Dobbs v Jackson: Now Is the Time for Prospective Public Health Measurement
Now is the time to set up to measure the impact of Dobbs v Jackson Supreme Court ruling within health departments.
The Dobbs v Jackson Supreme Court ruling has shaken the foundations of public health in the United States (US). While we here at the University of Minnesota are physically located in a state with strong statutory protections for access to reproductive and abortion care, we have staff and partners located across the US whose states have very different approaches dealing with Dobbs, and they are expecting very different impacts both practically and politically. Our nation’s federalist approach and our “laboratories of democracy” now promise differential access to abortion care, which was previously nearly a universal right (though not everyone experienced easy access). A number of explainers and rejoinders have come out in recent weeks about what comes next, but few have addressed the governmental public health system (see an excellent notable exception in Zaugg and Roberts). Our nation’s 3,000 health departments will likely keenly feel the impact of Dobbs, but it is challenging to know exactly how. Now is the time to set up to measure the impact of Dobbs within health departments.
In our view, there are several immediate, practical matters we as a field might 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 permissible, 2) make clear that while one may make the act of abortion illegal, it does not necessarily decrease demand for the service, and 3) begin measuring potential impacts of the Dobbs ruling on maternal health and associated health risks, the economy, and any change in demand for public health services. Currently, the Maternal and Child Health (MCH) Service Block Grants, Title V, WIC, and Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) are some of the primary Federal programs that focus solely on improving the health of mothers and children by providing states with accountability for systemic approaches.
Family planning in health departments is not synonymous with abortion care
Family planning is recognized by the Centers for Disease Control and Prevention (CDC) as one of the 10 great public health achievements during the 20th century and is one of the Healthy People 2030 topics and objectives. Family planning services includes pregnancy testing and counseling, infertility counseling and services, sexually transmitted infections (STIs) 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 babies. 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 across race, ethnicity and class. Specifically, White women, compared to Black and Latina women, are more likely to use contraceptive methods and have lower rates of unintended pregnancies. Within class, higher-income women have lower rates of unintended pregnancies compared to lower-income women. Unintended pregnancies are more common among Black women, teenage girls, and women with low socioeconomic status.
Importance of measurement for health equity
Since the overturning of Roe v. Wade several states have banned abortions and several more states are likely to ban abortions soon. These policies force any women and girls to carry unwanted pregnancies to term, jeopardizing their mental and physical health as well as putting them at greater risk of experiencing significant hardships. In 2020, the United States maternal mortality rate was 23.8 deaths per 100,000 live births (861 deaths), which was an increase from 2018 (maternal morality rate of 17.4 deaths per 100,000 live births). From 2018 to 2020, the greatest increase within maternal mortality rate were observed among Black women, where the rate has increased by 11 deaths per 100,000 live births (from 44 to 55.3). Based on this data, abortion bans could result in a further 21% increase in pregnancy-related deaths among all women, and Black women would experience the largest increase in deaths, a 33% increase. The Dobbs ruling further disproportionately affects Black women as they are more likely to live in southern states that ban abortion and, in 2019, accounted for the largest percentages of abortions. Advancing 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, anticipate the number of people who will engage in self-management of abortions, and provide residents with a list of states where they can go to obtain an abortion. This is important because data show that criminalizing abortion does not eliminate abortions, rather only partially decreases demand and increases risk and safety hazards associated with unsafe abortions and unwanted pregnancies. Historical and contemporary data show that self-managed abortions tend to increase where abortion is illegal or highly restricted. Self-managed abortions are more likely to cause women to experience pelvic-organ injuries, hemorrhage, dangerous clostridial infections, and sepsis, which often lead to emergency hysterectomies and sometimes death.
On the need for prospective measurement
As the US prepares for a post-Roe era, there are data-informed questions worth asking that have obvious political implications but are not forgone conclusions. Given the highly political nature of the abortion question, we think the “living” nature of these questions means they are highly relevant. First, what are the impacts of Dobbs on maternal and infant health outcomes? Will they improve, as abortion opponents have advocated, or decline, as abortion proponents have advocated? Will there continue to be differences by race, ethnicity, and class? Second, what are the impacts of Dobbs on social spending and related economic outcomes? A small number of studies have shown the financial consequences of abortion-related policies on public spending and social outcomes, including Medicaid-supported births, education spending, and public safety spending. This too is a place where proponents and opponents of abortion policy disagree on the likely outcomes of Dobbs, and where objective prospective measurement could inform such policy disagreements. Third, critically, we can set up prospective systems of measurement to identify differential patterns of demands for services in trigger states and non-trigger states for public health services (especially MCH and Family Planning), as well as trends in public health funding. Prior to COVID, in 2019, MCH services were provided by 70% of LHDs nationwide. A decline in abortion services might logically increase demand for either family planning serves or MCH services, or both. Prospective measurement of the total demand for these services and who is using these services is of paramount importance in characterizing the medium- and long-term impacts of Dobbs on public health and population health in the US and informing future policy decisions.
Chelsey Kirkland, PhD, MPH, CHW (she/her) is a researcher within the Center for Public Health Systems at University of Minnesota, School of Public. During her time there, she has collaborated on numerous nation-wide, mixed-methods research projects working to support and build-up the public health workforce. Her background is in a variety of public health issues including health equity, health disparities, social determinants of health, community health workers, and physical activity. When not working, she enjoys being outside with her family and two dogs. Her favorite activities include running, water-skiing, and playing violin.
Skky 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 interrelationship between public health and medical education. She has experience in qualitative methods and analysis, writing surveys, and using STATA to create and analyze quantitative datasets. Ms. Martin holds a master’s degree in sociology and a Certificate in Public Health from Loyola University Chicago. She is a doctoral candidate at Loyola University of Chicago in sociology. Her dissertation specializes in medical sociology and health education, focusing on the ways in which patients, providers, and medical schools experience and conceptualize racial and ethnic disparities in maternal health.
JP Leider, PhD, is the Director of the Center for Public Health Systems at the University of Minnesota School of Public Health, and a member of the JPHMP Editorial Board. He is available at leider (at) umn (dot) edu.