We need to talk about abortion: Roe v. Wade and its overturn

On June 24, 2022, the Supreme Court overturned Roe v. Wade, the 1973 case that provided women with a legal basis for a right to get an abortion. (Full text of opinion and dissent here--pay attention to page 148 to the end, the dissent.) This will make it difficult and dangerous for women in states whose legislatures oppose abortion to terminate a pregnancy. Many women, regardless of what state they live in, now believe that it is illegal for them to get an abortion. The amount of misinformation going around regarding this subject has been large, and now it is frustratingly larger.

In the face of all this confusion, I would like to praise the JAMA (Journal of the AMA) for publishing a very nice, straightforward article about how to provide medical abortion in the first 10-11 weeks of pregnancy. By medical, I mean pills. There is a pretty simple combination of a couple of common medications, one to reverse the effects of progesterone and the other to permit the cervix to open to allow passage of the products of conception. The effect is a very heavy period, with cramping and bleeding that can last a few weeks.

But the whole concept of abortion and how it has been treated in the US is fraught with difficulty. Roe v. Wade allowed that abortion was essential and that is should not be substantially regulated by the government in the first trimester and that prior to viability (a moving target, but somewhere toward the end of the second trimester) the government could not regulate it other than to provide for the health of the mother. As a fetus gets more mature, abortion gets more dangerous for the mother, and carries more emotional weight. At 15 weeks, far before it would be able to survive outside the uterus, a fetus is about the size of a small mango and looks like a baby. Having done many ultrasound exams on mothers in their first and second trimesters, I'd have to say that the little critter swimming around in the womb isn't nothing and choosing to end its brief journey would have to be heart wrenching. For both the mother and for the doctor performing the procedure. 

But women are not incubators and shouldn't be treated as that. Carrying a baby is a huge responsibility, changes ones body forever and often completely waylays ones education and life path, even if the mother decides to give up the baby for adoption. And if abortion were murder, which many anti-abortion/pro-life activists assert, does it even make sense that all of the women who decide to terminate a pregnancy and all of their doctors who provide that service are murderers? It just doesn't make sense. Getting an abortion is difficult and painful and women don't actually want to do it. When they do this difficult thing, it is to preserve their future, and in some cases their ability to have children for whom they can create a good home and a happy childhood. I see no reason to believe that state governments are more able to make a correct moral and ethical decision than individual women who are pregnant.

I am living in a state with a "trigger law" banning abortion after Roe v. Wade is overturned. The governor released a message saying that we need to support women more when abortion is no longer legal (which he is happy about), including allowing them time to take care of their babies and children and providing social support systems and family planning (I assume he means birth control.) We always needed that. If we had the ability to support young people in this way after my state bans abortion, why didn't we do it before? Was my state just being vindictive to young women? Encouraging women to get abortions because carrying a baby to term would be really hard?

But back to the JAMA article and more information I have been picking up about medical abortion. The basic facts of the process are that a women who is less than 77 days pregnant can take 200 mg of mifepristone, followed by an 800 microgram tablet of misoprostil, either dissolved in the mouth or in the vagina. These medications are easily available. Misoprostil has been used for years to protect the stomach from the irritating effects of anti-inflammatory drugs such as ibuprofen by reducing acid production and bolstering the protective mucus layer in the stomach. It is also commonly used for cervical "ripening" when inducing labor. Mifepristone, initially released as RU 486, in also useful in treating uterine tumors and Cushing's disease.  In states where abortion is legal, these drugs can be prescribed by a patient's doctor and covered by insurance. In states where abortion is prohibited, women can still buy the drugs online, with advice of a doctor, and the cost is not very high. Since the US mail is not regulated by the states, women should maintain the right to use a service like this. This does require that women be very tuned in to their cycles so that they can identify pregnancy early if they need to terminate it.

For now, there are good reasons to believe that this pill option for terminating a pregnancy will remain an option for the vast majority of women. But there is also room for doubt. States could pass laws making it illegal to obtain pills for use in a woman's own home. A congress with a particularly strong desire to control women's lives could pass a law making abortion illegal nationwide. Those are some chilling scenarios.

For now, though, what I see as the biggest impediment to women, especially those who are young or living in poverty, in getting the care they need in early pregnancy is misinformation and unwillingness to talk about these issues. I have hesitated to write about it, because I worried that strong feelings on both sides of the issue would reward me with the internet's version of hate mail. But that nice brief informative article in JAMA gave me courage. Those of us with useful information to share should do that. The shame some people feel associated with activities that result in unintended pregnancy stifles conversation and puts women in grave danger when it comes to protecting themselves from pregnancy complications, sexually transmitted diseases and sexual violence and coercion. We need to talk about these things.