It seemed like a Trump campaign promise come true when, in October, despite three sexual-assault allegations, Brett Kavanaugh ascended to a lifetime position on the US Supreme Court. Not only did Kavanaugh’s appointment tilt the court further right, but it also appeared to fulfil one of President Donald Trump’s stated goals: to appoint anti-abortion judges to some of the highest seats in government.
But on 10 December, Kavanaugh and his colleagues issued a surprise decision. The Supreme Court chose not to consider a pair of cases that could further limit public funds to Planned Parenthood, one of the nation’s largest reproductive-healthcare providers — and a frequent target for anti-abortion groups.
Kavanaugh’s vote helped Planned Parenthood win the day. It was an unexpected twist at the close of what many reproductive-health advocates saw as a grim year for American women’s rights.
“There is a political takeover of healthcare,” says Mary Alice Carter, executive director of the reproductive-rights watchdog group Equity Forward. As she looks forward to 2019, she fears greater challenges lie ahead — that there’s a real chance women in certain states could lose access to abortion care.
“It’s definitely a possibility. I’ll say that. And it’s an unfortunate possibility for women who live in those states, who are basically faced with two options at that point: travel — which, for most people, is not even a choice because of the monetary cost and the time — or carry a pregnancy to term,” Carter says.
Already, in 2018, the federal government curtailed programmes designed to improve access to family-planning methods. The Trump administration allowed more companies with “religious or moral objections” to drop contraceptive coverage from their insurance plans. It also announced it would pursue a new rule to prohibit the government’s family-planning programme — called Title X — from being used to fund any programme even indirectly tied to abortion.
Reproductive-rights advocates fear that decision would amount to a “gag rule", silencing doctors who might otherwise mention abortion as part of their family-planning consultations.
Carter sees these decisions as the direct result of President Trump’s hiring practices. “What the Trump administration has done is put people in the Health Department who are opposed to the very programmes they are overseeing,” she says, ticking off the names of government officials tied to anti-abortion lobbies and abstinence-only education.
“They’re taking their political ideology and, in some cases, their religious leanings into a health department and using that to guide science, instead of using evidence.”
When asked if she saw reason for optimism in the recent Supreme Court decision to pass on the Planned Parenthood cases, Carter’s answer was a decided “no”. That was a case about funding, she explained. She’s more worried about the myriad state laws passed each year to restrict abortion access — laws that could one day face a legal challenge before the Supreme Court.
The court’s right-leaning justices, Carter says, “are waiting for that right case to look at, to challenge the overall constitutionality and legality of abortion”.
Ushma Upadhyay, a professor at the Bixby Center for Global Reproductive Health, has seen a rise in what she calls “feminist arguments against abortion”. Laws like Mississippi’s recently overturned Gestational Age Act — which would have stopped abortions after 15 weeks of a pregnancy — explicitly claim to protect women’s health, as well as the foetuses’.
“I think it’s a way of appealing to people who care about women when, in fact, childbirth is many times more dangerous than abortion is, any day, at any gestational age,” Upadhyay says. “It’s not really a sound argument.”
As a researcher who studies abortion access, Upadhyay observes that these state-by-state restrictions have “immediate” ramifications. “Those who are the most marginalised — the least empowered — are the ones who are impacted most by these laws,” she says.
But the number of laws restricting abortion access has dramatically increased in the last decade, with the Guttmacher Institute tallying 423 restrictions in the last eight years alone. Missouri recently became the latest of seven states to have all but one of their abortion clinics shutter.
It’s a way of appealing to people who care about women when, in fact, childbirth is many times more dangerous than abortion is, any day, at any gestational age
For all the restrictions in place, a December report from the Guttmacher Institute suggests a possible backlash. It notes that 2018 was the first year in recent memory when the number of proactive policies designed to safeguard reproductive rights outnumbered new restrictions.
Upadhyay is on the frontline of one such proactive policy. She has researched the barriers California students face when accessing abortion, at a time when the state is considering a bill requiring healthcare centres at all public universities to carry abortion medication.
Proactive policies, she says, are “a new approach that more progressive states are pursuing”. Upadhyay readily admits that some of these proposals will likely die in state legislatures. But even so, “they are effective in highlighting the rights people currently don’t have”.
As she looks ahead to the future of reproductive rights in the United States, Upadhyay notes that there also “seems to be a growing interest in self-managed abortions”. In other words, women are using online services to facilitate medication abortions at home.
It’s a practice that has been happening underground for years, but the medical community is also investigating ways it might be conducted under a physician’s care.
Maine Family Planning is part of a long-term study into this practice, often called "telemedicine abortion". Patients who choose this option will teleconference with an abortion doctor and receive their medications by mail, once they have completed the necessary testing and ultrasounds.
So far, Leah Coplon, Maine Family Planning’s programme director, estimates that only 4-5% of patients opt for this approach. It is seen as a possible solution to America’s so-called “abortion deserts” — areas where women might otherwise have to travel 100 miles or more to reach abortion care. But Coplon nevertheless says she’s often confronted with worries over safety. “There’s so much misinformation about abortion specifically that, when you combine the word abortion with tele-health, people kind of freak out,” she says.
Medication abortions generally involve taking one pill at a doctor’s office, and a second pill at home. The only difference with telemedicine, Coplon explains, is that the doctor watches the first step on a screen, rather than in person.
Maine Family Planning is one of many reproductive service providers waiting to see what the new year brings. Already, none of the federal funds it receives go toward abortion services. Even something as small as an alcohol wipe has to be paid for from a separate budget, if it’s used during an abortion procedure.
But Coplon says there are "glimmers of hope” on the horizon. A record number of women were elected to public office in 2018. When they are sworn into Congress next year, those women can start to effect change in the realm of reproductive health, however modestly. Men will continue to hold just under 80% of Congressional seats.
“I’m hopeful as we have a more diverse Congress,” says Coplon. “Unfortunately, there’s just been centuries – millennia even – of trying to control women and control women’s sexuality.”