On its face, the June 2022 Supreme Court ruling on the Dobbs v. Jackson Women’s Health Organization case was straightforward. It removed the constitutional right to an abortion that had been established in 1973 by the court in Roe v. Wade. Decisions about access to abortion would now be left up to the states, many of whom quickly imposed tight restrictions, while a handful of other states, including Colorado, acted quickly to ensure a woman’s right to determine what is best for her health.
The effects of the Dobbs decision on the lives of women and the healthcare system writ large are much less clear, said Ned Calonge, MD, MPH, Associate Dean for Public Health Practice and associate professor of family medicine and epidemiology.
“The Dobbs decision moves beyond abortion and touches on other issues around the availability of reproductive care,” Calonge said.
A standing committee to address the effects of the Dobbs decision
Calonge was recently appointed to serve as an expert on the new Standing Committee on Reproductive Health, Equity, and Society of the National Academies of Sciences, Engineering, and Medicine. The committee is charged to “explore the health, social, and economic implications of access to reproductive health care in the United States and globally,” and will address questions raised by Dobbs, including who gets access to reproductive health services, the rights and responsibilities of providers who deliver them, and the long-term social effects of abortion restrictions on individuals, communities, states and the nation as a whole. The committee will host a public workshop October 5 to focus on identifying data needed to measure “the cascading effects” of the Dobbs decision.
“Laws laid out at the state level to severely limit access to abortion services have moved into other perinatal and reproductive health activities,” Calonge said. “The workshop will look specifically at the data sources we need to document and follow the many diverse outcomes associated with limiting reproductive health services in the United States.”
Questions of healthcare equity
Calonge noted, for example, that Dobbs “puts huge equity issues in play,” especially in those states that have made access to abortion difficult at best.
“Women who have access to resources because of their class and income can travel to get abortion services,” Calonge said. The situation is often different for low-income women and women of color living in the same states, he added. Their choices are often limited by financial pressures and the need to continue working. As a result, many of these women “will no longer have access to potential decisions around their reproductive health.” In a September 6 press release announcing the formation of the standing committee, National Academy of Medicine’s president Victor J. Dzau underscored the point.
“Access to high-quality reproductive health services was inequitable even before the Supreme Court decision on Dobbs v. Jackson, which has compounded existing challenges for women of color, from low-income backgrounds, or who live in rural areas,” Dzau said.
More broadly, Dobbs poses challenges to women as they decide on charting a course for their personal and professional lives, Calonge said.
“[The decision] may limit the ability of women to make choices about their fertility and when to time having a family,” he said.
In addition, Dobbs poses potential challenges for the healthcare workforce, Calonge said. States with tight restrictions on abortion and severe penalties for violating them “could challenge clinicians in providing care to save the life of a woman in certain circumstances,” he said.
In turn, OB-GYNs and other reproductive health providers who fear lawsuits and legal challenges have moved out of these states “because of an inability to practice,” Calonge said. “They are worried about the ethical dilemma of having to save a life versus violating state law.”
The departures can ripple through the entire healthcare system, Calonge said. States that lose providers face a decrease in the overall quality of reproductive care for women, while a state like Colorado, which protects access to abortion, must deal with the pressure of increased demand for services.
“You can’t silo abortion from other reproductive healthcare,” he said. “They are all interrelated.” As another example, he added, abortion laws that make no exception for prenatally diagnosed congenital conditions create questions about ensuring sufficient resources to care for babies and children born with physical and mental health challenges.
A demand for data
The October 5 workshop, Calonge said, aims to pinpoint the data needed “to make reasonable decisions around reproductive health services. Without it, we are hamstrung in understanding, demonstrating and addressing the downstream impacts of limiting access.”
The session will not produce recommendations for lawmakers and decisionmakers. However, the proceedings of the session will be published on the National Academy of Medicine website and the information could generate requests for follow-up studies and reports, Calonge said.
To illustrate the need for objective data about reproductive health services, he pointed to a committee he co-chaired for the National Academies that issued an exhaustive 2018 report on the safety and quality of abortion care in the United States. The report, Calonge noted, refuted unsupported claims about abortions – including that they impact future fertility, deteriorate women’s mental health, and increase their risk of breast cancer.
“The committee took the overall framework of abortion services and concluded that they are a safe and effective part of reproductive healthcare in the United States,” Calonge said.
The 2018 report was bolstered by extensive data sources. In the wake of Dobbs, robust data will again be needed to forge policies about abortion and other reproductive health services that move beyond rigid ideological positions and seek common ground, Calonge concluded.
“We have to respect the legislatures elected to represent constituencies in their states,” he said. “They bring to the table their beliefs and ethical frameworks. I hope they would have the same respect for the
fact that there are others who feel differently and at the end of the day we can find policies that provide protections for public health across the spectrum of reproductive health.”