What “choice” means for millions of women post-Roe

Amanda Northrop/Vox

Overnight, a generation of women born with the constitutionally protected right to an abortion saw it taken away. It has upended some of the biggest decisions of their lives.

When the Supreme Court ended the constitutional right to abortion enshrined by Roe v. Wade last June, there were near-immediate consequences for women, children, and families: A 10-year-old victim of rape was forced to cross state lines to receive an abortion. Women were denied care while having miscarriages due in part to confusion among health providers. Thirteen states enacted trigger laws, which banned nearly all abortions (though some faced legal challenges), while other states moved to severely restrict the procedure. In the following weeks, some women suffered from sepsis before receiving medically necessary abortions.

It will likely take years to understand the full scope of the consequences, though experts say it will mean more children born in states with high rates of maternal and infant death, and negative physical and mental health outcomes for mothers that will affect their children.

Other reverberations from the Court’s decision in Dobbs v. Jackson Women’s Health Organization will be harder to measure. Overnight, a generation of women born with the constitutionally protected right to an abortion saw it taken away. While earlier restrictions and legal challenges had meant that some women, particularly in the South, were living with a de facto ban before the fall of Roe, formally losing that right has had serious implications for people of reproductive age, plunging many women into uncertainty and forcing them to consider how a rapidly shifting political landscape could affect some of the biggest decisions of their lives.

To better understand how the fall of Roe – which was decided 50 years ago this week – is upending a generation’s family planning and reproductive decision making, Vox spoke with women across the country last fall. Many were wondering how they might prepare for worst-case scenarios they had never considered before. Those questions dogged women who were mothers, and those who weren’t, and were particularly fraught for women with medical conditions like endometriosis, which can cause complications during pregnancy. They also affected trans men who could get pregnant and cis men – some of whom decided to get vasectomies to prevent unwanted pregnancies.

“I find that I’m having more general conversations about pregnancy and pregnancy prevention,” said Dr. Taniqua Miller, an OB-GYN and assistant professor at the Emory School of Medicine.

Right after the ruling, Dr. Miller said, she heard from a few patients who were thinking about sterilization. “I think the Dobbs decision did make them really consider what the next phase of contraceptive care would be, not just abortion care, but more thinking about contraception,” Miller said. “I think that there is the thought: Will there be a slippery slope? Will contraception be available in the future? And I don’t think that we can really speak to that.”

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Abortion rights demonstrators react outside the US Supreme Court in Washington on June 24, 2022, after justices overturned the landmark 1973 Roe v. Wade decision and wiped out the constitutional right to abortion.

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Ellen, a 38-year-old who works in communications in Chicago, was pregnant when the Dobbs ruling was announced. (Because of new concerns about privacy, Vox is withholding the last names of women who requested it.) Ellen always knew she wanted children, but the experience of trying to start her family was complicated. Her first pregnancy, in 2020, was ectopic, meaning the pregnancy was nonviable: She needed emergency surgery to remove one of her fallopian tubes. In 2021, she and her husband again got pregnant but doctors later found a genetic abnormality, and lost the fetal heartbeat. Ellen was given the option of doing a dilation and curettage, or D&C procedure, to remove the fetal tissue, taking medication to expel it, or waiting until it happened naturally. “It was unbearable for me to think about just waiting for weeks or possibly a month to reach that natural termination process,” Ellen said.

Ellen got pregnant again after doing invitro fertilization (IVF) in 2022. After the court overturned Roe, even living in a state with legal abortion, she said, was suddenly little comfort. Three months after Dobbs, Republican Sen. Lindsey Graham introduced a bill banning abortion at 15 weeks; Ellen thinks that given the longstanding pressure from anti-abortion activists, it’s a very real possibility that if a Republican wins the presidency in 2024, the party could try to pass a national abortion ban. She wouldn’t be willing to risk pregnancy if that happened, which means that she wants to try to get pregnant with her second child before a Republican could be sworn in and further restrictions could be passed.

“I always imagined us having two children,” Ellen said. “Knowing that I could have an ectopic pregnancy again and watching what’s happening in states like Texas and Oklahoma, where people are going to the hospital with potential ectopic [pregnancies] and not being able to get treatment for that, even though it’s a non-viable pregnancy – it scares the hell out of me.” Like others who’ve done IVF, Ellen wonders what the vague language in many states’ abortion laws mean for the future of her embryos.

Ellen’s child was born in December. As Ellen considers trying to get pregnant again, she is thinking a lot about the very real implications of these new laws. “It doesn’t escape me, because I had an ectopic as my first pregnancy. A hundred years ago, there was no way to detect those pregnancies, women just died,” she said. “And to see those choices taken back from me…it’s really scary because, part of having a family, as I always wanted, was the presumption that I would be alive to enjoy it.”

“There are millions of people in the U.S. who are of childbearing age who are making these decisions,” Ellen said. She felt that policy was being made by politicians without a real sense of what she and other women experienced. “And it makes me feel like less of a citizen.”

Ellen wasn’t alone in feeling like she needed to decide quickly about a second child. Dorothy, 38, who lives in Washington, DC, and works in healthcare, also worries about a national abortion ban if Republicans took office, and about the possibility that a Republican controlled Congress–which has the ability to approve and reject laws passed in the District–might try to restrict abortion rights there. If a Republican wins the next presidential election, she doesn’t want to give birth after they are inaugurated, which means she’d need to be pregnant by early 2024, at latest.

“I would be scared about fetal abnormalities, I’d be scared about pregnancy complications and miscarriage … and I’d worry about my treatment options,” Dorothy says. She has friends and family in Texas, and has seen the ways in which this is already affecting them. In addition to fearing for her own health and well-being, Dorothy thinks a lot about what the lack of options would mean for her family, including her 4-year-old son.

“I know that this isn’t low risk. It feels very unwise to leave that level of uncertainty about my ability to protect myself. I’m a mom. I can’t die in childbirth. I have a child to take care of. That weighs on me,” she said. For that reason, she believes that she’s left with two choices: decide to try for another child within the next several months or resolve to not have any more children. “The fact that I’m making these decisions in the absence of a right I’ve always had is infuriating,” she said.

The decision has had major ramifications for women who have chosen not to have children, too. Kate Anderson, a student finishing her degree, lives in Minneapolis, Minnesota, with her husband. In her early 30s, Kate started suffering from fibroids and endometriosis, which causes heavy bleeding and painful, debilitating cramps. Her doctors suggested that Kate consider a hysterectomy, but the process was taking too long. Instead, she had the fibroids removed and an IUD inserted. Since that helped alleviate her symptoms, she didn’t feel the need to move forward with the hysterectomy, and she was feeling fine with her choices for years, until last summer.

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A doctor in Jakarta, Indonesia, shows an IUD birth control device. The Dobbs decision in the US caused a surge of interest in IUDs, which prevent pregnancies. Some women, fearing a threat to contraception, replaced their IUDs. Others wondered if IUDs were enough.

“The Dobbs decision kind of changed everything in my calculus, because now it’s just too risky,” Kate said. In the months before the decision came out, some abortion opponents suggested that they’d seek to restrict access to contraception–and Kate started worrying that the IUD she depended on to prevent pregnancy and treat her symptoms would become the next target. The day after the ruling, Kate called two surgeons to schedule appointments to discuss having her hysterectomy. She had the procedure done in the beginning of August. “This is the only way that I feel I could for sure never have to worry about this,” Kate said. “The reality is you are having a whole organ system removed, or most of it, and that is major surgery.”

“It makes me angry that I feel I had to go through a major surgery to feel safe,” Kate continued, “and it makes me even more angry that I have the privilege to have access to good enough insurance and surgeons that it was covered, while many women will not.”

Like Kate, Alice, a 34-year-old artist living in Augusta, Georgia, always knew she didn’t want to have kids. Before the Dobbs decision, she discussed the possibility of a tubal ligation, a sterilization procedure, with her doctor, but was relying on an IUD for birth control. She was working from home when a friend texted her that the Court had overturned Roe.

“I called my OB-GYN’s office that day, and I was like, put me on the schedule, as soon as you can. I’m done. I don’t want to take the risk,” Alice said. About a month after the Court’s decision, Georgia’s ban on abortion after five or six weeks went into effect – before many women know they’re pregnant. Alice got her tubal ligation in late August, and she said she has no regrets.

“I really do feel like I didn’t have any other choice. I had to choose to eliminate the possibility, rather than living with the idea that if I was assaulted or a victim of something horrible, that if a pregnancy resulted from that, that I would not have the option to choose what I wanted to do with my body. It’s not fair.”

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The pressures felt acute for women who were further along in their personal and professional lives, but they were also felt deeply by younger women. Kyle Siemers, a 24-year-old medical student from South Dakota who’s interested in becoming an OB-GYN, said she called her doctor the day of the Dobbs decision to inquire about having her IUD replaced – part of a surge of women looking into birth control options post-Dobbs. South Dakota had a trigger law that outlawed all abortions except in the case of life endangerment once the Dobbs decision came out. Siemers had her IUD replaced a month later, switching to one that prevents pregnancy for up to eight years.

“I definitely want to have a family at some point in time. The main driver for me right now is that I’m in graduate school, and financially, and I think time-wise as well, I could not support starting a family right now,” Siemers said.

Craig F. Walker/Boston Globe via Getty Images

Flo Ugoagwu leads protesters in a chant during the Womens Wave National Day of Action for Reproductive Rights demonstration in Boston in October 2022. Protests took place nationally to draw attention to reproductive rights before the midterm elections.

Rachel was finishing law school last year and considering where to start her career when the decision came out. She was moved to tears. Rachel, like Kate, has endometriosis, which can cause complications and high-risk pregnancies, and the notion that she might not have access to abortion if she needed one made her think differently about where she wanted to work.

“Now, states’ abortion laws are the most important factor in deciding where I’ll put down roots,” Rachel said. She was offered a job in Virginia, and her family wanted her to consider jobs in Pennsylvania, where she’s from. But even in Pennsylvania, a state where abortion is still legal through 23 weeks, Rachel didn’t feel safe: At the time she was considering her options, the Republican nominee for governor, Doug Mastriano, made national headlines for being one of the most hardline abortion opponents in the country. “It just doesn’t feel like the place I can start my career, a family or anything like that,” Rachel said. She chose a job in New York state instead. But before she did, Rachel voted early in the Pennsylvania election. It felt important to her, she said, to exercise her vote as a protest.

Exit-polls and interviews with voters after the 2022 midterm elections made clear that abortion was a major factor in voters’ decisions, and caused Republicans to underperform in key races, leading some analysts to argue that the Supreme Court’s decision overturning Roe cost Republicans a major midterm victory. Kelly Clancy, a 42-year-old academic editor and mother of three, noted that voting wasn’t the only way people acted on their convictions.

“One of the ways [people] practice their politics is thinking about the way they want their kids to be raised,” she said. Until recently, Kelly and her family lived in Lincoln, Nebraska, where Kelly was a professor. Once the pandemic began, she and her husband realized that they needed to be closer to family. They considered moving either to Austin, Texas, where her family lives, or New York, where his family lived. As they were deciding, Texas passed SB-8, a bill banning abortion after six weeks, and a precursor to the laws that would go into effect in other states several months later.

Kelly and her husband thought a lot about what would be best for their kids, who are still young but would be growing up under Texas’s new legal regime. They were concerned about the ban on abortion, and also the way Texas was investigating the parents of trans children and banning books from schools. “The conversation that we had wasn’t just about abortion, but about all of the other things that treating girls and women as second-class citizens impacts. Will they have access to birth control? What happens if one of their friends needs an abortion?” Kelly said. “I would like my daughters to live in a country where their gender matters as much or as little as they want it to. I certainly want them to live in a state where their rights are protected.”

Kelly thought about her son, too. If her family moved to Texas, she said, “My son would still be growing up in an environment where those were the prevalent conversations around women and their bodies.”

Her family ultimately decided to move to New York instead of Texas. It wasn’t an easy choice to make. On some level, Kelly felt like she was caught between wanting to fight for the future of a state that she feels a deep connection to, and protecting her kids. And like nearly every woman Vox spoke to for this story, Kelly felt like it was a privilege to be able to make any sort of decision about her and her family’s future, knowing that so many women will, because of these restrictions, find themselves with even fewer options.

gWhile many women were considering what the decision would mean for their families, some also weighed how it might affect those who can’t have kids on their own. Emily Morey, a nurse from Maine, is a mother of two who delivered two more babies as a surrogate, most recently in January 2022. Emily loved being able to help other parents start their families. She felt it was a gift she was able to give other people, one she felt deeply gratified to provide. In Maine, abortions remained legal up to the point of viability, but the state had an anti-abortion Republican for Governor until early 2019, and Emily felt strongly that her rights were now vulnerable to political interference. She decided she was done with surrogacy.

The decision was hard to make. “It was a really big part of my life, something that I wanted since I was very young. To be a mom, to be pregnant, to have babies, and to have babies for other people: it’s been so much of my life for such a long time. And to know, in that moment when I heard that the decision had come down, that it’s too risky, I cannot for any reason put myself in that position–it’s so sad and so hard to know that I didn’t get to pick when I was done.” Emily thought of the other parents, who often spent years on waitlists trying to find a surrogate. “It’s an immeasurable loss,” Emily said. “To know that those lines are getting longer, that those parents will have to wait longer and they may not be able to have children of their own because there isn’t a surrogate to help them, breaks my heart.”

Emily was now considering something else: tubal ligation. “It’s definitely not something I had made a plan for. It’s not something I had had a conversation with my doctor about. But now, it’s something I think about all the time. I have an upcoming visit with my OB-GYN to set up a surgical consult, because it’s time,” Emily said. “I hate to say it, I hate to think about it. But it’s time.”

For some women who were pregnant when Roe was overturned, the decision created stress and feelings of precarity around pregnancy itself. Caitlyn, a 33-year-old product designer from Richmond, Virginia, found out she was pregnant at the beginning of June. The fall of Roe, so early in her pregnancy, “scared me shitless” she said, as did the uncertainty over what would happen in Virginia, where Republicans have previously tried to restrict abortion, and the GOP governor, Glenn Youngkin, is currently seeking to limit the procedure to 15 weeks. Caitlyn wondered: If she miscarried early in the pregnancy, would there be time to get pregnant again before further restrictions on her right to an abortion were enacted? Caitlyn and her husband started looking at the state’s legislative calendar to determine when new laws might be enacted. In Virginia, new state laws are generally introduced in January and go into effect in July. “I did not expect to be thinking about what the legislative landscape was going to be looking like when I was thinking about what decisions I was making for myself and my family. I just didn’t even think that I’d be here,” Caitlyn said.

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An abortion rights activist painted LOVE ROE on her cheek as she attends a Women’s March rally held in October 2022 in Washington. Such protests have continued in the wake of the fall of Roe v. Wade last summer.

She and her husband knew they only wanted to have one child. The possibility of a ban coming into place this year, though, led them to a difficult question. If this pregnancy didn’t work out, would they be willing to try again, knowing the possibility that new laws might prevent her from having an abortion if something went wrong? “All of these different factors were the things we had to talk through,” she said. “And unfortunately, it means that this is the only shot for us, just given the priorities that we’ve set, which is: I’m just not willing to die for a couple of cells that are in my uterus,” Caitlyn said. “We decided this is going to be our only child, full stop. If we’re fortunate enough and she’s born healthy, that’s really exciting. And we’re really stoked. But if something goes wrong, this is the end of the line for us.” After they made their decision, Caitlyn’s husband got a vasectomy.

She thinks they would have ultimately chosen some form of sterilization after their child was born. But the decision that this would be her only attempt at having a child felt like it wasn’t fully hers. “It’s depressing. It’s frustrating,” Caitlyn said. By January, she was nearing the end of her pregnancy, and thinking about the world her daughter would grow up in. “I am overwhelmed sometimes by the responsibility that I feel to to parent a girl and raise a daughter in this environment. I want her to be so many things. I mean, ultimately, I want her to be happy and I want her to be healthy. And I want her to be comfortable with whomever she is,” Caitlyn said. “The weight of knowing that the way that she’s going to grow up, the rights that she’s going to have, are going to be very different than my own experience, it’s scary, as a parent. I don’t know how I’m going to navigate it. But I just know that it’s going to be very different for her than it was for me.”