U.S. Women Struggle to Get Abortions in a Post-Roe World

SHANOOR SEERVAI: Now that Roe v. Wade has been overturned, women in the U.S. face even more barriers than before to safe and effective reproductive health care. Access always varied from state to state, but because there’s no longer a guaranteed constitutional right to an abortion, many states are working to put in place partial or total bans. Some of the restrictions that have been rolled out were anticipated and some may be a surprise, but what we can already see is that the impacts will be disparate and fall unequally.

I’m Shanoor Seervai, and this is what we’re going to talk about on today’s episode of The Dose. My guest, Dr. Raegan McDonald-Mosley, is the CEO of Power to Decide. As a physician and policy expert, she focuses on addressing racial disparities in maternal and child health and well-being.

Dr. McDonald-Mosley, thank you so much for taking the time to be here today.

RAEGAN MCDONALD-MOSLEY: Thank you so much for having me and for lifting up this important issue for your listeners.

SHANOOR SEERVAI: Let’s start with your organization. You created abortionfinder.org. Can you talk about the origins of that digital tool, how the design took shape, and then the data you have on how it’s being used?

RAEGAN MCDONALD-MOSLEY: Absolutely. Looking at the landscape over the last few years, even before the overturn of Roe v. Wade, we’ve seen a significant increase in state-based restrictions on abortion access to care, knowing that it’s becoming increasingly harder for people to access care in particular states across the nation. In October of 2020, we launched abortionfinder.org to make it easier for people to identify what the laws are in each state and where they can access care across the country. Abortionfinder.org is a comprehensive, searchable database of providers, which includes state-specific guides to applicable laws and restrictions, support organizations, and funds. To keep this updated, we have a team that calls clinics every day to find out if they’re providing care or not. What we’ve seen, actually just since the overturn of Roe, is that 13 states have completely banned abortion and 31 states are now limiting abortion after a certain point in pregnancy. That has translated to 66 clinics across 15 states that have either closed or stopped providing care.

SHANOOR SEERVAI: That’s very concerning. Can you talk a little bit about how many people are using abortionfinder.org, particularly in these states that have bans and restrictions?

RAEGAN MCDONALD-MOSLEY: We’re finding that we’re having a lot of visits in particular in states with a lot of restrictions and bans. In fact, about 17 percent of our volume to our site right now is from Texas specifically.

SHANOOR SEERVAI: Wow.

RAEGAN MCDONALD-MOSLEY: The information is reaching people who need it and who are really concerned and are having a hard time finding care. I think it’s important to note that, right, that all of these places that are closing or have stopped providing care, there’s obviously far less access to abortion care, but that also means less exposure and opportunity for a myriad of other services that people encounter when they’re getting this care, including STI [sexually transmitted infection] testing and treatment, contraception, management of early pregnancy issues, identification of chronic hypertension, or other chronic health conditions, et cetera.

SHANOOR SEERVAI: There’s a full domino effect down the whole suite of reproductive health services that are extremely important for women.

RAEGAN MCDONALD-MOSLEY: Exactly. We know that the people that are going to be most impacted are people who are historically underserved by the health care system already, specifically people of color, people with lower incomes, and people who live in rural areas in particular.

SHANOOR SEERVAI: You said that you have been seeing more traffic to the site. But can you talk a little bit about the research you’ve been doing?

RAEGAN MCDONALD-MOSLEY: Yeah. Since the overturn of Roe, we’ve also conducted user research with people who’ve navigated the incredible journey of getting an abortion after Roe, and coming from states where abortion is either highly restricted or banned. Our qualitative research identified some important themes. Specifically, we found that people are experiencing an extreme amount of loneliness, isolation, and a lack of support.

There’s also a significant unmet need for emotional support, as people are afraid to talk about their experiences with loved ones for fear that they’ll be implicated with helping them get an abortion, or that they’ll get into legal trouble, or that their loved ones would actually report them for getting an abortion. We also found, not surprisingly, that the logistics of arranging an abortion are much more complicated, and that people need more help navigating the disjointed ecosystem of connecting to appointments, funding, travel support, and emotional support. Lastly, we found that people expressed feeling information overload, and just wanting help connecting to their best options for care and support more easily and readily.

SHANOOR SEERVAI: Let’s take a minute to sit with that, because I feel like we usually talk about abortion access at most as a clinical issue, and we talk about it as a political issue. But the points that you’ve raised bring up the emotional impact that this has on people seeking abortions and their mental health and well-being. That’s at of time when this country is in a mental health crisis to begin with.

RAEGAN MCDONALD-MOSLEY: Yes, and I think as an obstetrician-gynecologist who’s been providing abortion care as a part of the full scope of my practice for almost 20 years, I’m embarrassed, almost, to say that this was a blind spot for me. I think in part because we’ve been focused so much on the political landscape and the logistics of all this, and so I’m so glad that we did this research that really showed that the emotional needs are being neglected and really need to be a focus for the whole ecosystem moving forward as we’re connecting people to care and services.

I say that shouldn’t have been a surprise to me because there are real people on the end of these policy decisions, right? There is somebody waking up in Texas today who’s never thought about this issue, has a late period, is taking a pregnancy test, and now all of a sudden they’re being inundated with emotions and logistics of trying to figure out the what next and what’s possible. This is happening across the country every day, and again, it’s impacting young people, people of color, and people of lower income the most, because we know that well-connected folks and folks with higher resources are going to be able to navigate the system and to connect to the care and services that they need.

SHANOOR SEERVAI: Let’s talk about some of this navigation. On the one hand, digital tools are extremely useful. On the other hand, state laws are changing so fast and people are being asked to travel or are choosing to travel across state lines to seek care. Even before the Dobbs decision, anecdotally, we were hearing about women from St. Louis, Missouri, going to a clinic just across the river in Illinois. Have you seen that this is accelerating since Roe v. Wade was overturned?

RAEGAN MCDONALD-MOSLEY: Absolutely. We’re hearing about this anecdotally and in our conversations with providers and through the users of our platforms, and we’re also seeing this in literature, including some preliminary research that was done by researchers at the TxPEP Institute that analyzed habits and travel patterns of folks after SB-8 went into effect in Texas in late 2021. They found that, in large part, folks were able to connect to care and services outside of Texas, and also that many more people turned to online abortion pills to aid access and other resources to get the medication abortion pills as well.

SHANOOR SEERVAI: How are you tracking how abortionfinder.org is helping people with this interstate travel?

RAEGAN MCDONALD-MOSLEY: We are being very, very deliberate in our platforms to not collect any identifying data. We’re not collecting any information about who’s coming to our website. We can learn a little bit about folks based on how they’re using the website, their search criteria, how much time they spend on the website. But we’ve really prioritized confidentiality over being able to track information and data, which is critically important because that’s actually something else that our research found, that folks are very concerned about privacy right now.

SHANOOR SEERVAI: Sure.

RAEGAN MCDONALD-MOSLEY: But I think to your point, this just highlights the need for not just the digital tools that we have with abortionfinder.org, at Power to Decide, and with other organizations, but the network of support providers on the ground in all of these states through abortion funds and practical support organizations. If folks are interested in learning more about those, I would definitely recommend going to the National Network of Abortion Funds to learn more about the network of abortion funds in each state and across the country, as well as Apiary, which is a collective of practical support organizations that’s actively working to help people travel across state lines to get the care that they need.

SHANOOR SEERVAI: That’s very useful, thank you. Before we leave the digital space, I did also want to talk about your presence on TikTok. Why that platform, and how is the reach different from the ways you’ve worked in the past?

RAEGAN MCDONALD-MOSLEY: Yeah, it’s so interesting, right? Again, as I stated, I’m an OB/GYN who’s been practicing for almost 20 years, and I have reached more people, probably young people, through the TikTok platforms with short videos about contraception and abortion and monkeypox with these little explainer videos than I have in over 20 years of practicing medicine. The reality is we make a lot of value judgements about the amount of time that young people are spending online in social media, and whether or not these platforms are good or bad for society. But the reality is that they are just tools, and it’s incumbent upon us to make sure that there’s good information accessible on these tools so that people can connect to evidence-informed good information where they’re getting lots of information and where they’re entertaining themselves, and hopefully connecting more young people to useful information about their sexual and reproductive well-being.

SHANOOR SEERVAI: Is there a story or example you have of someone you reached on TikTok who you were then able to see or follow through the impact in their lives?

RAEGAN MCDONALD-MOSLEY: Well, I can say that, in addition to the TikTok videos, I’ve also started biweekly Dr. Raegan Twitter office hours. That allows for a little bit more interaction than TikTok does, and I am surprised that, number one, people are asking their medical questions and looking for medical information on Twitter, and that people seem to be asking the same types of questions over and over again. There’s a lot of appetite for, like, what’s the progress on male birth control? There are a lot of questions about side effects of birth control, and there are a lot of questions about the use of IUDs. It’s allowing for one answer for one person to reach a broader platform, so that’s pretty exciting.

SHANOOR SEERVAI: That’s great. I want to shift now a little bit to the role of public opinion in your work at Power to Decide. Can you talk a little bit about what you mean by that, how it shapes the work, and what led you to this orientation?

RAEGAN MCDONALD-MOSLEY: I mean, I think that the conversation specifically about abortion access tends to be extremely polarized. The actions taken by the Supreme Court and at state legislatures would have one believe that there isn’t public support for abortion access across the country, and that’s actually just not true. From polls that we’ve done at Power to Decide and many other organizations, we know that a majority of Americans, regardless of their race, ethnicity, political affiliation, or religious affiliation, support access to abortion to some extent.

I think it’s really important to remind people of that, because again, looking at what’s happening across the country, we might think that this is normal or this is what people want, but it really just highlights how out of touch lawmakers are with how Americans feel about this issue. I will say, if there’s any silver lining in what’s happening right now, is that there are more conversations and productive conversations happening across the country about abortion access. People understand that this is an essential health care service, even if it’s not something that they had thought about before, or really took an opinion on, or had supported or really were opponents of.

Now they’re forced to have conversations about it because it’s everywhere. It’s in every news story, it’s in every newspaper, it’s everywhere, it’s in every podcast. I think leaders of companies are now having to think about, “Wow, if I have staff in a particular state, how do I support them and maintaining their representation in our workforce?” for example, and “How do we take a stance here?” I do think that the pendulum will shift in the other direction, and that we will be in a better place as a nation regarding stigma for broad sexual reproductive health issues, including abortion in the long run.

SHANOOR SEERVAI: That was going to be my next question, because the U.S. actually has a uniquely high level of shame and stigma when it comes to reproductive health care. Are you seeing attitudes shifting in a surprising and hopefully optimistic way?

RAEGAN MCDONALD-MOSLEY: I think so. I think, again, it’s a reminder that these decisions and these laws are very unpopular, and that it doesn’t have to be this way. As a young high school student, for example, I spent a semester studying in Paris with a family that had two young teenage girls, and they lived in the suburbs but had a flat in Paris. In the flat they had a bowl full of condoms on the living room table. While I lived in a pretty progressive family, there was no bowl full of condoms on our living room table. But it just shows that the approach to informing people about their bodies and healthy relationships and how to make healthy decisions to protect themselves is done very differently in other countries and should be done differently here.

There’s no reason why we don’t have national standards for sex ed, so that everyone can have a common language around what their body does, how it works, what a healthy relationship looks like, what’s a healthy touch, what’s a bad touch. There’s no reason why contraception is still, at this point, still so hard to get. Particularly sometimes the more expensive methods, the longer-term methods, it’s still very, very challenging. I met with a group that works on contraceptive access in Dallas, Texas, for example, and it can take seven weeks for a young person to get access to an IUD or an implant. That’s not access. Again, this is the same state where if that young person then has an unintended pregnancy, it may be almost impossible for them to connect to care and services.

SHANOOR SEERVAI: Right, so it’s this whole continuum of care that, as you’re saying, starts from sex education.

RAEGAN MCDONALD-MOSLEY: That’s right.

SHANOOR SEERVAI: Is it accurate to say that we can just see that as abortion access is restricted, people of color will bear the brunt of these new state laws?

RAEGAN MCDONALD-MOSLEY: A hundred percent. We already know that the people who will be disproportionately impacted are people with lower incomes, Black women specifically, and people who live in rural areas who already had to travel far too long of a distance to get access to quality maternal health services and abortion care, even before all of this happened.

I know this is something that the Commonwealth Fund has done a lot of research on and highlighted: the issues around maternal mortality in our country. The reality is that even before the federal protections for abortion access were overturned, we were doing very badly as a country regarding maternal health. In fact, we have one of the highest maternal mortality rates in the developed world, and Black women have four times a higher rate of maternal mortality in this country. That’s just unconscionable. In a place with so many resources we should and can be doing better, and we know how to do better.

But instead of doing better, we’re now doing worse with these policy changes. Demographers have estimated that the impact of banning abortion in the United States will increase pregnancy-related mortality by 21 percent overall over time, and the increase will be as high as 33 percent for Black women. Again, instead of doing what we know we should be doing — investing in community solutions, investing in doulas and other community supports, increasing access to quality maternal health services on the ground in communities that need it — we’re literally doing the opposite: to make it harder for people to connect to care and services, early pregnancy management, et cetera.

SHANOOR SEERVAI: Of course, we have evidence, for example, in the Turnaway Study showing that when women have access to safe and legal abortions, they have better health outcomes, and denying a woman an abortion has worse financial, physical, and mental health outcomes, worse family outcomes. How does this track with the experiences of the women and birthing people that you work with?

RAEGAN MCDONALD-MOSLEY: Yeah, I think the Turnaway Study is an amazing research project that puts a point on what we’re facing. I think we’ll have trickle-down effects not just for people’s physical health, but for their mental health, for their economic health, for their ability to leave relationships that are unhealthy, and for the existing children that they already have. It’s very concerning what we’re facing now, but it does give me hope to know that this is not for forever, and that there are models of other countries that are doing this better. I think the collective consciousness and conversation about abortion access being essential health care services in our nation right now will make things better in the long run. But we may be talking about a five-to-10-year trajectory, and in that time period, how many people will be harmed?

Plus, we haven’t even talked about the overall impacts on the health care system, the lack of training that’s happening in all these places, and a whole generation of providers that will not have the training to know how to provide early pregnancy management, abortion care, et cetera.

SHANOOR SEERVAI: Right. I mean, anecdotally we’re hearing stories of providers being threatened, facing lawsuits. You can sort of understand why providers, like yourself 20 years ago, may be concerned about going into OB/GYN care.

RAEGAN MCDONALD-MOSLEY: Right. I mean, it’s an absolute terrible situation to be in, and I do not envy my colleagues living in these states, where immediately these laws were overturned, they likely had patients who were coming into their emergency rooms with an early pregnancy complication. They’re pregnant, they’re bleeding, and the normal clinical scenario would be to evaluate this patient, provide them with all of their options and say, “This is what I can offer you. What is it that you want?” But now, instead of being able to make those decisions based on the clinical scenario and the desires and wishes of their patient, they now have to consult a lawyer or their legal counsel, or they may have to wait until the patient is far too sick before taking action. The provider themselves, they’re put in a position where they have to choose between providing best-practice medicine and potentially having a damaging report to their clinical license or facing criminal charges.

It’s really an untenable situation, and just shows why legal parameters and policy should not be in place in between the provider–patient interaction, whether it’s related to abortion care or other sexual reproductive health services, or frankly, any clinical care whatsoever.

SHANOOR SEERVAI: We’ve touched on this, but I do want to come back to it. Other sexual and reproductive health services, of course, the places where people seek abortions are also the places where people seek, as you were saying, STI testing, family planning. Are we concerned that in the wake of the Dobbs decision, other forms of safe and effective reproductive health care will be rolled back?

RAEGAN MCDONALD-MOSLEY: Yes. I think some of these will be unintended negative consequences of just having clinics shut down in areas that already sort of have deserts of access for STI testing, for example. When you have less options for testing for STIs and treatment for STIs, STI rates are going to go up. There’s sort of an unintended consequence. But then we have lawmakers who’ve said, “Okay, now that we’ve overturned abortion, now we’re turning to contraception.” For example, last year the Missouri Senate voted to ban taxpayer funding for emergency contraception and IUDs, and there’s a lot of conflation with abortion and contraception that’s happening with many of these lawmakers. Other lawmakers have overtly stated, again, that they plan to ban contraception next. I think with the unintended consequences of fewer providers being trained on these issues, just limited access in places that already struggle to serve many populations and demographics where they are, and then also these concerted efforts to further limit sexual and reproductive health services, things are likely to worsen, and health disparities are likely to worsen before they get better.

SHANOOR SEERVAI: Basically what we’re going to do as a country is tell women and birthing people that they cannot get abortions, and also tell them that they cannot get contraception to prevent their unplanned pregnancy.

RAEGAN MCDONALD-MOSLEY: Right. In particular, it’s important to think about young people who have to navigate parental consent, parental notification, just the enormous barriers to connecting to a quality health care provider in these communities, and what they’re facing right now.

SHANOOR SEERVAI: Can we talk a little bit about the potential of medication abortions?

RAEGAN MCDONALD-MOSLEY: Absolutely. I mean, I think one huge thing that’s very different now than pre-1973, before Roe v. Wade was passed, was the ubiquity of medication abortion. It’s a medical technology that’s been available in the United States for over 20 years. It’s safe and effective. Over half of abortions now are done with medication abortion. But it’s not going to be a silver bullet, in that many of the states that have banned abortion also have restrictions in place that make medication abortion inaccessible. If you have a complete ban of abortion, it doesn’t matter if it’s medication abortion or an in-clinic abortion, abortion’s still banned.

SHANOOR SEERVAI: Right.

RAEGAN MCDONALD-MOSLEY: If you have a ban at six weeks, doesn’t matter if you’re at seven weeks, you still don’t have access to a medication abortion.

There are providers who are providing medication abortion with telehealth, which is a promising advancement. But again, many states have laws in place that either ban telehealth specifically for medication abortion or requiring in-person visits for medication abortion. It’s not going to be a solution everywhere, but it is a very safe, effective option that many people are turning to, whether it’s from a licensed provider in the United States or from an overseas provider.

SHANOOR SEERVAI: Let’s just wrap up between where we are now and what your work looks like ahead. We’re in this unprecedented moment where the Supreme Court decision on Dobbs has come down, and states are making new laws on reproductive and abortion access. What will be the most important areas of focus in your work going forward?

RAEGAN MCDONALD-MOSLEY: I think our work is just more important now than ever, and we’re in the process now of integrating all of the research that we recently did with abortion seekers post Dobbs, and thinking about how we might make our tool, abortionfinder.org, even more robust to help people connect to care and services. We want to make sure that they have access to all of their resident and relevant information there. Then, also, just thwarting and preventing attacks on contraception. The ACA has been a game-changer in terms of increasing access to contraception, and we know that more folks are using contraception now. That is great, and we can’t afford to reverse the trend and the tides there as well.

SHANOOR SEERVAI: Dr. Raegan, thank you so much for joining me on The Dose today.

RAEGAN MCDONALD-MOSLEY: Thank you so much for having me.

SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Mickey Capper, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thank you for listening.