Unless you have a time machine, the best way to understand the era before modern medicine is to watch Republican legislators discuss abortion.
In recent years, as they have proposed more and more restrictions on reproductive rights, they have had plenty of opportunities to air their shockingly primitive theories of the female body. An Idaho lawmaker suggested in 2015 that the uterus could be accessed within the digestive tract. A Texas regulator said in 2016 that abortions are performed by “cutting open people’s bodies”—as if the uterus, even with its ready-made exit route through the vagina, required an incision to retrieve its contents. And, of course, who could forget the Missouri congressman who claimed in 2012 that “legitimate rape” victims cannot get pregnant because “the female body has ways to try to shut that whole thing down”?
None of these would-be gaffes have dissuaded anti-abortion advocates from telling doctors what kind of care they can provide, and to which patients, and when. The human body as it exists outside the womb—its pain, its mess, its inconvenient and unpredictable foibles and realities—have always been beside the point of abortion bans.
But in the imminent wave of destruction wrought by the dismantling of Roe, the pregnant body will be ground zero. And understanding the complex realities of a pregnant body has never been more crucial.
Laws written by ideologues with no medical training, who invent imaginary procedures to dispel concerns about the hazards to women’s health, will determine how quickly a potentially fatal ectopic pregnancy can be treated. Coroners will paw through sewage to assess fetal remains from miscarriages. Women with wanted pregnancies will learn they are gestating a fetus with a critical anomaly and, months later, labor under coercion for hours, only to push out an infant without the necessary body parts to survive. There will be untreated infections; life-threatening spikes in blood pressure; bodies obliged to carry high-risk triplets instead of twins; and dangerous, desperate attempts at self-induced abortion, which will multiply as legislators crack down on the dissemination of abortion information.
After decades of debates that cloaked the issue of abortion in euphemism and legalese, the issue’s fleshly realities are about to become central to the conversation once more.
Historians agree that Roe v. Wade was decided, in part, because abortions could be dangerous and deadly when they happened underground. Legalizing abortion brought it into the fold of the medical establishment, where it was performed by trained professionals. Abortion had already been safer than childbirth, and it quickly became even more so.
In the decades that followed, the discourse on abortion split. Abortion-rights advocates, pleased with what seemed like a lasting Supreme Court precedent and intent on normalizing a procedure that hundreds of thousands of U.S. women sought each year, spoke of it in the sterile terminology of health care. Anti-abortion activists, in turn, homed in on the image of an idealized fetus: On the one hand, a pristine, beatific, ten-toed entity nestled peacefully inside a uterus, provenance unimportant; on the other, sensationalized post-abortion photos of blood and gore, implying the murder of an innocent.
Absent from both of these narratives, born as they were of an era of widespread legal abortion, were the particular indignities of forced pregnancy and childbirth—the bodily ramifications abortion rights were supposed to prevent and, thus, the most urgent argument for their defense and expansion. Neither side of the abortion discourse dwelled on the physical torment of those who continued to be denied the abortions they desired, though these women were the clearest reminder of the fate that awaited many more people were Roe to fall. These patients, many of them rural women who lived hundreds of miles from the nearest abortion clinic and low-income women of color who could not pay for their abortions through Medicaid, were ignored by both anti-abortion zealots who were happy to let them suffer and reproductive rights groups who prioritized other fights en route to more sanitized, less radical messaging.
Even as clinics shuttered across the U.S., there was no mass awakening to the physical punishment imposed on women who found themselves unable to exercise their “choice.” Court documents do not bleed. Committee hearings do not cramp, and tear, and cry out in pain. Women who bear unwanted pregnancies rarely approach the microphone, because to acknowledge the experience as a brutal burden would cast a shadow on the children they may continue to parent and love.
Often, at mainstream abortion-rights protests, the most visible nods to the bodies of pregnant patients have come in the form of increasingly outdated coat hanger imagery, twee protest signs that ask legislators to “keep your rosaries off my ovaries,” and the unfulfilled, abstracted promise of “my body, my choice.” Sometimes, in what appeared to be an attempt to destigmatize abortion, abortion-rights leaders have underplayed (or yassified) the stakes. In 2018, one month after Brett Kavanaugh joined the Supreme Court, Ilyse Hogue, then the president of NARAL Pro-Choice America, gave an interview in a shirt that read, “Pro-sciutto & Pro-Choice & Pro-secco”—a piece of fundraising swag promoted by the organization.
That sort of glib, catchphrase-y approach to reproductive justice missed the point by a mile back then, and it feels even more distasteful now. But the public discourse around abortion has undergone a drastic shift in recent months, beginning with the Texas ban last fall and intensifying with Samuel Alito’s leaked draft opinion that signaled the overturning of Roe. On the emboldened right, legislators are preparing to consign ever greater shares of the population into forced reproduction, especially as they do away with the exceptions for rape, incest, and patient health that have always served as shrouds of respectability for the anti-abortion movement. And among supporters of abortion rights, the flesh and blood of the issue has loomed back into view as Americans grapple with the knowledge that women’s bodies will now be surrendered to the state, subject to laws that favor the contents of their organs over the life that sustains them.
Some recent essays have emphasized the finer points of the physical punishment that roughly half of U.S. states will soon impose on unwilling women who commit the de facto crime of unintentionally procreative sex. “There is almost no part of the human body that does not transform in pregnancy,” wrote Irin Carmon in New York magazine. “One way or another, your flesh will be torn asunder, whether what you are carrying feels like an invited guest or an invader.” In the Washington Post, Kate Manning suggested that “we who oppose the annihilation of our bodily autonomy ought to plaster statehouses with photos of our episiotomy incisions, our Caesarean scars, our intravenous-line hematomas, our bloody postnatal sanitary pads and bloodstained bedsheets, our cracked nipples and infected breasts.” And those injuries may well be the result of a delivery that goes more or less according to plan.
Once the body—and its profound violation by anti-abortion laws—becomes the focus, the expansive consequences of abortion bans, which stretch far beyond unexpected pregnancies, are easier to see. As one employee at a Texas abortion clinic told me, it is impossible to criminalize one pregnancy outcome without affecting the others. Or, to put it another way, health care of all sorts will be mediated in ways that give preferential treatment to a patient’s reproductive capacity over the life she is currently living.
In Texas, where abortions became illegal after around six weeks of pregnancy last September, pharmacists are already refusing to dispense drugs prescribed for ectopic pregnancies and miscarriages. Multiple doctors in the state have told me about pregnant women whose water broke too early, weeks before their fetuses could survive outside their bodies. Normally, doctors would induce a miscarriage, since the pregnancy cannot be recovered. These days, they can’t provide that standard care in Texas without chancing expensive lawsuits. Instead, in each case I’ve heard about, doctors waited until the woman developed an infection—a great enough risk to her life to provide legal cover for a medically necessary abortion.
This exact scenario played out this month in Malta, where abortions are prohibited except when necessary to save a patient’s life. A pregnant U.S. tourist on a babymoon began bleeding at 16 weeks, and although all her amniotic fluid was gone and her placenta had begun to detach, Maltese doctors would not provide an abortion as long as they could detect fetal cardiac activity. They were prepared to wait until the patient was “imminently dying” to act. (She secured an emergency airlift to Mallorca for an abortion before she could develop an infection.) A similar sequence of events befell 31-year-old Savita Halappanavar in Ireland in 2012, several years before the country repealed its abortion ban. Denied an abortion for a nonviable fetus whose cardiac activity persisted after her water broke, Halappanavar died of sepsis.
This is what abortion bans do to pregnant bodies, and what we should expect will transpire in jurisdictions that restrict abortion in days and weeks to come. In ideal circumstances, with full reproductive autonomy and access to health care, pregnancy is already—as an evolutionary biologist at Harvard put it, a decade ago—a high-stakes game of tug-of-war between patient and fetus. When certain health care interventions come with a prison sentence attached, it’s no longer an equal match.