The ceiling of the main Rotunda inside Pennsylvania’s Capitol building. (Photo by Amanda Berg for the Capital-Star).

Ashley Hoffman is currently pregnant with a girl, and she’s determined to make her future bright.

That starts by telling the story of her daughter’s brother, “who was loved and lost, and whose mother lived because of an abortion,” Hoffman, a 32-year-old Bucks County resident, wrote in a personal essay she shared with the Capital-Star.

At a routine 18-week appointment, Hoffman’s doctor could not detect cardiac activity for her son, whom she named Quinn, and determined that she had miscarried — but not demonstrated symptoms — around 15.5 to 16 weeks of gestation.

“Due to reasons that we will never know — and trust me, we have done every test there is to do — Quinn died, and my body just never realized it,” she said.

After consulting her doctors, Hoffman opted for a dilation and evacuation procedure, a surgical abortion administered after the first trimester to remove fetal tissue. She had to wait an “agonizing” week due to scheduling issues, describing the delay as living in a “constant state of pain and fear.” She still looked pregnant and worried that her body would “realize that Quinn had died and suddenly start miscarrying.”

Aside from a cervical laceration that caused more bleeding than her doctors would have liked, the procedure went smoothly. Hoffman had to be “stitched up” and given different medications than initially planned to prevent further bleeding.

Hoffman received her abortion in Pennsylvania, where the procedure is legal up to 24 weeks of pregnancy — unless sought based on the sex of the fetus — under the Abortion Control Act. Later exceptions can be made for extraordinary circumstances, including when the health of the person giving birth is at risk.

But there is no guarantee the law will stay that way, and additional restrictions could have life or death consequences.

Every day since the U.S. Supreme Court stripped away federal constitutional protections for abortion, giving states authority over abortion and its legality, Hoffman asks herself about the what-ifs. What if her doctor, possibly afraid of losing their license or prosecution, would have said: “Well, we just have to wait until your body passes things naturally?” she wondered.

“Would I have then bled out at home in my bathroom or in the car on the way to the hospital? Would I have been forced to undergo a labor that would never produce a live child and risk dying on the hospital table?” she said. “These are all things that can and do happen when we don’t view abortion as necessary health care that saves lives.”

This November, Pennsylvania’s governor’s and legislative races could drastically change how, when, and why someone could receive an abortion — if at all — in the state. Some Republican lawmakers, with support from a handful of Democrats, have already proposed limiting the procedure and restricting funds to health care centers that perform abortions, despite Pennsylvanians supporting keeping abortion legal under all or some circumstances.

Democratic Gov. Tom Wolf, a former Planned Parenthood volunteer, has vowed to veto any legislation restricting abortion access in Pennsylvania. Since taking office in 2015, he has blocked three bills — including proposals that would make abortion illegal at 20 weeks of pregnancy, ban abortion after a Down syndrome diagnosis, and outlaw abortions obtained through telemedicine — sent to his desk by the Republican-controlled General Assembly.

But Wolf’s term ends in January 2023, meaning that future decisions about abortion access in Pennsylvania could come down to the results of the November general election.

“As we approach a critical election cycle here in Pennsylvania, I cannot stress enough how important it is to exercise your personal right to vote,” Wolf said after the U.S. Supreme Court ruling.

On the ballot

Legislative proposals to restrict access to reproductive health care have circulated in Harrisburg for years.

The most recent effort includes a proposed constitutional change that — if approved by voters — would amend the state Constitution to declare there is “no constitutional right to taxpayer-funded abortion or other right relating to abortion.” The measure was included as part of a five-pronged amendment package, Senate Bill 106, which passed the General Assembly last month.

The amendment package, currently the subject of an ongoing lawsuit filed by Wolf, could reach voters as early as May 2023 if it passes again in the next legislative session. A governor cannot veto a constitutional amendment.

Language for the abortion-related amendment came from a bill introduced by Sen. Judy Ward, R-Blair, a former nurse, last year, who — along with others who supported the proposal — said existing law won’t change immediately. They’ve also argued that a ballot question gives voters the ultimate say on abortion access in Pennsylvania.

“We don’t know how this is going to go,” Senate Majority Leader Kim Ward, R-Westmoreland, said in July of the proposed constitutional amendment. “It could go either way.”

Reproductive rights advocates and medical providers have said the proposed amendment would impose an abortion ban across the commonwealth, arguing that medical decisions should be between a patient and their doctor, not the general public.

“When I go to my doctor’s office, there is no room for the speaker of the House,” House Minority Leader Joanna McClinton, D-Philadelphia, told reporters last week.

The GOP nominee for governor, Sen. Doug Mastriano, R-Franklin, has been a vocal proponent of abortion restrictions, introducing a proposal banning abortions after six weeks, which is before most people know they’re pregnant.

During an April debate, Mastriano called legal abortion “a national catastrophe” and promised to push his six-week abortion ban if elected governor. He has also voiced support for punishing doctors who perform the procedure.

“It’s going to be a crime as governor,” Mastriano said during the televised forum.

Attorney General Josh Shapiro, the Democratic nominee for governor, has echoed Wolf’s vow to protect abortion access, promising to veto any legislation to restrict or outlaw the procedure during a series of press calls earlier this year.

“I’ll protect the reproductive freedoms here in Pennsylvania,” Shapiro said in June.

Addressing misconceptions, combating shame

Elected and appointed government officials have seized upon misinformation about reproductive health and the fight for abortion access, Debra Mollen, a psychology professor at Texas Woman’s University, told the Capital-Star. 

Continued misunderstanding and lack of knowledge about the nearly 50-year-old precedent and what life was like pre-Roe will only fuel decisions to curtail abortion access, she said. At the same time, Mollen noted the ongoing debate about what gets taught in K-12 schools and who makes decisions about educational instructions.

“Beyond just abortion, birth control itself was illegal for quite some time, and even heterosexual, married couples could not use birth control — or even access it,” Mollen said, adding that mailing information about contraception was once illegal in the United States.

The 1965 Griswold v. Connecticut decision from the U.S. Supreme Court established the right of married couples to buy and use contraception. Single people were not given the right to birth control until 50 years ago, with the high court’s 1972 decision in Eisenstadt v. Baird.

Justice Clarence Thomas, in his concurring opinion overturning Roe v. Wade, wrote that the U.S. Supreme Court “should reconsider” its past rulings with the same rationale, including the case that codified rights to contraception access.

Asked about the psychological effect of denying someone abortion access, Mollen cited research conducted at the University of California, San Francisco — The Turnaway Study — which included 1,000 women from clinics in 21 states. For more than 10 years, researchers tracked the experiences of those who received abortions or were denied them because of clinic policies for gestational limits.

According to the study, outcomes were much worse for those compelled to have children.

The Turnaway Study found that people denied an abortion are more likely to experience complications from the end of pregnancy, including eclampsia, a pregnancy-related high blood pressure disorder, and death. Research also found that they are more likely to stay with an abusive partner, suffer anxiety, lose self-esteem, and have poor physical health. They are also more likely to raise the child alone.

Individuals who receive a wanted abortion are more likely to be financially stable, set more ambitious goals, raise children under stable circumstances, and have a wanted child later in life, according to the study.

Donna, a 39-year-old Pennsylvania resident, told the Capital-Star about her decision to have two abortions. She received one in 2015, disclosing that she became pregnant while in an abusive relationship and after the morning after pill failed.

Without abortion access, Donna, who asked to be identified by her first name for safety reasons, and her child would have a connection to an abuser for the rest of their lives, she said.

“To this day, I wonder if he would’ve killed me,” Donna said, adding that she worried the abuse would have extended to the child.

The pregnancy also could have affected her ability to work at the time as she had a job in the outdoor recreation industry. Now, Donna is working in the nonprofit sector with a “vastly different” financial situation from when she had an abortion.

“Overall, I am in a much better place now — financially and psychologically — because I had an abortion and left my abuser,” she said.

Addressing abortions later in pregnancy, Mollen said the procedures are “relatively uncommon.” 

Pennsylvania has collected data on induced abortions since 1975, a requirement under state law. According to 2020 data, the latest available, of the 32,123 abortions performed that year, the majority — 21,934 — occurred eight weeks or less into a pregnancy. During the 18-20 week period, 599 abortions were performed; 438 were reported at 21-23 weeks. None occurred at 24 or more weeks.

Research also shows that relief is among the most commonly reported feelings after having an abortion, Mollen said. For people to say others feel regret after ending a pregnancy is a misconception, she added.

“The science does not bear that out,” Mollen said. “And even if it was regret, there are lots of other decisions that people make that they might regret. For example, getting married or having a child, and we don’t try to talk people out of doing those things.”

Regret festers when people are shamed into silence, she said, encouraging people to share their personal experiences to work toward destigmatization.

“If I have something I’m really ashamed of and society has told me I should feel ashamed — like having had an abortion — that is incredibly harmful,” Mollen said. “That’s what’s harmful. It’s not the abortion that’s harmful.”

Dr. Sarah Horvath, an OB-GYN physician and medical director for Planned Parenthood Keystone, told the Capital-Star that she talks to patients — and establishes their certainty — before performing an abortion. She also noted that people consider their options before ever scheduling an appointment for an irreversible decision.

“It’s really hard to regret a decision that you’ve come to with so much consideration,” Horvath said.

When Natasha Weller, who has never wanted kids, had an abortion after getting pregnant at 32, despite taking precautions in a new relationship — with someone who didn’t want to be a parent at the time — she didn’t talk about it publicly because she was worried about being stigmatized.

“Now, I want people to know that this happens to all kinds of people, and everyone deserves the right to choose whether or not they want to be a parent,’ she told the Capital-Star. “And having that choice is really important.”

Weller, now 35 and living in Lancaster County, has never regretted her choice, she said.

The risks of pregnancy, denied care

The United States ranks as the most dangerous industrialized country to give birth in, reporting the highest maternal mortality rate, which has increased since 2000. Rates are even higher among people of color.

“Pregnancy has the risk up to death,” Pennsylvania Physician General and acting Health Secretary Dr. Denise Johnson said last month while testifying before a panel of Democrats about reproductive health.

Before the Pennsylvania Maternal Mortality Review Committee formed in 2018, there was no statewide effort to review maternal deaths. The first statewide look at data, released in a report last year, found a 21 percent increase in pregnancy-related deaths from 2013 to 2018, totaling 547 pregnancy-associated deaths.

Johnson, a certified OB-GYN physician, also outlined how no case is “clear-cut,” describing patients who would have risked infection or their future fertility by continuing a pregnancy. She also cited a 2021 study that found states with restrictive abortion laws had higher maternal mortality rates between 1995 to 2017.

“Prior to Roe, there were all sorts of self-managed abortions, many of which resulted in permanent injury and even death to scores of women who were performing abortions on themselves or seeking abortions that were illegal or unsafe or hard to access,” Mollen said, noting that outlawing abortion won’t stop them from being carried out.

Being denied access to health care comes with “very large implications,” Horvath said. And as states move to enact stricter restrictions or bans, medical providers and clinicians have to consider how those laws affect them — the potential for lost licenses, prosecution, and jail time.

“If that is ever-present in the back of your mind before you act to care for a patient, that’s a problem,” Horvath said.