Dobbs vs. Jackson: Now is the time to prospectively measure public health

Now is the time to measure the impact of the Supreme Court’s Dobbs v. Jackson decision within health departments.

The Supreme Court’s Dobbs v. Jackson decision shook the foundations of public health in the United States (US). Although we here at the University of Minnesota are physically located in a state with strong legal protections for access to reproductive and abortion care, we have staff and partners located across the US whose states have very different approaches to Dobbs and very different expectations implications both practical and political. Our nation’s federalist approach and our “laboratories of democracy” now promise differentiated access to abortion care, which used to be a near-universal right (though not everyone had easy access). A number of explanations and rejoinders have emerged in recent weeks for what comes next, but few have addressed the government’s public health system (see an excellent notable exception in Zaugg and Roberts). Our nation’s 3,000 health departments will likely feel Dobbs’ impact strongly, but it’s challenging to know exactly how. Now is the time to measure Dobbs’ impact in health departments.

Prospective measurement

In our view, there are several immediate practical questions that we as a field could address. It is imperative for public health professionals to 1) clarify what “family planning” means to ensure continued access to family planning services in states where abortion care, per se, is no longer permitted, 2) clarify , that although one may perform the act of illegal abortion, it does not necessarily reduce demand for the service, and 3) begin measuring the potential impacts of the Dobbs decision on maternal health and associated health risks, the economy, and any change in demand for public health services. Currently, Block Grants for Maternal and Child Health (MCH), Title V, WIC, and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) are some of the major federal programs that focus solely on improving maternal and child health such as gives states responsibility for systemic approaches.

Family planning in health departments is not synonymous with abortion care

Family planning has been recognized by the Centers for Disease Control and Prevention (CDC) as one of the 10 great public health achievements of the 20th century and is one of the themes and goals of Healthy People 2030. Family planning services include testing for pregnancy and counseling, infertility counseling and services, sexually transmitted infection (STI) counseling and services, and contraceptive services. Family planning services are essential to reduce unintended pregnancies, which are more often associated with adverse health outcomes for women and infants. While public health is working to achieve equity in family planning services through the Biden-Harris Title X Rule, access to and quality of family planning services varies by race, ethnicity, and class. Specifically, white women, compared to black and Hispanic women, are more likely to use contraceptive methods and have lower unintended pregnancy rates. Within class, higher-income women have lower unintended pregnancy rates than lower-income women. Unintended pregnancies are more common among black women, teenage girls, and women of low socioeconomic status.

The importance of measurement for health equity

Since Roe v. Wade was overturned, several states have outlawed abortion, and it is likely that several more states will soon. These policies force women and girls to carry unwanted pregnancies to term, endangering their mental and physical health, and putting them at greater risk of experiencing significant hardship. In 2020, the maternal mortality ratio in the United States was 23.8 deaths per 100,000 live births (861 deaths), an increase from 2018 (maternal mortality rate of 17.4 deaths per 100,000 live births ). From 2018 to 2020, the largest increase in maternal mortality occurred among black women, where the rate increased by 11 deaths per 100,000 live births (from 44 to 55.3). Based on this data, abortion bans could lead to another 21% increase in pregnancy-related deaths among all women, and black women would experience the largest increase in deaths, a 33% increase. Dobbs’ decision further disproportionately affects black women, as they are more likely to live in southern states that ban abortion and in 2019 account for the largest percentage of abortions. Advances in New Standards in Reproductive Health (ANSIRH) suggests that state and local health departments can estimate the number of people who will be forced to carry pregnancies to term, predict the number of people who will commit to self-abortions, and provide residents with a list of states where they can go to obtain an abortion. This is important because data shows that criminalizing abortion does not eliminate abortion, but rather only partially reduces demand and increases the risks and safety hazards associated with unsafe abortions and unwanted pregnancies. Historical and contemporary data show that self-administered abortions increase where abortion is illegal or highly restricted. Self-administered abortions are more likely to cause women pelvic injuries, hemorrhage, dangerous clostridial infections, and sepsis, often leading to emergency hysterectomy and sometimes death.

On the need for prospective measurement

As the U.S. prepares for the post- Roe era, there are data-based questions worth asking that have obvious policy implications but are not forgone conclusions. Given the highly political nature of the abortion issue, we believe that the ‘live’ nature of these issues means that they are very relevant. First, what are the effects of Dobbs on maternal and infant health outcomes? Will they improve, as abortion opponents suggest, or decrease, as abortion advocates suggest? Will differences of race, ethnicity, and class continue to exist? Second, what are Dobbs’ impacts on social costs and related economic outcomes? A small number of studies show the financial consequences of abortion-related policies on public expenditures and social outcomes, including Medicaid-supported births, education costs, and public safety costs. It is also a place where supporters and opponents of abortion policy disagree about the likely outcomes of Dobbs, and where objective prospective measurement could inform such policy disagreements. Third, critically, we can create prospective measurement systems to identify different patterns of service demand in trigger states and non-trigger states for public health services (especially MCH and family planning), as well as trends in public health financing. Before COVID, in 2019, MCH services were provided by 70% of LHDs across the country. A decline in abortion services could logically increase demand for either family planning services or MCH services, or both. Prospective measurement of the overall demand for these services and who uses these services is critical to characterizing the mid- and long-term impacts of Dobbs on public health and the health of the US population and informing future policy decisions.

Chelsea Kirkland, PhD, MPH, CHW (she/he) is a researcher at the Center for Public Health Systems at the University of Minnesota, School of Public Health. During her time there, she collaborated on multiple national mixed methods research projects working to support and build the public health workforce. Her expertise is in a variety of public health issues, including health equity, health disparities, social determinants of health, community health workers, and physical activity. When she is not working, she enjoys being outside with her family and two dogs. Her favorite activities include running, water skiing and playing the violin.

Ski Martin, PhD (c), MA, is a researcher at the Center for Public Health Systems. Her research interests include health disparities, social determinants of health, and the relationship between public health and medical education. She has experience in qualitative methods and analysis, survey writing, and using STATA to create and analyze quantitative data sets. Ms. Martin holds a master’s degree in sociology and a certificate in public health from Loyola University Chicago. She is a doctoral candidate in sociology at Loyola University Chicago. Her dissertation specialized in medical sociology and health education, focusing on the ways in which racial and ethnic disparities in maternal health are experienced and conceptualized by patients, providers, and medical schools.

JP Leider, PhD, is director of the Center for Public Health Systems at the University of Minnesota School of Public Health and a member of JPHMP Editorial board. It is available at leider (at) umn (dot) edu.

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