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An Empty Promise of “Nice”

When the ruling of Dobbs v. Jackson Women’s Health Organization was given, many citizens of Midwest states lost access to abortion services.

Tory Makela

Fellow, University of South Dakota Sanford School of Medicine, 2022

“We hold that Roe and Casey must be overruled.” It was the judicial ‘shot heard round the world’ the morning of June 24th, 2022 [1]. On the warm summer morning that started off like any other Friday, the Supreme Court ruled in Dobbs v. Jackson Women’s Health Organization that abortion was not a constitutionally protected right. It was a ruling that undid decades of work by pro-choice advocates and impacted the lives of millions of individuals across the United States. Its effects were arguably felt nowhere greater than in the place I have called home for 26 years: South Dakota.

South Dakota, and its Midwest neighbors, have always prided themselves on their attitude of “Midwest Nice”, and in truth, I grew up surrounded by this Midwest Nice. Neighbors help neighbors, communities support each other, and generosity and kindness are taught almost simultaneously with the alphabet and numbers in grade school. Even one of the core values and main missions the sole medical school in South Dakota has is “Kindness in medicine”. I do not deny that “niceness” and kindness are plentiful throughout South Dakota and the Midwest. I would argue, though, that this “Midwest Nice” honorific feels hollow in light of the Supreme Court's ruling.

South Dakota was one of 13 states with trigger laws already in place to criminalize abortion in the event that Roe v. Wade was overturned [2]. It was also one of three states in which this abortion ban took effect immediately– the other two states being Kentucky and Louisiana [2]. The second the Supreme Court ruling became public, it was a Class 6 felony for a provider to perform an abortion, medical or surgical, in the state of South Dakota, with punishment being up to 2 years in federal prison, a $4000 fine, and loss of medical licensure. The only exception to this ban is harm to maternal health [2].

South Dakota is not the only Midwest state where access to abortion services was impeded by this new Supreme Court ruling. South Dakota’s neighbors to the north and south, North Dakota and Nebraska, both have significant abortion restrictions in place. In North Dakota, termination of pregnancy is only permitted in cases of rape, incest, or harm to maternal health [3]. Wisconsin’s abortion ban reads the same [3]. In states such as Nebraska and Iowa, abortions are still legal up to 20-22 weeks but with significant restrictions. These include counseling to discourage abortion and a 24-hour waiting period, prohibition of abortion services via telemedicine or mailed prescriptions, lack of coverage in private and public health insurance plans, and restrictions on abortion clinics [3]. Fortunately, places like Colorado, Minnesota, and Illinois still have comparably expansive abortion access and are likely to see an influx of patients in the coming months and years [3]. Unfortunately, these services will likely only be accessible to those who can afford to travel long distances for care.

Despite being at the forefront of most political debates, abortion care is so much more than a political matter: it is an issue of health equity. Pregnant individuals who are denied abortions face significantly higher odds of poverty 6 months and 4 years after denial, compared to those who did receive an abortion [4]. Pregnant individuals who are denied abortions are also less likely to be employed full time and are more likely to turn to public assistance for housing and healthcare [4]. Foster et al. found in their study that half of individuals seeking an abortion lived below the federal poverty level, and three-quarters of them reported not having enough money to cover housing, transportation, and food [4]. Two-thirds of these individuals already had children that they were supporting [4]. Additional studies have shown that states with the most restrictive abortion policies, South Dakota being one of them, not only have poor maternal outcomes but also have poor child health outcomes and are less likely to invest in at-risk populations [5]. South Dakota has the county with the highest poverty rate in the United States, ranks 46th in Medicaid coverage, and has the 6th highest infant mortality rate [6]. Restricting abortion access here, and across the Midwest, could have devastating health and economic impacts on pregnant patients and their families.

Given these medical, social, and economic impacts of restricted abortion access, the issue becomes even greater when examining who does and does not have access to such services. In particular, individuals of lower socioeconomic status account for a significantly greater proportion of unintended pregnancies [7]. Individuals of lower socioeconomic status are more likely to be underinsured and uninsured, and uninsured individuals are 30% less likely to use a prescribed contraceptive [7]. Thus, it is very likely that a component of the disparity in unintended pregnancies based on socioeconomic status may be related to lack of insurance coverage. For individuals of lower socioeconomic status who become pregnant and wish to obtain abortion services, they face further economic hurdles. In states with restrictive abortion access, patients may have to drive long distances and cover costs of lodging to obtain an abortion. Even in states with greater access to abortion services, the costs of the procedure itself can be prohibitive. Because the Hyde Amendment blocks the use of federal funds for abortion services, Medicaid patients often do not have coverage of abortion care, and state funding can be variable and limited [7].

Furthermore, individuals of historically marginalized races are more greatly impacted by restricted abortion services. Goyal et al. evaluated abortion access after the passing of Texas House Bill 2 in July 2013, which resulted in restrictions of abortion medications, a 20-week post-conception ban, and the closure of over half of the state’s abortion clinics [8]. The authors found that Hispanic and Black women experienced greater reductions in abortions after the passing of the bill, especially those living in a county with a clinic closure [8]. Thus, among populations who have historically been denied their reproductive rights, the right to or to not have a child was even further restricted.

The issue of abortion has traditionally been thought of singularly as a “woman’s issue”, and historically, White cisgendered women have dominated the conversation. However, it is a matter that impacts individuals across many races, genders, and socioeconomic categories, as discussed previously. Everett et al. explored how adolescent boys whose partners were able to attain an abortion faired compared to those whose partners were not able to attain an abortion [9]. They found that those who reported adolescent pregnancies ending in abortion had significantly greater rates of graduating from college and completing any post-high school education [9]. They also found a positive association between a reported abortion and personal income when compared to men who did not reside with their child during adolescence [9]. Thus, abortion access is not just a “woman’s issue”.

In places like South Dakota, North Dakota, and Nebraska, where the promise of Midwest Nice is steadfast and true, equity is not held in the same regard as “nice”. However, I would argue that it should be standard for “niceness”. Midwest Nice should extend past mere friendliness into compassion and empathy for the individuals that abortion bans impact. It should transcend “neighbors helping neighbors” and “communities supporting each other” into fighting for an equitable life for your neighbor and those in your community. Otherwise, it is an unsubstantiated and empty promise of “nice” that we choose to wear like a badge of honor. I, for one, would take action and progress over that hollow promise of niceties any day.

It is my hope that my fellow South Dakotans and Midwesterners will take a stand for equity as it relates to reproductive health. As physicians and future physicians, we need to assist our patients in seeking out-of-state abortion care when desired. We need to lobby to codify abortion access in our state laws so that our patients do not need to travel long distances to seek services they desperately need. We need to take a stand for reproductive justice and health equity and show that we will not let the issue of abortion rights rest quietly. After all, it is the “nice” thing to do.


[1] Dobbs v. Jackson Women’s Health Organization, 597 U. S. 5 (2022).

[2] Procurement of abortion prohibited--Exception to preserve life of pregnant female--Felony. South Dakota State Law § 22-17-5.1 (2005).

[3] US Abortion Policies and Access After Roe. Guttmacher Institute. July 20, 2022. Accessed 7/26/2022.

[4] Foster DG, Biggs MA, Ralph L, Gerdts C, Roberts S, Glymour MM. Socioeconomic Outcomes of Women Who Receive and Women Who Are Denied Wanted Abortions in the United States. Am J Public Health. 2018;108(3):407-413. doi:10.2105/AJPH.2017.304247.

[5] Rosenbaum S. A Public Health Paradox: States with Strictest Abortion Laws Have Weakest Maternal and Child Health Outcomes. The Commonwealth Fund. March 8, 2022. Accessed 7/6/2022.

[6] Patterns of Poverty in America. Population Reference Bureau. June 2022. Accessed 7/27/2022.

[7] Dehlendorf C, Rodriguez MI, Levy K, Borrero S, Steinauer J. Disparities in family planning. Am J Obstet Gynecol. 2010;202(3):214-220. doi:10.1016/j.ajog.2009.08.022

[8] Goyal V, Brooks IHM, Powers DA. Differences in abortion rates by race-ethnicity after implementation of a restrictive Texas law. Contraception. 2020;102(2):109-114. doi:10.1016/j.contraception.2020.04.008

[9] Everett BG, Myers K, Sanders JN, Turok DK. Male abortion beneficiaries: exploring the long-term educational and economic associations of abortion among men who report teen pregnancy. Journal of Adolescent Health. Oct 2019;65(4):520-526.

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