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On Friday, the Missouri legislature has banned abortions, among the most extreme of all states. It prohibits abortion after eight weeks of gestation, which places it in the category of "heartbeat bills", wrongly called, which use fetal heart activity as a marker of … well, illegality. In line with a law signed earlier last week in Alabama, the Missouri bill provides no exceptions in the event of rape or incest. That makes eight American states with similar extreme bans on their books – each vying to be the law that gets its way to the Supreme Court and overturns Roe v. Wade, the 1973 decision that legalized abortion in the United States.
None of these restrictions came into effect, either because of delays inherent in the legislation itself or because of legal difficulties. If they do, they will trigger a vast unintentional public health experiment. Already, states with the lowest access to abortion are also those with the highest rates of maternal and infant mortality. The link is not direct: access to abortion can be a substitute for access to all kinds of antenatal and postnatal health care, not to mention the approximate correlation with better funded education systems , lower poverty rates and stricter environmental regulations. However, historical evidence suggests a hypothesis: more women and babies will fall ill, become poor and die.
In the mid-2000s, posters concerned with the mental health of women who had an abortion were commonplace and Supreme Court justices expressed concern that these women would experience a psychologically detrimental "regret." Diana Greene Foster, a demographer at UC San Francisco, began to wonder if this was true. Until then, most research on abortion outcomes compared women who had had one to those who were pregnant and had a baby. This is science – isolate what you want to study by looking at those who have it and those who do not.
This is not a great science, however, because, as Foster understood, the control group did not really control. He did not isolate the variable. What you really need to do is look at women who have had an unwanted pregnancy and who have asked for abortion, and compare those who have had one with those who have not. made. "If you impose abortion restrictions, it's people who want an abortion and have a child, so it's important to master the science," says Foster. "What is the effect if women can get the abortion they want? Or can not get the abortion that they want? "
Foster and his colleagues have painstakingly put together a new experience. Between 2008 and 2010, they used visits to the abortion clinic to recruit women into three groups: 273 women who had a first trimester abortion, 452 women who had an abortion until two weeks later. the pregnancy limit of the clinic and 231 whose pregnancies were up to three weeks more than pregnancy limit of the clinic and were therefore denied an abortion. In other words: had, had hardly, did not have.
(It should be noted that half of these women had incomes below the federal poverty line, three-quarters of whom said they did not have enough money for food, shelter and transportation. children.)
Foster's team then spent five years on the phone following the women to find out what was going on. She called Turnaway Study and the first thing that was found was that the mental health problems of women who wanted an abortion and got them were unfounded. "We have not seen any difference in mental health over time, except that people who are denied treatment are getting worse in terms of self-esteem," Foster said. (Even this effect was short-lived, one week after the denial, the self-confidence of the groups was the same six months later.)
The Turnaway study however found some differences. Women in the women's waiting group were more likely to be poor six months after their visit to the clinic – and still poor four years later. Among the returnees, those who had more children after the one for whom they were repressed has tightened the maternal bonds with this initial child. If a laid-back woman had children – like 61% of them – these children scored below the standard measures of development and, again, were more likely to live below the federal poverty line. following years. And to be clear, poverty is a primary risk factor for health problems and for reducing access to health care. "Half of these women have said, the reason I want an abortion is that I can not afford to have a child," Foster said. "This study does not say that poor women should have an abortion. He says that women who want an abortion should do it. "
The Turnaway study also does not say that being a mother makes poor women. Not alone. "This is a major predictor of poverty in our country, not because of its prevalence, but because we are penalizing all aspects," Foster said. "The supports we have for low-income women are not enough to keep them from falling into poverty." Approximately 4,000 women are denied clinics every year because of the delay in gestation – which becomes more and more restrictive under the law. six-week prohibitions. If these laws come into effect, that number is likely to increase.
It is true, however, that poverty is only an indirect indicator of health outcomes. The Foster team reviewed an article on the actual and longer-term health consequences of delays, but it has not been published yet, and I have not found any studies comparing outcomes in states with different levels of access to abortion beyond the time when women have an abortion during a pregnancy. – second trimester abortions are becoming more common – and well-known statistical instruments against maternal and infant mortality.
Fortunately – well, maybe not "happily", but you know what I mean – other countries have already conducted this experiment.
Take Romania. Abortion was legal until 1966, when Nicolae Ceausescu became president and declared it illegal, as well as contraception. He said that he wanted to increase the number of Romanians born in the country. Women were forced to pass pelvic inspections at work. Police informants have been wandering in maternity wards. To abort was a crime.
As a result, the birth rate in Romania increased for a few years, then in 1970, it fell in free fall. The number of deaths due to complications resulting from illegal abortion attempts has been multiplied by ten compared to the rest of Europe – about 500 women per year, more than 10,000 women in two decades. The maternal mortality rate has reached 150 women per 100,000 births. This number is incredibly high. Today, while the United States has the worst maternal mortality rate in the industrialized world, it is only the sixth (except in Louisiana, where the maternal mortality rate for women over 35 years is 145.9 per 100,000 births). In addition, nearly 200,000 children were placed in infernal orphanages.
In December 1989, a revolution eliminated the Ceausescu government. The new leaders have put in place an emergency public health measure to legalize abortion and contraception. The maternal mortality rate dropped by 50% in the first year.
Does it disgust you? Here is the reverse. In the midst of its concerns about maternal mortality, Nepal legalized abortion in 2002. In the next decade or so, 1,200 clinicians have learned to perform abortions and 500,000 women have had abortions. had. The maternal mortality rate has dropped from 360 to 170 per 100,000 live births and, while the number of abortion complications has increased – along with the total number of hospitalizations and live births – the number of serious complications decreased.
While pregnancy, in general, is about 14 times more risky than a legal abortion, much of the danger in the past came from illegal abortions – often performed without qualified clinicians, sometimes with dangerous methods involving the insertion of objects into the womb of the woman. When we talk about clandestine abortions and the death of hangers in the United States, that's what they mean. Prior to legalization, in the United States, hundreds of women would die each year as a result of induced abortion (as opposed to "spontaneous abortion", a technical term used to describe a miscarriage). Legalization has also resulted in fewer births of low birth weight and premature births.
But there is a reason to hope here, in the back. If abortions become illegal again, the mifepristone and misoprostol drugs could fight the most dangerous surgical improvisations. Today, in the United States, both drugs are used, often in combination, to cause an abortion. It's oddly called a "medical" abortion (because of the drug, not because it needs a doctor), as opposed to a "surgical" abortion, even though it typically uses suction, aspiration , not the scalpel. By law, pharmacies can issue prescriptions for misoprostol; only abortion providers, clinicians, can provide mifepristone.
The usual dosages for abortion – up to 10 weeks' gestation – are 200 mg mifepristone and 800 microgram misoprostol, although lower doses of misoprostol, up to 400 μg, may also work. Taking these drugs at these doses will induce an abortion. An organization called Plan C has a lot of information about it.
For example, in Romania, "abortion mortality exploded because people were doing illegal things, and finally, people figured out how to do safer things," says Foster. "When this is illegal, it can be extremely dangerous, but I hope it will not happen in the United States. I hope that the pills online or something will meet the needs. "
As all recreational drug users on the Dark Web know (or men too embarrassed to ask a doctor for bonus pills), online sellers offer the same drugs, otherwise only available on prescription. It may sound like a scary prospect – are they reliable, are the pills real, are they just going to steal money? But when a team of researchers tried to get drugs for abortion online, they found that it actually worked. In the United States, misoprostol was lower in concentration than FDA approved pills. Some packaging was damaged, but what they received from 16 different online pharmacies were chemically tested in the same way and usually cost less than going to the clinic.
Online pills could make this chapter of the history of abortion better than the last. "It's not a crazy idea. It's not necessarily dangerous, said Elizabeth Raymond, a gynecologist and researcher at Gynuity Health Products, who led the study on online shopping. "Part of the problem of the situation is that it is not clearly legal … If a woman orders these pills abroad, its legality is not clear." Raymond is also conducting a study to see how telemedicine and prescriptions for these drugs could help displace the shrinking number of clinics in the United States.
If six-week bans come into effect, if roe is overthrown, some states will make the abortion essentially illegal or totally illegal, while others try to guarantee the maintenance of legality. The public health experience will begin and both populations will need it. Some women will have access to safe abortions; others will not do it. Gets, does not understand. Control group and experimental. And like any advanced science, no one really knows how that experience will unfold.
Graphics and additional research by Joanna Pearlstein.
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