The Community Cost of Abortion Restrictions
Access to safe and legal abortion is a crucial issue with vast implications that go far beyond individual freedom and bodily autonomy. Its denial not only restricts doctors from providing necessary medical care based on a patient’s clinical needs and erodes the physician-patient relationship, but it also weakens the quality of health care delivery and availability of health care services. Further, these laws could potentially lay the foundation for the intrusive surveillance of women’s bodies, increase criminalization and justify a system of separate legal treatment for women because of their reproductive capabilities. The denial of abortion access and reproductive rights harms entire communities.
In the United States, access to health care has never been equitable. Black patients are more likely to receive lower quality, outdated and less effective treatments from providers, and the Dobbs decision has only deepened this divide in access for marginalized communities.[1] When clinics close, communities lose more than just access to abortion services; women’s health clinics also offer cancer screenings, sexually transmitted infection (STI) testing and treatment, contraception and annual health checkups.
In 2016, researchers explored the impact of clinic closures in Wisconsin and Texas and found that increasing the distance of the nearest clinic decreases preventative care for breast and cervical cancer.[2] Similarly, another study found that laws resulting in clinic closures are correlated with decreases in cervical cancer screenings and early-stage diagnosis, as well as a significantly higher risk of dying from the cancer.[3]
For people who are struggling to make ends meet, uninsured or live in rural areas with limited access to health care, abortion clinics may be the only place they can access reproductive care. One 2012 survey of women receiving care at a Planned Parenthood or another family planning clinic found that roughly 4 in 10 (41%) were dependent on their clinic as their primary source of health care that year.[4] Experts have warned and research has demonstrated that without these clinics, other federally funded health centers would not be able to pick up the slack — and instead, hundreds of thousands of people would lose access to absolutely crucial health care services.[5]
Restrictive laws that criminalize abortion may also mean fewer doctors are willing to provide care to pregnant patients in these states. Federal documents obtained by the Associated Press reveal complaints of pregnant women being turned away from emergency rooms spiked in 2022 following the Dobbs ruling. Physicians and other medical professionals have reported how the hostile legal climate and threat of criminal penalties make it harder for them to properly care for their patients.
According to one survey, 17.6% of obstetricians and gynecologists reported that the Dobbs ruling influenced where they intend to practice medicine, and those who initially planned to practice in states that passed abortion restrictions were more than eight times more likely to relocate.[6] Another survey of over 2,000 current and future physicians found that more than three-quarters were not willing to work or train in states with abortion restrictions. An analysis by the Association of American Medical Colleges found that residency applications for all medical specialties declined by 4.2% in states that ban abortion, but by 6.7% for OB-GYNs In many states that ban abortions, doctors who are convicted of breaking abortion laws — by providing an abortion in what they consider an emergency, for example — face steep fines, the loss of their medical license and even prison time.
In March 2023, Bonner General Health hospital in Idaho cited local laws that “criminalize physicians for medical care nationally recognized as the standard of care” which are leading doctors to leave because, they say, they were forced to stop providing obstetrical services. On Jan. 5, 2024, the Supreme Court permitted Idaho to impose its extremely harsh abortion ban that even applies to medical emergencies. The state can imprison anyone who performs or assists in an abortion for up to five years.[7]
With the closure of this Bonner’s maternity ward, women in this community must travel at least 45 minutes to access a hospital with a labor and delivery department. The percentage of women who live further than 30 minutes from a hospital that offers these services is twice as high (20.1%) in the 14 states that banned abortion compared to the national average. Additionally, 43.4% of the counties in these states are considered maternity care deserts, meaning they have no birth hospitals or center, OB-GYNs or certified nurse midwives.
As of May 2024, 29 states and Washington, D.C., permit abortions at or beyond 21 weeks of pregnancy. Abortions at this gestational stage are atypical, accounting for just 1% of abortions in the United States. Individuals may choose to have this medical procedure later in pregnancy because of a range of factors including the discovery of medical conditions such as fetal abnormalities or threats to maternal health, or financial barriers resulting in a delay in care.
For many financially insecure women, the cost of traveling out of state for the procedure is too high. “Not everyone has the resources and opportunities to travel for an abortion,” Kristen Schultz, the Chief Strategy and Operations Officer for Planned Parenthood Illinois, explained to the Southern Poverty Law Center. “Patients who are already facing immense barriers to health care are the ones that are most likely harmed by these restrictive state laws and bans.” This includes people of color, people with disabilities as well as those who are incarcerated, lacking shelter or living in rural communities.
The average cost of an abortion was $500 in the first trimester and $2,000 or more in the second trimester in 2022, according to The New York Times. Patients traveling from a state with restricted access must also account for the cost of travel, lodging, food, child care and lost wages. For a patient flying from a rural town in Missouri to Chicago, Times reporters found, the costs added up to $2,368. Traveling from Idaho to Washington for a second trimester abortion cost another patient $4,884. As inflation continues to rise while wages remain stagnant, this financial burden grows annually.
In a country where most people would be unable to pay an unexpected $500 medical bill without going into debt, this financial barrier means many American women will be forced to carry an unwanted pregnancy to term. Research from 2014 estimated that three-quarters of abortion patients are struggling financially or even living below the poverty line.[8] Income inequality and unequal access to abortion among states in the U.S. have created a system of “haves” and “have-nots” when it comes to women exercising sovereignty over their own bodies.
Even when women can travel to another state for an abortion, the challenges do not end there. Women’s health clinics in states where abortion remains legal are overwhelmed by the surge in women who are seeking care from another state. Schultz of Planned Parenthood of Illinois, describing how Dobbs has affected clinics in her state one year after it was decided, explained, “we’ve experienced over a 50% increase in our overall abortion care patient volume, and we’ve seen an unprecedented number of out-of-state patients.” She added that approximately a quarter of their patients seeking an abortion traveled from another state compared to just 7% prior to Dobbs. Planned Parenthood Illinois told the SPLC that, since Dobbs, they’ve seen out-of-state patients from 40 states.
For those traveling from another state, these delays lead to additional lost wages, hotel costs and other expenses. Schultz estimates that “the number of patients needing financial assistance or travel support to get care at Planned Parenthood Illinois has more than doubled.” Many women are turning to abortion fund charities for help as a result. The Chicago Abortion Fund (CAF), which provides financial and logistical support for people seeking abortions, reported in May 2024 that have responded to 18,000 to their helpline since the Dobbs decision and, in that same period, have distributed over $6.5 million in financial assistance for people seeking abortions in the Midwest. They expect their needs to increase, thanks largely to Florida’s newly implemented ban on abortion after six weeks of gestation. CAF’s deputy director recently told Axios that the fund will likely need $100,000 more each month to aid abortion patients coming to Illinois from the South.
Doctors and other medical professionals often lack the resources needed to meet this increased demand. In the months following the Dobbs ruling, some clinics in Illinois at one point saw their wait time increase sevenfold, with appointments booked weeks in advance. Similarly, a clinic in Oklahoma City reported receiving 10 times the number of calls compared to before, while their appointments are booked weeks in advance. Longer wait times for appointments will force some women to continue an unwanted or unsafe pregnancy if they are unable to get an appointment before they reach a given state’s gestational limit on abortion.
In Alabama, reproductive justice activists are concerned about providing even basic information to people considering an out-of-state abortion. Alabama Attorney General Steve Marshall has threatened to use anti-conspiracy laws to prosecute individuals and groups who assist women traveling to another state to obtain an abortion. Though the Department of Justice warned that these prosecutions would be unconstitutional, Marshall stood by his threats.
The SPLC spoke to Kelsea McLain, the Deputy Director of Yellowhammer Fund – an abortion advocacy and reproductive justice organization that serves the Deep South – about the organization’s work in Alabama. She explained how the state’s political climate and hostility to reproductive rights has had “an incredibly huge chilling effect on people feeling safe reaching out for information and resources.” The attorney general’s threats and fear of criminalization forced Yellowhammer Fund to stop financially supporting Alabamians seeking safe and legal abortion care in another state. The Lawyering Project and the SPLC have filed a lawsuit on behalf of Yellowhammer Fund seeking to prohibit the attorney general from following through on his threats.
This fear of criminalization not only affects the support Alabamians can get in accessing abortion, but also the medical care they receive when they return home. Abortion is a safe procedure with an extremely low rate of complications, but those who are (or believe they are) experiencing complications may not be able to access quality care. “We have a lot of people that we know, we hear about, that are seeking after [abortion] care but are fearful to visit an ER or urgent care because of the criminalization,” McLain explained. In some cases, patients are likely being turned away because physicians are concerned that they may be implicated in the abortion which, under Alabama law, could mean up to 99 years in prison.
Robin Marty, the Executive Director of Operations for WAWC Healthcare (formerly the West Alabama Women’s Center), has seen a similar pattern, telling the SPLC, “We are seeing patients who are leaving the state in order to access abortion, and then come back to Alabama but believe that they have an issue and are not being able to be seen by their hospitals.”[9] Some of these women, she explains, are being told to return to the out-of-state clinic that provided the abortion care.
The fear of criminalization has damaged the relationship between doctors and their patients, resulting in a chilling effect where women are afraid to ask for necessary health information or care and physicians are afraid to provide it. Yellowhammer Fund hopes to help correct this. “One thing we’ve been working on is trying to build up networks of trusted health care providers and clinics and health care facilities that we know we can send someone to [for abortion aftercare],” McLain explained, “and they won’t be facing any sort of heightened interrogation or potential reporting.”
Even prior to the Dobbs decision, the organization Pregnancy Justice reported that at least 1,379 people were arrested because of their pregnancy between January 2006 up until the day before the Supreme Court decided to overturn the constitutionally protected right to abortion on June 24, 2022. Nearly half (46.5%) of these arrests were made in Alabama, including the arrest of Ashley Caswell, who was booked in March 2021 in Etowah County on charges of “chemically endangering a child” while pregnant. In 2013, the Alabama Supreme Court ruled that a fetus at any stage of a pregnancy is considered a child and is therefore protected by child endangerment statutes, making it one of four states to imprison women due to “fetal personhood.” In her book, Policing the Womb, Michele Goodwin, professor of constitutional law and global health policy at Georgetown University, explains, “fetal protection efforts, which are often purported to justify states’ persistent intrusions in poor women’s lives, serve to mask other politically expedient interests: controlling women and demanding their obedience, gerrymandering, pandering to tough-on-crime strategies, achieving electoral victories, and heightening moral panic.”[10]
In the name of protecting Alabama’s “unborn children,” Caswell spent the remainder of her high-risk pregnancy in jail, where she slept on a concrete floor with only a thin mat. She was denied prenatal care and her prescription medication. When her water broke in October, she was denied medical care as guards refused to take her to the hospital. She was scolded for screaming out in pain, offered only Tylenol. She spent hours vomiting, hemorrhaging blood and losing amniotic fluid, which increased the risk of infection for both Caswell and her child.
After 12 hours of labor, Caswell delivered her baby alone in a jail shower. As she fell unconscious, the guards continued to deny her even the most basic aid or medical care. Instead, they posed for photos with the baby, who was still attached to Caswell’s unconscious body through the umbilical cord. When she was finally taken to the hospital, doctors determined she had suffered a placental abruption, a life-threatening condition that could have suffocated her baby and carries a seven times higher risk of maternal mortality.
Caswell, who filed a federal civil rights lawsuit in Alabama and is being represented by the SPLC and Pregnancy Justice, is now serving a 15-year sentence, symbolizing the disparate treatment of pregnant women and their male counterparts for otherwise minor offenses. Between 2015 and 2023, Etowah County, Alabama, alone arrested 257 pregnant women and new moms under chemical endangerment of a child statutes.[11]
The law was passed in 2006 to target people who expose children to harmful chemicals and hazards like fires and explosions after converting their homes into methamphetamine labs. Instead, it has been used to effectively criminalize pregnancy and disproportionately target women — who account for 93% of arrests under this statute in Etowah County. Other arrests include a woman who smoked marijuana before she knew she was pregnant, and another who was accused of exposing her fetus to drugs and falsely imprisoned when she wasn’t even pregnant. Laws that view fetuses as people deprive women of their basic civil rights and legal protections.[12]
These laws incorrectly assume that a woman’s behavior during pregnancy is the only factor determining fetal health. In Caswell’s case, it was disproportionately enforced, ignoring how the jail environment, stress, denial of prenatal care, insufficiently nutritious meals, and the denial of urgently needed emergency medical care threatened the life of her son. Etowah County Detention Center has a history of denying medical care to pregnant women, threatening the lives of both the mother and her baby. However, no corrections officer, jail physician or administrator has faced any charges for endangering the life of a child.
In the aftermath of Dobbs, reproductive justice organizations including Yellowhammer Fund, WAWC Healthcare and Reproaction are working at the national and community level to advocate for the human right to bodily autonomy and expanding their own services in this area beyond abortion.
McLain explained that Yellowhammer Fund’s work has shifted in the post-Dobbs environment. “We’re really trying to scale up and expand our services to families because we know that there are going to be more families in need,” noting that the social service programs that are already insufficient will soon be overwhelmed.
Research has consistently demonstrated that women who are denied abortions have worse financial outcomes than women who were able to successfully get an abortion. Women denied abortions are less likely to graduate, have more debt, and are nearly four times more likely to have a household income that falls below the federal poverty level. However, the same states with the most restrictive abortion laws also offer less financial assistance to low-income families, resulting in the highest rates of child poverty in the country. Now that people are further restricted in their ability to make decisions about when and if they have children, Yellowhammer Fund’s work to expand their social safety is more important than ever.
In states that allow abortion, reproductive justice organizations are working to ensure resources that help people maintain their bodily autonomy beyond abortion access are available, including to patients from other states. Schultz emphasized Planned Parenthood’s commitment to gender-affirming care and recognizes “the same [people and institutions] that are banning and restricting abortion are targeting gender-affirming care.” She added that just as they are seeing an increase in out-of-state patients seeking abortions, the same is true for those seeking gender affirming care. Her organization is working to expand their capacity to fill this gap in care.
Attacks on abortion rights and gender-affirming care are part of the same political project that seeks to revive a white-dominated patriarchal social order by enforcing rigid gender roles. Evonnia Woods, the senior vice president of research and movement building at Reproaction recognizes this connection. Speaking with SPLC, she said, “Reproductive access [is] a really good way to subjugate half the population.” She sees this as a means to an end and, just as with attacks on the LGBTQ+ community, “they use morality as a tool to ultimately get to this end to dominate everyone. And to do it by any means necessary.”
Illustration at top by Cristiana Couceiro.
[1] Kara M. Bridges, “Implicit Bias and Racial Disparities in Health Care,” Human Rights Magazine, Vol. 43: The State of Healthcare in the United States, August 1, 2018, https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-state-of-healthcare-in-the-united-states/racial-disparities-in-health-care/.
[2] Yao Lu and David J.G. Slusky, “The Impact of Women’s Health Clinic Closures on Preventive Care,” American Economic Journal: Applied Economics 8(3) (2016): 100-124, https://pubs.aeaweb.org/doi/pdfplus/10.1257/app.20140405.
[3] A. Srivastava et al., “The Impact of the Closure of Women’s Health Clinics on Cervical Cancer in the United States,” International Journal of Radiation Oncology, Biology, Physics Vol. 105, Issue 1 (Elsevier Inc. 2019), https://www.redjournal.org/article/S0360-3016(19)31416-6/fulltext.
[4] Jennifer J. Frost, Rachel Benson Gold, Amelia Bucek, “Specialized Family Planning Clinics in the United States: Why Women Choose Them and Their Role in Meeting Women’s Health Care Needs,” Women’s Health Issues Volume 22, Issue 6 (November 2012), 519-525, https://www.guttmacher.org/sites/default/files/pdfs/pubs/journals/j.whi.2012.09.002.pdf.
[5] Hal C. Lawrence, Debra L. Ness, “Planned Parenthood Essential Services That Improve Women’s Health, “ Annals of Internal Medicine Volume 166, Number 6, https://doi.org/10.7326/M17-0217; Congressional Budget Office, American Health Care Act: Budget Reconciliation Recommendations of the House Committee on Ways and Means and Energy and Commerce, March 9, 2017.
[6] Alexandra Woodcock, et al., “Effects of the Dobbs v. Jackson Women’s Health Organization Decision on Obstetrics and Gynecology Graduating Residents’ Practice Plans,” Obstetrics & Gynecology 142 (November 2023), https://journals.lww.com/greenjournal/fulltext/2023/11000/effects_of_the_dobbs_v_jackson_women_s_health.15.aspx.
[7] Mark Sherman, “The Supreme Court is allowing Idaho to enforce its strict abortion ban, even in medical emergencies,” The Associated Press, January 5, 2024. https://apnews.com/article/supreme-court-abortion-medical-emergencies-idaho-8ca89d7de0c1fa9256dcd27d1847e144; Idaho Legislature, Defense of Life Act 18-622, Title 18: Crimes and Punishments, Chapter 6: Abortion and Contraceptives, https://legislature.idaho.gov/statutesrules/idstat/title18/t18ch6/sect18....
[8] Jenna Jerman, Rachel K. Jones, Tsuyoshi Onda, “Abortion Patients in 2014 and Changes Since 2008,” Guttmacher Institute, New York (2016), https://www.guttmacher.org/report/characteristics-us-abortion-patients-2014.
[9] West Alabama’s Women’s Center v. Marshall, Civil Action 2:23cv451-MHT (WO) (United States District Court, M.D. Alabama 2023), https://www.aclu.org/cases/west-alabama-womens-center-et-al-v-marshall-et-al#press-releases.
[10] Michele Goodwin, Policing the Womb: Invisible Women and the Criminalization of Motherhood (Cambridge University Press, 2020), 191.
[11] Amy Yurkanin, “One Alabama county cracked down on pregnant drug users. 10 years later, has it gone too far?” AL.com, Alabama: July 31, 2023, https://www.al.com/news/anniston-gadsden/2023/07/one-alabama-county-pledged-to-crack-down-on-pregnant-drug-users-ten-years-later-has-it-gone-too-far.html.
[12] E.M. Dadlez, William L. Andrews, “Not Separate, But Not Equal: How Fetal Rights Deprive Women of Civil Rights,” Public Affairs Quarterly Vol. 26, No.2 (University of Illinois Press, 2012), 103-122, https://www.jstor.org/stable/41697902.
