Undue Burden: Life and Death Decisions in Post-Roe America

“This is a very important book and should be required reading for everyone interested in civil rights and gender equality in the health sector and beyond.”

While Undue Burden: Life and Death Decisions in Post-Roe America has been in the making for three years, it is still profoundly topical. It is rare that a day passes without media coverage of some aspect of the impact of the end of Roe v Wade on June 24,2022.

However, as is clear from Shefali Luthra’s excellent analysis, since 1973 when the US Supreme Court ruled that the Constitution guaranteed the right to abortion, Roe had been under constant threat from the anti-abortion movement, including lawmakers, in many different states.

As Luthra also shows, while the general population was in general pro-abortion their support tended to be rather passive until they or their loved ones were directly affected. People usually assume that it won’t happen to them . . . until it does! Luthra is also meticulous in detailing the many conditions which might impel a woman (or a transman) to seek abortion: ectopic pregnancy, fetal abnormalities, contraceptive failure, the mother’s own reproductive and general health, aside from other concerns such as poverty, marriage break-up, pressing career and family concerns etc., rather than the often- assumed negligence on the part of the concerned woman.

In 1976 the US Congress passed a law prohibiting the use of federal money to pay for abortions which therefore presented the procedure as outside and separate from normal medical care. The US currently has the highest maternal mortality rate among industrialized countries and Black women are three times more likely than white women to seek abortion.

In 1992 the Supreme Court issued a new ruling that further weakened Roe by agreeing that states could limit access to abortion as long as they did not impose “undue burden,” though the precise definition of the term was not clarified. As Luthra shows this ruling (in the case Planned Parenthood v. Casey) opened the door for state lawmakers in states that so wished to add new barriers and limitations which made abortion access difficult or even impossible in some states.

Typical restrictions are limiting the procedure to the first six weeks of pregnancy, when many people do not know that they are pregnant; limiting access to medical as opposed to surgical abortions by making purchase of mifepristone and misoprostol drugs difficult or impossible; requiring multiple and expensive clinic visits; and ensuring that only physicians and not nurses can perform what in many cases is a relatively simple procedure. These limitations have affected medical staff who fear losing their license, as well as patients desperate for bodily autonomy.

As Undue Burden clearly shows states responded very differently. In Texas and Oklahoma for example Roe was effectively undermined even before its technical fall in 2022 by the insistence on a six-week limit. Other conservative states imposed similar limits, which have given rise to massive cross-state movements by people seeking abortions in states where that is still possible. Costs of travel, hotels, and clinic fees add massively to the stress for abortion-seekers and inevitably caused in those states regarded as abortion sanctuaries massive overload of the clinic system, and of the larger health care system as the finite number of staff can no longer adequately cope.

Luthra mentions several times without going into detail that the attack on the civil rights protections represented by the overturning of Roe have already led to assaults on other protections against discrimination affecting in particular LGBTQ equality.

Special chapters are dedicated to Texas, Oklahoma, New Mexico and Illinois, Kansas, California, Colorado, New York, Florida, Arizona, and Washington D.C. where she analyzes the political, legislative, and cultural background to anti-abortion actions as well as showing the important movements across and between states by desperate patients and by medical staff anxious to serve as many people as possible.

Excellent and detailed case studies follow the progress of unwanted pregnancies, some of which result inevitably in a birth.

The careers, decisions, and fears of medical staff caught up in a situation where they can very often not provide the best patient care to which they have pledged an oath are depicted in detail and with great empathy. Legal protection for clinic staff performing abortions for out-of-state patients has also become a major issue. As has the need to protect the privacy of patients seeking abortion outside their home state in states where it is still legal. The search for service would usually involve a great deal of informal social media networking and research, and the possibility of search engine histories being leaked to law enforcement authorities, or being used for blackmail is considered a serious hazard.

Some more detail would have been appreciated on the establishment and management of abortion funds in a number of states, as would provision of a timeline of abortion-related rulings at state and federal level. And for non-American readers a clear map!

This is a very important book and should be required reading for everyone interested in civil rights and gender equality in the health sector and beyond.