‘I Still Would Have Had That Abortion’

Two years after the Supreme Court overturned Roe v. Wade, I am starting to see women come back. They are crossing state lines for a second time, or a third. At the reproductive health clinic where I work in California, I recently met a thirty-two-year-old woman who was in tears, practically inconsolable, before her abortion. She’d had this done before, she said. It was a “bad experience.”

When I asked her to tell me more, she began with the words I hear from many of my patients these days: “Well, see, I’m not from here. I’m from Texas.” The last time she was pregnant she’d caught it early, at about five weeks, and was able to have a medication abortion at a local clinic. She had what she thought was the appropriate cramping and bleeding at home. But when she returned a few weeks later for her follow-up appointment, she learned that the abortion hadn’t worked. She was still pregnant.¹ “But the law had changed in the meantime,” she explained, “and this time they couldn’t help me.”

That was early September 2021, nearly ten months before the Supreme Court’s Dobbs decision but just after Texas passed SB 8, a law prohibiting abortion after the detection of fetal cardiac activity, or around six weeks of gestation (two weeks after the first missed period). “So I came here,” she said, “but by that time I was too far to get it done even in California. So I had to go to Colorado. And by the time I got to Colorado, I was so far that I had to deliver the baby in order to, you know, have the abortion.”²

She was nowhere near this far along in her current pregnancy—about eleven weeks. “But I’m reliving it all over again,” she said.

For supporters of reproductive autonomy, the fact that this woman had to make three trips out of her home state for two abortions will prompt outrage at draconian bans like SB 8 (which has since been joined in Texas by a stricter criminal ban). Why, they will ask, should anyone be forced to cross state lines to access what should be a basic human right?

Others—even among those who consider themselves broadly supportive of abortion—might ask a different question: Why did this woman need multiple abortions in the first place? From a review of my patient’s medical record, I knew that the abortion in Colorado hadn’t been her first. She had been pregnant ten times and had two living children; the rest of her pregnancies had ended in miscarriage or abortion.

In Undue Burden: Life-and-Death Decisions in Post-Roe America, the journalist Shefali Luthra examines the immediate and far-reaching consequences of the state abortion bans that directly preceded the June 2022 overturning of Roe v. Wade and those that followed it. Under Roe abortion was a constitutionally protected right, but in the language of Planned Parenthood v. Casey, a 1992 decision that upheld Roe, states were permitted to restrict abortion as long as the restrictions did not impose an “undue burden” on patients; they could not ban abortion outright until after the point of fetal viability (roughly twenty-four weeks). When Texas enacted SB 8, and when Oklahoma instituted its six-week ban in May 2022, they were in direct defiance of Roe. The Supreme Court, in an act of defiance of its own, declined to intercede. This was the period when my patient, like thousands of other women, found herself pregnant—and trapped.³

When the Dobbs decision was officially announced, it codified the reality already unfolding in Texas and Oklahoma, allowing other states to follow suit. Abortion is now banned or severely restricted in more than twenty states. Luthra focuses her reporting on the stories of four pregnant people⁴ seeking abortions in two of these states: Texas and Florida. Along the way she interviews several other patients, as well as providers, clinic managers, and staff from both restrictive and permissive states, showing how and why, in appointment lines and waiting rooms from Florida to Oklahoma to Arizona, women were turned away, or brought in for an ultrasound only to be told they would need to travel elsewhere for care.

Well-meaning supporters of abortion tend to tell stories that focus on decisions rather than experiences, dwelling on questions of prevention (how she became pregnant in the first place) and justification (why she doesn’t just “want” an abortion but “needs” one). This is the rhetorical legacy of a reproductive rights movement that has for too long focused on “choice” rather than “rights.” It is the familiar, stern eyebrow raise implied by Bill Clinton’s infamous slogan that abortion should be “safe, legal, and rare”—something the public will tolerate, but only once our questions have been answered, our standards met.

It is immediately and refreshingly apparent in Luthra’s reporting that she is uninterested in questions of prevention. Her stories begin with a positive pregnancy test, or sometimes a bit earlier: “Her period was a few days late, and she was starting to worry.” This is Tiffany (“Tiff”), a sixteen-year-old from Texas who, “like so many teenage girls,” has “had pregnancy scares and near-misses before.” So, Luthra writes,

she did what she’d always done. She went to the bathroom. She peed on her test…hoping to put her mind at ease. One pink stripe appeared. That was good. It was just a sign the test worked, and that she’d taken it correctly.

But then came the second one—the one that meant her luck had finally run out.

Few of Luthra’s interview subjects mention—or Luthra chooses not to emphasize—the use of birth control. Again and again they encounter pregnancy as a surprise, even when it’s not their first. In Texas in April 2023, twenty-nine-year-old Kaleigh, who’d had an abortion once before, was nauseated, and her period was “weeks late”—but when her pregnancy test came back positive, “it felt like a gut punch.” Kelly, a twenty-six-year-old in Houston, tells Luthra that she felt her “heart sink” at the positive test. She’d had an abortion just seven months earlier.

After a few stories like this, questions about prevention might begin to nag at even the most sympathetic reader. If she wasn’t doing anything to prevent pregnancy, how could she be so surprised? And why wasn’t she more careful? It’s a culturally primed response that leans heavily on the idea that individuals—specifically, those who can become pregnant—are the ones responsible for preventing unintended pregnancies. But as I often tell my patients, “It takes two people, minimum, to make an unintended pregnancy.” Other responsible parties include politicians who legislate abstinence-only sex education in schools, a health care system that creates enormous gaps in birth control coverage, and a patriarchal society that aids and abets intimate partner violence and reproductive coercion.

To be clear, as a doctor I care very much about helping people prevent pregnancy when that is their goal. But as a rule I do not ask my abortion patients whether they were using contraception—or whether they plan to use it in the future.⁵ For me, as for Luthra, a woman’s abortion story begins with a positive pregnancy test. How she came to be pregnant in the first place is not my concern.

It is human instinct to try to explain our own and others’ behavior, to tell stories about why we make the decisions we do. The problem occurs when we—readers, writers, doctors, voters—assign a moral weight to those reasons, consciously or unconsciously. Luthra rightly criticizes a tendency in the national debate

to speak about abortion in only the starkest terms…focusing on the people who would die without an immediate abortion, or, on the flip side, characterizing every abortion as a mistake people regret forever.

In Undue Burden, she resists such simplistic storytelling. “People of all circumstances get abortions for all sorts of reasons,” she writes. “They relate to those experiences differently, and those different stories are all equally valid and deserving of our attention.”

Tiff, the teenager from Dayton, Texas, is the subject of the first of Luthra’s in-depth profiles. She has no partner (the boy who got her pregnant stops speaking to her soon after she shares the news) and a complicated home life: she lives with adoptive parents, of whom we learn little other than that her father drinks a lot. Tiff’s parents, like those of many of Luthra’s subjects, seem fundamentally opposed to abortion. Some families cite religious beliefs; in others, like Tiff’s, abortion is apparently so taboo that it simply isn’t up for discussion. When Tiff tells her parents she’s pregnant, they promise her they’ll help raise the baby.

But Tiff herself resists the idea of becoming a mother. She “was supposed to finish her own childhood first, finish school,” Luthra writes. Tiff has a history of severe depression, and as the pregnancy progresses, she spends more and more time alone in her room, researching self-managed abortion online. Eventually, at nearly five months pregnant,

Tiff snapped. She cut herself again. It was something she hadn’t done in years.

In a way, she said, it wasn’t that scary. The blood was the sign she was waiting for—the indication that this was one of the bad times when she needed real help, the kind that only professionals could give.

She turns to her mother, and spends a little less than a week in a psychiatric hospital, where she receives a prescription for a mood stabilizer—but she remains pregnant. Ultimately she develops preeclampsia, a complication of pregnancy involving high blood pressure, and is induced three weeks before her due date. She spends two and a half days in labor before giving birth to a healthy son, Mateo. “As much as I love this baby, I would wish this on absolutely no one,” Tiff says a few days after his birth. “I still ideally would have had that abortion.”

More than half of Americans who seek abortions already have at least one child at home. This statistic often surprises people, because early antiabortion strategists successfully portrayed women who seek abortion as young, unmarried, and irresponsible—an image at odds with our idealized notions of motherhood as selfless and sacrificial. “I love my kids,” my patients often tell me. “I can’t believe I’m doing this. I feel so selfish.” To which I often reflexively reply: “But it’s not selfish! You’re doing this for the kids you already have.” This may be true—but even as I say it, I realize it could be misconstrued as an indictment of women seeking abortion who are not already mothers.

Two of Luthra’s main subjects—Angela and Darlene—have children at home. Angela, a twenty-one-year-old in San Antonio, is raising her infant son when she learns in the fall of 2022 that she is pregnant again. Her parents are Catholic immigrants from Guatemala and are staunchly opposed to abortion. Angela has a tenuous relationship with her mother, and Luthra alludes to heavy alcohol use in her past, but in many ways Angela seems to be thriving: she has a stable partner, rents an apartment with him, and works a contract job that pays “decently.” Nevertheless, she and her boyfriend struggle financially. In addition to other debts, she is still paying off nearly a thousand dollars in medical bills from her son’s birth.

Angela hopes to get a degree and become an accountant or a nurse, to give her son a good life with a bigger home, instead of barely getting by on each month’s paycheck. In order to afford the trip to an abortion clinic in New Mexico (a nine-hour drive), she and her boyfriend are forced to cut back however they can—limiting trips outside their apartment to save on gas money, even “buying less formula for her baby.” Angela needs an abortion “for a million reasons,” writes Luthra, “but most importantly, getting an abortion would help her be the parent she wanted to be. She needed to do this so she could take care of the baby she already had.”

Darlene also lives in Texas. At forty-two, she “loved being a mom,” and she and her husband “would have been thrilled at the prospect of their daughter getting a younger sibling.” In January 2022 Darlene had surgery to remove uterine fibroids—a procedure that can improve fertility for women who want to have children in the future. Because of the incisions on her uterus, her doctors gave her the standard advice not to attempt pregnancy for three to six months following her procedure.

Two weeks after the operation Darlene began to feel familiar symptoms of nausea and fatigue. By the time her doctors took her seriously enough to perform an ultrasound, they found that she was eleven weeks pregnant. Although she’d taken multiple pre- operative pregnancy tests, all of which had been negative, the only possible explanation was that Darlene had already been pregnant—just under five weeks—at the time of her surgery, and that somehow the surgeon’s scalpel had managed to remove her fibroids while leaving the tiny, invisible embryo untouched.

A pregnant uterus that has been previously cut open—in a Cesarean section or a surgery like Darlene’s—is at risk of a complication called uterine rupture. When the uterus is stretched to maximum capacity and then subjected to extreme contractile forces, as occurs during labor, its muscular walls can split. This is an obstetric emergency, immediately life-threatening to both mother and fetus. Though exceedingly rare, uterine rupture can also occur earlier in pregnancy. This was the fear for Darlene, who was nearing the end of her first trimester with Texas’s six-week abortion ban in effect.

In a chilling moment, the physician who first identifies the pregnancy on ultrasound mutters to himself, “I can’t intervene. I can’t intervene.” Darlene quickly puts the pieces together:

She knew that here in Texas abortions were largely illegal. And she could see what course of action her physician clearly wanted to recommend, and what the laws wouldn’t allow him to say. What she didn’t know—what she couldn’t fully understand in that moment—was how grave the threat to her life was.

After a series of “vague, even timid” responses from her doctor, Darlene travels to see a specialist in Houston. He tells her that he doesn’t think she can safely carry her pregnancy to term, but when he asks his supervisors to approve an abortion, “he was shocked to learn that the answer was no. Because she wasn’t literally about to die, they didn’t believe Texas’s medical exceptions to its abortion ban would apply here.”

“Weeks of uncertainty” follow, until at about twenty weeks pregnant Darlene travels to California for the abortion she is “fairly sure she would need”—only to learn from doctors there that her scars appear to be well healed. Based on an MRI and measurements of her uterine walls, they determine that “the odds of rupture seemed quite low: maybe around 4 or 5 percent.” If she doesn’t want to get an abortion, they tell her, she and the fetus are very likely to make it through the pregnancy without complication. Ultimately Darlene decides to keep the pregnancy and gives birth to a healthy girl via Cesarean section.

Darlene’s case is an excellent illustration of how simply having the option of abortion—whether or not a woman takes that option—allows health care providers to offer patients truly informed consent, meaning a full discussion of the risks and benefits of a medical intervention as well as its alternatives. In the case of abortion, the alternative is to remain pregnant, which, even in the best of circumstances, entails some health risks.⁶

But Darlene’s case is also an extremely unusual clinical scenario, and not representative of the decisions most women will face. (The Texas doctor who diagnoses the pregnancy tells her that “in all his years of providing ob-gyn care, he’d never seen something like this.”) Luthra also plays a bit loose with terms like “grave,” “threat,” and “danger.” She seems to want very much to present Darlene’s case as one of life or death.

Elsewhere Luthra takes similar liberties with the language of medical risk. In the case of a twenty-eight-year-old woman named Amber, whose unplanned, undesired pregnancy is complicated by a short cervix, Luthra states: “It was a pregnancy dangerous for herself and for the fetus growing inside her.” This is not accurate. Cervical insufficiency is strongly associated with severe prematurity and pregnancy loss, but it does not in itself pose serious health risks to the pregnant person. Here Luthra falls into exactly the trap she aims to avoid, of speaking about abortion “in only the starkest terms”—as though she feels the need to explain or justify something to us.

Luthra’s last case study is Jasper, a nineteen-year-old trans man from Florida—and his abortion is the only one she makes no effort to justify. Perhaps we are to infer that being a trans man is self-evident justification—although some trans men can and do conceive intentionally, and others with unintended pregnancies decide to become parents.

Despite a somewhat tumultuous relationship with his family after coming out as trans, Jasper lives with his parents and has a mostly stable life. He has a job and a loving romantic relationship, and is working toward a college degree. His pregnancy comes as a shock; he “never even considered that he might be pregnant” when he became troubled by back pain and fatigue. His absent period “didn’t even register”: he’d started taking testosterone about six months earlier, as part of gender-affirming care, and as a result (or so he believes) he “barely menstruated.”

In fact, Jasper had had irregular periods since menarche, and testosterone therapy, even when it results in the cessation of menses, is not considered a reliable form of birth control. After doctors run multiple rounds of tests for his mysterious symptoms (but not one pregnancy test), an ultrasound technician discovers Jasper’s pregnancy while scanning his kidneys. It is August 2022. He is twelve weeks pregnant—just three weeks shy of Florida’s fifteen-week ban, which went into effect the week after the Dobbs decision (and has since been replaced with a six-week ban).

At moments during the harried and emotional process of scheduling his abortion, Jasper finds himself imagining that “he would give birth to a healthy baby, that he’d be able to do a good job being a dad.” He describes to Luthra the feeling that “his body wanted to protect the being that was growing inside him, which he’d begun to think of as a baby.” It is a tender ambivalence I often see in my own patients, who can struggle visibly with the meaning and value of the pregnancy inside them, even as they affirm their decision to end it. Jasper’s case is in this regard quite typical, even unremarkable—and in some ways the most instructive of all of Luthra’s examples. He is a person with a uterus who is pregnant and doesn’t want to be. This is the one common story beneath all abortion stories—and yet it can be the hardest story to accept.

In the opening line of Undue Burden, Luthra calls the end of Roe a “public health crisis,” and it is one. Noting Angela’s concerns about contributing to the state’s “overrun” foster care system (“It seemed wrong to have a child if you couldn’t take care of it yourself”), Luthra cites deeply disturbing reporting by The Texas Tribune about the state’s foster care system, including its “inability to account for hundreds of children who go missing each year.” She also effectively uses public health data to highlight disproportionate racial impacts of abortion bans; she notes, for example, that “in Texas, as is true nationally, Black people are more than twice as likely to die from pregnancy compared with white people.”

But it is when discussing abortion as a human right that Luthra makes her most powerful points: about the limitations of Roe, which was “never enough to ensure that everyone could easily, safely access legal abortions”; the injustices of legislation like the 1977 Hyde Amendment, under which no federal health insurance dollars can be used to pay for abortions; and the vulnerable and marginalized individuals in this country who have always been left behind, or left out entirely, in conversations about “choice.” She writes that the individual stories in Undue Burden “reinforce what should be obvious: abortion access is a story of economic inequality, a story of health care, and a story of human rights.” Denying people abortions treats them “as second-class citizens” and “denies them ownership over their own bodies.”

Yet it is not obvious that a view of abortion as a human right follows from these stories. The troubled teenager, the struggling young mother, the woman whose desired pregnancy is complicated by an ostensibly life-threatening complication, the trans man “confused” in his pregnant body—these read as types, not by any fault of Luthra’s, but because this is what abortion rights advocates have turned them into, largely for purposes of legislative persuasion. They have been designed to appeal to our sympathy, to persuade us that abortion can, at least in some cases, be justified.

It is up to the reader to ask whether we can summon the same level of sympathy for anyone seeking an abortion—without knowing their reasons, without asking whether they were using birth control or whether they plan to use it in the future. Conversely, can we extend this same compassion to individuals who decide to continue a pregnancy, planned or unplanned, despite circumstances or risks others might view as reasonable cause to terminate? When we trust anyone who is pregnant to make such a complex and personal decision for themselves, then we—politicians, health care providers, all of us—have to accept that they don’t owe us any explanation.