研究人員正在監測最高法院廢除墮胎權的後果。

資料來源：Mariana Lenharo / 2023 年 6 月 23 日 / 新聞 / 自然

美國墮胎意見分歧的不同支持者在最高法院推翻羅伊訴韋德案後舉行示威。

圖片來源：Michael Siluk/UCG/Universal Images Group via Getty

一直在監測該裁決影響的研究人員表示，美國最高法院一年前撤銷墮胎權的決定已開始對美國婦女的健康造成損害。 儘管現在衡量全面影響還為時過早，但嚴峻的形勢已經開始顯現。

推翻羅伊訴韋德案的影響

在法院做出推翻羅伊訴韋德案（Roe v. Wade）的裁決後，一些州禁止墮胎。該裁決於 1973 年做出，具有里程碑意義，幾十年來一直保護美國墮胎權。 現在的調查顯示，在這些州出現妊娠併發症的人由於醫生無法正確治療而處於危及生命的境地。 位於科羅拉多州丹佛市的計劃生育協會（一家專注於墮胎和避孕研究的組織）的一項研究還估計，在德克薩斯州、俄克拉荷馬州和阿肯色州等實施墮胎禁令的州，墮胎的平均數量已大幅減少。 但在附近的州，例如允許墮胎的堪薩斯州，墮胎人數幾乎同樣增加，因為人們前往那裡尋求照護。

這種平衡效應意味著，總體而言，美國每月平均墮胎數量減少了約3%。 佛蒙特州米德爾伯里學院 (Middlebury College) 的經濟學家凱特琳·邁爾斯 (Caitlin Myers) 一直在追踪墮胎的情況，她表示，這似乎只是一個小幅度的減少。 但是「這意味著，有五分之一到四分之一的人試圖擺脫『禁令州』進行墮胎，卻沒有成功」，而是繼續意外懷孕， 她說。

預期變化

去年 6 月 24 日最高法院發布裁決後，長期研究墮胎機會的公共衛生研究人員警告說，該國最弱勢群體將面臨更大的經濟困難和健康危害，因為他們缺乏前往墮胎的資源，或者是撫養新生兒。 研究人員還預測，這一項名為「多布斯訴傑克遜婦女健康組織」的決定將特別影響那些因缺乏互聯網鍵接而無法預訂遠程醫療預約的人，從而擴大差距。

預見到這些變化，邁爾斯和她的同事一直在監測人們現在到達最近的墮胎設施所需的距離。 根據他們未發表的研究結果，23% 的美國育齡女性的出行距離有所增加，現在距離最近的服務提供者平均超過 300 英里（約 480 公里）。

資料來源：#WeCount 報告/計劃生育協會

後羅伊案後的景觀：暗灰色為遵循美國2022年6月24日最高法院決定推翻羅伊訴韋德案之決議後完全禁絕墮胎之州可看出此一操作的減少（橘黃色）；而集中在禁絕墮胎州邊緣允許墮胎州的此一操作可見到大幅上升（藍色），懷孕的民眾旅行到當地尋求協助。整體而言，美國每月平均墮胎數下降了3%為79,031。（每月平均墮胎數改變之計算，採推翻羅伊案前的2022年四月及五月之數據，和推翻羅伊案後的2022年七月至2023年三月之數據進行比較）。

德克薩斯大學奧斯汀人口研究中心的公共衛生專家卡里·懷特（Kari White）重點研究了德克薩斯州頒布的禁令的影響。 在羅伊案被推翻之前，該州就通過了一項法律，禁止在懷孕六週左右進行墮胎照護，而許多懷孕的人甚至沒有意識到這一階段。 當時，這是該國限制最嚴格的墮胎法，儘管它受到法律挑戰，但最高法院拒絕阻止它，這預示著即將發生的事情。

懷特說，雖然為期六週的禁令生效，但「人們在半夜開車，一天往返七個小時去墮胎，因為他們無法承擔更多的休假時間」。 她補充說，現在，隨著德克薩斯州和路易斯安那州和俄克拉荷馬州等一些鄰近州的全面禁令，有時最近的診所距離 600 英里（965 公里）遠。 此外，由於德克薩斯州還有許多「內部邊境檢查站」——特工人員在這些檢查站監視無證移民——所以有些人不可能進行這些旅行，她說。

懷特指出，與允許墮胎的州相比，在羅伊法案被推翻之前，許多禁止墮胎的州在孕產婦和兒童健康方面的記錄就已經很差了，特別是在有色人種和低收入人群中。 她預計這種差距會進一步惡化——儘管目前還無法衡量確切的變化，因為今年早些時候才開始出現因羅伊案後意外懷孕而導致的分娩。

分享經驗

儘管一年的時間還不足以量化墮胎限制的一些後果，但研究人員一直在採訪衛生專業人員，以了解總體情況。 其中一項名為後羅伊案的照護 (Care Post-Roe) 的倡議於五月公佈了其早期發現。

加州大學舊金山分校社會科學研究項目「推進生殖健康新標準Ｊ」主任丹尼爾·格羅斯曼表示，他和同事發起這一倡議是因為他們聽說醫療服務提供者的雇主建議他們不要這樣做—-與媒體交談。 研究人員希望給醫生、護士和助產士一個分享他們的故事的機會，儘管是匿名的。

羅伊訴韋德案之後：美國研究人員對即將發生的事情發出警告

該倡議迄今為止的調查結果顯示，在禁止墮胎的州，某些妊娠併發症的治療受到了影響。 例如，當一個人在懷孕早期出現危險的羊水破水時（在胎兒能夠獨立生存之前），標準照護是進行墮胎，以防止危及生命的感染。 然而，根據醫療服務提供者的報告，在許多情況下，人們必須被送回家，並被告知在分娩開始或出現感染跡象時返回。

在一個案例中，一名患者後來因敗血症返回醫院，必須在重症監護室接受治療。 她分娩了胎兒，但需要進行胎盤切除手術。 格羅斯曼說：「在經歷了這一切之後，患者仍然擔心她或醫生所做的事情可能會讓他們面臨被起訴的風險」。「她問他這種情況是否會被視為『足以危及生命』，聽到這個消息真是令人震驚。 它凸顯了這些法律在醫生和患者中引起的恐懼」。

研究人員才剛剛開始監測後羅伊時代墮胎被拒絕的長期影響。 他們需要的信息，例如 2023 年的出生數據，要到明年才會發布。 邁爾斯說，我們的目標是利用這些數據來估計有多少人被「困在」墮胎禁令的州，從而生下了孩子。

doi：https://doi.org/10.1038/d41586-023-02083-w

編者註：《自然期刊》認識到跨性別男性和非二元性別人士可能會懷孕並尋求墮胎照護。 我們在這個故事中使用「女性」來反映我們引用的研究中如何報告參與者。

After Roe v. Wade: dwindling US abortion access is harming health a year later

Researchers are monitoring the consequences of the Supreme Court abolishing the right to an abortion.

Mariana Lenharo / 23 June 2023 / NEWS / Nature

Advocates on both sides of the abortion divide in the United States demonstrated after the Supreme Court overturned Roe v. Wade. Credit: Michael Siluk/UCG/Universal Images Group via Getty

The US Supreme Court’s decision one year ago to revoke the right to an abortion has begun to take a toll on women’s health in the United States, say researchers who have been monitoring the effects of the ruling. Although it is too soon to measure the full impact, a grim picture has begun to emerge.

The effects of overturning Roe v. Wade

After the court issued its decision, which overturned Roe v. Wade, a landmark 1973 ruling that had protected abortion access in the United States for decades, some states banned abortion. Surveys now indicate that people who experience pregnancy complications in these states have been put in life-threatening situations because physicians couldn’t treat them properly. A study by the Society of Family Planning, an organization focused on abortion and contraception research based in Denver, Colorado, also estimates that in states with bans, such as Texas, Oklahoma and Arkansas, the average number of abortions has decreased drastically. But they have increased nearly as much in nearby states, such as Kansas, where abortion is allowed, because people travel there to seek care (see ‘A post-Roe landscape’).

This balancing effect means that, overall, the average number of abortions per month in the United States has decreased by about 3%. That might seem like a small reduction, says Caitlin Myers, an economist at Middlebury College in Vermont who has been tracking abortion access. But “what that means is that somewhere between one-fifth and one-quarter of people who are trying to get out of the ‘ban states’ to obtain an abortion aren’t making it out”, and are instead continuing with unwanted pregnancies, she says.

Anticipating change

After the Supreme Court issued its decision on 24 June last year, public-health researchers, having long studied abortion access, warned that financial hardships and health harms would increase for the country’s most vulnerable, who lack the resources to travel for an abortion, or to raise a newborn. Researchers also predicted that the decision, known as Dobbs v. Jackson Women’s Health Organization, would particularly affect those who would be unable to book telehealth appointments because of a lack of Internet access, thereby increasing disparities.

Anticipating these changes, Myers and her colleagues have been monitoring the distances people now have to travel to get to the nearest abortion facility. According to their unpublished findings, 23% of US women who are of reproductive age have experienced an increase in that travel distance, and are now, on average, more than 300 miles (about 480 kilometres) away from the nearest provider.

Source: #WeCount Report/Society of Family Planning

Kari White, a public-health specialist at the University of Texas at Austin’s Population Research Center, has focused on the impact of the ban enacted in Texas. Before Roe was even overturned, the state had passed a law prohibiting abortion care after around six weeks of pregnancy, a stage when many people who are pregnant do not even realize it. At the time, it was the most restrictive abortion law in the country, and although it was the subject of legal challenges, the Supreme Court declined to block it, foreshadowing what was to come.

While the six-week ban was in effect, White says, “people were driving in the middle of the night, making a seven-hour trip out and back in a single day because they couldn’t afford to take more time off work” to get an abortion. Now, with a complete ban in Texas and some neighbouring states, such as Louisiana and Oklahoma, sometimes the closest clinic is 600 miles (965 kilometres) away, she adds. In addition, because Texas also has a number of ‘interior border checkpoints’ — where agents surveil for undocumented immigrants — it is impossible for some people to make those trips, she says.

White notes that, compared with states where abortions are allowed, many of the states that ban abortions already had poor track records for maternal and child health before Roe was overturned, especially among people of colour and those with low incomes. She expects the disparities to worsen — although it’s not yet possible to measure the exact changes, because births resulting from unwanted post-Roe pregnancies only started to happen earlier this year.

Shared experiences

Although one year isn’t long enough to quantify some of the consequences of abortion restrictions, researchers have been interviewing health professionals to get an idea of the big picture. One such initiative, called Care Post-Roe, published its early findings in May.

Daniel Grossman, director of Advancing New Standards in Reproductive Health, a social-sciences research programme at the University of California, San Francisco, says that he and his colleagues launched the initiative because they had heard that health providers were being advised by their employers not to speak to the media. The researchers wanted to give physicians, nurses and midwives an opportunity to share their stories, albeit anonymously.

After Roe v. Wade: US researchers warn of what’s to come

The initiative’s findings so far suggest that, in states with abortion bans, the treatment of certain pregnancy complications has been compromised. For example, when a person’s water breaks dangerously early in a pregnancy — before the fetus is able to survive on its own — the standard of care is to offer an abortion to prevent life-threatening infections. According to the providers’ reports, however, in many cases, people had to be sent home and told to return when labour started, or if they had signs of infection.

In one case, an individual later returned to the hospital with sepsis and had to be treated in the intensive care unit. She delivered the fetus, but required a procedure to remove the placenta. “After everything she went through, the patient was still worried that maybe something either she had done or the physician had done could put them at risk for being prosecuted,” Grossman says. “She asked him if this situation would b