Why post-Roe abortion restrictions worry domestic violence experts

WARNING: This story contains descriptions of intimate partner violence.

If you or someone you know is struggling with intimate partner violence and want to discuss safety planning, they can contact the National Domestic Violence Hotline by calling 1-800-799-SAFE (7233), chatting at thehotline.org or texting “START” to 88788.

Elizabeth Holmes knew she was in trouble. After rekindling a relationship with her ex-boyfriend, she became pregnant a month later. And then, she said, his old patterns of abuse resurfaced, despite his promises that he had undergone therapy to change his possessive, controlling and violent behavior. He would deny being the father of their child one day, only to wake up the next with plans to buy a house for their family, Holmes said, in addition to other verbal, emotional and physical abuse.

She often regretted telling him that she was pregnant, but had also worried about what would happen if she had hid it from him.

At the time, she lived in Massachusetts, where a pregnant person is legally bound to inform the other parent before putting a child up for adoption. Holmes said she was afraid that she would be arrested and jailed if she lied about the pregnancy – both its existence and its end – and her partner found out. He had told her she could get an abortion, but refused to pay for it. Holmes could not afford the procedure on her own and did not know where else to turn.

“I did not know what to do,” she said. “I was faced with impossible decisions.”

Holmes is not alone. Advocates call this form of abuse reproductive coercion, and it can take many forms, including forcing sexual activity, sabotaging or refusing to use contraception, or restricting the victim from seeing a health care provider. The end result is a pregnancy where “one partner is exerting power over another,” said Crystal Justice, chief external affairs officer for the National Domestic Violence Hotline. According to the American College of Obstetricians and Gynecologists, one in five women who sought care in family planning clinics and reported a history of abuse also experienced pregnancy coercion.

Over time, Holmes’ partner “became very violent around the subject” of her pregnancy, she said. One morning, he attempted to smother her with a pillow. She filed a restraining order shortly thereafter, in 2015.

Exactly how many pregnant and postpartum people wrestle with reproductive coercion is unknown – under-reporting often undermines the little data that does track those trends. According to a 2019 study published in the Journal of Interpersonal Violence, roughly one in 10 people in the U.S. reported experiencing reproductive coercion in their lifetime.

But long before the Supreme Court’s decision to end Roe v. Wade a year ago, researchers have noticed a link between abortion access and a reduced risk for being the target of violence from men. More recently, advocates for reproductive health, social support and legal services have cautioned that the revocation of abortion rights would bear direct and indirect consequences, including the likely increase of this form of domestic abuse. Preliminary data and anecdotal evidence suggest that this prediction is starting to materialize.

What the data say

Domestic violence, which includes intimate partner violence, is often misrepresented as a private family issue, according to Justice. But this form of violence is “extremely pervasive,” she said, and people should “really talk about it in terms of a public health crisis, impacting millions of people in the U.S.”

Since the National Domestic Violence Hotline started in 1996, it has answered 6.5 million calls, Justice said. Through isolation, stress and unrelenting circumstances, the coronavirus pandemic ratcheted up the likelihood of “more frequent and more severe abuse,” she noted. On average, the hotline now receives 3,000 daily calls, “the highest incoming volume we’ve had in our history.”

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“Abusive partners will do anything to further isolate, control and abuse,” Justice said. “These tactics and tools can be shaped by external factors.” That could include shifting laws around reproductive health.

When Texas enabled people to collect a “bounty” by suing someone for performing an abortion or helping a patient get one, the 2021 law offered abusers one more tool to manipulate their victims, Justice said. Since then, lawmakers in several states have introduced similar bills.

From 2021 to 2022, more than 1,200 people called Justice’s hotline with concerns about reproductive coercion, she said. In the past year since the Dobbs v. Jackson Women’s Health Organization ruling reversed Roe’s protections, calls about reproductive coercion have nearly doubled, Justice said, and more than 27,000 people overall reported non-consensual sex with an intimate partner.

“Denying the individual the right to control their own body is now a tool,” she said. “And now, because of these laws and what wound up being the Dobbs decision, [abusive partners] have even more power and control, because survivors have even less options and increased barriers to obtain that care.”

For years, a majority of Americans have opposed the elimination of Roe v. Wade. The Supreme Court’s decision to remove federal protections for abortion rights did not change those attitudes, according to the latest PBS NewsHour/NPR/Marist poll. Another poll from April found that people were more likely to oppose laws against abortion when they lived in states where heightened restrictions are in place, compared to people who have not yet lived under those measures.

In Aurora, Colorado, Dr. Michael Belmonte has noticed a 50-percent uptick in patients coming to his OB/GYN clinic because they have nowhere else to turn after the Dobbs decision was finalized. Some of them are arriving later in their pregnancies and with more complications. One patient had crossed state lines, driving while hemorrhaging after she had been told she could not receive care, Belmonte said.

Some experts, like Jacquelyn Campbell, a professor of nursing at Johns Hopkins University, are concerned that states with abortion restrictions will see a rise in maternal mortality and deaths among pregnant and postpartum people due to homicide, suicide and overdose.

“They’re all connected with domestic violence,” she said.

Abusers tend to hide their behavior from everyone except their victim, who may feel compelled to conceal their harmful relationship for fear of further escalation and chaos. Campbell said she remembered once interviewing a patient who told Campbell that her partner raped her after she had given birth and returned home from the hospital. When the patient was due for a postpartum doctor’s visit, she skipped the visit because she had been told to avoid sex for at least two weeks after delivery. The patient knew her doctor would recognize that she had had sex, so she avoided the conversation by forgoing her checkup altogether.

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Starting in 2008, researchers from the University of California at San Francisco began to examine the reverberating effects of unwanted pregnancy and access to abortion on women’s lives, in what became known as the Turnaway Study. They conducted thousands of interviews with women in dozens of states, analyzing their answers to identify patterns.

As part of that ongoing analysis, researchers in 2014 found that women who had access to abortion experienced reduced risk of economic insecurity and a lower risk of physical violence from men, linked to the pregnancy, than women who could not get an abortion and ultimately gave birth.

Over time, more data and research have further supported that finding. In 2018, Maeve Wallace, a reproductive epidemiologist at Tulane University’s Violence Prevention Institute, began to analyze newly available data from the National Violent Death Reporting System. Out of that data, generated from death certificates as well as reports from coroners, medical examiners and law enforcement, Wallace saw a disturbing pattern emerge.

“Pregnancy itself is a risk factor for homicide,” she said.

Limited available data erodes the evidence of intimate partner violence experienced by pregnant and postpartum people, Wallace said, making the actual figures likely greater and more grim than shown in current studies. She noted that relying on death records alone “can be very limiting” because they do not include information on perpetrators. Unless a thorough autopsy was performed after the person’s death, early pregnancies often go undetected. Similarly, coroners, medical examiners and law enforcement typically don’t record that a person died while postpartum if the child was not in that individual’s custody.

Furthermore, Wallace said, for pregnant and postpartum people already at risk of intimate partner violence, policies that limit access to abortion-related services, further fueled by the Dobbs ruling, pose a danger that will worsen over time, and disproportionately harm communities of color and people with few financial resources.

“Everything we know from existing data suggests there’s a relationship between availability of abortion and women’s risk for fatal violence,” Wallace said.

Help for survivors

Massive bottlenecks in abortion-related services have led to a spillover of demand that a shrinking number of states and health care providers must then meet. In Colorado, Belmonte believes patients might be more forthcoming with their problems if they trusted their health care providers to not judge them.

After growing up in an Illinois household where his mother and sister survived intimate partner violence, Belmonte feels it is not his place to tell someone they should leave an abusive relationship. Rather, he said, it is his responsibility to “bear witness” and to tell his patients he can provide resources for their health and safety planning.

“My job is to keep them safe while they remain in that relationship,” said Belmonte, who specializes in complex family planning needs. He works alongside the advocacy group Physicians for Reproductive Health, which has vocally opposed the loss of federal protections for abortion health care.

Often, he said, physicians neglect to ask about intimate partner violence (even though doing so has been part of standard prenatal and postpartum screening for years) because they don’t know how to navigate the conversation further if a patient confirms the presence of abuse. To get around that, he recommends asking every single patient that question.

“If you make it routine and normal, it takes away that stigma and anxiety that comes with doing something new,” Belmonte said. “If you do get a positive screen, there are resources within every health system that can help connect people,” such as a hospital social worker or domestic violence resource centers with 24-hour helplines.

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While he does not expect health care providers, who are often overburdened, to be experts on the complexities of intimate partner violence, Belmonte said “just being present with the patient while they call that line in a private clinic space can really solidify you as a person who is willing to help.”

Holmes now works as a recovery coach for people struggling with substance use, and advocates for people targeted by intimate partner violence. Over the last decade, Holmes said she was clueless about how to navigate a relationship that became increasingly abusive and has continued to affect her even after they had separated because they now have a child together. In one year, she had to change jobs 13 times, as she was trying to reestablish her life. She said he would call and harass her, putting her so visibly on edge that her coworkers would ask if everything was O.K.

Everyone had told Holmes that giving birth to and raising a child was a two-person decision, but “The reality is, it isn’t — I’m the one who makes the decisions,” she said. She soon realized that she had descended into a complicated situation with no idea how to escape. “I was just out in the world hoping for the best without the tools and skills to make these decisions.”

She currently has limited visitation rights with her son, seeing him every other week for five hours, and says she faces a churn of court hearings and continued psychological and legal abuse. She doesn’t like to disclose where she lives because she fears that her ex-partner may find her and kill her. When she testified in court against her ex-partner, she said no one believed her: “Not only did they not help, but they discredited and dismissed me.”

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She loves her son, now age 7, but he has developed for years at a distance from her and is a child “who looks lost in this world, who doesn’t know who to go to for help.”

Years ago, Holmes spoke with a domestic violence expert in Vermont who told her that no one, not family courts or law enforcement, would save her – only she could do that. She had never felt so alone, but she hasn’t given up, as hard as it has been.

Now when she talks to people who are pregnant and struggling to free themselves from abusive relationships, Holmes said through tears that if she thinks they are “anywhere close to what I’m experiencing,” she urges them to get an abortion. But with more states putting those services farther out of reach for more people, Holmes said, “you are just committing young women to this life.”