Abstract
The June 24, 2022 US Supreme Court decision in Dobbs v Jackson Women’s Health Organization resulted in an expansive restriction on abortion access that had been constitutionally guaranteed for nearly half a century. Currently, 14 states have implemented complete bans on abortion with very limited exceptions, and an additional 7 states have implemented abortion bans at 6 to 18 weeks’ gestation.
It has been well demonstrated that restrictive policies disproportionately limit abortion access for minoritized people and people of low socioeconomic status; the financial and geographic barriers of these post-Dobbs restrictions will only exacerbate this disparity. Proponents of abortion restrictions, who identify as pro-life, assert that these policies are essential to protect children, women, and families.
We examine whether the protection of these groups extends past conception by evaluating the association between state abortion legislation and state-based policies and programs designed to provide medical and social support for children, women, and families. We found that states with the most restrictive post-Dobbs abortion policies in fact have the least comprehensive and inclusive public infrastructure to support these groups. We suggest further opportunities for advocacy. (Am J Public Health. 2024;114(10):1043–1050. https://doi.org/10.2105/AJPH.2024.307792)
Although the state restrictions on abortion care imposed after the June 24, 2022 US Supreme Court decision in Dobbs v Jackson Women’s Health Organization (Dobbs) dramatically affect all people who are able to become pregnant, certain groups bear a greater burden. Previous research documents that people of low socioeconomic status and minoritized individuals are overrepresented in the population of people seeking abortion, and they are also less likely to be able to overcome the geographic and financial barriers imposed by abortion bans and restrictions.1,2
Equitable access to abortion care was a longstanding issue even before the Dobbs decision. For people of low socioeconomic status insured by Medicaid, the Hyde Amendment, which was first enacted in 1977 and has been renewed annually by Congress since, prohibits the use of federal funds to pay for abortion.3 As a result of financially restrictive policies and the overrepresentation of low-income populations among people seeking abortion, more than 50% of people seeking abortion pay for their care out of pocket.1 The average cost of a first trimester medication abortion, which accounts for more than half of abortions in the United States, is estimated to be $560.4 For a single person with an income at the federal poverty line in 2022, even the cost of the earliest and least expensive abortion represents close to half of their monthly income.5 New previability abortion bans are likely to increase these financial barriers because more individuals will be required to travel out of state to receive care or to delay care until a later point in pregnancy, resulting in higher procedural costs.6
These increased costs are often insurmountable barriers to those who are financially disadvantaged. In a 2009 review on the restrictions on Medicaid funding for abortions, the Guttmacher Institute concluded that 1 in 4 individuals who have Medicaid and seek an abortion instead continue the pregnancy and give birth because of lack of insurance coverage to fund the abortion.7 Although this review is based on older data and Medicaid coverage for abortion has expanded in some states, it highlights the important evidence that financial barriers to abortion coverage can result in people continuing unwanted pregnancies. Since Dobbs, we have seen an increase in telehealth provision of medication abortion and the expansion of private “abortion funds” to overcome financial and logistical barriers to abortion care; however, these work-arounds are likely to face political challenges and are no substitute for legal accessibility.8,9
As abortion restrictions expand, opportunities for a safer, relatively inexpensive procedure will increasingly be replaced by forced pregnancy, which is significantly more costly, both financially and physically, particularly for minoritized people.10,11 We also know from the Turnaway Study—a large prospective evaluation of the impact of being denied an abortion—that lack of access to abortion care can cement poverty among disadvantaged populations and have negative reverberating financial and relational ramifications that last for decades for both the person seeking the abortion and their families.12
As demonstrated by this previous research, post-Dobbs abortion restrictions are likely to have unprecedented impacts, in both the short and long terms, on the most vulnerable people in the United States. These individuals include the populations that seek abortion care the most, are least likely to be able to overcome barriers to receiving abortion care, and are most likely to experience the negative consequences of abortion denial. Proponents of previability abortion bans have described themselves as pro-life and often explicitly invoke support for women and families in arguments against abortion access, yet states with abortion bans have traditionally been more fiscally conservative and less socially supportive of their most vulnerable populations.13,14
Although these conflicting messages have been described in the lay press, few academic studies have systematically examined the intersection between post-Dobbs state abortion policies and state access to reproductive health care and family social policies and programs.15,16 As we observe in this analysis, in the states that most severely restrict abortion, the women, children, and families that abortion proponents seek to “protect” are the populations that are left behind—with less access to health care and family social services—if pregnancy is continued.
DATA REVIEW
We compiled publicly available data published by several nonpartisan organizations as well as individual states to complete a descriptive analysis of population and policy differences between states of varying abortion restriction severity. A summary of the sources for these data is provided in the Appendix (available as a supplement to the online version of this article at http://www.ajph.org). The March of Dimes defines a “maternity care desert” as a county with no hospitals providing obstetric care, no birth centers, no obstetricians or gynecologists, and no certified nurse midwives.17 We use the term “reproductive health care” to describe care other than abortion, including gynecologic, preconception, and pregnancy and postpartum care. We acknowledge the importance of abortion in the definition of comprehensive reproductive health care, but for the purpose of this evaluation of the differences in access to care by abortion restriction level, it is necessary to exclude this component of care from the definition. We use the term “women” in the presentation of these data to maintain the integrity of how the data were originally reported; however, we recognize that not all individuals who may become pregnant identify as women, and we advocate the use of inclusive practices.
RESTRICTION CATEGORIES AND DEMOGRAPHICS
We categorized states into 3 post-Dobbs abortion restriction groups based on state abortion policies as of April 2024.18,19 These are shown in Figure 1. The most restrictive group includes 21 states where abortion is severely restricted, 14 of which have complete abortion bans with very limited exceptions and 7 of which have an early gestational age ban of 6 to 18 weeks’ gestation. The moderately restrictive group includes states where abortion is legally available but Medicaid coverage of abortion is prohibited, making abortion largely inaccessible to a significant portion of the population. These states also often have additional restrictive and burdensome policies (e.g., waiting periods, mandatory parental notification for minors) in place.18 In this group, there are states that may eventually ban abortion but hostile legislation is currently blocked by courts (Wyoming and Iowa).20 The least restrictive group includes states where abortion is both legally available and accessible. These states either have no gestational age ban or ban abortion at 24 weeks’ gestation or later and allow Medicaid funds to pay for abortion.
FIGURE 1—
Map of the United States Showing 3 Severity Levels of Post-Dobbs Abortion Restrictions as of April 2024
Note. Colorado and Washington, DC, are included in the “moderately restrictive” group because despite being highly protective with no gestational age limit on abortion, they ban use of Medicaid funds to pay for abortion. The most restrictive states have complete abortion bans with the following exceptions: Florida (6-wk ban), Georgia (6-wk ban), South Carolina (6-wk ban), Nebraska (12-wk ban), North Carolina (12-wk ban), Arizona (15-wk ban), Utah (18-wk ban).
Source. Mapping created by Kelsey Rydland, Data Services Librarian at Northwestern University Libraries. Data citations are provided in the Appendix (available as a supplement to the online version of this article at http://www.ajph.org).
Table 1 shows the population characteristics by post-Dobbs state abortion restriction category. In 2020, almost 32 million women of reproductive age lived in the 21 states that we identified as having the most restrictive post-Dobbs abortion laws, representing nearly half of the total US population of women of reproductive age. Before the Dobbs decision, the states that are now the most restrictive had the lowest cumulative abortion rate, but there were still close to 300 000 abortions performed in these states in 2020, which is approximately 32% of all US abortions that year.
TABLE 1—
Population Characteristics by Post-Dobbs State Abortion Restriction Category: United States, 2020
| Characteristic | Least Restrictive (n = 17) | Moderately Restrictive (n = 13) | Most Restrictive (n = 21) |
| Total population of girls and women of reproductive age combined, no. | 28 037 000 | 15 186 000 | 31 615 000 |
| Range of girls and women of reproductive age per state | 131 000–9 200 000 | 120 000–2 800 000 | 168 000–7 000 000 |
| Total no. of abortions combined | 480 850 | 159 990 | 289 360 |
| Range of abortions before Dobbs per state | 1 230–154 060 | 100–32 370 | 130–77 400 |
| Abortion rate per 1000 girls and women of reproductive age | 17.2 | 10.5 | 9.2 |
| Total no. of births combined | 1 312 000 | 731 178 | 1 620 000 |
| Range of births per state | 5 400–420 600 | 6 200–132 600 | 10 100–373 600 |
| Birth rate per 1000 girls and women of reproductive age | 46.8 | 48.1 | 51.2 |
Note. Data citations are provided in the Appendix (available as a supplement to the online version of this article at http://www.ajph.org). Figure 1 shows the states included in each abortion restriction category.
In an analysis of the demographic characteristics of reproductive age women in the state abortion restriction groups (not shown), we found that the most restrictive states had the highest median percentage of non-Hispanic Black women, whereas the least restrictive states had the highest median percentage of women who identified as Hispanic and Asian. The most restrictive state group also had the highest percentage of reproductive age women with income less than 200% the federal poverty line (33%).
Across all 3 groups, approximately two thirds of reproductive age women had private insurance and one third had either Medicaid or were uninsured. In this one third, the most restrictive group had the lowest median percentage of women insured by Medicaid (16%) and the highest median percentage of women who were uninsured (13%), which included 5.2 million reproductive age women. By contrast to lower rates of Medicaid coverage outside pregnancy, the percentage of births paid for by Medicaid was highest in the most restrictive states (44%), likely reflecting the higher proportions of their populations that are uninsured if not pregnant who then qualify for Medicaid because of pregnancy. The most restrictive states also had the highest median percentage of births in which there was no insurance payor (4%), including close to 83 000 births in 2021.
As shown by these data, states with the most severe post-Dobbs abortion restrictions include nearly half of the total US population of women of reproductive age and, on average, have the highest percentages of individuals of reproductive age and birthing people who identify as non-Hispanic Black and who are of low socioeconomic status. As discussed previously, these are the populations that seek abortion care the most, and given their higher representation in states with more severe abortion restrictions, once again, these groups will disproportionately bear the burden of legislative limitations on access to care.1,2
ACCESS TO CARE AND SOCIAL SERVICES
One might hope that states with the most restrictive abortion policies—which advocate banning abortion on the grounds of protecting children and families and have the highest preexisting rates of socioeconomically disadvantaged reproductive age and birthing people—would have a highly developed public infrastructure to support access to reproductive health care and maternal and family social services. As we observe here, that is not the case. In fact, the inverse relationship is identified in several metrics.
Table 2 shows the relative access to reproductive health care and maternal and family social services by abortion restriction group. In general, states with more severe abortion restrictions are more likely to have limitations on access to reproductive health care, are less likely to implement policies that support families, have lower enrollment in state-funded assistance programs, and require that women and families be poorer to qualify for these programs compared with the least restrictive state group.
TABLE 2—
Access to Reproductive Health Care and Maternal and Family Social Services by Abortion Restriction Category: United States, April 2024
| Measure of Access to Reproductive Health Care and Social Services | Least Restrictive (n = 17), No. (%) or Median (IQR) | Moderately Restrictive (n = 13), No. (%) or Median (IQR) | Most Restrictive (n = 21), No. (%) or Median (IQR) |
| Access to general preconception/gynecologic health care | |||
| ACA Medicaid expansion | 17 (100) | 10 (76.9) | 14 (66.7) |
| Pharmacists allowed to prescribe contraception | 14 (82.4) | 7 (53.9) | 9 (42.9) |
| Access to prenatal and postpartum health care | |||
| Medicaid income eligibility limit for pregnancy, % of FPLa | 213 (205–258) | 205 (200–263) | 202 (162–214) |
| States with Medicaid income eligibility for pregnancy < 200% of FPL | 4 (23.5) | 3 (23.1) | 10 (47.6) |
| Individuals of reproductive age that live in maternity care deserts | 0.3 (0–3.3) | 3.0 (0.7–5.4) | 9.8 (4.5–16.3) |
| States with higher than average % of individuals of reproductive age living in maternity care deserts | 2 (11.8) | 3 (23.1) | 14 (66.7) |
| WIC enrollment for pregnant and postpartum people, % of those eligible | 56.3 (50.9–61.2) | 52.7 (50.8–55.1) | 52.0 (49.0–59.0) |
| States with WIC enrollment for pregnant and postpartum people < the national rate | 11 (64.7) | 10 (76.9) | 14 (66.7) |
| Medicaid expansion for 1 y postpartum | 17 (100) | 11 (84.6) | 18 (85.7) |
| Access to state-run family social services | |||
| Paid family and medical leave | 11 (64.7) | 3 (23.1) | 0 |
| WIC enrollment for infants, % of those eligible | 78.9 (72.3–85.7) | 79.5 (71.8–88.2) | 78.4 (75.1–85.5) |
| States with WIC enrollment for infants < the national rate | 10 (58.8) | 9 (69.2) | 13 (61.9) |
| WIC enrollment for children, % of those eligible | 43.3 (36.3–50.5) | 38.5 (35.0–41.8) | 37.5 (28.9–42.4) |
| States with WIC enrollment for children < the national rate | 6 (35.3) | 8 (61.5) | 15 (71.4) |
| Maximum monthly income eligibility for TANF for a family of 3, $ | 1018 (908–1618) | 818 (519–1061) | 673 (401–908) |
| Maximum monthly income eligibility for TANF, % of FPL | 56 (50–88) | 45 (28–58) | 37 (22–50) |
| Maximum monthly TANF benefit for a family of 3, $ | 632 (588–727) | 508 (426–608) | 292 (272–387) |
| States with income eligibility for childcare assistance < 200% of FPL | 1 (5.9) | 6 (46.2) | 9 (42.9) |
Note. ACA = Affordable Care Act; FPL = federal poverty level (according to the Department of Health and Human Services5); IQR = interquartile range; TANF = Temporary Assistance for Needy Families; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children. Data citations are provided in the Appendix (available as a supplement to the online version of this article at http://www.ajph.org). Figure 1 shows the states included in each abortion restriction category.
For reference, in 2022, 200% of the FPL was $27 180 for an individual, $36 620 for a family of 2, and $46 060 for a family of 3.
In our measures of access to general health care, the most restrictive states are less likely to implement policies that promote this access for reproductive age women. There are still 10 states that have not accepted Affordable Care Act funds to expand their Medicaid eligibility criteria, including 3 states in the moderately restrictive group and 7 states in the most restrictive group. In comparison, there are no states in the least restrictive group that have chosen to go against implementation of this expansion. This pattern is consistent with data demonstrating that the most restrictive states have the highest percentages of women of reproductive age who are uninsured. Notably, Medicaid expansion pursuant to the Affordable Care Act has been associated with a significant increase in the use of contraception, including long-acting reversible contraception, with the greatest gains in adolescents, which decreases the rate of unintended pregnancy.21 The most restrictive states are also less likely to have policies that allow pharmacists to prescribe contraception (42.9% vs 82.4% of the least restrictive states), another barrier to access to general reproductive health care and reproductive autonomy.
People with reproductive potential continue to face restrictions to access to care in these states when they become pregnant. Of states in the most restrictive group, 10 (47.6%) have a Medicaid income eligibility level for pregnancy of less than 200% of the federal poverty line compared with only 4 (23.5%) states in the least restrictive group. Additionally, the most restrictive states have a higher median percentage of the population of reproductive age living in a maternity care desert: 9.8% versus just 0.3% in the least restrictive group. In the most restrictive states, this amounts to almost 1.1 million people of reproductive age who live in an area with no access to a hospital or birth center offering obstetric care or an obstetric provider.
Median WIC (the federally sponsored and locally administered Special Supplemental Nutrition Program for Women, Infants, and Children) enrollment for eligible pregnant and postpartum people was slightly higher in the least restrictive group but was notably barely greater than 50% across all 3 state groups. Finally, although Medicaid expansion to 12 months postpartum has become widely implemented in the past several years, there are still 3 states in the most restrictive group and 2 states in the moderately restrictive group that have not yet implemented this vital policy, compared with no remaining states in the least restrictive group.
Even after pregnancy, families and children living in the most restrictive states receive less support than those in the least restrictive states. One of the most important findings of our analysis concerns state policies mandating paid family and medical leave. Although the federal Family and Medical Leave Act (1993) guarantees most workers access to unpaid, job-protected parental, family caregiver, and personal medical leave, it does not require employers to continue to pay their employees during this time. Despite the American College of Obstetricians and Gynecologists’ endorsement of paid parental leave after childbirth, more than 50% of postpartum people do not have access to paid leave.22 Notably, the United States is one of the only high-income countries without a national paid family caregiving or medical leave policy and, as of the writing of this essay, only 14 states have passed state-mandated paid family and medical leave policies.23,24 Of these 14 states, 11 (78%) are in the least restrictive state group. Of the states with the most restrictive abortion bans, none has a mandatory paid family and medical leave policy.
Many states with the most severe abortion restrictions also make it harder for people with children to qualify for state-funded assistance programs, and they provide less support for those who do qualify. In 2020, the national percentage of eligible children enrolled in WIC was 40.6%. The group of most restrictive states included the highest number of states with WIC enrollment for eligible children below the national average (71% vs 35% in the least restrictive group). Additionally, in the most restrictive state group, on average, families of 3 need to make less than $673 per month to qualify for the TANF (Temporary Assistance for Needy Families) program and receive an average benefit of $292 per month. By contrast, families in the least restrictive states can make almost twice as much and still qualify, and they receive twice the benefit. Similarly, families need to be poorer to qualify for childcare assistance in the most restrictive states.
Table 3 summarizes these outcomes in each of the 21 most restrictive states. We selected 11 of these metrics of access to reproductive health care and maternal and family social services that we feel are most relevant and representative to visually compare these restrictive states. The states are ordered by the number of items they score poorly on from least to most. Some states, such as North Carolina and Kentucky, score poorly on only a few of these metrics, whereas others, such as Idaho, Alabama, Arkansas, Florida, Georgia, Mississippi, and Missouri, fail to support children, women, and families on most of these metrics. By presenting these data, we sought to highlight individual state-specific areas and policies for future advocacy efforts and research endeavors.
TABLE 3—
Most Restrictive States and Access to Reproductive Health Care and Maternal and Family Social Services: United States, April 2024
| State | No ACA Expansion | Medicaid Income Eligibility for Pregnancy < 200% FPL | Higher Than Average % of Reproductive Age People Living in Maternity Care Deserts | WIC Enrollment for Pregnant and PP People Less Than the National Rate | No PP Medicaid Expansion | No Paid Family and Medical Leave | WIC Enrollment for Infants < the National Rate | WIC Enrollment for Children < the National Rate | Lowest Third of TANF Income Eligibility | Lowest Third of TANF Benefits | Income Eligibility for Childcare Assistance < 200% of FPL |
| NC | X | X | |||||||||
| KY | X | X | X | ||||||||
| OK | X | X | X | X | |||||||
| IN | X | X | X | X | X | ||||||
| NE | X | X | X | X | X | ||||||
| SD | X | X | X | X | X | ||||||
| TX | X | X | X | X | X | ||||||
| ND | X | X | X | X | X | X | |||||
| TN | X | X | X | X | X | X | |||||
| WV | X | X | X | X | X | X | |||||
| AZ | X | X | X | X | X | X | X | ||||
| LA | X | X | X | X | X | X | X | ||||
| SC | X | X | X | X | X | X | X | ||||
| UT | X | X | X | X | X | X | X | ||||
| AL | X | X | X | X | X | X | X | X | |||
| AR | X | X | X | X | X | X | X | X | |||
| FL | X | X | X | X | X | X | X | X | |||
| GA | X | X | X | X | X | X | X | X | |||
| MS | X | X | X | X | X | X | X | X | |||
| MO | X | X | X | X | X | X | X | X | |||
| ID | X | X | X | X | X | X | X | X | X |
Note. ACA = Affordable Care Act; FPL = federal poverty level (according to the Department of Health and Human Services5); PP = postpartum; TANF = Temporary Assistance for Needy Families; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children. Data are provided in the Appendix (available as a supplement to the online version of this article at http://www.ajph.org).
CONCLUSIONS
The creation and funding of state-based programs and policies that support access to care for disadvantaged pregnant persons and their children and families clearly demonstrate the importance these states place on these populations’ well-being. The data presented here highlight the noticeable absence of participation in such value statements by states with the most severe abortion restrictions. Abortion opponents often assert that they are motivated by an ethical issue of fetal personhood and that by banning or significantly restricting abortion access, they are acting to protect children, women, and families.13,14 In our analysis, states with the most severe abortion restrictions have the least comprehensive and least inclusive public infrastructure to support access to reproductive health care and family social services. It would seem in these states that the abortion opponent, pro-life attitude not only begins at conception but ends there as well.
Although it may not be surprising that the most politically conservative states with the most restrictive post-Dobbs abortion policies are also the most socially and financially conservative with regards to reproductive health, the degree to which these states fail to support their most disadvantaged populations warrants immediate attention and action. Although we maintain that abortion is essential health care and advocate continued efforts to eliminate restrictive abortion policies, our results also highlight an opportunity to use the child protection arguments of conservative policymakers and encourage them to “put their money where their mouth is” by advocating the implementation and improvement of policies that support individual and family well-being.
We highlight several policies and programs throughout this essay that advocates may choose to target in their own state, and Table 3 outlines these opportunities for the 21 most restrictive states. Such advocacy campaigns may target adding new policies (e.g., postpartum Medicaid expansion or paid family and medical leave), expansion of existing policies (e.g., increasing eligibility for state-based assistance programs such as WIC and TANF), or the creation of new programs (e.g., mobile health clinics to serve pregnant people in maternity care deserts).
Improvements in policies and programs designed to support vulnerable populations during pregnancy and beyond can never justify a lack of access to abortion care; however, if policymakers insist on restricting reproductive autonomy on the grounds of protection, then we believe they must also ensure that pregnancy and family building are safe, supported, and equitable.
ACKNOWLEDGMENTS
We would like to thank Kelsey Rydland, data services librarian at Northwestern University Libraries, for assistance in creation of the map showing the post-Dobbs abortion restrictions categories.
CONFLICTS OF INTEREST
The authors report no conflicts of interest.
HUMAN PARTICIPANT PROTECTION
This study is exempt from institutional review board review, as all data used in the analysis were publicly available. No human participants were involved.
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