By Katelyn Jetelina

Public health touches on all aspects of our lives, not just during a pandemic and not just with infectious diseases. Thanks to your feedback, this newsletter will continue with COVID updates but will start touching on other epidemiological topics, too. For example, women’s health. If you would only like COVID19 updates, go to your settings HERE and deselect “Your Local (Women’s Health) Epidemiologist”, “Your Local (Violence) Epidemiologist” and “Your Local (MH) Epidemiologist.”

On Monday, a Supreme Court document was leaked and concluded what we already knew was coming: Roe v. Wade will be overturned in the United States. For now abortion is federally legal, but this is expected to change in June. This decision will have a ripple effect through many sectors, including public health.

Epidemiology
Abortions are not rare. One in four women will have an abortion by the time they reach 45 years old. This means that you know someone who has gotten an abortion, like me.

The CDC has an abortion surveillance program so we can understand the rate of abortions in the U.S. and how they’ve changed over time. Unfortunately this data isn’t perfect due to the voluntary reporting structure (i.e. all data is underreported), but it’s the best we have. The latest data published was from a 2022 study in MMWR:

In 2019, 629,898 people in the U.S. received an abortion. This equals 11.4 abortions per 1,000 women aged 15–44 years or 191 abortions per 1,000 live births.

This is an underestimate; the true number of abortions in the United States is closer to 1.2 million a year.

In 2019, New York had the highest number of abortions (78,587), followed by Florida and Texas.

Abortion rates have declined overtime. Since the 1990s, the total number of reported abortions declined 50% and, in 2010, there was another significant push downwards thanks to the Affordable Care Act and increased access to birth control.

Abortions won’t stop
One thing that is evident is that abortions won’t stop because laws change. This is best illustrated by Texas in recent months. On September 1, 2021, Texas enacted a law banning all abortions after the detection of a heart beat—typically 5 or 6 weeks after conception. This was the most restrictive state-level abortion law in the U.S. This health policy change provided a critical insight on a post-Roe world in the U.S.

Almost immediately, the number of legal abortions dropped in Texas. In August 2021, Texas recorded 5,377 legal abortions. In September 2021, this fell to 2,164. Compared to September 2020, this was a 50% decrease in abortions.

This number decreased for several reasons, but most dramatically because of a shift in where people got an abortion. Legal abortions in nearby states skyrocketed. From September to December 2019 (before the law), 514 Texans went to nearby states for legal abortions. From September to December 2021 (after the law), 5,574 Texans went to nearby states. Among those who traveled, the majority went to New Mexico or Oklahoma.

Requests for mailed abortion pills also significantly increased. A study published in JAMA assessed the request rates for Aid Access—an international nonprofit medication abortion service that sends pills in the mail while sidestepping U.S. abortion restrictions, by connecting people with overseas doctors and pharmacies. The team found that abortion pill usage in Texas increased after the state’s law. In the first week, requests to Aid Access spiked by more than 1,180% —from about 11 requests per day to almost 138 requests per day. During the following three weeks, requests remained 245% higher than before the law. Overall, Aid Access received 1,831 requests from Texas for self-managed abortion in September 2021.

If we add # out-of-state abortions + # abortion pills + # in-state abortions, a small decrease (10%) in overall abortions was observed in Texas after the law was enacted. Even then, though, the discrepancy may be accounted by other avenues of abortion that are not readily available in data sources, like traveling to Mexico for prescriptions or procedures, or illegal procedures within the state. Nonetheless, a close to zero change in abortions is consistent with international research: the abortion rate is 37 per 1000 in countries that prohibit abortion and 34 per 1000 in countries that allow abortion.

Nationwide problem
Of course, Texas illustrates the impact of one law in one state. And, thankfully, many women were able to travel or find other ways for an abortion. With the overturn of Roe v. Wade and power handed to the states, 12 states are expected to automatically ban abortion and another 13 states will enact stricter restrictions. This will result in expansive abortion deserts across the U.S., and especially in the South. A Nature article displayed this dramatic effect nicely in a figure here.

With increased desperateness, the rate of illegal and unsafe abortions will start increasing, or people will be forced to have an unwanted pregnancy. Together, this will have immediate impacts on physical and mental health among Americans:

Mortality. Women will die. Each year, 7 million women worldwide are admitted to hospitals for unsafe abortions. 4.7-13% of those women typically die.

Morbidity. Women with illegal abortions are at higher risk for serious medical problems, including infections and damage to the genital tract and internal organs (due to inserting dangerous objects like sticks, knitting needles, broken glass).

Mental illness. Women denied an abortion have higher mental illnesses and lower well-being. A JAMA study found women denied an abortion reported more anxiety, lower self-esteem, and lower life satisfaction compared to women who were able to get an abortion. No evidence shows that getting an abortion causes negative mental health or well-being outcomes.

Economic hardship. A study in American Journal of Public Health found that women denied an abortion experience an increase in household poverty lasting at least four years longer compared to women who received an abortion. Also, years after an abortion denial, women were more likely to not have enough money to cover basic living expenses like food, housing, and transportation. The National Bureau of Economic Research found denying an abortion lowered a woman’s credit score and increased a woman’s amount of debt.

Violence. Another study found denying abortions kept women in contact with violent partners, putting themselves and their children at risk for physical and emotional harm.

Child outcomes. The Turnaway Study —at UCSF—found that when women have control over the timing of having children, the children benefit. Specifically they found: “Children born later to women who are able to get an abortion experience more economic security and better maternal bonding than the children born because a woman was denied an abortion.”

Bottom line
A law will not decrease the number of abortions. It will shift where people get abortions, increase the number of illegal abortions, directly and indirectly impact the health of women, and worsen health disparities in the U.S. We are going backwards, and it will be a public health disaster for decades to come.

Love, YLE

“Your Local Epidemiologist (YLE)” is written by Dr. Katelyn Jetelina, MPH PhD—an epidemiologist, biostatistician, wife, and mom of two little girls. During the day she works at a nonpartisan health policy think tank, and at night she writes this newsletter. Her main goal is to “translate” the ever-evolving public health science so that people will be well equipped to make evidence-based decisions. This newsletter is free thanks to the generous support of fellow YLE community members.