Choice: A Public Health Policy Crisis

By Jennifer Villavicencio, MD

There is a U.S. public health policy crisis occurring that threatens the health and wellbeing of 74 million reproductive aged Americans and their families. It is a unique crisis that suffers from laser targeted attacks at the legislative and regulatory levels that fly in the face of one of the most robust evidence bases in health policy. These attacks seek to eliminate access to one of the safest outpatient medical procedures an American can undergo, one that 1 in 4 women* will experience by the time she is 45.

This crisis is abortion restriction.

People of all ages (25% of abortion patients are in their 30s), all races (39% are white, 28% black), all faiths (68% identified as religious) and all families (59% of women obtaining an abortion are already mothers) have abortions. Ninety percent of abortions occur in the first 12 weeks of pregnancy and less than 1% after 21 weeks. All abortions carry one of the lowest complication rates of any outpatient procedure in medicine (0.5-1%). Forty-five percent of pregnancies in the U.S. are classified as unplanned, and nearly half of those end in abortion. The proportion of unplanned pregnancies ending in abortion has remained steady despite the overall decline in the U.S. abortion rate.

Access to this care is critical to safety of reproductive age people. “Pre-Roe” era reports of hospital wards filled with women undergoing treatment for life threatening complications of unsafe, illegal abortion was enough to catalyze a nation wide movement in the US, culminating in the legalization of abortion in 1973 in the landmark Supreme Court decision Roe v Wade. Current global data of unsafe abortion further demonstrates how restrictions continue to threaten safety even in the modern era. Approximately 22,000 women die annually from unsafe abortion globally, with the majority concentrated in the most restrictive countries.

Despite what some American lawmakers claim, restricting abortion doesn’t necessarily decrease abortion rates (as mentioned above, the proportion of unintended pregnancies ending in abortion has remained steady over many decades). Restricting abortion does however, increase the risks to people seeking abortion. Unfortunately, abortion access is still being directly targeted by the nearly exponential increase in state level restrictions enacted over the last decade.

Abortion is unique in the public health arena. While it is extremely effective and safe, it is not universally recommended like vaccines or blood pressure screening. It is one of several options for a common health condition – pregnancy. The options for pregnancy include continuing the pregnancy to parent, adoption or ending the pregnancy in abortion. These options are never equivalent given the unique physical, psychosocial and financial implications for every pregnant person. Therefore, traditional public policy arguments like positive health impacts of having an abortion and cost effectiveness are less salient, given that the most ethical and appropriate intervention is to allow a person to decide for themselves about how their pregnancy should or should not continue. This public policy crisis is not only about abortion restriction; it is about the elimination of an incredibly important public health intervention: choice.

Choice is critical to the economic success of women in U.S. For example, women living in states with supportive reproductive health policies and laws have higher earnings than those living in less supportive states. A groundbreaking longitudinal qualitative study, shows that there are psychosocial detriments of being refused a wanted abortion, such as being more likely to be living below the federal poverty level, suffering from anxiety in the short term, staying tethered to an abusive partner, and being more likely to experience serious complications from the continued pregnancy.

We also know that the states enacting some of the most draconian abortion restrictions, like Louisiana, Mississippi, and Missouri, also have some of the highest maternal mortality rates in the U.S., signaling that when there is a political focus on restricting choice to end a pregnancy, the choice to continue one suffers as well. For example, in Alabama, when a senator attempted to add an amendment to the now passed near abortion ban that would provide maternal and child healthcare to those denied an abortion, it was defeated 23-6.

And so why, in the face of powerful evidence that demonstrates that chosen motherhood is clearly beneficial, are states racing to ban choice? Why, with the knowledge that these restrictive laws disproportionately impact poor women of color, would states focus on restricting healthcare access rather than expanding it?

It depends on who you ask.

If you ask the legislators in the six states that have voted to ban nearly all abortions in 2019 or the governors from over 40 states who have signed into law the more than 400 state level abortion restrictions from 2011-2017, it is to protect the life and wellbeing of mothers and children. This however is in direct opposition to the existing body of scientific evidence mentioned above, and rather in line with specific religious beliefs about “sanctity of life” and “when life begins.”

However, if you ask abortion providers like myself, legislatures are playing their god with my patients. The highly sophisticated and organized anti-choice movement has been working to overturn Roe v Wade for nearly 5 decades. Their vested interest in political power, religious dominance, and social engineering lays the foundation for legislating pregnancy and female bodies.

I know this because I used to be one of them. I used to stand on the protest lines, screaming the same mantras about the sanctity of life – until I became a physician. I witnessed the unparalleled joys and heartbreaking horrors of pregnancy. I learned from my patients, who taught me that lived experiences meant more than ideology, and that controlling one’s body is the key to liberty. I listened as patients explained to me that they needed to end this pregnancy so that they could take care of their children at home; needed to end this pregnancy because the child she was carrying would suffer needlessly as a result of a devastating fetal diagnosis; needed to end this pregnancy so she could continue to recover from substance use disorder in their inpatient facility that doesn’t allow pregnant patients. I realized that the sanctity of life I had been fighting for more than half of my life was sitting in front of me, begging me to see her life.

Because of my time as a “pro-lifer,” I understand on a deep level why abortion is contentious. I do not begrudge those whose personal beliefs bring them to a different understanding than mine. But what I cannot stand for is the government choosing conviction over science, narrow morality over their constituents.

These unscientific, plainly unconstitutional laws and policies aren’t just theoretical. They are an act of defiance against the 7 in 10 Americans who support the right to end a pregnancy. And they are an act of violence against the health and wellbeing of my patients, the people I have dedicated my life to serving. At some point, we the electorate, we the policy shapers, need to stand up and demand accountability for them.

Photo by bior on Flickr.


Jennifer Villavicencio is a Cuban American woman pursuing a Master’s of Public Policy at the University of Michigan. She is also a practicing obstetrician gynecologist and Family Planning specialist that incorporates abortion care into her medical practice. Her other passions include the impact of messaging on public opinion about abortion, the intersection of public policy and clinical medicine as well as fighting for reproductive justice.