June Medical Symposium

By Michele Goodwin*

In 2000, nations throughout the world agreed to participate in the United Nations Millennium Development Goals (MDGs). One of the key objectives specifically targeted reducing pregnancy-related deaths. Nearly two dozen international organizations and 191 member state nations publicly committed to achieve eight goals, among them reducing maternal mortality. All but a few nations showed demonstrable progress. The United States was among the few nations to fail and dramatically regress.

Maternal mortality rates actually increased in the United States at a rate of nearly 140 percent since 1990. As one reporter noted, “Just as the world turned its attention to this matter with marked success, the United States stopped offering data and began moving backward.”

What accounts for this? Texas holds some clues. Texas has the regrettable distinction of the deadliest state in the developed world in which to birth a child. As one commentator explained, “the Texas maternal mortality rate ‘now exceeds that of anywhere else in the developed world.’” It is also a state with an overwhelmingly male legislature, which prides itself on enacting the most restrictive abortion laws in the nation. As the Texas Tribune reported in 2017, “Once again, the Texas Legislature is mostly white, male, middle-aged.” At that time, men held nearly “80 percent of the Legislature’s seats.” Members of the Texas legislature filed nearly twenty antiabortion bills in 2017 alone.

Perhaps this shouldn’t be surprising, because Texas lawmakers pride themselves on efforts to criminalize and suppress reproductive rights. This is exemplified by the Texas targeted regulation of abortion providers (TRAP) laws the U.S. Supreme Court struck down in Whole Woman’s Health v. Hellerstedt. Even with such a victory, many abortion clinics had already shuttered. What Texas legislators failed to account for is that Texas abortion clinics also provided contraceptive and maternal care for the overlooked and underserved poor women in their state.

However, Texas is not alone. Alabama, Kentucky, Georgia, and other states similarly engage in efforts to eviscerate reproductive rights. Behind their antiabortion legislating are staggering rates of maternal mortality. A common thread in these abusive practices is the impact they have on Black women. For example, Louisiana, which enacted the TRAP law at issue in June Medical Services, exceeds the nation’s maternal mortality rate by a dramatic proportion. While maternal mortality is dire among Black women in the United States generally, in Louisiana the incidences of death are far greater. The average maternal mortality for white women is 18.1 deaths per 100,000 live births in the United States and 27.3 in Louisiana. For Black women, the U.S. incidence of maternal mortality is 47.2 and in Louisiana 72.6.

Policing the Womb shows history and power matter to any contemporary discourse regarding reproductive health, rights, and justice, including the legacies of slavery and Jim Crow in making complex, enduring chattel of Black women and girls. As DNA evidence confirms, during the antebellum period Black girls and women endured forced sexual bondage and well as physical labor imposed by people who claimed power over them. Simply put, American capitalism relied not only on their physical labor, but also literally their reproductive capacities. Yet, the cruelties of slavery also rendered Black women and girls expendable, making fungible, vulnerable chattel of them. In the past, self-described (private) masters claimed dominion over Black women’s reproductive capacities. Today, the state does so.

In other words, robust legislating that chips away at reproductive rights and encroaches on women’s reproductive healthcare is about more than abortion. It is about a fundamental lack of respect for the humanity, dignity, and citizenship of girls and women. It shows how conservative movements, combined with the rise and influence of a religious orthodoxy, successfully express themselves at the legislative level, particularly in the realms of reproductive autonomy and privacy. The book sharpens its gaze on the sex and gender asymmetries in legislatures, which more likely than not lead to the enactment of TRAP laws.

Policing the Womb considers how these strategic moves undermine fundamental constitutional rights. The book issues a cautionary tale to highlight the weaknesses in current Supreme Court’s jurisprudence, particularly the framework articulated in Casey, which revived paternalistic ideologies associated with women’s capacity to reason, consent, and make autonomous reproductive healthcare decisions, because historically the state and courts have been complicit in undermining women’s economic capacities and liberty interests.

Given what is at stake, it is critical to bring attention to how the recent robust lawmaking that restricts when and under what circumstances people may access reproductive healthcare rights not only functions to undermine constitutional rights, but also leads to the surveillance of reproduction, criminalization of conduct during pregnancy, and ultimately the burdening of health. In the abortion context, antiabortion lawmaking purposefully and strategically operates in the shadow of Supreme Court decision-making to intentionally thwart the spirit of the Court’s guidance in Roe v. Wade and Planned Parenthood v. Casey, which articulated that “a provision of law is invalid, if its purpose or effect is to place substantial obstacles in the path of a woman seeking an abortion before the fetus attains viability.”

As scholars, we should commit ourselves to reflecting on the personal costs associated with states policing women’s pregnancies and bodies. In doing so, our task must be to highlight how states’ selective interest in and punishment related to reproductive rights often targets women of color and the poor. As states enact measures to prosecute women for drug dependence during pregnancy or any conduct that endangers their pregnancies, what becomes clear is that such rules are not intended to be universalized and applied to all women, but rather to profiled, vulnerable subgroups.

The intergenerational suffering of Black women in former slave states remains visceral and part of the horrific legacies of institutionalized chattel bondage. For Black women in Texas, Louisiana, Alabama, Georgia, West Virginia, and elsewhere, not only is their reproductive freedom illusory, but staying alive during pregnancy is not a guaranteed, foregone conclusion. Private reproductive bondage in these former slave states is now public. That is, where planters once controlled Black women’s reproduction on their plantations and elsewhere, now the state controls what Black women (and others) may do with their bodies during pregnancy. In neither case has the regard for Black women resulted in the autonomy, independence, or privacy deserved.

Policing the Womb provides an important intervention, elevating the concerns of women too frequently ignored, disregarded, and overlooked in an ongoing domestic reproductive chattel system, which has outlasted the Antebellum period and morphed into present-day state surveillance of pregnancy. And, just as with slavery, states impose their reproductive interests and demands on poor women who are left to bear the weight of those legislative decisions lest they experience cruel civil or criminal punishment.

*Michele Bratcher Goodwin is a Chancellor’s Professor at the University of California, Irvine and founding director of the Center for Biotechnology and Global Health Policy. She is renowned nationally and internationally for her work in health policy, constitutional law, reproductive health, rights and justice, and cultural politics. She is the author/editor of six books, including Policing the Womb: Invisible Women and the Criminalization of Motherhood. Her commentaries appear in Ms. Magazine, the New York Times, Washington Post, Forbes, Salon, and the Chicago Sun Times, among others.

By David S. Cohen*

What’s the test in lower court cases challenging abortion restrictions? Is it the burdens versus benefits balancing test from Whole Woman’s Health v. Hellerstedt? Or is it the substantial obstacle test, with no balancing, from Chief Justice Roberts’ concurring opinion in June Medical v. Russo? This is the burning question in the post-June Medical world. Answering it takes us into the world of pornography, voting paradoxes, horizontal versus vertical stare decisis, and the simple-yet-beguiling dictum/holding divide.

The solution to this problem bridges two scholarly interests of mine—reproductive rights and Supreme Court decision-making. I’ve already written about June Medical’s implications for future Supreme Court abortion cases, with the Chief signaling that he is perfectly fine to allow most restrictions to go into effect. Here, I want to focus on the lower courts, who are bound to follow Supreme Court precedent, as opposed to hints as to what the Court might do in the future. But what is the precedent from the divided decision in June Medical?

So far, two lower courts have tackled this problem, reaching opposite conclusions. First, in early July, the District of Maryland found that the FDA’s requirement that abortion pills be dispensed at the clinic rather than being sent by mail is unconstitutional during the coronavirus pandemic. In doing so, the court applied the Whole Woman’s Health balancing test. It reasoned that the “common denominator” between the June Medical plurality and concurring opinions was that the Louisiana law was a substantial burden. Beyond that, there was no common denominator about a test, so the Whole Woman’s Health’s balancing test continues to be the law.

In early August, the Eighth Circuit ruled otherwise. In a case challenging a series of Arkansas abortion restrictions, the Court of Appeals instructed the lower court to re-evaluate the claims based on the Chief’s June Medical concurrence. The court reasoned that the Chief’s opinion “is controlling” because his “vote was necessary in holding” that the Louisiana law was unconstitutional. The court also noted, quoting Justice Kavanaugh’s June Medical dissent, that five Justices (the Chief and the four June Medical dissenters) rejected the Whole Woman’s Health test.

In dueling letter briefs to the Fifth Circuit in a case challenging Texas abortion restrictions, attorneys on both sides of the abortion divide have also produced different analyses. The attorneys representing the abortion clinics[1] told the court that there was no common denominator between the Breyer and Roberts opinions, so neither opinion is controlling, leaving Whole Woman’s Health the decisional rule. The attorneys for the state of Texas,[2] of course, took the opposing position, claiming that Chief Justice Roberts’ rejection of the balancing test in favor of a substantial burden test (without balancing benefits) was now the correct test .

So who’s right here? The District of Maryland and the abortion clinic attorneys have reached the right result, but their analyses are not technically correct.

The right way to get there relies on what’s called the Marks rule. Marks v. United States is a 1977 Supreme Court case that addressed the proper standard for pornography convictions. Deciding the case meant the Justices had to determine what to make of a prior obscenity decision that had fractured opinions from the Justices. Justice Powell’s opinion in Marks announced what is now known as the narrowest grounds rule: “When a fragmented Court decides a case and no single rationale explaining the result enjoys the assent of five Justices, ‘the holding of the Court may be viewed as that position taken by those Members who concurred in the judgments on the narrowest grounds.’”

As easy as it is to find and quote this rule, there has been deep scholarly and judicial disagreement (and confusion) over how it is applied (and even whether it should be the rule in these situations). The best scholarly work about the rule comes from Professor Maxwell Stearns, who has long written about Marks. In an excellent forthcoming article (“Modeling Narrowest Grounds”), Professor Stearns describes the theoretical underpinnings of the rule and explains its benefits and limitations. The rest of the analysis in this post is based on my synthesis of emails he and I have traded about his article, which is still in draft form, and June Medical over the past two weeks. (Though any flaws in this analysis are mine alone.)

The key issue in determining if and how Marks applies is whether the Court’s judgment is based on a single dimension. A single dimension means the Court’s decision turns on determining whether the applicable legal principle should be broader or narrower along a single scale. If there is a second issue that is essential for the judgment, such as determining the applicability of a second legal principle that cannot be scaled consistent with the first issue, there are two dimensions. Marks can only apply when there is a single dimension. When there are two dimensions, such as a disagreement over a separate jurisdictional issue, there is a risk of a voting paradox, something I’ve written about extensively.

For instance, in McDonald v. Chicago, the case in which the Supreme Court incorporated the Second Amendment against state and local governments, the split decisions created a voting paradox. In that case, eight Justices rejected incorporation of the Second Amendment under the Privileges or Immunities Clause and five Justices rejected incorporation under the Due Process Clause. Since both claims were rejected by a majority of the Justices, it would seem that the Second Amendment wouldn’t be incorporated. However, because four Justices thought it was incorporated under the Due Process Clause and a separate Justice believed it was incorporated under the Privileges or Immunities Clause, the outcome of the case is that the Second Amendment was incorporated. Thus, the paradox—separating out the dimensions leads to a conclusion that there is no incorporation, but the outcome of the case is that there is incorporation.

In June Medical, there is no paradox because there is only one dimension that determines the outcome of the case—how protective the Constitution is of the abortion right. Characteristic of one-dimension cases in which Marks applies, the fragmented opinions in the case can be aligned along a spectrum of more protective to least protective: Justice Breyer’s plurality opinion would protect the abortion right the most, the varying dissenting opinions would protect it the least, and Chief Justice Roberts’ opinion is in the middle. Thus, under Marks, the Chief Justice’s opinion—the narrowest that supports the judgment in the case—is the controlling opinion.

However, that isn’t the end of the analysis. The Chief’s opinion can be recast as one that has two parts to his analysis of this one dimension. First, he says that he disagrees with the legal analysis in the Breyer plurality because he doesn’t believe the Constitution requires balancing burdens and benefits to determine if an abortion restriction is unconstitutional. Rather, under the Chief’s rule, if an abortion law has a legitimate basis, it is constitutional as long as it doesn’t create a substantial burden. This is a rejection of the legal standard from Whole Woman’s Health. But second, the Chief says that, even though he rejects the legal standard from that case, as a matter of stare decisis he will follow the specific factual holding of the case (which he dissented from in 2016)—that admitting-privileges laws constitute a substantial burden. Because he follows this part of Whole Woman’s Health, he concludes the Louisiana law is unconstitutional.

If the Marks analysis ended with concluding that the Chief’s entire opinion controls, lower courts would have to apply both parts of his opinion—his relaxed test as well as the conclusion that admitting privileges laws are unconstitutional. However, the Marks analysis, by its very language, also requires determining the holding of the controlling opinion in order to determine what part of the Chief’s controlling opinion creates the binding precedent for lower courts.

Looking for the holding from the Chief’s opinion gets us to our final answer. The first part of his analysis—about the proper test for future cases—is dicta because it is not essential to the resolution of the matter before the Court. Why not? Because he says in the second part of his analysis that he is going to apply the factual holding from Whole Woman’s Health to determine that the law is unconstitutional. In other words, the new standard the Chief puts forth in the beginning of his opinion is not necessary to reach his conclusion that Whole Woman’s Health should apply to the Louisiana law as a matter of stare decisis.

What this means is that June Medical produces a very limited holding, one that is only about the unconstitutionality of admitting privileges. That is all we can take away by applying Marks to the fractured opinions. Beyond that, we have no new holding from the Supreme Court about a legal standard to apply in abortion cases. That means Whole Woman’s Health’s balancing test, which was announced in a majority opinion from the Supreme Court, continues to be the test lower courts must apply going forward.

What the Supreme Court will do as a matter of horizontal stare decisis is a different matter, as five Justices have signaled their support for a test that allows more state abortion restrictions. But, as a matter of vertical stare decisis, Whole Woman’s Health continues to bind the lower courts because any language to the contrary in the Chief’s controlling June Medical opinion was merely dictum.

*David S. Cohen (J.D.) is a Professor of Law at the Thomas R. Kline School of Law at Drexel University.

[1] Letter Brief of Plaintiffs-Appellants at 3–6, Whole Woman’s Health v. Smith, No. 18-50730 (5th Cir. July 10, 2020), 2020 WL 4060434.

[2] Letter Brief of Respondents at 5–7, Whole Woman’s Health v. Smith, No. 18-50730 (5th Cir. July 10, 2020), 2020 WL 4060435.

By Mary Ziegler*

The Supreme Court’s decision in June Medical Services v. Russo was more than a little ironic. Chief Justice Roberts’s controlling concurrence read as a celebration of stare decisis, the principle that the Court should usually defer to its past decisions. And yet Roberts upended precedent. If Roberts’s concurrence becomes the standard for testing the constitutionality of abortion regulations, the courts will not have to consider whether abortion restrictions have any benefit for patients, as Whole Woman’s Health v. Hellerstedt required. In short, Roberts’s proposed rule will make it easier for states to regulate abortion. Although the Chief Justice made a point of noting that no one had asked the Court to reconsider Roe v. Wade or Planned Parenthood v. Casey, he may well be game if that invitation eventually arrives.

June Medical could be bad news for anyone committed to abortion rights. Nevertheless, it is not easy to figure out where the anti-abortion movement goes next. At first, the Court’s decision might seem to discourage patient-protective anti-abortion laws. These statutes—which claim to prevent the psychological and physical harm done by abortion—have a poor win-loss record in the Supreme Court. The Court has used patient-protective reasoning in upholding laws focused on fetal life, such as the federal Partial-Birth Abortion Ban Act. But before 2016, the Court had struck down only one restriction, a husband-notification measure, under the undue burden test. Since then, the Court has rejected every patient-protective measure it has considered. The anti-abortion movement has no shortage of options if patient-protective restrictions have backfired. Sweeping bans, like so-called heartbeat laws, focus on fetal life rather than patients. So do several restrictions that focus on procedures later in pregnancy.

As I show in my new book, Abortion and the Law in America, patient-centered arguments against abortion may be here to stay. The dissents in June Medical foreshadow some of the arguments that will likely be key to efforts to reverse Roe, many of which suggest that abortion hurts patients. The dissenters accepted Louisiana’s argument that doctors should not have third-party standing to challenge abortion restrictions on their patients’ behalf. Justice Alito agreed that there was “a blatant conflict of interest between an abortion provider and its patients.” Justices Alito, Thomas, Gorsuch, and Kavanaugh also concluded that Louisiana’s law should stand precisely because it protected pregnant people against real dangers tied to abortion. Had the dissenters prevailed, their opinion would have made it much harder to challenge any abortion restrictions.

The dissenters’ views tell us as much about what at least four members of the Court think about the reality of abortion care in the United States—and how those views may lay the groundwork for reversing Roe. Justice Alito described abortion providers as profit-driven businesspeople who barely know their patients. He invoked Kermit Gosnell, a provider convicted of killing one patient and three infants who were born alive, in detailing the risks of abortion to all pregnant people.

These descriptions reflect an anti-abortion argument that has been decades in the making. Since the 1970s, abortion opponents have tried to undermine abortion rights not by advocating for fetal rights but by contesting what abortion in the United States is really like. This approach made considerable strategic sense. The Court had not been receptive to arguments seeking to establish constitutional rights for fetuses, but incremental restrictions have fared much better. To defend these laws, abortion foes detailed the supposed benefits of abortion restrictions (and condemned the purported dangers of abortion).

Since Casey, anti-abortion leaders have focused particularly on the consequences of abortion on patients’ health and wellbeing. The Casey Court declined an invitation to unravel abortion rights. The plurality reasoned that Roe was not only a workable decision but also one that had created substantial reliance interests. “The ability of women to participate equally in the economic and social life of the Nation has been facilitated by their ability to control their reproductive lives,” Casey reasoned. In the years after Casey, leaders of the anti-abortion movement concluded that the Court would never reverse Roe unless the public and the Justices believed that pregnant people should not rely on abortion to lead more equal lives. Anti-abortion lawmakers introduced laws intended to show that abortion made patients sick. Targeted regulations of abortion providers, like the one struck down in June Medical, relied on this patient-protective justification. So did laws claiming that medication abortions could be reversed, that abortion caused breast cancer, or that specific abortion techniques could be banned without a health exception. These arguments have played a key role in anti-abortion advocacy for nearly thirty years. June Medical is unlikely to change that.

If anything, anti-abortion leaders increasingly emphasize claims that abortion access undermines racial justice as well as equality for women and pregnant people. This summer, new states, including Mississippi and Tennessee, have joined the list banning abortion for reasons of race, sex, or disability.

These laws, like the patient-protective statutes at issue in June Medical, thrive because of growing distrust of public-health authorities, medical experts, and even the media. A focus on the reality of abortion in the United States has undermined any consensus about the basic facts and deepened polarization. Now, the courts are asked to decide whether pregnant people often have abortions for racist, sexist, or ableist reasons, whether abortion providers are irresponsible, or whether abortion has serious side effects.

Polarization of this kind has serious costs. During the COVID-19 pandemic, the kind of distrust of medical authorities that has long defined the abortion struggle has sparked conflict about everything from mask mandates to the safety of a possible vaccine. In the context of reproductive justice, polarization has made it all but impossible for those with clashing views on abortion to work together on any reproductive justice issue, including maternal mortality to pregnancy discrimination at work.

Despite the damage they have done, we should not expect anti-abortion leaders to give up on arguments about the reality of abortion. After all, these claims just might be working. June Medical is proof of that.

*Mary Ziegler is the Stearns Weaver Miller Professor at Florida State University College of Law and the author of Abortion and the Law in America: Roe v. Wade to the Present (Cambridge University Press, 2020).

By Aziza Ahmed*

Among the many important critiques made by reproductive justice (RJ) advocates, a key claim is that “choice” is a myth for poor women seeking reproductive health services. According to RJ advocates and scholars, a combination of laws and social realities—from welfare restrictions to discrimination in the hospital setting—have made it nearly impossible for poor pregnant women to have autonomy and agency in their health-related decision making. Some scholars have argued that the myth of “choice” reifies the woman’s responsibility for her purportedly bad reproductive decisions.

The idea that the “choice” rhetoric allows for blame is especially relevant to the criminal legal response to pregnancy and childbirth, where we see prosecutors, doctors, and nurses seeking to hold women responsible for their birth outcomes. This use of the criminal law to manage women’s pregnancies is an expected outcome of the expansion of the criminal legal system. Starting in the late 1960s and early 1970s, as the welfare state retracted, perceived social problems were recast as criminal problems. Criminal law encroached into nearly every aspect of social welfare from food assistance to the delivery of health services. For poor women, this often meant that their pregnancies—the types of foods they could afford to eat, as well as their healthcare from pregnancy to birth—took place under the specter of criminal law.

The persistent use of the criminal law to regulate pregnancies raises the need to explore how expertise—from forensic science to medical evidence—is utilized to prosecute women for crimes related to pregnancy. I recently explored the way particular modes of expertise and evidence operate in cases of still birth and abortion with regard to the controversial floating lung test (FLT). The FLT is often used in prosecutions of women for still births or self-induced abortion, and is designed to test whether an infant was born dead (a still birth) or alive. The FLT requires taking pieces of a fetus’ lung and placing it in water. If the pieces of the lung float, the baby had taken at least one breath and is classified as having been “born alive”; if the lungs sink, then the baby was a still birth. If born alive, women are frequently prosecuted for infanticide or homicide.

The FLT came to national attention in the case of Purvi Patel. Patel had ingested an abortifacient that she ordered from Hong Kong after learning she was pregnant. Trial records suggest that she had no idea how pregnant she was and assumed that she was still early in her pregnancy. After delivering the fetus, Patel placed it in a bag and went to the hospital. After examining her, a physician dated her pregnancy at a later stage and called the police, believing the child was still alive. To answer the question of whether or not there was a live birth, forensic scientists turned to the floating lung test. If the child had been born alive, Patel could be—and was—charged with numerous crimes in Indiana, including feticide and neglect of a dependent leading to death. The test, as I describe in detail in a recently published paper, is highly contested and viewed as unreliable by forensic scientists. This is primarily because there are numerous ways lungs can become oxygenated and generate false positives. And yet, even today, courts continue to accept this faulty evidence against women who have had still births. Some of these women, though not all, may have attempted to induce their abortions.

The FLT is not the only example. The supposed “crack baby” epidemic is another instance of the intersection of criminal law, expertise, and reproductive health. Documented in detail by Dorothy Roberts, the myth of the crack baby epidemic had catastrophic consequences for poor Black women. Starting in the 1980s, public officials and the media advanced a narrative of Black women as uncaring mothers who passed drugs to their fetus and resulting child. Hospitals doubled down on reporting drug use to law enforcement and social services, often targeting pregnant women of color in ways that neither addressed their health needs nor ensured better birth outcomes for their children.

Since then, research has found that the impact of crack cocaine on children’s lives was far less pernicious than that of poverty, inspiring a national conversation about the failed carceral response to the purported “crack baby” epidemic. This has spawned a public reckoning for the mainstream media, most notably the New York Times. Yet, despite the public reconsideration of criminal approaches to policing pregnancy and motherhood, Michele Goodwin’s pathbreaking new book, Policing the Womb: Invisible Women and the Criminalization of Motherhood, powerfully shows how little has changed. Goodwin carefully documents the variety of ways in which the criminal law continues to entangle poor women, especially poor women of color, throughout the courses of their pregnancies, whether by regulating their ability to decline surgeries or by prosecuting them for drug use.

The role of scientific expertise and evidence in the “crack baby” epidemic has raised several questions about the social and political environment facilitating the uptake of particular expert claims. Why were the media, courts, and legislatures so willing to accept “small n” studies asserting correlations between crack cocaine and birth outcomes in order to enable the prosecution of pregnant women? Why were courts and the public so willing to accept the narrative of the purported epidemic, when from the outset there were experts who argued that babies born to mothers using crack or cocaine were not experiencing the neurological symptoms and long-term effects that other physicians claimed?

The successful prosecutions of women who have still births, self-induce abortion, or use drugs during pregnancy is significant for another reason. Courts were not only accepting, but legitimating, problematic forensic science or research by allowing it to pass through procedural hoops and make it out the other side. This raises the question of why courts allowed unreliable evidence to survive procedural hurdles in the first place. In the case of the floating lung test, as well as in other forensic tests used in the pregnancy and abortion context, there are a few possibilities that I lay out below (which are discussed at greater length in my paper).

First, rules of evidence and procedure have been poor tools for excluding faulty science in the courts. Many scholars have documented how the flexibility of evidentiary standards allows judges—who may lack the capacity to understand and grapple with scientific questions—to admit forensic science of questionable merit. There is a general sense in the criminal law and procedure literature that such tests have failed defendants by allowing forensic tests riddled with issues to substantiate claims that lead to conviction.

Second, judges are not immune from societal bias or political pressure. As legal scholar Deborah Tuerkheimer has noted in the context of Shaken Baby Syndrome, the desire to blame someone for the death of a child can create its own momentum in courts. As I argue in my work, this momentum also has racial and gender dynamics, which are driven in part by moral panics surrounding pregnancy and mothering. The role of race is abundantly clear in the context of crack cocaine use in pregnancy. Public figures such as President Reagan churned out a narrative about Black mothers exploiting their children to extract payments from the welfare state. The criminalization of pregnancy flowed naturally from this narrative as the war on drugs took hold. Negative ideas about Black motherhood were so powerful, and prosecutions so common, that the research suggesting Black women were hurting their fetuses simply served to confirm an existing story.

Finally, as in the context of the supposed crack baby epidemic, prosecuting women for their still births and self-induced abortions expressed a moral panic about women who had betrayed their motherly instincts. This can be seen in the prosecutor’s painting of Patel as a cold-hearted murderer:

On July 13 the little boy was born on a cold, hard bathroom floor. The only touch he got from his mother was to move him from that bathroom floor into a garbage can. In that garbage can he was lying on and surrounded by waste that no one wanted. From there he went to the bottom of a cold, metal dumpster. He was born and died without being cared about, without experiencing anything good. Not one second of comfort, not one second of warmth. We’re here for a little boy that we can’t call by name because he never got one.[1]

Aside from discounting Patel’s version of events in which she described being in a state of shock after delivering a dead fetus, the prosecution suggests that as a mother she should have instinctively cared for the child she gave birth to. By painting her in this light, the prosecution implied that Patel deserved to be punished for failing to live up to a set of prevailing notions of pregnancy and motherhood. And by accepting these arguments and the outcome of the floating lung test over the protestations of Patel’s defense attorney, the court legitimated both the faulty forensic science and the idea that mothers have not only moral but also legal duties towards their fetuses.

The criminalization of pregnancy and abortion is still rampant. Questioning expert claims that enable these prosecutions, as well as the procedural mechanisms that fail to check questionable and unreliable science, helps to dismantle the regulation of pregnancy and abortion through the criminal law.

*Aziza Ahmed is a Professor of Law at Northeastern University.

[1] Transcript of Record at A7, State v. Patel, No. 71D08-1307-FA-00017 (St. Joseph Super. Ct. Mar. 30, 2015).

By Seema Mohapatra*

In the midst of a global pandemic and horrifying examples of police injustice, the Supreme Court added to the pain by delivering several blows to reproductive justice in the last few weeks. Although June Medical v. Russo was a technical victory, the dissenting and concurring opinions, written by five men, make it clear that the majority of the Court seeks to restrict access to abortion care, regardless of how it affects pregnant people’s lives. Legal scholars, including Melissa Murray, Leah Litman, and Caroline Mala Corbin, note that June Medical actually may make abortion easier to restrict. Chief Justice Roberts upheld Whole Woman’s Health v. Hellerstedt in name only. According to Roberts, courts can only overturn abortion regulations that place a substantial obstacle for people seeking abortions, even if those laws do not benefit pregnant people’s health and safety. This is a departure from a faithful reading of Whole Woman’s Health, which would require the court to balance the burdens on pregnant people with health and safety benefits. Although some commentators interpreted Roberts’ concurrence as being good news for abortion rights, there are some worrying signs, such as the Court ordering the Seventh Circuit to reconsider, in light of June Medical, two Indiana abortion regulations they had previously invalidated. That doesn’t feel like a win.

Little Sisters of the Poor v. Pennsylvania was a definite loss for reproductive justice with seven Justices upholding the Trump Administration’s legal authority to issue broad exemptions to the Affordable Care Act’s (ACA) contraceptive requirement based on moral or religious objections. This was the third time the policy was before the Supreme Court, and the seven Justices did not appear to care that up to 125,000 women (by the government’s own admission) would lose their contraceptive coverage if Trump’s rules went into effect.

These cases show how the Supreme Court is largely indifferent to people’s reproductive realities, particularly the lives of poor, Black women. Amicus briefs filed in June Medical and Little Sisters tried to focus the Court’s attention on how the decisions regarding abortion care and contraception affect poor people of color, especially Black women, the most. Yet, there was no mention of race at all in either case.

This willful omission of race has always undercut the goals of racial justice, but it is inexcusable in the present moment. The COVID-19 pandemic has laid bare deep racial inequities in healthcare, and COVID-19 related restrictions on reproduction and lack of support for childbearing and childrearing disproportionately burden Black women and other women of color. The Supreme Court seems unwilling to take into account who their decisions impact most. Additionally, even with a different composition of the Court, courts alone cannot achieve justice. With input from communities of color, legislative action and policy decisions that ensure access to health care and financial support would be better able to support reproductive justice. This essay views the COVID-19 pandemic through a reproductive justice (RJ) lens to demonstrate how a comprehensive health justice approach is needed to address these issues.

I. Reproductive Justice

The RJ movement was started by Black women who felt unseen by the reproductive rights movement, which had focused mainly on abortion rights and the concept of choice. Black communities faced (and continue to face) involuntary sterilizations and criminalization of their pregnancies. The RJ framework focused on three tenets: 1) the right not to have a child, 2) the right to have a child, and 3) the right to parent one’s child safely. As the National Network of Abortion Funds puts it, “Reproductive justice is as much about raising our children without fear of being killed by a police officer as it is about accessing an abortion.”

II. Reproductive Justice and COVID-19

The COVID-19 pandemic has been devastating to people of color, especially Black people, who are more likely to have lost a job, work as low wage essential workers, and are more likely to die from COVID-19. Looking at the COVID-19 pandemic through an RJ lens shows how facially neutral laws and policies disproportionately harm Black women and why relying on only courts for help is inadequate. Not only are courts often unwilling to address who is harmed by their decisions, but courts are primarily limited to interpreting laws. Directed legislative action and policies that are consciously designed to help achieve equity for communities of color is needed to achieve health justice in these areas.

A. The Right Not to Have a Child

RJ requires affordable, safe access to abortion care and contraception. Being denied abortion care is not only an affront to one’s dignity, but it is also unhealthy. Among people with unwanted pregnancies, “those who experience childbirth report worse overall health five years later than those who underwent an abortion.” When one compounds that with the fact that Black and Native American individuals are already sicker and live shorter lives than white people, the negative health consequences of not having access to abortion are stark.

During the pandemic, many states restricted medical services deemed as non-essential while stay-at-home orders were in effect. Twelve states led by officials already hostile to abortion care opportunistically deemed abortion as non-essential in order to restrict access. The penalties for violating such orders included steep fines and jail time.

Even as states started allowing non-essential services, roadblocks for abortion remained. For example, Arkansas instituted a requirement that a pregnant person must test negative for COVID-19 two days in advance of an abortion. One woman had to drive to Little Rock seven times before she was able to obtain an abortion, which almost cost her a job as a result. She is one of many who experienced increased costs and unnecessary delay. Multiple trips and lost wages are not minor inconveniences, and not everyone has the ability to travel, due to lack of money, transportation, childcare, or time off from work.

Low-income people have the highest rates of abortion, in part because a person living in poverty is more than five times as likely as someone not living in poverty to have an unintended pregnancy. Thus, abortion restrictions overwhelmingly impact poor women given that a staggering 76% of people who have abortions are at or below 200% of the federal poverty level. And poverty is racialized in America. According to the Kaiser Family Foundation, Black, Native American, and Latinx women are disproportionately poor: 22% of African Americans and 19% of Latinx individuals live below the poverty level, compared with only 9% of whites and 11% of Asian Americans

Two of the most common reasons to seek abortion care are economic insecurity and an inability to financially care for a child, and both stressors have been exacerbated by the economic effects of COVID-19. Due to worsening employment conditions since the pandemic began, people are concerned about their own economic well-being and adding the expenses of a child may be more difficult than before. Unlike any other type of health care, abortion is specifically carved out by Medicaid via the Hyde Amendment and the appropriations bills that incorporate the Hyde Amendment each year. This means poor pregnant people who are covered by Medicaid have to pay out of pocket for abortion care in most states

B. The Right to Have a Child

The second tenet of an RJ approach moves beyond abortion rights and delivery to support for people during pregnancy and at birth. Carrying a pregnancy to term has long been fraught for people of color and low-income individuals. The pandemic has only deepened the disparities in prenatal care and post-birth assistance for Black and poor women.

Consider that the United States has the worst maternal mortality rate among similarly situated countries, and Black women are up to four times more likely to die from a pregnancy-related death than white women. Due to the pandemic, many pregnant people have received care via telemedicine, rather than in in-person visits. Although telemedicine has the potential to improve access to prenatal care, studies that have demonstrated that it does not result in worse birth outcomes included “mainly white, usually wealthy, and privately-insured populations.” Given that Black, Latinx, and Native American pregnant people receive less prenatal care than other racial groups, and that many Black women’s prenatal and postnatal complaints are dismissed even in pre-pandemic times, it is important to ensure that telehealth is not exacerbating the divides that already exist. In one recent case in New York City, where Black women die in childbirth at rates twelve times that of white women, a pregnant Black woman died due to complications that could have been detected with in-person visits. The issue of what is adequate prenatal and postnatal care during the pandemic for people of color needs more attention, especially when physicians report that pregnant patients are delaying care due to fear of contracting the virus.

Pregnant people experience acute effects of COVID infection and can pass the virus to their infant via nursing or other contact. To protect healthcare workers or preserve equipment, two New York hospital systems prohibited visitors to delivery and labor departments. After an outcry, the Governor issued an order preventing hospitals from barring all visitors. Some medical facilities now permit just one person to visit. People who rely on the care of a doula or birthing support person then have to choose between that their birth assistant person and a partner or family member to be present during labor. Having in-person support is especially important for pregnant people of color. The Giving Voices to Mothers study found that poor Native American, Black, and Latinx women report much higher rates of mistreatment by providers during birthing than white women. Although safety in a pandemic is certainly important, we need to ensure that even protective measures passed with good intentions do not have disparate racial impacts.

C. The Right to Parent a Child

The third tenet of RJ is recognition of a right to parent one’s children with dignity. With disturbing recent reminders like George Floyd and Ahmaud Arbery caught on video, the crisis of over-policing and punishing the Black community could not be clearer. Black men are disproportionately incarcerated; in addition to the injustice they face, their children bear the consequences of having their fathers unfairly in the criminal justice system. Over-policing is associated with a higher infant mortality rate. Black women also suffer financial, emotional, and childrearing burdens related to mass incarceration. In addition, Black mothers are more likely to work in low wage jobs and need affordable childcare options.

Many child care facilities are closed due to the pandemic but, as discussed above, many women of color are essential workers who cannot work from home. The lack of affordable child care is a challenge during normal times. But with schools closed and a shortage of child care, single mothers, who are disproportionately Black, Latinx, and Native American, are particularly vulnerable. Financial instability could result in greater involvement by child welfare officials, who have long targeted Black single mothers. As Dorothy Roberts has documented, Black mothers disproportionately have their parenting decisions questioned and subject to “extraordinary scrutiny and vilification” by the state, which in turn leads to the overrepresentation of Black children in the foster care system. Khiara Bridges critiques how poor mothers are more likely to be subject to child welfare investigations and how “the fact of poverty itself gives the state reason to suspect child maltreatment.”

As an overarching, and concluding, concern, Americans are facing unprecedented economic uncertainty with high unemployment rates and loss of income, loss of health insurance, and lack of ability to pay rent or mortgage. These economic realities are worse in states that did not expand Medicaid. The dim economic outlook makes it difficult to raise children for all people, but especially people of color, who are facing more dire financial consequences from this pandemic. These problems are outside the ambit of the courts and we need to refocus the conversation on policymakers, not courts.

III. Much Work Left to Do

Though there are numerous reproductive injustices exacerbated by the pandemic, the purpose of this essay is to survey some of the most salient, particularly as they impact communities of color.

In taking up these injustices, advocates cannot look to courts alone to address the RJ challenges posed by COVID-19. In Policing the Womb, Michele Goodwin suggests that a “RJ Bill of Rights” may be helpful, at least conceptually, to focus on the broad RJ challenges facing women. David Cohen and Carol Joffe, in their book, Obstacle Course, note that “addressing the massive income inequality that characterizes American society” could improve the lives of people who seek abortion. Community-led policies, long term financial and legislative support, universal health insurance, and dismantling structural discrimination are vital to restoring reproductive justice.

* Seema Mohapatra (J.D., M.P.H.) is a tenured associate professor of law and Dean’s Fellow at the Indiana University Robert H. McKinney School of Law.