Missing from Roe debate: Pregnancy is not health-neutral

The Supreme Court opinion leak and comments made in oral arguments on Dobbs v. Jackson Women’s Health make it clear to me as a practicing OB-GYN that the justices don’t understand one huge medical fact: Pregnancy is not a health-neutral event.

When debating whether pregnant people have a right to decide what is best for them and their body, it seems that society (and the justices) mistakenly refers to the alternative to abortion as adoption. This is not accurate. Adoption is an alternative to parenting.

The only alternative to abortion is continuing the pregnancy, which carries immediate and long-term health effects.

Pregnancy remains a major cause of morbidity and mortality in the United States, and is much higher here than in other developed nations. Black pregnant people are 2.5 times more likely to have perinatal death than their white counterparts. OB-GYNs sometimes say “an uncomplicated pregnancy is a diagnosis only made in hindsight” as even low-risk, healthy individuals may have any number of complications specific to pregnancy and birth such preeclampsia, gestational diabetes, hemorrhage, preterm birth, blood clots, serious depression and more. Common experiences in pregnancy translate to long-term health outcomes. For example, about one-third of all births in the United States happen by C-section, which is a major abdominal surgery. Preeclampsia and hypertensive disorders in pregnancy are common and associated with cardiovascular disease and a five times higher risk of high blood pressure.

In contrast to pregnancy, abortion is safe: The risk of death with continued pregnancy and birth is 14 times higher than induced abortion. Medical complications associated with termination of pregnancy are overwhelmingly mild and lower than those reported with common dental procedures like wisdom teeth removal.

This dichotomy between the safety of pregnancy and abortion was shown in “The Turnaway Study,” a longitudinal study from researchers at the University of California San Francisco. They collected data from abortion facilities nationwide comparing outcomes for people who accessed abortion and those who could not. Compared to those who terminated their pregnancies, those who continued pregnancy were more likely to experience perinatal death and serious pregnancy complications. They also were more likely to remain in relationships with intimate partner violence, a risk to themselves and their children.

It’s notable that multiple studies show that states with the most restrictive abortion laws also have the highest pregnancy morbidity and mortality as well as infant mortality. A 2021 study projected a that a total abortion ban would cause a 7 percent increase in pregnancy-related death the first year and 21 percent increase the second year, with a 33 percent increase for non-Hispanic Black people.

Laws that restrict access to abortion —including mandatory waiting periods, targeted regulation of abortion providers and requirements of abortion-providing clinicians — delay access to care that increases the rates of complications, although abortion-related complications are generally rare and rarely serious. This increases the cost of abortion care, which disproportionately impacts poor Americans. The Hyde Amendment, implemented four years after the court’s Roe decision, bans the use of federal funds for abortions, and only a minority of states use their own funds to cover abortion services for Medicaid recipients. This leaves millions of disproportionately low-income people and people of color — who already have higher rates of unintended pregnancy and pregnancy-related morbidity and mortality — to shoulder an even higher, often inaccessible cost, than those with private insurance.

Economically, pregnancy and birth are a sacrifice for American families. The United States has no mandatory paid sick time for employees. This means my patients often take unpaid time to attend prenatal care and manage the common symptoms of pregnancy including nausea and vomiting, fatigue, extreme physical discomforts, which are all “normal” parts of a healthy pregnancy, not to mention the common medical complications. There is no paid parental leave policy in the United States, and only 10 states have a paid family leave program. One in four American women return to work two weeks after birth as a result. As an OB-GYN who has given birth, let me clarify this is absolutely not enough time to recover from the medical event of birth and the postpartum period.

Abortion restrictions disproportionately impact the most vulnerable American families. Those who try to access abortion but cannot are four times more likely to live below the federal poverty level and experience long lasting financial struggles than those who successfully receive abortion care. As noted above, Black individuals have the highest maternal morbidity and mortality in pregnancy and stand to see this disparity increase if abortion is inaccessible.

Pregnancy increases the risk of mental health conditions. Perinatal depression and anxiety affect approximately one in seven pregnant people. Rates of postpartum mental health disorders have doubled during the pandemic. The myth that women may experience mental health difficulty following an abortion isn’t accurate, multiple studies show that 95 percent of those who access termination of pregnancy still believe it was the right choice several years later.

As an OB-GYN, I take care of families experiencing both the joys as well as the tragedies of pregnancy and birth every day. Every person deserves to decide whether to undergo pregnancy and birth, with all its medical, economic and psychological consequences. The Supreme Court, our state legislatures and Congress need to affirm the inherent right of individuals to make choices about their bodies and medical care. Abortion is essential health care. It is preventative health care.

Marta Perez, MD, is a board-certified OB-GYN practicing in St. Louis, MO, with a focus on obstetrics. She is an incoming Maternal Fetal Medicine fellow, specializing in medically complex pregnancies and fetal conditions. Perez is a fellow of the American College of Obstetricians and Gynecologists. She is a board member of Renewing Dignity, a nonprofit dedicated to ending local period poverty in Jacksonville, Florida. Follow her on Twitter: @DrMartaPerez