Competency 12: Policy

Marieh Scales is a second-year Master of Public Health student at Emory University’s Rollins School of Public Health pursuing her degree in Health Policy & Management. As a Maternal and Child Health Fellow, Marieh has interests in reproductive health, maternal and child health, comprehensive sex education for all, and health care consulting. In addition to her graduate studies, Marieh works as a Graduate Research Assistant with SisterLove, Inc. assisting with the Georgia Access to Medication Abortion project and she also teaches the comprehensive sexual education Personal Responsibility Education Program (PREP) to students in middle and high school. In her spare time, Marieh likes to play Spyro, Call of Duty: Zombies, and looking at random pins on Pinterest.

Reproductive Justice is the human right to maintain personal bodily autonomy; to have children, to not have children, and to parent children in safe and sustainable communities (1). Reproductive Justice, a theory crafted by Black women in 1994, seeks to combine the tenets of reproductive health and social justice and at its core, Reproductive Justice is about access, not choice. What does access mean for Reproductive Justice? It means healthcare availability is baseline–people need to be able to get to their nearest provider and afford healthcare services. There is no choice where there is no access. While the southern states of the US are known for enacting laws to reduce access to reproductive healthcare, there is also a rich history of Black-women led reproductive justice organizations fighting to secure the continued reproductive rights of women in the southeast, and nowhere is that more true than in Atlanta, Georgia.

In May 2019 House Bill 481 (HB 481), The Living Infants Fairness and Equality Act, was signed into Georgia law. House Bill 481 is a measure that prohibits practicing physicians in Georgia from terminating pregnancies after embryonic or fetal cardiac activity can be detected, which can be as early as six weeks gestation. In addition, women found in violation of HB 481 could be punished with life imprisonment. While HB 481 is colloquially referred to as the Heartbeat Bill, it is important to remember that the presence of cardiac activity is not the same as a functioning heart that produces a heartbeat (2). Many women find out they are pregnant between 4-7 weeks gestation (3), with most abortions being performed after 6 weeks gestation (4). Since women often seek out abortion services after 6 weeks of gestation, House Bill 481 serves as a near-total abortion ban. In June of 2019, SisterSong Women of Color Reproductive Justice Collective and a wide range of health care providers filed a lawsuit to prevent the enforcement of Georgia’s HB 481. They argued that the law practically banned all abortions and disproportionately would impact people of color, those struggling financially, and rural Georgians–all classes of people who struggle to access needed healthcare services (5). In October 2019, the U.S. District Court in Atlanta granted an injunction which blocks HB 481 from taking effect while litigation proceeds. The triumph of SisterSong demonstrates that while there are political forces seeking to whittle away reproductive healthcare rights, reproductive justice advocates serve as bastions of access for those who need it most.

Abortions are still legal in Georgia. Yet similar to many other states, abortion services are regulated at a much higher rate than other healthcare procedures, despite its general safety. In the case of abortions, there are current state and federal regulations that make accessing and affording abortion services unneccesarily burdensome. Currently in Georgia, in-clinic abortions can be performed past 22 weeks from the last menstrual cycle only in cases of life endangerment, rape or incest (6). Medication abortion can be administered up to 10 weeks gestation and the first pill in the regimen, mifeprostone, must be dispensed by a physician. The Women’s Right to Know Act requires informed consent from patient’s at least 24-hours prior to receiving abortion services (7). Finally, the methods in which women can use to fund abortion services are regulated by law as well. Insurance plans purchased through the ACA Marketplace are required to fund abortions only in cases of life endangerment and severly compromised physical health (6). Public funding is not available for pregnancy termination with the only exceptions being if the mother’s life is in danger, rape, or incest.

In 2018, at the annual fall Rollins School of Public Health career fair, I learned of a Graduate Research Assistant position to work on the Georgia Access to Medication Abortion (GAMA) project with Sisterlove, Incorporated and Emory’s Center for Reproductive Health Research in the Southeast (RISE). The GAMA project is a community-based research project that investigates the barriers and facilitators for Black and Latinx people who may become pregnant and potentially use medication abortion. While I was familiar with Sisterlove, Inc. as an Atlantan native and familiar with RISE as a Rollins student, I had never heard of medication abortion to understand the barriers around medication abortion and develop novel solutions to increase access to medication abortion. Further–abortion is such a taboo topic–I was eager to be part of the efforts to make it an ordinary subject. The GAMA project can be broken into three phases. Phase One of the project includes in-depth qualitative interviews. Phase two will be an online survey about Black and Latinx women’s medication abortion perceptions, intentions, and use. In Phase Three, findings will be disseminated through web-based videos, manuscripts, clinical guidelines, and a training program for community-based advocates.

As a Graduate Research Assistant at Sisterlove, Inc., I have facilitated, transcribed, and coded Phase One key-informant interviews, helped develop the Project’s Community Advisory Board, and participated in many formative meetings. The conversations I personally had during these interviews as well as the ones I read during the coding process provided me with insight on the tangible effects of abortion policies and regulations on the accessibility of abortion services, especially for Black and Latinx women. The remainder of the article will focus on the preliminary findings from Phase One of the research and how policies and regulations concerning abortion impact Black and Latinx women in Georgia. More specifically, I will discuss how policies and regulatins such as HB 481, the Women’s Right to Know Act (WRKA), restrictions of public funding for abortions, and the long wait times that are associated withthe mediation abortion process.

The ratification of HB 481 and subsequent injunction left many women confused on whether abortion was still legal. One key informant stated that the week after the passing of HB 481, there was a decline in the number of women seeking abortions and call center employees still receive calls from women asking if abortion is legal in Georgia. The confusion of the legality of abortion may lead some women to seek out do-it-yourself abortion options or go to different states to access abortion services. The absence of safe, legal abortions, and increased travel times further reduces access to abortion services.

Other interviews detailed how the 24-hour delay in the WRKA seriously endangered the safety of the mothers in domestic violence situations. The multiple trips associated with the 24-hour delay can result in multiple requests for times off, multiple instances of childcare, and/or multiple round-trip transportation costs. To work around this, many abortion providers are requiring the WRKA to be read over the phone during the first phone consultation–in this way the patient’s first visit to the office can be for the abortion service, reducing the numbr of repeat logistical plans.

The further along a woman is in her pregnancy the more it generally costs to terminate the pregnancy. For many people, raising the funds for an abortion can be hard when the goal is always a moving target. The prohibition of using public funds for abortions compounds this problem. For Black and Latinx women who on average earn less than their white counterparts for the same work, securing the funds needed for an abortion in a timely manner can prove difficult. Compounding the cost of an abortion with the assocaited costs of taking time off of work, childcare, and traveling to and from the clinic, the total costs of an abortion can be much greater than just the cost of the procedure. To alleviate this issue, some clinics will provide discounts or will provide a list of resources to secure funding.

The most eye-opening of all is the medication abortion process. Since a physician is required to dispense medication abortion, many abortion clients wait 6-8 hours while the only abortion physician on hand finishes all in-clinic procedures prior to administering medication abortion. In key informant interviews, it was recounted many times that women had the conception that the process for a medication abortion would be faster than an in-clinic abortion. While that line of thinking is correct, policy at the federal level requiring physicians to dispense a pill, and policies at the organizational level on when patients can receive that pill seriously impacts the experience of individuals seeking a medication abortion. Considering work, childcare, transportation, and/or domestic violence, the wait time associated with medication abortion makes it an unlikely choice for many women.

Policies at the state and organizational level affect women’s access to medication abortion by making the initial medication abortion process even more tedious than it truly needs to be. While there are a few policies at the organizational level intended to assist in making access to abortion services easier, this can be tedious for Black and Latinx women due to intersecting forms of oppression. Public policy should be used as a means to maintain safe and efficient access to needed healthcare services. Unfortunately, public policy has been used to limit abortion services and the effects of these policies manifest themselves in different ways for Black and Latinx women. The use of public policy to limit the access to reproductive health services is a Reproductive Justice issue because it hinders one’s self-determination to family creation. As a theory, Reproductive Justice allows us to utilize our lived experiences to interrogate the systems and policies that create barriers to accessing healthcare, and imagine futures where the needs of the most marginalized are top priority. My time at SisterLove has demonstrated that nonprofit organizations, healthcare providers, community members, and academic institutions can and should collaborate to uplift the voices of those who face barriers to accessing healthcare.

1.Reproductive Justice. (n.d.). Retrieved from https://www.sistersong.net/reproductive-justice

2. Dabney P. Evans & Subasri Narasimhan (2020) A narrative analysis of anti- abortion testimony and legislative debate related to Georgia’s fetal “heartbeat” abortion ban, Sexual and Reproductive Health Matters, 28:1, 1686201, DOI: 10.1080/26410397.2019.1686201

3.Pregnancy Week 5 – 5 Weeks Pregnant. (2019, October 15). Retrieved from https://americanpregnancy.org/week-by-week/5-weeks-pregnant/

4. Chapman, G., Chapman, G., & Shalhoup, M. (2019, March 29). Who stands to lose the most under Georgia’s anti-abortion bill? Retrieved from https://www.atlantamagazine.com/news-culture-articles/who-stands-to-lose-the-most-under-georgias-anti-abortion-bill/

5. SisterSong v. Kemp. (2019, June 28). Retrieved from https://www.aclu.org/cases/sistersong-v-kemp

6. State Facts About Abortion: Georgia. (2020, January 3). Retrieved from https://www.guttmacher.org/fact-sheet/state-facts-about-abortion-georgia

7. Stam P. Woman’s Right to Know Act: a legislative history. Issues Law Med. 2012 Summer;28(1):3-67. PubMed PMID: 22953381.

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