Earlier this week, the Supreme Court heard the case of Whole Woman's Health v. Hellerstedt — the latest battle royale over access to abortion services. The case focuses on Texas "TRAP" (Targeted Regulation of Abortion Provider) laws that further restrict access to abortion in a state that has been eliminating abortion clinics. A similar law in Louisiana went into effect last week after the Fifth Circuit Court deemed that all abortion providers must have hospital admitting privileges. As a result of such policies, the entire state of Texas has been left with just nine abortion providers, Louisiana with two and Mississippi with just one. TRAP laws are threatening the practical elimination of legal abortion in the Southern United States by creating geographic limits on abortion services.
To date, the legal arguments related to abortion in the U.S. have largely centered on the right to privacy. In the hallmark case of Roe v. Wade, the high court found that the state must balance individual liberty against its interest in protecting women's health. Access to legal abortion, the sweeping effect of Roe, has gradually been eroded over time, most notably by Planned Parenthood v. Casey.
That case instituted the "undue burden" standard which has resulted in a steady increase in restrictive policies related to abortion since 1992. Mandatory waiting periods, compulsory ultrasounds and hospital admitting privileges for medical providers are among the many restrictive — yet medically unnecessary — measures. In recent years, restrictions have been occurring at an even steeper rise on a state by state basis. According to the Guttmacher Institute, states enacted nearly as many abortion restrictions in the past five years as in the prior 15.
While increasing access to health services is a national goal, TRAPs laws stand as road blocks by literally placing miles between women and the providers they seek. These limitations run the risk of negatively impacting women's health, the protection of which is an objective of the state; they may force women to pursue unsafe abortions as a means of terminating a pregnancy.
According to the World Health Organization, unsafe abortion is one of the top three leading causes of maternal death. Globally, over 47,000 women die each year as a result of complications from such unsafe procedures. Most of these women die in countries where abortion is illegal or otherwise restricted. Not only do TRAP laws prevent healthcare access, but they can actually harm women's health by forcing women to pursue unsafe and clandestine abortions.
Abortion in and of itself is not unsafe; rather, it becomes so when conducted under unhygienic conditions. Restrictions to legal abortion do not eliminate the practice. Rather, they drive women underground where they face a higher risk of complications and even death. Despite all of their requirements ostensibly based on medical safety, policies like the one is Texas make abortion less safe for women, not more so.
In contrast, where abortion is legal, it is also safe. Romania, South Africa, Bangladesh and Nepal have all seen significant decreases in maternal mortality following the liberalization of abortion policy. In the U.S. nearly 90 percent of abortions occur in the first trimester and less than .05 percent of these result in major complications. Existing Texas policy jeopardizes women's health by limiting women's access to the qualified healthcare providers and facilities they deserve. The Texas policy — and others like it — geographically restrict access to healthcare and abortion services and force women to undergo unsafe procedures; each negatively impact women's health.
Yet the individual freedom of a woman to receive an abortion and the protection of women's health at the population level need not be in conflict. The surest way to protect women's health is a full package of sexual and reproductive health services, including comprehensive sexual education, contraception and access to safe abortions.
More than half of American women experience an unintended pregnancy. As a result, while few woman want to have an abortion, many do for a variety of reasons. One in three American women will have an abortion in their lifetime, making the procedure surprisingly common. Restrictions on abortion serve to limit women's ability to exercise their reproductive autonomy and to reach their full potential. The outcome of Whole Women's Health will determine whether American women will have access to safe and legal abortion services. The alternative is the restriction of women's access to a safe medical procedure to which they are entitled as a matter of both privacy and gender equality.
Evans, Ph.D., MPH is an assistant professor of global health at Emory University.