Reflections on post-Roe America, one year after Dobbs

This weekend marked one year since the Supreme Court overturned Roe v. Wade in the historic Dobbs vs. Jackson case — removing the federal protection for abortion that existed for 50 years prior. This is not an anniversary to celebrate, but one that merits taking a pause to unpack the innumerable impacts, and reignite activism as we further our fight towards expanding equitable access to women’s health and women’s rights in a radically new world.

So what’s changed? The short version is… a lot — both things we long predicted, like long wait-times and geographic barriers to abortion, but also many things we didn’t predict, or fully anticipate would manifest — like declines in OB/GYN residency programs.

Here’s a recap of the top 10 primary and secondary effects of Dobbs on women and our world (including some reasons to be hopeful!).

Primary effects of Dobbs:

#1: Abortion access is now severely limited for 1 in 3 American women, who live in states where abortion is completely unavailable or severely restricted. 14 states currently have total abortion bans and 11 states have some restrictions on abortion access.

#2: Abortion bans compound existing inequities in the healthcare system — disproportionately impacting Black, Latinx, Indigenous people, trans and nonbinary individuals, adolescents, immigrants, and people with low income or disabilities.

For example, the majority of women seeking abortions in states with total bans are Black, due to the intersection of race, geography, contraceptive access, health insurance coverage, and systematic bias and discrimination.

#3: While abortion remains legal in 25 states + Washington D.C., women in protected states also face risks and more limited access.

Despite legal complications, cross-state-line travel for abortion is the new norm and on the rise. In California for example, demand has quadrupled at many clinics due to out-of-state travel. This surge in demand from women out of state creates an abortion “supply gap” with longer wait-times that affects all women — an obvious “domino effect” given gestational limitations.

Secondary effects of Dobbs:

While these primary effects were, in certain ways, predictable and also a byproduct of a long and slow erosion of rights over the last two decades, the second order effects have been more surprising, and especially harrowing.

#4: Dobbs has exacerbated the national OB/GYN shortage — Resident applications in OB/GYN have dropped 5% nationally and by more than 10% in states with total abortion bans since the Dobbs ruling.

For some context — the U.S. already faces a national OB/GYN shortage and many states with total bans were characterized as OB/GYN or maternity “deserts” pre-Dobbs. The drop in applications will exacerbate access to reproductive healthcare in these states, which already have the highest maternal mortality rates in the U.S.

How can we call upon the next generation to sign up for the “frontlines” when our system fundamentally restricts the ability for OB/GYNs to get their full training, operate in their full capacity as a physician, imposes significant legal risk on their practice, and for those delivering abortion services, puts the safety of physicians and their families in jeopardy?

#5: Worsening overall health outcomes — Abortion access and women’s health tend to go hand in hand. Research from the Commonwealth Fund found that states with abortion restrictions have fewer maternity care providers, contributing to higher rates of maternal mortality and infant death, and higher overall death rates for women of reproductive age — especially among women of color.

We see the inverse as well; states with abortion access have as high as 30% better health outcomes than states with abortion restrictions for EVERYONE across key indicators such as premature death and use of preventative health care services.

#6: Curbing women’s economic & social empowerment — While it’s likely too soon to see the long-term effect of Dobbs on women’s economic and social empowerment quantitatively, research has long shown that legal abortion access increases women’s education, labor force participation, occupational prestige, and earnings and that all these effects are particularly large for Black women. Studies also show that access to abortion not only affects women’s economic and social lives, but also improves the lives of their children.

UCSF’s landmark Turnaway Study shows that denying a woman an abortion creates economic hardship and insecurity that lasts for years and negatively impacts the financial wellbeing and development of their children.

Bright Spots: Innovation & Reasons for Hope

While the primary and secondary impacts of the Dobbs ruling are far-reaching and significant, it’s not all doom and gloom. There have been a number of innovations and bright spots in the reproductive health landscape that show the potential for increasing access and outcomes — even amidst unprecedented restrictions.

#7: Medication abortion expansion — In the heat of the Dobbs oral arguments in 2021, the FDA issued new guidance removing the medically-unnecessary in-person dispensing requirements for medication abortion, which paved the way for the expansion of access to medication abortion through telemedicine. As a result of this decision, and the growth in providers like Tia offering medication abortion, the use of medication abortion has grown significantly and is a rare bright spot in the abortion access landscape. Despite recent attempts to revoke its FDA approval, medication abortion remains legal and available both in-person and virtually in 24 states & Washington D.C. And 12 additional states allow medication abortion, but restrict its use via telemedicine.

#8: Progressive states “cement” abortion protections — 17 states and Washington D.C. have passed laws that protect the right to abortion. Some, such as California, Michigan, and Vermont, have gone even further to enshrine the right to abortion in their state constitutions.

Due to the rise of cross-state line travel for care, several states have taken steps to pass “shield laws” in order to protect providers and patients from legal action and make their states a “haven” for abortion access by, for example, prohibiting state agencies from complying with out-of-state investigations or ending out-of-pocket costs for abortion.

#9: Political mobilization via elections & ballot initiatives — In the first national election after the Dobbs ruling, abortion was cited as a central issue for 2022 midterm voters — mobilizing women and men to the pools. And, we saw the ability for abortion to sway local elections even in more conservative or purple states. As an example, a ballot initiative to add a constitutional amendment enshrining the right to abortion in the Michigan constitution got the most signatures of any ballot initiative in state history.

#10: Over-the-counter birth control — Just last month in May, FDA advisors voted to make the birth control pill available over-the-counter; the FDA is expected to approve the pill this summer. At a time of growing restrictions on abortion access, expanding access to contraception is a critical step to preventing unwanted pregnancies and increasing women’s reproductive autonomy.

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These wide-ranging primary and secondary effects to abortion access make it evident just how integral the ability (or lack thereof) for women to make independent choices over one’s own body and life is to everything else.

One year later, I continue to mourn the loss of Roe and what this fundamental erosion of rights represents. But, the pragmatic, idealist in me is also looking ahead; instead of trying to save Roe, I am focused instead on innovating within new confines — more determined and inspired than ever to continue expanding access to comprehensive women’s healthcare for all. The moral and economic imperative has never been greater.