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  • Dobbs’s Confounding Effect on Abortion Rates

    Dobbs’s Confounding Effect on Abortion Rates

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    When the Supreme Court overturned Roe v. Wade, Diana Greene Foster made a painful prediction: She estimated that one in four women who wanted an abortion wouldn’t be able to get one. Foster, a demographer at UC San Francisco, told me that she’d based her expectation on her knowledge of how abortion rates decline when women lose insurance coverage or have to travel long distances after clinics close.

    And she was well aware of what this statistic meant. She’d spent 10 years following 1,000 women recruited from clinic waiting rooms. Some got an abortion, but others were turned away. The “turnaways” were more likely to suffer serious health consequences, live in poverty, and stay in contact with violent partners. With nearly 1 million abortions performed in America each year, Foster worried that hundreds of thousands of women would be forced to continue unwanted pregnancies. “Having a baby before they’re ready kind of knocks people off their life course,” she told me.

    But now, more than a year removed from the Dobbs v. Jackson Women’s Health Organization decision, Foster has revised her estimate. After seeing early reports of women traveling across state lines and ordering pills online, she now estimates that about 5 percent of women who want an abortion cannot get one. Indeed, two recent reports show that although Dobbs upended abortion access in America, many women have nevertheless found ways to end their pregnancy. A study by the Guttmacher Institute, a research group that supports abortion rights, signals that national abortion rates have not meaningfully fallen since 2020. Instead, they seem to have gone up a bit. A report released this week by the Society of Family Planning, another pro-abortion-rights group, shows that an increase in abortions in states that allow the procedure more than offset the post-Dobbs drop-off in states that closed down clinics.

    Read: The abortion backup plan that no one is talking about

    Some of this increase may be a result of trends that predate Dobbs: Abortion rates in the U.S. have been going up since 2017. But the reports suggest that the increase may also be due to travel by women who live in red states and the expanded access to abortion that many blue states enacted after the ruling. Still, it is not yet clear exactly how much each of these factors is contributing to the observed increase—and how many women who want an abortion are still unable to get one.

    Alison Norris, a co-chair of the Society of Family Planning study, told me that she fears that the public will “become complacent” if they see the likely increase in abortion rates and believe that everyone has access. “Feeling like the problem isn’t really that big of a deal because the numbers seem to have returned to what they were pre-Dobbs is a misunderstanding of the data,” she said.

    It seems illogical that more than a dozen states would ban abortion and national rates would hardly change. But even as red states have choked off access, blue states have widened it. And the data show that women have flooded the remaining clinics and ordered abortion pills from pharmacies that ship across the country. More than half of all abortions are done using medication, a pattern that began even before the Dobbs decision.

    “It just doesn’t work to make abortion illegal,” Linda Prine, a doctor at Mount Sinai Hospital, told me. “There may be some people who are having babies that they didn’t want to have, but when you shift resources all over the place, and all kinds of other avenues open up, there’s also people who are getting abortions that might not have gotten them otherwise.”

    With mail-order abortion pills, “it’s this weird moment where abortion might, ironically, be more available than it’s ever been,” Rachel Rebouché, an expert in abortion law and the dean of the Temple University Beasley School of Law, told me.

    The Guttmacher Institute sampled abortion clinics to estimate the change in abortion counts between the first halves of 2020 and 2023. Areas surrounding states with post-Roe bans saw their abortion numbers surge over that period of time. In Colorado, which is near South Dakota, a state with a ban, abortions increased by about 89 percent, compared with an 8 percent rise in the prior three-year period. New Mexico saw abortions climb by 220 percent. (For comparison, before Dobbs, the state recorded a 27 percent hike from 2017 to 2020.) Even states in solidly blue regions saw their abortion rates grow over the three-year interval from 2020 to 2023: Guttmacher estimates that California’s abortion clinics provided 16 percent more abortions, and New York’s about 18 percent more.

    Some shifts predated the court’s intervention. After a decades-long decline, abortions began ticking upward around 2017. In 2020, they increased by 8 percent compared with 2017. The researchers I spoke with for this story told me that they couldn’t point to a decisive cause for the shift that started six years ago; they suggested rising child-care costs and Trump-era cuts to Medicaid coverage as possible factors. But the rise in abortion rates reflects a broader change: Women seem to want fewer children than they used to. Caitlin Myers, a professor at Middlebury College, told me that abortion rates might have increased even more if the Court hadn’t reversed Roe. “It looks like more people just want abortions than did a few years ago,” she said. “What we don’t know is, would they have gone up even more if there weren’t people trapped in Texas or Louisiana?”

    One of the most significant factors in maintaining post-Roe abortion access dates from the latter half of 2021. As the coronavirus pandemic clobbered the health-care system, the FDA suspended its requirement that women pick up abortion medications in person. A few months later, it made the switch permanent. The timing was opportune: People became accustomed to receiving all of their medical care through virtual appointments at the same time that they could get abortion pills delivered to their doorstep, Rebouché told me. People no longer have to travel to a clinic and cross anti-abortion picket lines. But access to mifepristone, one of the most commonly used drugs for medication abortions, is under threat. After an anti-abortion group challenged the FDA’s approval of the drug, a federal court instated regulations that would require women to visit a doctor three times to get the pills, making access much more difficult. The Supreme Court is weighing whether to hear an appeal, and has frozen the 2021 rules in place while it decides.

    But paradoxically, several of the factors that may have contributed to the rise in abortion rates seem to have sprung directly from the Dobbs decision. In the year since the ruling, six blue states have enacted laws that allow practitioners to ship abortion pills anywhere, even to deep-red Texas. Although these laws haven’t yet been litigated to test whether they’re truly impenetrable, doctors have relied on them to mail medication across the country. Aid Access, an online service that operates outside the formal health-care system, receives requests for about 6,500 abortion pills a month. (The pills cost $150, but Aid Access sends them for free to people who can’t pay.) Demand for Aid Access pills in states that ban or restrict medication abortion has mushroomed since the Dobbs decision, rising from an average of about 82 requests per day before Dobbs to 214 after. The Guttmacher report doesn’t count abortions that take place in this legally fuzzy space, suggesting that actual abortion figures could be higher.

    As the Supreme Court revoked the constitutional right to an abortion and turned the issue back to the states, it also hardened the resolve of abortion-rights supporters. In the five months after Roe fell, the National Network of Abortion Funds received four times the money from donations than it got in all of 2020. People often donate as states encroach on abortion rights. In many cases, they bankrolled people’s travel out of ban states. Community networks also gained experience in shuttling people out of state to get abortions. “There’s definitely been innovation in the face of abortion bans,” Abigail Aiken, who documents abortions that occur outside of the formal health-care system, told me.

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    Some researchers believe that the Dobbs decision has actually convinced more women to get abortions. Abortion-rights advocacy groups have erected highway billboards that promise Abortion is ok. Public opinion has tilted in favor of abortion rights. Ushma Upadhyay, a professor at UC San Francisco, told me that California’s rising abortion rates cannot all be due to people traveling from states that ban abortion. “It’s also got to be an increase among Californians,” she said. “It’s just a lot of attention, destigmatization, and funding that has been made available. Even before Dobbs, there was a lot of unmet need for abortion in this country.”

    Abortion used to be a topic that was “talked about in the shadows,” Greer Donley, an expert in abortion law and a professor at the University of Pittsburgh, told me. “Dobbs kind of blew that up.” Still, she believes that it’s unlikely that people are getting significantly more abortions simply because of changes within blue states. Just as obstacles don’t seem to have stopped people from seeking abortions, efforts that moderately expand access are unlikely to lead people to get an abortion, she said.

    The people I spoke with emphasized that even though overall abortion rates might be going up, not everyone who wants the procedure can get it. People who don’t speak English or Spanish, who don’t have internet access, or who are in jail still have trouble getting abortions. “What I foresee is a bunch of Black women being stuck pregnant who didn’t want to be pregnant, in a state where it’s incredibly dangerous to be Black and pregnant,” Laurie Bertram Roberts, a founder of the Mississippi Reproductive Freedom Fund, told me.

    Bertram Roberts’s fund used to provide travel stipends of up to $250. Now women need three times that. Most people travel from Mississippi to a clinic in Carbondale, Illinois. The trip takes two days—48 hours that women must take off work and find child care for. “If you are in the middle of Texas, and you have to travel to Illinois, even if funds covered all the costs, to say that abortion is more accessible for that person seems callous and wrong,” Donley told me.

    Many women spend weeks waiting for an abortion. “It is excruciating to be carrying a pregnancy that one knows they’re planning to end,” Upadhyay said. And although studies show that abortion pills are safe, women who take them can bleed for up to three weeks, and they may worry that they’ll be prosecuted if they seek help at a hospital. Only two states—Nevada and South Carolina—explicitly criminalize women who give themselves an abortion (and few women have been charged under the laws), but the legislation contributes to a climate of fear.

    More than a year out from the Dobbs decision, the grainy picture of abortion access is coming into focus. With the benefit of distance, the story seems not to be solely one of diminished access, widespread surveillance, and forced births, as the ruling’s opponents had warned. For most Americans, abortion might be more accessible than it’s ever been. But for another, more vulnerable group, abortion is a far-off privilege. “If I lived in my birth state—I was born in Minnesota—my work would be one hundred times easier,” Bertram Roberts told me, later adding, “I think about that a lot, about how the two states that bookend my life are so different.”

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    Rose Horowitch

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  • Where End-of-Life Care Falls Short

    Where End-of-Life Care Falls Short

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    This article originally appeared in Undark Magazine.

    When Kevin E. Taylor became a pastor 22 years ago, he didn’t expect how often he’d have to help families make gut-wrenching decisions for a loved one who was very ill or about to die. The families in his predominantly Black church in New Jersey generally didn’t have any written instructions, or conversations to recall, to help them know if their relative wanted—or didn’t want—certain types of medical treatment.

    So Taylor started encouraging church members to ask their elders questions, such as whether they would want to be kept on life support if they became sick and were unable to make decisions for themselves.

    “Each time you have the conversation, you destigmatize it,” says Taylor, now the senior pastor at Unity Fellowship Church NewArk, a Christian church with about 120 regular members.

    Taylor is part of an initiative led by Compassion & Choices, a nonprofit advocacy group that encourages more Black Americans to consider and document their medical wishes for the end of their life.

    End-of-life planning—also known as advance care planning, or ACP—usually requires a person to fill out legal documents that indicate the care they would want if they were to become unable to speak for themselves because of injury or illness. There are options to specify whether they would want life-sustaining care, even if it were unlikely to cure or improve their condition, or comfort care to manage pain, even if it hastened death. Medical groups have supported ACP, and proposed public-awareness campaigns aim to promote the practice.

    Yet research has found that many Americans—particularly Black Americans—have not bought into the promise of ACP. Advocates say that such plans are especially important for Black Americans, who are more likely to experience racial discrimination and lower-quality care throughout the health-care system. Advance care planning, they say, could help patients understand their options and document their wishes, as well as reduce anxiety for family members.

    However, the practice has also come under scrutiny in recent years: Some research suggests that it might not actually help patients get the kind of care they want at the end of life. It’s unclear whether those results are due to research methods or to a failure of ACP itself; comparing the care that individuals said they want in the future with the care they actually received while dying is exceedingly difficult. And many studies that show the shortcomings of ACP look predominantly at white patients.

    Still, researchers maintain that encouraging discussions about end-of-life care is important, while also acknowledging that ACP needs either improvement or an overhaul. “We should be looking for, okay, what else can we do other than advance care planning?” says Karen Bullock, a social-work professor at Boston College, who researches decision-making and acceptance around ACP in Black communities. “Or can we do something different with advance care planning?”

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    Advance care planning was first proposed in the U.S. in 1967, when a lawyer for the now-defunct Euthanasia Society of America advocated for the idea of a living will—a document that would allow a person to indicate whether to withhold or withdraw life-sustaining treatment if they were no longer capable of making health-care decisions. By 1986, most states had adopted living-will laws that established standardized documents for patients, as well as protections for physicians who complied with patients’ wishes.

    Over the past four decades, ACP has expanded to include a range of legal documents, called advance directives, for detailing one’s wishes for end-of-life care. In addition to do-not-resuscitate, or DNR, orders, patients can list treatments they would want and under which scenarios, as well as appoint a surrogate to make health-care decisions for them. Health-care facilities that receive Medicare or Medicaid reimbursement are required to ask whether patients have advance directives, and to provide them with relevant information. And in most states, doctors can record a patient’s end-of-life wishes in a form called a Provider Order for Life-Sustaining Treatment. These documents encourage patients to talk with their physician about their wishes, which are then added to the patient chart, unlike advance directives, which usually consist of the patient filling out forms themselves without discussing them directly with their doctor.

    But as far as who makes those plans, research has shown a racial disparity: A 2016 study of more than 2,000 adults, all of whom were over the age of 50, showed that 44 percent of white participants had completed an advance directive, compared with 24 percent of Black participants. Many people simply aren’t aware of ACP or don’t fully understand it. And for Black individuals, that knowledge may be especially hard to come by—one study found that clinicians tend to avoid discussions with Black and other nonwhite patients about the care they want at the end of life, because they feel uncomfortable broaching these conversations or are unsure of whether patients want to have them.

    Other research has found that Black Americans may be more hesitant to fill out documents in part because of a mistrust in the health-care system, rooted in a long history of racist treatment. “It’s a direct, in my opinion, outcome from segregated health-care systems,” Bullock says. “When we forced integration, integration didn’t mean equitable care.”

    Religion can also be a major barrier to ACP. A large proportion of Black Americans are religious, and some say they are hesitant to engage in ACP because of the belief that God, rather than clinicians, should decide their fate. That’s one reason programs such as Compassion & Choices have looked to churches to make ACP more accessible. Several studies support the effectiveness of sharing health messages, including about smoking cessation and heart health, in church communities. “Black people tend to trust their faith leaders, and so if the church is saying this is a good thing to do, then we will be willing to try it,” Bullock says.

    But in 2021, an article by palliative-care doctors laid bare the growing evidence that ACP may be failing to get patients the end-of-life care they want, also known as goal-concordant care. The paper summarized the findings of numerous studies investigating the effectiveness of the practice, and concluded that “despite the intrinsic logic of ACP, the evidence suggests it does not have the desired effect.”

    For example, although some studies identified benefits such as increased likelihood of a patient dying in the place they desired or avoiding unwanted resuscitation, others found the opposite. One study found that seriously ill patients who prioritized comfort care in their advance directive spent practically just as many days in the hospital as did patients who prioritized life-extending experiences. The authors of the 2021 summary paper suggested several reasons that goal-concordant care might not occur: Patients may request treatments that are not available; clinicians may not have access to the documentation; surrogates may override patients’ requests.

    A pair of older studies suggested that these issues might be especially pronounced for Black patients; they found that Black patients with cancer who had signed DNR orders were more likely to be resuscitated, for example. These studies have been held up as evidence that Black Americans receive less goal-concordant care. But Holly Prigerson, a researcher at Cornell University who oversaw the studies, notes that her team investigated the care of Black participants who were resuscitated against their wishes, and in those cases, clinicians did not have access to their records because the patients had been transferred from another hospital.

    One issue facing research on advance care planning is that so many studies focus on white patients, giving little insight into whether ACP helps Black patients. For example, in two recent studies on the subject, more than 90 percent of patients were white.

    Many experts, including Prigerson, agree that it’s important to devise new approaches to assess goal-concordant care, which generally relies on what patients indicated in advance directives or what they told family members months or years before dying. But patients change their mind, and relatives may not understand or accept their wishes.

    Read: My mom will email me after she dies

    “It’s a very problematic thing to assess,” Prigerson says. “It’s not impossible, but there are so many issues with it.”

    As for whether ACP can manage to improve end-of-life care specifically in areas where Black patients receive worse care, such as pain management, experts such as Bullock note that studies have not really explored that question. But addressing other racial disparities—including correcting physicians’ false beliefs about Black patients being less sensitive to pain, improving how physicians communicate with Black patients, and strengthening social supports for patients who want to enroll in hospice—is likely more crucial than expanding ACP.

    ACP “may be part of the solution, but it is not going to be sufficient,” says Robert M. Arnold, a University of Pittsburgh professor of palliative care and medical ethics, and one of the authors of the 2021 article that questioned the benefits of ACP.

    Many of the shortcomings of ACP, including the low engagement rate and the unclear benefits, have prompted researchers and clinicians to think about how to overhaul the practice.

    Efforts to make ACP more accessible have spanned creating easy-to-read versions absent any legalese, and short, simple videos. A 2023 study found that one program that incorporated these elements, called PREPARE for Your Care, helped both white and Black adults with chronic medical conditions get goal-concordant care. The study stood out because it asked patients who were still able to communicate if they were getting the medical care they wanted, rather than waiting until after they died to evaluate goal-concordant care.

    “That, to me, is incredibly important,” says Rebecca Sudore, a geriatrician and researcher at UC San Francisco, who was the senior author of the study and helped develop PREPARE for Your Care. Sudore and her colleagues have proposed “real-time assessment from patients and their caregivers” to more accurately measure goal-concordant care.

    In the past few years, clinicians have become more aware that ACP should involve ongoing conversations and shared decision-making among patients, clinicians, and surrogates, rather than just legal documents, says Ramona Rhodes, a geriatrician affiliated with the University of Arkansas for Medical Sciences.

    Rhodes and her colleagues are leading a study to address whether certain types of ACP can promote engagement and improve care for Black patients. A group of older patients—half are Black, and half are white—with serious illnesses at clinics across the South are receiving materials either for Respecting Choices, an ACP guide that focuses on conversations with patients and families, or Five Wishes, a short patient questionnaire and the most widely used advance directive in the United States. The team hypothesizes that Respecting Choices will lead to greater participation among Black patients and possibly more goal-concordant care, if it prepares patients and families to talk with clinicians about their wishes, Rhodes says.

    Taylor, the pastor, notes that when he talks with church members about planning for end-of-life care, they often see the importance of it for the first time. And it usually persuades them to take action. “Sometimes it’s awkward,” he says. “But it’s now awkward and informed.”

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    Carina Storrs

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