimating the consequences of abortion restrictions.

Objective

To use TRAP law enactment as a natural experiment to quantify the association between restricted abortion access and foster care entries.

Design, Setting, and Participants

In this cohort study, data on the enactment of TRAP laws and case-level data on foster care entries were used to estimate the association between restricted abortion access and foster care entries in each of the 50 US states and the District of Columbia. The sample included children conceived between January 1, 1990, and December 31, 2011, who were placed into foster care at any point between January 1, 2000, and December 31, 2020. Data analysis was performed from January 2023 to July 2023.

Exposures

Restricted abortion access due to state-level TRAP laws during pregnancy.

Main Outcomes and Measures

The main outcome was the number of children entering foster care in each state, measured by year of child conception. The analysis was performed using a generalized difference-in-differences design, comparing entries into foster care in states with TRAP laws to states without TRAP laws, before and after their implementation.

Results

This study included 4 179 701 children who were placed into foster care during the study period, with 11 016 561 entries. More than half of the children were male (51.4%), and the mean (SD) age was 7.4 (5.2) years. There was an 11% increase in foster care placement after abortion access was restricted in states with TRAP laws, relative to states without TRAP laws (incidence rate ratio [IRR], 1.11 [95% CI, 1.01-1.23]). These laws had significant consequences for Black children (IRR, 1.15 [95% CI, 1.05-1.28]) and racial and ethnic minority children (IRR, 1.15 [95% CI, 1.02-1.30]). The increase in entries due to TRAP laws was particularly attributable to housing inadequacy (IRR, 1.21 [95% CI, 1.11-1.32]).

Conclusions and Relevance

Restricted abortion access can have numerous consequences, and these findings reveal a heightened strain on the US foster care system, particularly affecting marginalized racial and ethnic communities and financially vulnerable families. These placements have been shown to have lifelong consequences for children and substantial costs for both states and the federal government. To further examine the widespread implications of the overturning of Roe v Wade, future studies should forecast the expected increase in foster care entries and estimate the expenditure needed to support these children.

The impact of hostile abortion legislation on the United States maternal mortality crisis: a call for increased abortion education

The growing restrictive abortion policies nationwide and the Supreme Court decision on Dobbs v. Jackson Women's Health Organization place increasing barriers to abortion access in the United States. These restrictions disproportionately affect low-income people of color, immigrants, and non-English speakers, and have the potential to exacerbate already existing racial inequities in maternal and neonatal outcomes. The United States is facing a Black maternal health crisis where Black birthing people are more than twice as likely to experience maternal mortality and severe maternal morbidity compared to White birthing people. Restrictions creating geographic, transportation, and financial barriers to obtaining an abortion can result in increased rates of maternal death and adverse outcomes across all groups but especially among Black birthing people. Restrictive abortion laws in certain states will decrease already limited training opportunities in abortion care for medical professionals, despite the existing abortion provider shortage. There is an immediate need for federal legislation codifying broad abortion care access into law and expanding access to abortion training across medical education. This commentary explores the impact of restrictive abortion laws on the Black maternal health crisis through multiple pathways in a logic model. By identifying current barriers to abortion education in medical school and residency, we created a list of action items to expand abortion education and access.

Reproductive Justice as a Framework for Abortion Care

This article presents an in-depth analysis of abortion access and rights within the Reproductive Justice framework, underscoring the health, social, and economic consequences of limited access. It emphasizes the critical role of abortion as essential, safe health care and highlights the complexities surrounding abortion decisions and the barriers faced by poor and historically marginalized populations. Amid the escalating access restrictions, the article concludes with a call to action for obstetricians and gynecologists and our allied health care providers to recognize, support, and advocate for safe, legal, and affordable abortion services as fundamental to health care equity and human rights.

Travel for later abortion in the USA: lived experiences, structural contributors and abortion fund support

As abortion restrictions expand in the USA, pregnant people will continue to experience delays and be forced to travel for abortion. The study aims to describe later abortion travel experiences, understand structural factors influencing travel, and identify strategies to improve travel. This qualitative phenomenological study analyses data from 19 interviews with people who travelled at least 25 miles for abortion after the first trimester. Framework analysis used a structural violence lens. More than two-thirds of participants travelled interstate, and half received abortion fund support. Key considerations of travel include logistics, challenges during the journey, and physical and emotional recovery during and after travel. Restrictive laws, financial insecurity and anti-abortion infrastructure are forms of structural violence that created challenges and delays. Reliance on abortion funds facilitated access but also entailed uncertainty. Better resourced abortion funds could organise travel in advance, facilitate the travel of accompanying escorts, and tailor emotional support to reduce stress for those travelling. Clinical and practical support systems must be prepared to support people travelling for abortion, as later abortion and forced travel is increasing since the constitutional right to abortion in the USA was overturned. Findings can inform interventions to support the increasing number of people travelling for abortion.

Characteristics and Outcomes of Patients With Pregnancy-Related End-Stage Kidney Disease

Importance

The incidence of pregnancy-related acute kidney injury is increasing and is associated with significant maternal morbidity including progression to end-stage kidney disease (ESKD). Little is known about characteristics and long-term outcomes of patients who develop pregnancy-related ESKD.

Objectives

To examine the characteristics and clinical outcomes of patients with pregnancy-related ESKD and to investigate associations between pre-ESKD nephrology care and outcomes.

Design, Setting, and Participants

This was a cohort study of 183 640 reproductive-aged women with incident ESKD between January 1, 2000, and November 20, 2020, from the US Renal Data System and maternal data from births captured in the US Centers for Disease Control and Prevention publicly available natality data. Data were analyzed from December 2022 to June 2023.

Exposure

Pregnancy-related primary cause of ESKD, per International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes reported at ESKD onset by the primary nephrologist on Centers for Medicare and Medicaid Services form 2728.

Main Outcomes Measures

Multivariable Cox proportional hazards and competing risk models were constructed to examine time to (1) mortality, (2) access to kidney transplant (joining the waiting list or receiving a live donor transplant), and (3) receipt of transplant after joining the waitlist.

Results

A total of 341 patients with a pregnancy-related primary cause of ESKD were identified (mean [SD] age 30.2 [7.3]). Compared with the general US birthing population, Black patients were overrepresented among those with pregnancy-related ESKD (109 patients [31.9%] vs 585 268 patients [16.2%]). In adjusted analyses, patients with pregnancy-related ESKD had similar or lower hazards of mortality compared with those with glomerulonephritis or cystic kidney disease (adjusted hazard ratio [aHR], 0.96; 95% CI, 0.76-1.19), diabetes or hypertension (aHR, 0.49; 95% CI, 0.39-0.61), or other or unknown primary causes of ESKD (aHR, 0.60; 95% CI, 0.48-0.75). Despite this, patients with pregnancy-related ESKD had significantly lower access to kidney transplant compared with those with other causes of ESKD, including (1) glomerulonephritis or cystic kidney disease (adjusted subhazard ratio [aSHR], 0.51; 95% CI, 0.43-0.66), (2) diabetes or hypertension (aSHR, 0.81; 95% CI, 0.67-0.98), and (3) other or unkown cause (aSHR, 0.82; 95% CI, 0.67-0.99). Those with pregnancy-related ESKD were less likely to have nephrology care or have a graft or arteriovenous fistula placed before ESKD onset (nephrology care: adjusted relative risk [aRR], 0.47; 95% CI, 0.40-0.56; graft or arteriovenous fistula placed: aRR, 0.31; 95% CI, 0.17-0.57).

Conclusion and Relevance

In this study, those with pregnancy-related ESKD had reduced access to transplant and nephrology care, which could exacerbate existing disparities in a disproportionately Black population. Increased access to care could improve quality of life and health outcomes among these young adults with high potential for long-term survival.

Implications of Overturning Roe v Wade on Abortion Training in US Family Medicine Residency Programs

In June 2022, the US Supreme Court overturned Roe v Wade, opening the door to state-level abortion bans. By August 2023, 17 states banned abortion or instituted early gestational age bans. We performed an analysis to assess the proportion of accredited US family medicine residency programs and trainees in states with abortion restrictions. Twenty-nine percent of family medicine residency programs (n = 201) and residents (n = 3,930) are in states with bans or very restrictive policies. Family medicine residency programs must optimize training and exposure to abortion within their contexts, so graduates are able to care for patients seeking abortions or needing follow-up care.

The association between reproductive rights and access to abortion services and mental health among US women

Background

This study examines whether living in US states with (1) restrictive reproductive rights and (2) restrictive abortion laws is associated with frequent mental health distress among women.

Methods

We operationalize reproductive rights using an overall state-level measure of reproductive rights as well as a state-level measure of restrictive abortion laws. We merged data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) with these state-level exposure variables and other state-level information. We used multilevel logistic regression to assess the relationship between these two measures and the likelihood of reporting 14 or more days of frequent mental health distress. We also tested whether associations differed across race, household income, education, and marital status.

Results

In the adjusted models, a standard deviation-unit increase in the reproductive rights score was significantly associated with decreased odds of reporting frequent mental health distress (OR = 0.95, 95% CI = 0.91, 0.99). Women in states with very hostile abortion restrictions had higher odds of frequent mental health distress. Associations between state-level abortion restrictions were larger among women 25-34 years old and women with a high school degree. For example, women aged 25-34 years residing in moderate (OR = 1.54, 95% CI = 1.14, 2.04), hostile (OR = 1.59, 95% CI = 1.15, 2.18), and very hostile (OR = 1.29, 95% CI = 1.02, 1.64) states were more likely to report frequent mental health distress than women living in states with less restrictive abortion policies.

Conclusion

We found the association between state-level restrictions on reproductive rights and abortion access and frequent mental health distress differed by age and socioeconomic status. These results suggest abortion rights restrictions may contribute to mental health inequities among women.

Examining ethno-racial attitudes of the public in Twitter discourses related to the United States Supreme Court Dobbs vs. Jackson Women's Health Organization ruling: A machine learning approach

Background

The decision of the US Supreme Court to repeal Roe vs. Wade sparked significant media attention. Although primarily related to abortion, opinions are divided about how this decision would impact disparities, especially for Black, Indigenous, and people of color. We used advanced natural language processing (NLP) techniques to examine ethno-racial contents in Twitter discourses related to the overturn of Roe vs. Wade.

Methods

We screened approximately 3 million tweets posted to Roe vs. Wade discussions and identified unique tweets in English-language that had mentions related to race, ethnicity, and racism posted between June 24 and July 10, 2022. We performed lexicon-based sentiment analysis to identify sentiment polarity and the emotions expressed in the Twitter discourse and conducted structural topic modeling to identify and examine latent themes.

Results

Of the tweets retrieved, 0.7% (n = 23,044) had mentions related to race, ethnicity, and racism. The overall sentiment polarity was negative (mean = -0.41, SD = 1.48). Approximately 60.0% (n = 12,092) expressed negative sentiments, while 39.0% (n = 81,45) expressed positive sentiments, and 3.0% (n = 619) expressed neutral sentiments. There were 20 latent themes which emerged from the topic model. The predominant topics in the discourses were related to "racial resentment" (topic 2, 11.3%), "human rights" (topic 2, 7.9%), and "socioeconomic disadvantage" (topic 16, 7.4%).

Conclusions

Our study demonstrates wide ranging ethno-racial concerns following the reversal of Roe and supports the need for active surveillance of racial and ethnic disparities in abortion access in the post-Roe era.

Trends in Abortion- and Contraception-Related Internet Searches After the US Supreme Court Overturned Constitutional Abortion Rights: How Much Do State Laws Matter?

Importance

The US Supreme Court ruling in Dobbs v Jackson Women's Health Organization on June 24, 2022, revealed immediate and distinct differences between states regarding abortion legality. Whether the ruling was associated with population-level changes in seeking information on reproductive health care-related information is unknown.

Objective

To determine whether the US Supreme Court ruling on Dobbs v Jackson Women's Health Organization was associated with increased information seeking for reproductive health care access in the states with immediately effective (trigger and pre-Roe) abortion laws vs other states.

Design, Setting, and Participants

This was a retrospective cross-sectional study of nationwide real-time internet search data by state-week from January 1, 2021, through July 16, 2022. Difference-in-difference event study estimates were used to evaluate abortion- and contraception-related internet searches after the Supreme Court draft majority decision was leaked on May 2, 2022, and the final ruling was issued on June 24, 2022, in states immediately affected vs other states. Data analyses were performed from July 18 to January 14, 2022.

Exposures

The Supreme Court's draft majority decision leaked on May 2, 2022, and the final ruling on Dobbs v Jackson Women's Health Organization on June 24, 2022. Preexisting state trigger laws and pre-Roe bans that became effective immediately when Roe was overturned by the decision on Dobbs.

Main Outcomes and Measures

Number of searches per 10 million Google queries in a state-week for terms related to abortion or contraception.

Results

Searches for abortion-related terms increased from 16 302 to 75 746 per 10 million searches per state-week during the weeks before vs after the May 2, 2022, leak of the draft majority decision in states with trigger laws or abortion bans. This was a 42% (95% CI, 24%-59%) higher increase than in states with laws that protect abortion access. Searches for contraception also increased from 56 055 to 82 133 searches per state-week after the ruling in the states with abortion bans, 25% (95% CI, 13%-36%) higher than the increase in states protecting abortion access.

Conclusions and Relevance

The findings of this retrospective cross-sectional study suggest that changes in internet searching for terms related to reproductive health care can capture immediate population-level changes in information-seeking behavior regarding reproductive health care access. These data are critical for shaping health policy discussions.

Estimation of Multiyear Consequences for Abortion Access in Georgia Under a Law Limiting Abortion to Early Pregnancy

Importance

Following the US Supreme Court ruling in Dobbs v Jackson Women's Health Organization, Georgia's law limiting abortion to early pregnancy, House Bill 481 (HB481), was allowed to go into effect in July 2022.

Objectives

To estimate anticipated multiyear effects of HB481, which prohibits abortions after detection of embryonic cardiac activity, on abortion incidence in Georgia, and to examine inequities by race, age, and socioeconomic status.

Design, Setting, and Participants

This repeated cross-sectional analysis used abortion surveillance data from January 1, 2007, to December 31, 2017, to estimate future effects of HB481 on abortion care in Georgia, with a focus on the 2 most recent years of data (2016 and 2017). Abortion surveillance data were obtained from the 2007-2017 Georgia Department of Public Health's Induced Termination of Pregnancy files. Linear regression was used to estimate trends in abortions provided at less than 6 weeks' gestation and at 6 weeks' gestation or later in Georgia, and χ2 analyses were used to compare group differences by race, age, and educational attainment. Data were analyzed from July 26 to September 22, 2022.

Exposures

HB481, Georgia's law limiting abortion to early pregnancy.

Main Outcome and Measures

Weeks' gestation at abortion (<6 vs ≥6 weeks).

Results

From January 1, 2007, to December 31, 2017, there were 360 972 reported abortions in Georgia, with an annual mean (SD) of 32 816 (1812) abortions. Estimates from 2016 to 2017 suggest that 3854 abortions in Georgia (11.6%) would likely meet eligibility requirements for abortion care under HB481. Fewer abortions obtained by Black patients (1943 [9.6%] vs 1280 [16.2%] for White patients), patients younger than 20 years (261 [9.1%] vs 168 [15.0%] for those 40 years and older), and patients with fewer years of education (392 [9.2%] with less than a high school diploma and 1065 [9.6%] with a high school diploma vs 2395 [13.5%] for those with some college) would likely meet eligibility requirements under HB481.

Conclusions and Relevance

These findings suggest that Georgia's law limiting abortion to early pregnancy (HB481) would eliminate access to abortion for nearly 90% of patients in Georgia, and disproportionately harm patients who are Black, younger, and in lower socioeconomic status groups.

Alignment of state-level policies and public attitudes towards abortion legality and government restrictions on abortion in the United States

BACKGROUND

Contextual factors can shape public opinion towards abortion. We investigated the association between the state-level abortion legislative climate and individual attitudes towards abortion legality and government restrictions of abortion access in the United States.

METHODS

Data come from the 2020 Cooperative Congressional Election Study (n = 61,000). Using multivariable logistic regression with generalized estimating equations, we explored whether state-level abortion policy climates (based on the Guttmacher Institute's 2020 rating of state abortion policies) were associated with individual attitudes (1) towards abortion legality, and (2) towards government restriction of abortion access, controlling for individual socio-demographic factors.

RESULTS

Eighty-eight percent of participants supported the legality of abortion in some or all circumstances. Conversely, 30% of the sample opposed all federal government restrictions on abortion. More than 60% of the sample lived in highly abortion-restrictive states. Participants living in states with a more supportive abortion legislative climate were more likely to support the legality of abortion in some or all circumstances (AOR = 1.07, (95% CI 1.05, 1.09). Participants in states with more supportive abortion policies were more likely to oppose federal governmental restrictions (AOR = 1.03, 95% CI 1.02, 1.04). Low religiosity, higher educational attainment, and politically liberal views were associated with increased support for abortion legality and increased opposition to government restrictions on abortion.

CONCLUSIONS

State-level abortion policy contexts were positively associated with public attitudes towards abortion. While attitudes towards abortion legality are favorable across the country; there is also strong support at least one type of government restriction on abortion access. Results highlight a disconnect between multifaceted public attitudes towards abortion and polarized state contexts, suggesting that policymaking on abortion represents a higher level of polarization than exists at the individual level. Policymakers and legislators should more carefully consider the desires of the public when designing abortion legislation.

Patient concerns about accessing sexual and reproductive health services outside of primary care: A survey in rural and urban settings in the Pacific Northwest

OBJECTIVES

While primary care providers are a major source of sexual and reproductive health (SRH) services in the United States, particularly in rural areas, not all primary care settings offer a full range of SRH services. We aimed to understand primary care patient concerns regarding accessing SRH services, including abortion care, outside of their primary care clinic and if those concerns differed by urban or rural setting.

STUDY DESIGN

An anonymous survey was distributed over a 2-week period between December 2019 to March 2020 to all adult patients in four primary care clinics in Idaho, Washington, and Wyoming. The survey assessed patient concerns regarding accessing SRH services outside of their primary care clinic and their willingness to travel to access SRH services.

RESULTS

The overall response rate was 69% (745/1086). Over 85% of respondents identified at least one concern to seeking SRH services outside of a primary care setting, with cost, insurance coverage, length of wait time, and lack of an established relationship being the most frequently reported concerns. A majority of respondents were willing to travel a maximum of 1 hour for most SRH services. Respondents from rural-serving clinics were significantly more likely to be willing to travel longer amounts of time for medication abortion, aspiration abortion, and intrauterine device placement.

CONCLUSION

Our findings highlight that a majority of both urban and rural primary care patients have concerns regarding accessing SRH services outside of their primary care clinic and are unwilling to travel more than 1 hour to access most SRH services.

IMPLICATIONS

A majority of primary care patients have concerns regarding accessing SRH services outside of primary care settings. Health care policy changes should aim to strengthen the SRH services available in primary care settings to alleviate the burdens primary care patients face in accessing SRH services outside of their primary care clinic, particularly for rural populations.

Medication Abortion "Reversal" Laws: How Unsound Science Paved the Way for Dangerous Abortion Policy

Objectives. To longitudinally examine the legal landscape of laws requiring abortion patients be informed about the possibility of medication abortion (MAB) "reversal" (in quotes as it does not refer to an evidence-based medical procedure). Methods. We collected legal data on enacted state MAB-reversal laws across all 50 US states and Washington, DC, (collectively, states) from 2012 through 2021. We descriptively analyzed these laws to identify legal variation over time and geography, and conducted a content analysis to identify qualitative themes and patterns in MAB-reversal laws. Results. As of 2021, 14 states (27%)-mostly in the midwestern and southern United States-have enacted MAB-reversal laws. States largely use explicit language to describe reversal, require patients receive information during preabortion counseling, require physicians or physicians' agents to inform patients, instruct patients to contact a health care provider or visit "abortion pill reversal" resources for more information, and require reversal information be posted on state-managed Web sites. Conclusions. Reversal laws continue a dangerous precedent of using unsound science to justify laws regulating abortion access, intrude upon the patient‒provider relationship, and may negatively affect the emotional and physical health of patients seeking an MAB. (Am J Public Health. 2023;113(2):202-212. https://doi.org/10.2105/AJPH.2022.307140).

A global review of penalties for abortion-related offences in 182 countries

Public health research and human rights bodies have demonstrated the risks involved with criminalising abortion services and noted a need for full decriminalisation. Despite this, abortions are criminalised in some circumstances in almost all countries in the world today. This paper uses data from the Global Abortion Policies Database (GAPD) to analyse what criminal penalties exist for those who are seeking, providing and assisting in abortions in 182 countries.This paper uses data on abortion-related penalties available on the GAPD as of October 2022. It includes which actors are penalised, whether specific penalties exist for negligence, non-consensual abortions, whether any secondary additional considerations/judicial discretion exist in sentencing and the legal sources for these penalties.134 countries penalise abortion-seekers, 181 countries penalise abortion-providers and 159 countries penalise persons assisting in abortions. The maximum penalty is between 0 and 5 years of imprisonment in a majority of countries; however, it can be much higher in other countries. Some countries further prescribe fines, and professional sanctions for providers and those who assist. 34 countries restrict the dissemination of information about abortion.The range of possible penalties across countries and associated aggravating and mitigating factors for imposing these penalties support arguments for the decriminalisation of abortion on the grounds of arbitrariness. Abortions are also predominantly regulated through the criminal law, which may compound the stigma associated with seeking, assisting with and/or providing abortions when it is criminalised.There has been no comprehensive study of penalties for abortion at a global level. This article describes what specific penalties abortion seekers and providers face, what factors may increase or decrease these penalties, and the legal sources for these penalties. The findings provide additional evidence of the arbitrariness and potential for stigma associated with the criminalisation of abortion and strengthen the case for decriminalisation.

In Support of Reproductive Health Justice

Restrictions to the provision of essential health care during pregnancy is dangerous, erodes efforts to improve maternal health and reduce inequities, and violates the code of ethics we pledge to uphold.

Post-Roe emergency medicine: Policy, clinical, training, and individual implications for emergency clinicians

In June 2022, the United States Supreme Court decision Dobbs v. Jackson Women's Health Organization overturned Roe v. Wade, removing almost 50 years of precedent and enabling the imposition of a wide range of state-level restrictions on abortion access. Historical data from the United States and internationally demonstrate that the removal of safe abortion options will increase complications and the health risks to pregnant patients. Because the emergency department is a critical access point for reproductive health care, emergency clinicians must be prepared for the policy, clinical, educational, and legal implications of this change. The goal of this paper, therefore, is to describe the impact of the reversal of Roe v. Wade on health equity and reproductive justice, the provision of emergency care education and training, and the specific legal and reproductive consequences for emergency clinicians. Finally, we conclude with specific recommended policy and advocacy responses for emergency medicine clinicians.

"They're forcing people to have children that they can't afford": a qualitative study of social support and capital among individuals receiving an abortion in Georgia

Abortion is common but highly stigmatized in the United States, and the overturning of Roe v. Wade severely restricted abortion access in many states across the nation. Data reveal that maternal morbidity and mortality are already increasing, and research suggests existing inequities in abortion access across racial/ethnic and socioeconomic groups will be exacerbated. Research has shown that social support (perceived and received aid from one's social network) and social capital (resources accessed through those social connections) can improve access to health services and decrease barriers to care. Given the escalating barriers to abortion, including longer travel distances, it is imperative to better understand the roles of social support and social capital within abortion access, especially for people living on lower incomes and people of color. Our team conducted in-depth interviews with post-abortion patients (n = 18) from an urban abortion clinic in Georgia in 2019 and 2020, shortly after a six-week gestational age abortion limit had been passed but before it was enacted. We examined how people described their social support and social capital - or lack thereof - when making decisions about their pregnancy and their ability to access abortion. We found that social support and social capital - economic support in particular - were key facilitators of both abortion access and parenting, but participants often experienced barriers to economic support within their social networks due to poverty, unstable partnerships, structural inequality, and abortion stigma. Women experienced constraints to their reproductive autonomy, wherein they had no alternatives but abortion. Our findings suggest that increased economic support and de-stigmatization of abortion are needed to improve reproductive autonomy. Our findings also indicate that restricting and outlawing abortion services is significantly detrimental to the well-being of pregnant people, their families and networks, and their communities by perpetuating cycles of poverty and deepening socioeconomic and racial/ethnic inequities.

Mifepristone: A Safe Method of Medical Abortion and Self-Managed Medical Abortion in the Post-Roe Era

BACKGROUND

The U.S. Supreme Court's Dobbs v. Jackson Women's Health Organization decision on June 24, 2022 effectively overturned federal constitutional protections for abortion that have existed since 1973 and returned jurisdiction to the states. Several states implemented abortion bans, some of which banned abortion after 6 weeks and others that permit abortion under limited exceptions, such as if the health or the life of the woman is in danger. Other states introduced bills that define life as beginning at fertilization. As a result of these new and proposed laws, the future availability of mifepristone, one of two drugs used for medical abortion in the United States, has become the topic of intense debate and speculation.

AREAS OF UNCERTAINTY

Although its safety and effectiveness has been confirmed by many studies, the use of mifepristone has been politicized regularly since its approval. Areas of future study include mifepristone for induction termination and fetal demise in the third trimester and the management of leiomyoma.

DATA SOURCES

PubMed, Society of Family Planning, American College of Obstetrician and Gynecologists, the World Health Organization.

THERAPEUTIC ADVANCES

The use of no-touch medical abortion, which entails providing a medical abortion via a telehealth platform without a screening ultrasound or bloodwork, expanded during the COVID-19 pandemic, and studies have confirmed its safety. With the Dobbs decision, legal abortion will be less accessible and, consequently, self-managed abortion with mifepristone and misoprostol will become more prevalent.

CONCLUSIONS

Mifepristone and misoprostol are extremely safe medications with many applications. In the current changing political climate, physicians and pregnancy-capable individuals must have access to these medications.

Community-led research for reproductive justice: Exploring the SisterLove Georgia Medication Abortion project

Introduction

While reproductive injustice indicators are improving globally, they are worsening in the United States particularly for Black and other marginalized communities. Eugenics and obstetric violence against low-income and communities of color create well-founded distrust of sexual and reproductive health (SRH). Transformational, reparative ways of conducting SRH research are needed.

Proposed principles of community-led research for reproductive justice

Drawing on our collective experience as reproductive justice leaders, SRH researchers, and clinicians, we propose the following principles of community-led research for reproductive justice: 1) Center the marginalized community members most affected by SRH inequities as leaders of research; 2) Facilitate equitable, collaborative partnership through all phases of SRH research; 3) Honor multiple ways of knowing (experiential, cultural, empirical) for knowledge justice and cross-directional learning across the team; 4) Build on strengths (not deficits) within the community; 5) Implement the tenets of reproductive justice including structural-level analysis and the human rights framework; 6) Prioritize disseminating useful findings to community members first then to other audiences; 7) Take action to address social and reproductive injustices.

SisterLove's community-led georgia medication abortion project

We offer the community-led Georgia Medication Abortion (GAMA) Project by reproductive justice organization SisterLove from 2018-2022 as a case study to demonstrate these principles along with the strengths and challenges of reproductive justice research.

Discussion

Community-led reproductive justice research offers innovative and transformational methods for truly advancing SRH in an era of increasing policy restrictions and decreasing access to care. Yet existing funding, research administrative, and publishing systems will require structural change.

Projected Implications of Overturning Roe v Wade on Abortion Training in U.S. Obstetrics and Gynecology Residency Programs

In June 2022, the U.S. Supreme Court is expected to issue a decision on Dobbs v Jackson Women's Health Organization, a direct challenge to Roe v Wade. A detailed policy analysis by the Guttmacher Institute projects that, if Roe v Wade is overturned, 21 states are certain to ban abortion and five states are likely to ban abortion. The Accreditation Council for Graduate Medical Education requires access to abortion training for all obstetrics and gynecology residency programs. We performed a comprehensive study of all accredited U.S. obstetrics and gynecology residency programs to assess how many of these programs and trainees are currently located in states projected to ban abortion if Roe v Wade is overturned. We found that, of 286 accredited obstetrics and gynecology residency programs with current residents, 128 (44.8%) are in states certain or likely to ban abortion if Roe v Wade is overturned. Therefore, of 6,007 current obstetrics and gynecology residents, 2,638 (43.9%) are certain or likely to lack access to in-state abortion training. Preparation for the reversal of Roe v Wade should include not only a recognition of the negative effects on patient access to abortion care in affected states, but also of the dramatic implications for obstetrics and gynecology residency training.