University of Wisconsin–Madison ⋅ Medical College of Wisconsin
WMJ

Abortion Access and Birth-related Outcomes and Inequities: A Call to Dismantle Abortion Restrictions in Wisconsin to Improve Health and Well-being

Jenny Higgins, PhD; Jane W. Seymour, PhD; Tiffany Green, PhD

WMJ. 2024;123(6):466-467.

Download full-text pdf.

We applaud this WMJ issue’s focus on maternal and child health, which we will refer to as reproductive and birth outcomes to include birthing people who do not identify as mothers. (This group includes cisgender women, transgender men, and gender-expansive individuals.) As this issue underscores, Wisconsin faces a reproductive and birth equity crisis—one that disproportionately harms Black, Brown, and Indigenous Wisconsinites, as well as those living in rural areas and/or on low incomes. Eliminating these inequities requires a multilevel approach, from strengthening obstetrical referral systems, to addressing the criminalization of substance use disorder, to dismantling racism within health care systems and society at large.

In this commentary, we wish to foreground another important but often overlooked domain necessary for reproductive and birth equity: abortion access.

From a human rights perspective, abortion access is worth preserving regardless of its effect on reproductive and birth outcomes. However, the science is conclusive that restricting abortion access is associated with myriad health and social consequences, including increases in infant mortality1 – as well as (but not limited to) increased chronic health problems, such as hypertension; increased anxiety and depression; reduced ability to achieve educational, career, and other life aspirations; and negative developmental and economic impacts on children.2 In other words, Wisconsin medical and public health professionals have many reasons to protect abortion access.

But in the spirit of this special issue, we focus here on one reason: birth equity. We make three larger points about the intersections between Wisconsinites’ ability to obtain abortion care and their ability to have safe and healthy pregnancies, births, and reproductive lives.

First, abortion restrictions force people to remain pregnant and deliver against their wishes, increasing their morbidity and mortality risks. While death from pregnancy is a rare event (22.3 deaths per 100,000 live births in 20223), a person who carries a pregnancy to term and gives birth is 14 times as likely to die compared to a person who has a standard-of-care abortion.4 Unsurprisingly, states that restrict abortion have significantly higher pregnancy-related mortality rates compared to states that either protect or are neutral toward abortion access.5

While many strategies can help decrease the risks of pregnancy and birth, some risks will persist due to the biology of these processes. Wisconsinites should have the ability to choose whether to take on these risks. However, Wisconsin abortion clinic closures between 2009 and 2017 led to increased birth rates in counties with the greatest increases in driving distance to abortion care, indicating restrictions’ harms to reproductive autonomy.6 Further, while Wisconsin has chosen not to use state Medicaid funds to cover the vast majority of abortions,7 evidence indicates that states that do so experience decreases in pregnancy-related morbidity.5 Thus, we expect that Wisconsin’s limits on abortion access – including the outright suspension of all abortion care between June 2022 and September 2023 due to the US Supreme Court’s decision in Dobbs v Jackson Women’s Health Organization,8 which overturned Roe v Wade9 and federal protections for abortion – may have resulted in increased numbers of people being forced to carry pregnancies to term and adverse pregnancy-related outcomes.10 It will be critical to document these potential consequences when vital statistics and hospital data become available.

Second, lack of abortion access increases mental health stressors and struggles, also increasing pregnancy-related morbidity and mortality. The Centers for Disease Control and Prevention estimates that upwards of 1 in 4 pregnancy-related deaths stem from mental health conditions such as depression and substance use disorder.11 In Wisconsin, more than half (52%) of pregnancy-related deaths in 2016 and 2017 were due to mental health conditions.12 Research is clear that people who are unable to access wanted abortion care are more likely to experience intimate partner violence and declines in mental health, both in the short term and long term.13 Pregnant people who do not have reproductive autonomy and cannot choose abortion are therefore at elevated risk for a major but preventable cause of pregnancy-related morbidity and mortality.

Third, abortion restrictions disproportionately affect the communities that experience the worst birth outcomes, which amplifies existing inequities. Both abortion access and complication-free births are most out of reach for individuals and communities facing social oppression, systemic racism, and socioeconomic scarcity: people of color, rural residents, and/or people living on low incomes. For example, most African American, American Indian and Alaskan Native people live in states with abortion bans or restrictions,14 and for many Americans, including many Wisconsinites, the cost of abortion care is catastrophic.15 Abortion restrictions can push the cost of abortion care further out of reach when they result in additional costs, such as more time away from work, childcare or eldercare coverage, transportation to services, and/or lodging close to care. Additionally, compared with their White counterparts, people who face systemic racism are more likely to experience poorer reproductive and birth outcomes, including lack of high-quality prenatal care,16 infants born prematurely and at greater risk of dying before age 1,17 and pregnancy-related mortality.3 In other words, abortion restrictions cause the greatest harm to those already subject to systemic racism and economic injustice, widening existing health, economic, and social inequities – including the ability to have healthy pregnancies, births, and babies.

At the time of this writing, abortion care services are currently available in Wisconsin after the Dobbs-related suspension of services for over a year. However, a plethora of restrictions still make abortion difficult if not impossible for many Wisconsinites to access.18 Clinics are few and located in large cities far from rural communities, Medicaid and other payor prohibitions are fierce, telemedicine provision of abortion care is banned, and antiscience regulations such as a two-visit requirement pose unnecessary barriers. These constraints threaten Wisconsinites’ health and well-being, as well as their reproductive autonomy. Given the incredibly restrictive environment, as well as the longstanding birth inequities in Wisconsin, we urge readers to work to dismantle the abortion restrictions that stand in the way of reproductive health and well-being for all.

REFERENCES
  1. Gemmill A, Margerison CE, Stuart EA, Bell SO. Infant deaths after Texas’ 2021 ban on abortion in early pregnancy. JAMA Pediatr. 2024;178(8):784-791. doi:10.1001/jamapediatrics.2024.0885
  2. New CORE brief documents impacts of abortion restrictions on individuals, families, and communities. Collaborative for Reproductive Equity. July 10, 2023. Accessed June 24, 2024. https://core.wisc.edu/2023/07/10/new-core-brief-documents-impacts-of-abortion-restrictions-on-individuals-families-and-communities/
  3. Hoyert DL. Maternal Mortality Rates in the United States, 2022. National Center for Health Statistics. Centers for Disease Control and Prevention. Published May 2, 2024. Accessed June 24, 2024. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2022/maternal-mortality-rates-2022.pdf
  4. Raymond EG, Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol. 2012;119(2 Part 1):215-219. doi:10.1097/AOG.0b013e31823fe923
  5. Addante AN, Eisenberg DL, Valentine MC, Leonard J, Maddox KEJ, Hoofnagle MH. The association between state-level abortion restrictions and maternal mortality in the United States, 1995-2017. Contraception. 2021;104(5):496-501. doi:10.1016/j.contraception.2021.03.018
  6. Venator J, Fletcher J. Undue burden beyond Texas: an analysis of abortion clinic closures, births, and abortions in Wisconsin. J Policy Anal Manage. 2021;40(3):774-813. doi:10.1002/pam.22263
  7. ForwardHealth: Limited Abortion Coverage. Wisconsin Department of Health Services. Revised January 11, 2023. Accessed January 9, 2025. https://www.dhs.wisconsin.gov/forwardhealth/customerhelp/abortion.htm
  8. Dobbs v Jackson Women’s Health Organization, 597 US 215 (2022).
  9. Roe v Wade, 410 US 113 (1973).
  10. Dench D, Pineda-Torres M, Myers C. The effects of post-Dobbs abortion bans on fertility. J Public Econ. 2024;234:105124. doi:10.1016/j.jpubeco.2024.105124
  11. Four in 5 pregnancy-related deaths in the U.S. are preventable. News release. CDC Newsroom; September 19, 2022. Accessed June 24, 2024. https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html
  12. Wisconsin maternal mortality review: Pregnancy-associated overdose deaths (2016-2019). University of Wisconsin–Madison Prevention Research Center and Wisconsin Department of Health Services; 2021. Accessed July 1, 2024. https://prc.wisc.edu/wp-content/uploads/sites/1127/2021/09/MMR-RMOR-Repor.pdf
  13. The mental health impact of receiving vs. being denied a wanted abortion. Mental Health Issue Brief. Advancing New Standards in Reproductive Health; July 2018. Accessed July 2, 2024. https://www.ansirh.org/sites/default/files/publications/files/mental_health_issue_brief_7-24-2018.pdf.
  14. Goutos D, Cesare N, Vu C, et al. Race and ethnicity of reproductive-age females affected by US state abortion bans. JAMA. 2024;331(20):1765-1767. doi:10.1001/jama.2024.6023
  15. Zuniga C, Thompson TA, Blanchard K. Abortion as a catastrophic health expenditure in the United States. Womens Health Issues. 2020;30(6):416-425. doi:10.1016/j.whi.2020.07.001
  16. Green TL. Unpacking racial/ethnic disparities in prenatal care use: the role of individual-, household-, and area-level characteristics. J Womens Health (Larchmt). 2018;27(9):1124-1134. doi:10.1089/jwh.2017.6807
  17. Green T, Hamilton TG. Maternal educational attainment and infant mortality in the United States: Does the gradient vary by race/ethnicity and nativity? Demogr Res. 2019;41:713-752. doi:10.4054/DemRes.2019.41.25
  18. CORE Brief: Wisconsin state laws impacting abortion access. Collaborative for Reproductive Equity; January 2024. Accessed February 13, 2024. https://core.wisc.edu/documents/wisconsin-state-laws-impacting-abortion-access-as-of-january-2024/
Author Affiliations: Collaborative for Reproductive Equity, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health (UW SMPH), Madison, Wisconsin (Higgins, Seymour); Departments of Obstetrics and Gynecology and Population Health, UW SMPH, Madison, Wisconsin (Green).
Corresponding Author: Jane W. Seymour, PhD, Research Scientist, Collaborative for Reproductive Equity, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, 1300 University Avenue, 4245 Medical Sciences Center, Madison, WI 53706; phone 608.262.7738; email jwseymour@wisc.edu; ORCID ID 0000-0002-8410-7483
Funding/Support: This work was supported by an anonymous family foundation. The funder had no role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
Financial Disclosures: None declared.
Share WMJ