七個簡圖說明「羅訴韋德案」 (Roe v. Wade) 被推翻的影響
墮胎將繼續，但可能更難安全地獲得。
資料來源：新聞特寫 / 2022 年 8 月 10 日 / 自然/ 財團法人台灣紅絲帶基金會編譯
美國各地的墮胎診所都面臨著不確定的未來。圖片：艾琳克拉克/波士頓環球報/蓋蒂
六月，美國最高法院裁定憲法沒有賦予墮胎權。現在，有 13 個州嚴格限制了該程序的使用，預計還會有大約有約一打的州會仿效。
對於一個高收入國家來說，在許多人認為是基本人權方面上朝著禁止的方向邁出了如此巨大的一步幾乎是前所未有的。健康研究人員正爭先恐後地預測這種變化的影響。大多數專家預計墮胎將繼續發生，但將更難合法獲得 – 有時需要大量旅行 – 並且可能變得不那麼安全。對墮胎率、公共衛生和孕婦經濟前景的長期影響不太確定。「如果人們想讓我從先前的證據推斷現在發生的事情，我認為沒有任何可比的證據」，紐約市專注於性健康和生殖健康權利的政策組織 Guttmacher Institute 的社會學家 Jonathan Bearak 說。
隨著美國衝入未知領域（參見「不斷變化的景觀」），有證據顯示，實施墮胎限制將為尋求墮胎的人和繼續提供這些程序的診所帶來巨大的負擔。
資料來源：古特馬赫研究所。
不斷變化的景觀：美國有13州處在觸發禁令的位置，在「羅訴韋德案」 (Roe v. Wade) 被推翻後立即受影響；衛生政策研究者預測另外9州肯定會通過禁令，另4州很可能亦會通過禁令；甚至其他對墮胎權有保護的州，其法規亦有可能會改變。
墮胎不會停止
來自世界各地的證據顯示，限制墮胎並不能結束墮胎。事實上，有時情況正好相反。 Bearak 和瑞士日內瓦世界衛生組織 (WHO) 的行為科學家 Bela Ganatra 及其同事收集了世界195個國家和地區 2,415 個數據點，包括調查結果和健康記錄，以估計年意外懷孕的數量和墮胎率。分析發現，墮胎普遍合法的高收入國家的墮胎率最低（參見「合法性與現實」）。
資料來源：參考文獻1。
合法性與現實：在墮胎是允許的許多國家其墮胎率反而較低，尤其在高所得國家更甚。
在這項分析中，中等收入國家的情況特別說明其結果：無論該國墮胎的法律地位如何，它們的意外懷孕率都相似。然而，限制取得似乎只能將墮胎率降低約 25%。「當你施加限制時，人們的生殖意圖並沒有改變」，加納特拉說。「他們會嘗試做他們決定做的事情」。
取得將變得更加困難
佛蒙特州米德爾伯里學院的經濟學家凱特琳·邁爾斯（Caitlin Myers）維護著一個提供墮胎服務的設施數據庫。就在最高法院推翻 1973 年保護墮胎合法性的 Roe v. Wade 判決兩週後，在美國大陸的診所尋求照護的人的平均旅行距離翻了一番，達到約 80 公里。如果所有處於禁止墮胎高風險的州都這樣做，預計這一距離將增加到約 217 公里。
根據邁爾斯收集的數據，如果這種情況發生，大約 2,400 萬年齡在 15 至 44 歲之間的女性的旅行距離將增加超過 160 公里（見「走遠一點」）。這是該人口中三分之一以上的人。
資料來源：凱特琳·邁爾斯，米德爾伯里學院
走遠一點：如果禁令如預期般的進展，將有為數幾百萬計的人面臨影響，估計約有2,400萬育齡婦女所居住之地區距其最近的墮胎診所將增加100英哩。
當前許多目的所在的州是未來墮胎不明朗的地方，例如佛羅里達州，因此這些州的服務提供者可能會避免將資源用於增加產能。「服務供應者可能會考慮到很多問題」，邁爾斯說。
鄰近周邊的州將受到影響
在德克薩斯州已經是人們為合法墮胎需要旅行最遠的距離，這個大州十多年來一直在增加對墮胎程序的限制。儘管有些人會轉向郵購藥物或其他秘密方法來終止妊娠，但許多人會前往其他州的診所。
德克薩斯大學奧斯汀分校的公共衛生研究員 Kari White 和她的同事測量了墮胎限制給這些診所帶來的負擔。在這裡，最近的歷史是有助於提供訊息。
去年，德克薩斯州通過了一項法律，一旦可以檢測到胎兒心跳，就禁止墮胎程序——在這個非常早期的階段，許多人甚至可能不知道自己懷孕了。結果，德克薩斯州居民旅行出他州墮胎的人數增加了十倍以上，尤其是前往鄰近的俄克拉荷馬州和新墨西哥州的人數增加了。 （俄克拉荷馬州是預計將進一步收緊限制的州之一。）
White 和她的同事發現，在引入該法律後，德克薩斯州附近的一些診所報告的等待時間約為三週，而一些診所不再進行預約（請參閱「等待時間增加」）。與此同時，德克薩斯州的墮胎數量下降了近一半——從 2020 年 9 月的 4,313 例降至 2021 年 9 月的 2,164 例。
資料來源：K. White 等人。德克薩斯州參議院第 8 號法案對德克薩斯州和州外設施墮胎等待期的初步影響。研究簡報（2021 年），請參考 go.nature.com/3DHQZQO
預約等待期增長：在2021年德州對墮胎設限後，鄰近較具有允許法規的州，其預約等待期便增長了，有些診所並停止接受新病患。
加州大學舊金山分校的公共衛生科學家 Ushma Upadhyay 說：「一旦德克薩斯州完全禁止墮胎，每個月出州旅行的患者數量就會猛增」。紐約市紐約大學的社會學家 Nicholas Mark 表示，在不久的將來，這種趨勢可能會變得更加難以研究，因為人們不太可能洩露有關墮胎的細節。
人們將在經濟上受到打擊
調查顯示，美國的許多婦女要求墮胎是因為她們缺乏養育孩子的經濟能力。但對被拒絕墮胎的人的經濟影響之了解一直是一個持久的挑戰。
在 「拒絕」(Turnaway) 研究中，加利福尼亞大學舊金山分校的研究人員追踪了來自美國各地的數百名女性，她們抑或是在其所在地區接受了接近妊娠限制的墮胎手術，或者是因剛剛超過限制而被拒絕接受墮胎手術。
這兩個群體在某些方面有所不同——那些被拒絕墮胎的人往往更年輕，不太可能已經有了孩子，更有可能失業，更有可能與其他成年家庭成員住在一起——但是，Ganatra 說，這項研究是處理導致人們要求墮胎的複雜情況的合理方法。
在對 Turnaway 數據的一項分析中，研究中超過一半的女性在要求墮胎時生活在聯邦貧困線以下，而被拒絕墮胎導致她們的家庭收入低於聯邦貧困線的危險對比值增加了四倍。
2020 年，一項將信用數據與 Turnaway 研究聯繫起來的分析發現，那些接受墮胎的人與被拒絕墮胎的女性相比，被拒絕墮胎的女性至少 30 天的債務逾期之債務增加了 78%，破產和驅逐等負面公共記錄增加了 81%。繼續生育的女性在財務困境指數上得分更高，該指數包括將債務出售給催收機構或信用評分降至 600 以下（參見「財務不安全」）等事件。根據該研究的作者，「被拒絕墮胎會對女性的財務狀況產生巨大而持續的負面影響」。
資料來源：參考文獻 6
財務不安全：在所居住的州內被拒絕墮胎的女性，相較於那些能夠在接近合法妊娠年齡限制時能獲得墮胎的女性，更容易經歷財務上的困擾，例如將債務出售給催收機構或信用評分降至 600 以下。
更多的墮胎可能不安全
墮胎不會停止，但全球數據顯示它們可能會變得不那麼安全。 Ganatra 和她的同事搜索了科學文獻、論文、非政府組織的網站和線上討論，以找到有關世界不同地區如何進行墮胎的信息。他們將這些信息與統計模型相結合，以估計有多少墮胎是安全的（使用 WHO 推薦的方法）、不太安全（由受過培訓的專業人員使用過時的方法或沒有足夠的信息或培訓）或不安全的（由未經訓練的人使用危險的方法）。
研究人員估計，在允許應要求墮胎的國家，幾乎 90% 的墮胎都是安全的（參見「限制與安全」）。在限制墮胎的地方，屬於「不太安全」和「最不安全」類別的墮胎更為普遍。
資料來源：參考文獻 7
限制與安全：對合法墮胎設立更多障礙的國家，傾向於經歷更高比率的非法和不安全的操作過程
孕產婦死亡人數可能上升
在安全實施的情況下，墮胎對人的健康構成的風險低於將嬰兒帶入足月。由於獲取的減少，與妊娠相關的死亡人數預計會上升。
在一項預印本之研究中，科羅拉多大學博爾德分校的社會學家阿曼達·史蒂文森 (Amanda Stevenson) 和她的同事模擬了 2020 年如果在 26 個實施了禁令或合理狀況有可能這樣做的州若未來沒有人可以進行墮胎的情況下。該研究的作者做出了一些假設：例如，要求墮胎的人與生育嬰兒的人具有相同的年齡分佈，並且墮胎的人和不墮胎的人的孕產婦死亡風險相同。考慮到這些限制和其他限制，他們估計，如果 2020 年沒有墮胎，將會有額外的 64 名孕婦死亡——增加 14%（參見「死亡率上升」）。
資料來源：參考文獻 8
死亡率上升：研究者估計了在美國26個可能對墮胎操作予以限制的州，其對懷孕有關死亡的衝擊，如在2020年在這些地區墮胎均未發生，將會有額外的 64 名孕婦死亡。
他們的分析還顯示，非西班牙裔黑人的全國死亡率最高，他們面臨的孕產婦死亡率平均比非西班牙裔白人高 2.9 倍，比西班牙裔高 3.0 倍。 （美國統計數據通常以這種方式分解種族和倫理人口統計數據。）
大約 50 年前，當最高法院裁定「羅訴韋德」 (Roe v. Wade) 案時，流行病學家 Roger Rochat 正在美國疾病控制與預防中心 (CDC) 調查墮胎死亡事件。現在於喬治亞州亞特蘭大的埃默里大學工作的羅查特說，那是一個令人振奮的時期。自由墮胎法緊隨避孕法的合法化，為人們提供了更多保護其生殖健康的機會。
1972 年，疾病預防控制中心收到 39 起因非法墮胎而死亡的報告，但到 1976 年，這一數字已降至 2 起，自 1979 年以來一直保持在或低於該數字。現在，隨著墮胎法規的迅速變化，羅查特不確定會發生什麼。他想知道孕產婦死亡人數是否會再次開始增加，以及目前的監測基礎設施是否足夠強大足以檢測到增加的情況。「我們習慣了正向的變化」，他說。現在，「我不知道它會如何的去擺脫」。
《自然》 608, 254-257 (2022) ；doi：https://doi.org/10.1038/d41586-022-02139-3
The effects of overturning Roe v. Wade in seven simple charts
Abortions will continue, but might be harder to access safely.
NEWS FEATURE / 10 August 2022 / Nature
Abortion clinics around the United States are facing an uncertain future. Credit: Erin Clark/The Boston Globe/Getty
In June, the US Supreme Court ruled that the constitution does not confer the right to an abortion. Now, 13 states have greatly restricted access to the procedure, and about a dozen more are expected to follow suit.
For a high-income country to take such a giant leap towards prohibiting what many people consider a basic human right is nearly unprecedented. Health researchers are scrambling to predict the effects of such changes. Most experts expect that abortions will continue to happen, but will be harder to obtain legally — sometimes requiring extensive travel — and could become less safe. Less certain are the long-term effects on abortion rates, public health and pregnant people’s economic prospects. “If people want me to extrapolate from prior evidence to what’s going on now, I don’t think there’s any comparable evidence,” says sociologist Jonathan Bearak at the Guttmacher Institute, a policy group in New York City focused on sexual and reproductive health rights.
As the United States hurtles into the unknown (see ‘Changing landscape’), evidence suggests that enacting abortion restrictions will create substantial burdens, both for people seeking abortions and for the clinics that continue to offer these procedures.
Source: Guttmacher Inst.
Abortions won’t stop
Evidence from around the world suggests that restricting abortion doesn’t put an end to it. In fact, sometimes the opposite is true. Bearak and Bela Ganatra, a behavioural scientist at the World Health Organization (WHO) in Geneva, Switzerland, and their colleagues compiled 2,415 data points, including survey results and health records, to estimate the number of unwanted pregnancies and the rate of abortions in 195 countries and territories around the world. The analysis found that high-income countries where abortion is broadly legal have the lowest rates of abortion (see ‘Legality and reality’).
Source: Ref. 1
Middle-income countries were particularly telling in this analysis: their rates of unintended pregnancies were similar, irrespective of the legal status of abortion in the country. However, restricting access seems to cut the rate of abortion by only about 25%. “It’s not that people’s reproductive intentions change when you put in restrictions,” Ganatra says. “They will try to do what they’ve decided to do.”
Access will become harder
Caitlin Myers, an economist at Middlebury College in Vermont, maintains a database of facilities that provide abortion services. The average travel distance for those seeking care at a clinic in the continental United States doubled, to around 80 kilometres, just two weeks after the Supreme Court overturned Roe v. Wade, the 1973 decision that had protected the legality of abortion. If all states that are at high risk of banning abortion do so, this distance is expected to increase to about 217 kilometres.
If this situation comes to pass, roughly 24 million women between the ages of 15 and 44 will see increases in travel distance in excess of 160 kilometres, according to the data Myers has collected (see ‘Going the distance’). That’s more than one-third of the people in that demographic.
Source: Caitlin Myers, Middlebury College
Many current destination states are places where the future of abortion is unclear, such as Florida, so providers in these states might avoid putting resources into increasing capacity. “There’s a lot of questions that are likely going through providers’ minds,” Myers says.
Neighbouring states will be affected
Some of the greatest distances that people already travel for legal abortions are in Texas, a large state that has been increasing restrictions on the procedure for more than a decade. And although some people will turn to mail-order medications or other clandestine methods to end a pregnancy, many will travel to clinics in other states.
Public-health researcher Kari White at the University of Texas at Austin and her colleagues have measured the burden that abortion restrictions place on these clinics. Here, recent history is informative.
Last year, Texas passed a law banning the procedure once a fetal heartbeat can be detected — a very early stage at which many might not even be aware they are pregnant. As a result, the number of Texas residents travelling out of state to obtain abortions increased more than tenfold, with particular increases in those going to the neighbouring states of Oklahoma and New Mexico. (Oklahoma is one of the states expected to further tighten its restrictions.)
White and her colleagues found that, after the law was introduced, some clinics in states adjacent to Texas were reporting wait times of around three weeks and some were no longer making appointments (see ‘Increased waiting times’). Meanwhile, the number of abortions performed in Texas dropped by almost half — from 4,313 in September 2020 to 2,164 in September 2021.
Source: K. White et al. Initial Impacts of Texas’ Senate Bill 8 on Abortions in Texas and at Out-of-State Facilities. Research Brief (2021), available at go.nature.com/3DHQZQO
“Once Texas bans abortion altogether, the number of patients travelling out of state each month will skyrocket,” says Ushma Upadhyay, a public-health scientist at the University of California, San Francisco. Sociologist Nicholas Mark at New York University in New York City says that this trend is likely to become more difficult to study in the near future, as people become less likely to divulge details about their abortions.
People will be hit financially
Surveys have shown that many women in the United States request abortions because they lack the financial means to support a child. But understanding the economic impact on people who are denied abortions has been an enduring challenge.
In the Turnaway Study, researchers at the University of California, San Francisco, tracked hundreds of women from around the United States who either received abortions close to the gestational limit in their area or were denied the procedure because they were just over the limit.
The two groups differed in some ways — those who were denied abortions tended to be younger, less likely to already have children, more likely to be unemployed and more likely to be living with other adult family members — but, Ganatra says, the study is a reasonable approach for tackling the complex circumstances that lead people to request abortions.
In one analysis of the Turnaway data, just over half of women in the study were living below the federal poverty line when they requested an abortion, and being denied one led to a fourfold increase in the odds that their household income would fall below the federal poverty line.
In 2020, an analysis that linked credit data to the Turnaway Study found that women who had been denied an abortion had 78% more debt that was at least 30 days overdue and 81% more negative public records, such as bankruptcies and evictions, compared with those who received abortions. Women who went on to give birth scored more highly on an index of financial distress, which incorporates events such as having debt sold to a collection agency or having a credit score that drops below 600 (see ‘Financial insecurity’). According to the authors of the study, “Being denied an abortion has large and persistent negative effects on a woman’s financial well-being.”
Source: Ref. 6
More abortions could be unsafe
Abortions won’t stop, but global data indicate that they could become less safe. Ganatra and her colleagues scoured the scientific literature, theses, non-governmental organizations’ websites and online discussions to find information on how abortions are performed in different parts of the world. They combined this information with statistical modelling to estimate how many abortions are safe (done with a method recommended by the WHO), less safe (done by a trained professional using an outdated method or without sufficient information or training) or unsafe (done by an untrained person using a dangerous method).
The researchers estimated that almost 90% of abortions in countries that allow abortion on request are safe (see ‘Restrictions and safety’). Abortions that fell into the ‘less safe’ and ‘least safe’ categories are much more prevalent in places where abortion is restricted.
Source: Ref. 7
Maternal deaths are likely to rise
When carried out safely, an abortion poses less risk to a person’s health than does carrying a baby to term. As a result of reduced access, the number of pregnancy-associated deaths is expected to rise.
In a preprint study, Amanda Stevenson, a sociologist at the University of Colorado Boulder, and her colleagues modelled what would have happened in 2020 if no one had had access to abortions in 26 states that have imposed bans or are reasonably likely to do so in the future. The authors of the study made some assumptions: for example, that people who request abortions have the same age distribution as do those who have babies, and that the risk of maternal death is the same in people who have abortions as in those who don’t. With those and other limitations in mind, they estimated that if there had been no abortions in 2020, an additional 64 pregnant people would have died — an increase of 14% (see ‘Death rates rising’).
Source: Ref. 8
Their analyses also suggest that national death rates would be highest in non-Hispanic Black people, who already face a maternal death rate that is on average 2.9 times higher than that for non-Hispanic white people and 3.0 times higher than for Hispanic people. (US statistics typically break down racial and ethic demographics in this way.)
Almost 50 years ago, when the Supreme Court decided Roe v. Wade, epidemiologist Roger Rochat was working at the US Centers for Disease Control and Prevention (CDC) to investigate abortion deaths. It was an uplifting time, says Rochat, who now works at Emory University in Atlanta, Georgia. Liberalized abortion laws came on the heels of decriminalized contraception, giving people more opportunities to protect their reproductive health.
In 1972, the CDC received 39 reports of deaths from illegal abortions, but by 1976, this number had dropped to 2, and it has remained at or below that number since 1979. Now, with abortion regulations shifting rapidly, Rochat isn’t sure what to expect. He wonders whether maternal deaths will start increasing again, and whether the current surveillance infrastructure is even robust enough to detect an increase. “We got used to positive change,” he says. Now, “I don’t know how it’s going to shake out”.
Nature 608, 254-257 (2022)
doi: https://doi.org/10.1038/d41586-022-02139-3