America’s New Reality: Forcing Birth With No Support

It’s been nearly a year since the Supreme Court voted to overturn Roe v. Wade, a landmark decision that handed decisionmaking on safe abortion access back to the states. Since then, abortion has been entirely banned with limited exceptions in 13 states, abortion in Georgia has been banned at six weeks, Ohio’s six-week ban is currently being litigated, Florida is preparing to enact its six-week ban, and North Carolina and Nebraska have approved 12-week bans.

Banning abortion has extensive and rolling ramifications, from exacerbated health inequities to increased pressure on inadequate safety nets, like paid family leave (PFL). Both access to abortion and paid family leave are crucial to reproductive justice. In Forced Birth and No Time off Work: Abortion Access and Paid Family Leave Policies, researchers Jackie Jahn and Alina Schnake-Mahl, along with their colleagues, explore the lived reality of forcing birth in a country where supportive policies are lackluster, missing, or undersupported.

In a conversation with Better Life Lab Senior Writer Julia Craven, Jahn, and Schnake-Mahl — joined by BLL Senior Fellow Vicki Shabo — discuss the history that informs our current societal conditions, the importance of not siloing issues, and why paid family leave, like abortion access, is very much a public health concern.

This conversation has been edited for length and clarity.

Craven: Can you connect the dots between the need for abortion access and paid family leave? As someone new to the paid family leave space but who has a background in health, it wasn't very obvious to me.

Jahn: When we start to think about abortion access, not only as a policy debate or healthcare service, but instead fundamentally shift the focus to center women and birthing people’s reproductive rights and dignity, then the connections between supportive policies become clearer.

Accessing abortion is only one part of allowing people to choose when, how, and under what circumstances they parent. Recent abortion restrictions mean that in many states, birthing people are forced to have children but then lack paid time off from work to care for them, and this particularly affects people who can’t afford to travel to access abortion services and don’t have paid family leave through their employer. Recent data suggest that only 6 percent of workers in the lowest-paying jobs have access to paid family leave, compared to 24 percent of workers in the highest-paying jobs.

Shabo: Plus, it's beyond hypocritical to force people to have babies and not guarantee workplace flexibility and stability through scheduling laws or guarantee time to recover from having had a child or care for a child or care for a partner who's had a child or guaranteed childcare. Beyond thinking just about paid family medical leave, but thinking about the full suite of what it takes, the scaffolding and support that it takes to raise a healthy, happy child and have a healthy, happy, secure household. We don't have guarantees about those things in this country.

So we're legislating something that should be very private in terms of abortion decisions, but failing to regulate something that should be publicly available, which are things like paid leave and childcare and some rules and regulations around work schedules, the guarantee of paid sick days and the other supports that people need to be able to take care of themselves and their families.

Schnake-Mahl: Reproductive justice has a rights-based framework that says reproductive rights are not just about access to abortion. One of the rights that reproductive justice puts forward is the right to parent children in safe and healthy environments. That's where the connection comes in. The ability to raise children in a safe environment necessitates that you can take time off and that you continue to be able to be paid in the period after giving birth. You really can't provide a safe and healthy environment for children if you can't take that time to bond, parent, and recover yourself.

Paid family leave is one example of the types of policies that we need to have to create those conditions for people to parent healthily and safely.

Craven: I found interesting in the article that none of the states banning or that are hostile to abortion have paid family leave. We're seeing this stunning lack of investment in families from state governments with a lot of Black constituents. How does this reality reflect America's sordid history of institutionalized racism and how it affects policy — especially forcing birth without providing adequate care, which reminded me of the conditions during enslavement.

Schnake-Mahl: This is a great and complicated question, but I'm going to start with federalism, which creates these structures by having a decentralized decision-making apparatus. This created the foundation upon which structural racism has been built in this country, and that has allowed differential policies that often disproportionately harm Black people. Often, policies that would benefit these populations are restricted by states, and, sometimes, policies are intentionally put in place to harm those populations.

With Dobbs being pulled back, we're creating conditions for more states' rights, and we are seeing disproportionate harm from this decision on Black birthing people because there are larger Black populations in these states and low-income populations. In many places, these populations will be least likely to be able to access these services because of the larger structural factors that create economic conditions.

Jahn: There is a long history of reproductive violence against Black women in the U.S. that dates back to slavery and is foundational to medical gynecology. This is not my area of expertise, but I’d recommend Killing the Black Body by Dorothy Roberts and Medical Bondage by Deirdre Cooper Owens as just two examples of in-depth scholarship on these issues. Today, structural racism is perpetuated through social policies that disproportionately harm Black, Indigenous, and other minoritized people, including paid family leave. These policies interact and have amplifying effects. For example, because of structural racism and workplace discrimination, Black, Latine, and other minoritized women are less likely to have jobs that provide access to paid family leave, and removing reproductive autonomy worsens the already adverse effects of not having paid leave. This is also true of other policies that disadvantage minoritized and low-income people, including affordable childcare, healthcare, and paid sick leave.

Craven: As Jackie said, Black birthing people are less likely to work a job that offers paid leave. They’re also three times as likely to die during the postpartum period than their white counterparts. And, as we've talked about, paid family leave has been proven to improve maternal and infant health outcomes. Considering this, should we look at paid family leave through a public health lens?

Shabo: Absolutely. There's a clear rationale for paid leave to be considered a public health issue. It’s essentially a policy that connects all types of concerns — public health, economic justice, gender justice, gender equity, and racial justice.

But it's also really important to note that most of the paid family and medical leave policies that exist in the 12 states and D.C. also cover leave for personal, serious health conditions. So, for example, it allows a birthing person to prepare for recovery from childbirth. When people don't have paid time off from their jobs, they might be unable to do that. If they get preeclampsia or some other pregnancy complication without paid leave, they may be unable to stay employed.

Paid family leave also covers people who need to care for a family member who's seriously ill. That could be somebody caring for the pregnant person. But it could also be circumstances that arise later on if, God forbid, the child has a serious health condition. Children live in systems where loved ones and parents need to provide or receive care. The economic disruption of doing that without access to paid leave and without having job protection can create challenges that have implications for economic security, health, and overall well-being.

Craven: The study says that a lack of paid family leave can result in a birthing person returning to work before they fully recover from the postpartum period. How is this damaging to the economic, physical, and emotional well-being of families?

Jahn: The postpartum period is recognized by medical professionals as a critical period for birthing people, their families, and newborns because it has important implications for health and well-being in the long term. It can include recovering from childbirth, managing complications from childbirth, difficulties with breast/chestfeeding, lack of sleep, pain, stress, and new or exacerbated mental health challenges, all alongside caring for a newborn. For those forced to return to work because of financial necessity, this can mean attempting to care for oneself and one’s family in this particularly precarious time while juggling the demands of employment.

Schnake-Mahl: There have been several studies that have looked at this. Most have come out of other countries, but we've also increasingly gotten some research within the U.S., particularly in states like California that have passed paid family leave. What we see is that there are health harms to not having paid sick leave and that there are benefits for birthing people who have access to paid sick leave or paid family leave.

For example, infants of people with paid family leave are more likely to get preventive care services, which are super important in the early period, particularly for longer-term development. So you see improvements in infant development, and you see lower rates of maternal mortality and morbidity among populations with access to paid family leave.

Shabo: Studies from California, in particular, show that women who take paid leave through the state program are more likely to return to work. Women who take paid leave are more likely to have higher earnings over time. Latino women and women who earn lower wages were able to take a longer period of leave, which could lead to some of the health outcomes and improvements that Alina and Jackie mentioned.

Again, research from California shows less shaken baby syndrome, fewer behavioral problems, and more engagement from men. Men are taking longer periods of leave when paid leave is available. When California's program started, something like 17 percent of claims for paid leave made by new parents were from men, and now it's more than 40 percent. About 45 percent of baby bonding claims are filed by men. So policy changes culture, creates economic stability and opportunity where it didn't exist, and has positive health outcomes.

Craven: How would uplifting groups that are disproportionately affected by the lack of abortion access and the lack of paid family leave help everyone? Because when you focus policy solutions on the most marginalized groups, you will uplift everybody else. How would that be the case here?

Schnake-Mahl: Creating baseline standards is never going to root out inequality entirely, unfortunately. But it will at least ensure everybody has the basic level of support needed to get ahead. And that means we have a healthier and more educated population, a stronger workforce, and people who are happier and better able to care for themselves and their families. That has benefits that accrue to individuals, their families, their communities, the civic and social institutions in their community, the employment situation, and the economy.

Shabo: Also thinking through the way that policy is designed so that we're not reinforcing the kinds of exclusions that have existed in policies before, which have tended to disproportionately carve out younger women, birthing people of color, single parents — who are disproportionately people of color — people in rural communities, immigrants, and domestic workers. So being really intentional about the equity implications of how policy is designed and that state policies have improved upon each other to become more equitable in most circumstances.

Craven: What does America look like with true access to safe abortion and adequate paid family leave? How would families and individuals be able to thrive under those conditions?

Jahn: In our research, we often look to places or population groups that already have access to safe abortion services and adequate paid family leave to help us understand why these policies are important for health and well-being. What we hope for, then, is that when all people have access to these vital services and supports, we’d see reductions in the racial and socioeconomic gaps in adverse maternal and infant health outcomes.

Schnake-Mahl: That also includes things like paid sick leave, living wage laws, affordable housing policies, and others that allow people to live productive and healthy lives. Minnesota passed a bunch of really interesting laws that could create those kinds of conditions.

Shabo: It’s considering what circumstances and conditions allow for each person to live the life and make the family-related decisions that they want, the economic security and stability that they need to be able to do that, and then to have the ability to make decisions about their own bodies and reproductive choices. And then to know that, whatever that choice is, they will be able to be economically secure, healthy, and safe.

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