Opinion: Many post-Dobbs abortion fears have not come to pass. What does that mean for advocates?

The biggest surprise over a medical career is how often you find yourself surprised. Theories perfect on paper flounder in the real world. Proposed treatments that fit our understanding of disease will unexpectedly fail human trials. Cells, organs, human bodies, and health care systems are complicated, so as a doctor, you train yourself to be humble and wait for data that might not arrive for years. But we still make predictions, and often find ourselves startled by the outcome. Like many people, I assumed several things would happen after Roe v. Wade was overturned: Abortion rates would fall, infant and maternal deaths would both worsen, and doctors practicing in states where abortion become heavily restricted would flee to other parts of the country. These were all reasonable presumptions at that time but would also require years of data to evaluate. Now, more than four years since the Supreme Court decision in Dobbs v. Jackson Women’s Health Organization, we have an emerging picture, and many outcomes are surprising. But the fact that many of the worst predictions have not come to pass does not mean anyone should change their views on abortion restrictions, provided our guiding principles are autonomy and freedom. So, where do health measures currently stand after Dobbs? Let’s first unpack the prediction that proved correct: Infant mortality has increased in states where abortion access is heavily restricted — a relative increase of 5.6%, according to one study. There are two likely reasons for this. First, numerous states banned abortion for any congenital or genetic anomalies, even those inconsistent with survival — a cruelty to which we should never inure. More babies are being born with these conditions, and thus more babies are dying. The second is that patients with high-risk conditions are also being forced to continue — often resulting in adverse outcomes for their pregnancies. So, if infant mortality has risen, has maternal mortality worsened also? Surprisingly, a net increase has not been clearly identified. This carries many caveats, including the fact that bans coincided with the tail of the Covid-19 pandemic. As the virus alone drove mortality, attempts to measure overlapping effects are complicated. Also, a stable overall mortality can mask worse outcomes in restrictive states or within minoritized groups. Mortality rates are worse in states that have abortion bans, though these differences predated Dobbs and on average have been stable after. Even if the total national rates have not changed, we know that, since Dobbs, individual patients have died as direct results of bans. For these patients, and their loves ones, the epidemiology is forever meaningless. America’s maternal and pregnancy-associated mortality rates are also the worst among high income countries, so only improvement should be acceptable; an unchanged rate is a tragedy rather than celebration of stability. Another eminently logical assumption at the time of Dobbs was that the number of abortions would decrease. But abortions may instead be increasing. Why? First, abortion frequency is a result of multiple drivers of which laws are but one piece alongside economics, contraception, societal changes, and many others. The adage that laws don’t stop abortions proves valid again. Additionally, the historic moment was met by an army of activists, advocates, and health care workers laboring to preserve access, often taking advantage of telehealth and even putting themselves at legal risk. The national averages, however, risk masking the legions in restrictive states still not accessing care. Additionally, much of the preserved access depends upon mifepristone, which faces legal peril. And what of the fourth prediction, that doctors would leave restrictive states? Collectively across the country, recent estimates have identified net changes of zero or only 1%-2% for OB-GYNs moving from restrictive to unrestrictive locations. Though individual physicians have relocated in response to changing laws, the nationwide exodus that was feared has not occurred. In science, results that are counterintuitive are also often fascinating. As a doctor, my habit is to read new studies focused on their methodologies: their pitfalls, caveats, and potential for false negatives. But to focus too narrowly upon the statistics, data, and results will also risk missing the point. Broadly, our views here can be consequentialist or deontological; is something good or bad because it yields good or bad outcomes, or bad on a basis of our values alone? In medicine, our nature is to err toward consequences. Measurable outcomes are how we select medications or procedures, how we evaluate clinical trials. We can slip into viewing abortion bans through the same lens, judging their impacts on mortality rates or workplace demographics. But we can’t lose sight of the foundational ethical assault. Bans need not increase or decrease public health measures for opposition, but are opposed as misogynistic violations of autonomy. A consequentialist viewpoint risks dependence on outcomes, which in medicine are dastardly unpredictable. Opponents of abortion, for example, also adopt outcome-centered arguments to their peril, claiming that abortion increases risks of breast cancer and mental illness, which are, in rigorous studies, invalid. As a result, they emerge on the wrong side of oncologic and psychiatric debates. In the years to come, our data on the consequences of abortion bans may well further shift. In particular, I suspect that changes in mortality and our workforce may just be delayed rather than circumvented. But contingency is best avoided. When arguments are based on consequences, we then argue about data when we should be fighting for freedoms. David N. Hackney, M.D., M.S., is professor of reproductive biology at Case Western Reserve University and division chief of maternal fetal medicine. His new book is “Impossible Choices: A Physician’s Guidance on High-Risk Pregnancy in a World Without Roe,” out now from The MIT Press.