You might expect that two decades working in maternity care would bring a person moral clarity on the issue of abortion. Instead, my experience as a certified nurse-midwife caring for women over the course of their reproductive lives has deepened my ambivalence.
As an employee of a federally qualified health center (FQHC), I am bound by the constraints of the Hyde Amendment, which restricts federal funding for most abortions. While I have mixed feelings about this law, it has been a convenient refuge from the tension I have not resolved for myself: I do not want to participate personally in abortion, but I cannot summon anger or judgment toward the women I have cared for who find someone who will. In certain circumstances, I have even breathed a sigh of relief when they do, grateful that I do not live in a state that severely restricts abortion.
The teenager in foster care who is raped. The mom whose water breaks at 17 weeks, with no contractions and a strong fetal heartbeat. The woman who finds herself pregnant with an anencephalic fetus and can’t bear carrying a child who will die soon after it is born. The patient who is unexpectedly pregnant after nearly bleeding to death during her third C-section less than six months ago. Whatever moral weight I give to the developing life within these mothers, it does not override the danger and complexity of their pregnancies, or their careful decision to prioritize their own life and health, and the care of their existing children. The closer I have come to the realities of pregnancy, the more reluctant I am to impose my judgment on someone else’s circumstances, and the more grateful I am that these decisions do not fall to me.
Most people agree that abortion is morally permissible when the mother’s life is at risk, but there is little consensus about when that threshold is reached. How probable does maternal illness or death need to be for abortion to be acceptable in the eyes of a pro-life person? How high does the baby’s chance at a meaningful life outside the uterus need to be for a mother to be forced to continue a high-risk pregnancy? And why do so many lawmakers, ethicists, and religious authorities feel comfortable answering these questions for a mother?
The ethics board of a Catholic hospital where I once attended births gave confident edicts to staff, not allowing us to intervene in cases of preterm premature rupture of membranes until the baby’s heart stopped beating. What irritated me was not merely the policy, but the distance from which it was made. The members of the ethics board did not sit beside the woman as she absorbed the news of their decision. They did not watch her weigh a small but real risk of sepsis against the slim chance that her baby might survive or have any quality of life. They did not explain that another hospital across town would offer a different set of options.
We healthcare providers were left to worry and wait, and sometimes whisper alternatives while wondering whether that subversive act of honesty would be viewed as insubordination, a fireable offense. If I felt constrained by those pressures in a state where abortion remained legal, I can only imagine the moral and professional burden of practicing in a state where defying such policies may place a clinician’s license, livelihood, or freedom at risk. These pressures may be responsible for the lower rate of growth in the number of OB/GYN practitioners in the states with the strictest abortion bans since the Dobbs decision, compared to states without such restrictions.
The consequences of pregnancy complications do not end when an ethics board reaches its decision or a legislature passes its law. They are borne by women and, vicariously, the healthcare providers who serve them. As a member of my state’s maternal mortality review team, I am privy to the details of cases where women came to pregnancy with complex medical or psychological problems and did not survive the experience, even within a state that has comparatively broad abortion access and low maternal mortality. Although the question is debated, there is some evidence that restrictive abortion policies contribute to higher maternal mortality, an association that would be completely unsurprising to me.
A pro-life person might believe that this increased risk in individual cases is justified by the hundreds of thousands of lives saved by disallowing abortion. What they do not acknowledge is that a child’s survival, health, and long-term outcomes are deeply connected to the physical and emotional wellbeing of the woman who gives birth to and, usually, raises them. Lawmakers can compel a woman to continue her pregnancy, but they cannot compel her to attend prenatal appointments, control chronic conditions like hypertension or diabetes, or quit using substances that may threaten the fetus’s life. Whatever authority politicians have over abortion, pregnant women still hold the ultimate trump card in determining the wellbeing of their children.
Yet the states most committed to restricting abortion can seem more interested in punishing pregnant mothers than helping them raise healthy children. The same political coalition that has invested enormous energy in restricting abortion has invested considerably less energy in supporting women and children after birth. States with the strictest abortion laws tend to have weaker social safety nets and poorer maternal and infant health outcomes. At the national level, the political coalition most committed to restricting abortion has shown far less interest in providing families with healthcare, nutrition assistance, or paid parental leave.
Anti-abortion laws also shape the everyday care of pregnancy loss. In the current landscape, I have felt frustrated and constrained in my ability to care for patients experiencing miscarriage. Pharmacies have denied my prescriptions for misoprostol because I accurately documented the diagnosis as missed abortion, the medical term for a miscarriage in which the fetus has died but has not yet been expelled. At no point in my career have I been able to prescribe mifepristone, even though the combination of mifepristone and misoprostol is considered the evidence-based standard of care for medical management of pregnancy loss. This is because my state’s laws restrict mifepristone’s availability in pharmacies.
My experiences are not isolated. A recent JAMA study found that state abortion bans were associated with a shift in miscarriage management away from medication and toward waiting for miscarriage to occur on its own, and that patients in certain states (like my own) continued to receive less effective misoprostol-only regimens. Policies intended to restrict elective abortion have therefore narrowed options for women enduring the heartbreak of miscarriage, increasing the duration of uncertainty, pain, and medical risk, and in some cases delaying their ability to try for another badly wanted pregnancy. It bothers me when vulnerable women are treated as acceptable collateral damage in efforts to restrict abortion.
Yet honesty requires acknowledging another kind of loss as well. Beyond the rare and tragic circumstances that often dominate abortion debates, it is simply true that many children who might otherwise have been born are not born because of abortion.
Throughout my career, being proximate to so many pregnant women, I have absorbed a certain amount of tragedy that is unavoidable. I have seen the well-formed twelve-week fetus brought in by a mother after a miscarriage. I have sat with the mother who gave birth at 21 weeks and heard her ask in desperation, “Are you sure there is nothing we can do?” I have seen tiny babies in the NICU survive at earlier and earlier gestational ages thanks to medical advances, and I have seen others die despite every effort. I have attended births of full-term stillborn babies.
It is difficult to care for all of these people—to witness the fleeting preciousness of life, while also accompanying those who have struggled in vain to become pregnant—and to regard ending a normal pregnancy due to the inconvenience it may pose as morally neutral. Despite my reluctance to call myself pro-life or advocate for laws forbidding abortion, I cannot help but acknowledge my sadness that abortion is so common, with more than a million occurring in the United States each year.
To me, abortion can sometimes feel like a permanent, pessimistic solution to a temporary crisis. Pro-choice discourse does not always engage honestly with the ordinary, non-catastrophic reality of most unplanned pregnancies. It is common to assert a false equivalency between rare and tragic complications, such as a fetus with lethal anomalies, and a pregnancy that is ill-timed but would otherwise result in a healthy child. Slogans such as “abortion is healthcare” seem incomplete to me. Few of us would treat life-saving surgery and cosmetic procedures as equivalent, even if both technically fall under the umbrella of “medicine.”
Over my career, I have sat with hundreds of women absorbing the shock of an unexpected pregnancy. I have been the one to pass them the box of tissues and sit quietly while they cried. But I have also watched many of those same women gradually make peace with it. They leave the clinic uncertain but return weeks later having decided to continue the pregnancy. They have had difficult conversations with boyfriends, parents, and friends. Over time, many come to seem not merely resigned, but genuinely excited about the pregnancy. They are eager to learn whether the baby is a boy or girl, to debate names, and to imagine a future that initially frightened them. By the time they give birth, I cannot tell which pregnancies were planned and which were not. A mother reaches for her baby, cuddles him, or speaks to her in a way that feels instinctual and universal.
The hardships that make women consider abortion should be named. Most women who obtain abortions are already mothers to young children, and many are poor. Financial insecurity, unstable relationships, structural racism, and lack of support all shape reproductive decisions. Yet abortion does not eliminate poverty, end domestic violence, or dismantle racism. I worry that treating abortion as the answer allows communities and policymakers to avoid confronting the conditions that make raising a child feel impossible in the first place. And I am uncomfortable with the implication—sometimes stated, sometimes not—that a life touched by poverty, instability, or discrimination may be better off not being lived at all. Having spent my whole career caring for low-income women, mostly people of color, I am convinced otherwise.
I am not the only American dissatisfied with what is offered by the politics of the pro-life and pro-choice movements. In fact, most Americans hold conflicted views about abortion, supporting access in some circumstances while also favoring limits in others. Yet the loudest voices on both sides are often the least ambivalent, and their slogans can flatten realities that are morally and medically complex. “Heartbeat laws” reduce a complicated pregnancy to a single biological marker, often ignoring other relevant facts, such as fetal brain development or the likelihood of survival after birth. Meanwhile, “my body, my choice” can be invoked as though there are no morally relevant limits society might consider, such as fetal viability outside the uterus or advanced gestational age.
Still, I do not doubt that many pro-choice advocates are motivated by a genuine concern for women’s health, stability, and right to make decisions. I agree that motherhood is safest when it is desired, supported, and planned for, and I understand why many see access to abortion as part of that equation. It is a biological fact that pregnancy and early parenting place unique physical, emotional, and economic demands on women that cannot be compared to anything our male counterparts experience. Nor is it controversial to observe that children generally fare better when they are born into stable families and communities with access to healthcare, adequate nutrition, and good schools.
I also do not doubt the sincerity of many people in the pro-life movement in their concern about human life. I have visited pregnancy resource centers and seen rooms filled with donated diapers, formula, and baby clothes. I have known people who would, without hesitation, adopt a stranger’s child rather than see a pregnancy end in abortion. The sadness they feel about abortion is real, and it is not foreign to me. If reducing the number of fetal lives lost to abortion is the ultimate goal, then these acts of assistance may be among the most persuasive forms of pro-life advocacy.
If there is any hope for a less polarized debate, and a resolution on abortion that is acceptable to most Americans, it may lie in a willingness to recognize what each side sees clearly and what it overlooks. A politics that holds together both the moral weight of fetal life and the real consequences of unplanned pregnancy for women and their children would not resolve every disagreement. But it would be a far more honest and humane debate than the one we are having now.
