Dr. Elizabeth Mack, a pediatric critical care physician with extensive experience in child health advocacy, joins Grace to discuss the complexities of abortion rights today, the scientific and ethical dimensions of reproductive health, and the implications of restrictive laws on women and healthcare professionals. This episode delves into the transformation of attitudes towards sex, abortion, and women's reproductive rights in America from the 1960s to the present day. It highlights how the introduction of the birth control pill in 1960 and the legalizing of abortion through Roe v. Wade in 1973 significantly changed women's control over their bodies and futures. The episode also explores the resurgence of conservative movements aiming to restrict these rights, emphasizing the often-overlooked impact of class and education level on the abortion debate. Dr. Mack shares poignant stories from her practice to highlight the real-world consequences of limited access to comprehensive reproductive care and abortion services. The conversation also touches on the challenges of recruiting medical professionals in states with stringent abortion laws and the long-term implications for women's health and autonomy.

00:00 The Evolution of Attitudes Towards Premarital Sex and Birth Control

01:00 The Birth Control Pill and Its Impact on Society

01:27 The Abortion Debate: Gender, Class, and the Legal Landscape

02:17 Introducing Dr. Elizabeth Mack: A Champion for Child Health

02:22 Dr. Mack's Background and Achievements

03:23 A Deep Dive into Abortion Rights and Women's Health

04:20 The Harsh Realities of Restrictive Abortion Laws

07:42 Understanding the Medical and Social Implications of Abortion

14:10 The South Carolina Bill: A Case Study

22:24 The Impact of Legislation on Healthcare and Education

29:16 Strategies for Advocacy and Change in Reproductive Rights

33:06 Concluding Thoughts on Women's Health and Advocacy

Copyright 2024 Grace Cowan

• The Poets of Rhythm - "South Carolina

Leading into the 1960s. Premarital sex was taboo, although it happened. It was considered a moral failure and shameful, something to be embarrassed of. The boomer generation as teenagers would be the first generation to begin the change of that perspective. In 1967, in a nationwide survey, 85 percent of U. S. adults said that premarital sex was wrong. But by 1979, only 37 percent agreed with that statement. As time went on, the average age of marriage rose And maintaining a virgin status for the majority of the population was no longer moral code. Unintended pregnancies prior to this shift were devastating, either resulting in a shotgun marriage at a young age, girls and women being sent to maternity homes, and giving babies up for adoption in secrecy or brutal backroom abortions.

Women were always on the receiving end of the responsibility. They were the ones considered in trouble. Or immoral, they were scarred and damaged between 1960 and 1973. There was a huge decline in childbearing. The biggest reason for this was the birth control pill introduced in 1960, which allowed women to determine and plan pregnancies.

The pill was the biggest factor in the decline of births. Abortion was not legalized federally through Roe v. Wade until 1973. College educated women waited longer than their peers to have children, and this trend began in the late 70s and early 80s, and pop culture reflected this through TV shows, movies, and media.

And at the same time, there was a movement by Christian fundamentalists to stop what was going on. This movement intersected with class. A study by Kristen Luker in 1984 found more pro-choice advocates were college graduates and more pro-life women were less likely to be employed and earned less than their female counterparts.

The abortion debate became not only about gender, but also about class conflict. To some, it represents the elite's obsession with self-development and self-actualization. And the devaluing of family life. Abortion is one of the most controversial medical procedures. Not because it isn't safe or effective, but because it involves how we as a society look at family structures, who has the power within that family structure and the question of who has control over fertility.

Today my guest is Dr. Elizabeth Mack. Dr. Mack is a pediatric critical care physician. She's esteemed by her colleagues in her profession. And she was raised in South Carolina and did most of her training in this state. She did her pediatric critical care fellowship at the Cincinnati Children's Hospital.

In Cincinnati, she also earned her Master's of Science with a focus in biostatistics, epidemiology, and informatics. She is very active in leadership roles with the American Academy of Pediatrics and the Society of Critical Care Medicine. Dr. Mack is passionate about child health advocacy. Global health, education, and patient family engagement.

I'm so excited to introduce the listeners of Frogmore Stew. Dr. Mack, welcome to Frogmore Stew. Oh, thanks so much, Grace. It's really a pleasure to be here. One of the things that made me really excited in doing research on you is that you did some training in Cincinnati, my hometown.

I sure did. For three years. The temperature ranged from zero to a hundred and I didn't know that was a thing, but yeah, I learned to shovel snow and I learned a lot of critical care.

In just doing a brief sort of history of abortion and how we have come to view it in this current moment. I wanted to ask you if you can help us understand.

Why we now are even in this place protecting abortion rights. It seems feminism of the seventies really brought women forward. And right now it feels so strange that we're reverting back to this other place.

Yeah, no, very important to think about how we got here, and I think this is really about control, and I didn't fully understand that until I started doing a bit of advocacy in this space.

Obviously, I believe that this decision should be left to women and those that are caring for them in these very fragile moments. It's interesting to watch people, uh, make arguments when they're really not educated on the science of this. And you may wonder, with this topic and harsh reality, I lost a nine-year-old patient who was Raped and impregnated by her uncle, and she didn't understand that she was missing her period because as as we ladies, no periods are irregular for the first few years after menarche.

And so this is made even worse by, by stress, which often that age is. Accompanied, uh, by stress, and so she didn't realize she was pregnant for a long time. And once she realized it, she didn't perceive that she had any options and she killed herself. And did you say she was nine? She was nine years old.

Yeah. I think that, I mean, that really takes me to one of the things that people don't understand. One of the questions I was asked when testifying at one point was, when women get their period, and I said, I'm so sorry to interrupt you. I just want to talk about. when people get their period. This is in childhood.

People are ovulating around the time of menarche when you start your period, which can be as as young as eight years of age. And the youngest child actually who delivered a child on record was five years of age, which is obviously aberrant. But the But most commonly this is around 10, 11, 12 years of age.

And so these are children we're talking about.

And one sort of critical piece that I think is part of this right now is that feminism of the seventies felt like a lot of change happened very quickly and women couldn't get a credit card. You couldn't buy a house. There were a lot of things that impeded women from having successful lives without being married.

And as all of that happened, I feel like there now is this sort of backlash. This traditional wife concept is all over Tik TOK and Instagram and the people having tons of babies that are in the media, like the Duggars that makes me look at the power and control of abortion is deeply tied to religion.

There's a concept that you need this. Religious foundation in order to be a moral person or have good moral values. What that looks like is a heterosexual family with the father is the head of the household and abortion really gives up this underlying message that it's tied to women. Being free with their sexuality or being irresponsible and careless with their sexuality and using abortion as birth control.

But in all of your research, have you found that that correlates with most abortions?

This has been very strategic messaging all along, right? Uh, there, the religious right has really honed in on this particular issue. And there's a reason when you look at economic potential and opportunity, by age 22, only 50 percent of teen mothers have received a high school diploma, as opposed to 90 percent of teens who did not give birth during adolescence.

So this is defining our ability. To progress, to become successful, to get out of the cycles. Only 3 percent of teens who have a baby receive their college diploma by age 30. This is really defining our potential as women and as childbearing people to be able to progress in life. This is to keep us in our place, to keep us from really achieving our ultimate potential.

Often used in this fight over abortion. is the question of when does life begin? And that oftentimes is tied to your religious beliefs.

I think there's the ability to hold both religious beliefs that are fairly standard and traditional and the ability to hold up science. I am a Christian woman. I'm an Episcopalian and believe in God and all the things, and I am able to hold up science.

And so there's this messaging that would indicate you must choose one or the other, and that's certainly not the case, and I obviously take care of and respect people that have other faiths than I do, so they're not mutually exclusive.

In biological terms, you can discuss that's really the scientific side of it, but then you have philosophically what makes an organism.

And so the implication Is that there's a determined amount of time when the developing embryo or fetus is a human being with rights worth protecting and equal to a person walking around on the planet. So now we're in this place where disagreement over abortion policies, a fight over what it means to be human, the tension between conception and birth and then church and state.

And I think With where we are right now is that we aren't adhering to the separation of church and state like we once used to. This personhood of life begins at conception is really taking over the government.

These are going down a path where the fetus's rights are above all else. But I think sometimes we forget that none of us would argue or should argue that a childbearing person is a human.

And so when that person's health is threatened or their economic opportunity is threatened, that person too has rights. That should not be argued if it is. And I think sometimes we go down this rabbit hole of only considering the rights of a fetus. Or an embryo when really we are neglecting to have the conversation about the rights of the woman or the protections and rights around that child once they're born.

When you actually listen to the language of pro-life, pro-choice, when you talk about Pro-choice. That makes it sound like it's an inconsequential decision. You're making a choice because every day you make a million choices without any deliberate thought. Do you want Coke or Pepsi? When you frame abortion as a choice, it reinforces This belief that makes women out to be careless, and it feeds the notion that women are using abortion as contraception, when in fact, it is a critical piece of health care.

That's part of where we need to drive the train on a different set of tracks in how abortion is discussed. When you ask someone, do you think that women should be able to have abortions versus do you think a woman should be able to have an abortion? The difference is a woman, because when you ask about women, it evokes stereotyping.

But when you ask about a woman, Unconsciously, you make the connection about yourself or someone in your life. And I think that challenges how abortion is perceived.

It's a very important point. So many of these issues, they hit differently when they occur within our own families or close circles, right?

And look at the science, but also to talk to a human who's gone through whatever issue we're discussing because the stories matter. I will just say that as somebody in healthcare, not an OBGYN, but often on the other end of that equation, people are not using abortion as contraception. These are very carefully considered decisions, and hey, let's just also invoke the fact that pregnancy is not without risk.

I think people just disregard that, and as we know, the surest path to healthy babies is healthy mothers, and let's not forget that in this state, disturbingly high. We rank in the bottom 10 in this country of mortality, and 25 women per 100, 000 live births die. That's compared to the 16 women per 100, 000 live births in the U.S. on average. We have to look deeper, and there are definite inequities when it comes to race and ethnicity. That is 25 women per 100, 000 live births die in this country. Well, that's 16 for white women and 43 for black women. We also know that maternal mortality increases as we limit access to abortion.

We have to give women safe choices, otherwise we will lose the living, breathing, thinking human beings that are amongst us. We can go down these sort of rabbit holes without seeing the larger picture. But at the end of the day, we have to make this environment better for the women in this state. We are not in a good place and pregnancy is not without risk.

And speaking of that, throughout your career, you have been and you continue to be on the front lines in our state for comprehensive medical care. And given that you're a pediatric critical care specialist, your job is to save children and babies. Can you help us understand why the care of women is so intertwined with healthy children and babies?

This is really important. Obviously, many women Our mothers of existing already living children and the experience of those children, the economic opportunity, the health, the wellbeing of those children depends on their parents health, uh, wellbeing, ability, opportunity, all of that. So part of what we try to do in pediatrics and in child health in general is avoid ACEs or adverse childhood experiences.

We know that children who undergo trauma and live, uh, stressful lives, whether it's in poverty or traumatic things happening around them or to them, this severely limits their opportunity in life. And unfortunately, people like to talk about women being pregnant, but children also get pregnant and the risk of death associated for children who are pregnant is much higher.

And in fact, Complications during pregnancy and childbirth are the leading cause of death for girls globally, 15 to 19. So this is not a small thing that we're talking about. And I always try to enter into these discussions, women and children, because it's not just happening to their mothers, it's happening to them.

You were on the front lines of the South Carolina bill that finally passed. We all see the top line. But we don't ever know like the nitty gritty of what's in it. You were there through all of it. You have a good sense what's in it and how this will really affect women and children in the state.

This concept of the fetal heartbeat, that is the Senate version of that and the six week ban that ultimately passed and was initially blocked.

Talks about banning abortion when the fetal heartbeat is detected. There was a house version that banned abortion at conception. I think those concepts, fetal heartbeat, conception, all of this, it's very nuanced. When you look at the science, you say, well, you should know when conception was, not everyone knows exactly when conception happened.

Most people don't know when conception.

For anyone who's been pregnant, dates are not always certain, right? And depending on your technology and all that, even though lawmakers would love them to not be gray areas, these are gray areas. The life of the mother was listed as an exception in all three, both in the House version, the Senate version, and then the, the law.

However, that is not straightforward either because healthcare providers are afraid that they will end up in jail. when these laws pass. And so less people are willing to say that the life of the mother is on the line. And also, we are only human. Health care providers don't know everything. So can we say with 100 percent certainty that this mother will die without X, Y, or Z?

We cannot always say that. If I told you as a woman, it's 90 percent chance you'll die. Is that life with a mother exception? This is going to be decided in the courts, not by people who have the medical expertise you. This is why these decisions should be between a woman and her health care provider.

Also, the rape and incest exception, there's a requirement for the provider to file a report with the police. I don't even have to say why that's a problem, right? That could also limit the life of the mother. I've taken care of, uh, many people who are afraid to file a report because their life, uh, may then be ended, and I have seen that happen.

And also, should a physician be in the mix of a woman filing a report if she doesn't want to? I wouldn't do that to a man. And then there's fatal fetal anomaly provision. But that again is very gray. If the fetus were born at x many weeks with this condition, will they live an hour? Will they live zero minutes?

Will they live two days? We're only human.

And the responsibility of every doctor on the planet is first do no harm. That's the ethos of don't harm the patient that is in front of you. And I that really is telling.

The reality is that Most women don't know if they are pregnant until six weeks or after I, as an adult woman, when I was first pregnant, I had never really learned all the ins and outs of what happens to your body. You don't learn that in high school. At least I didn't. And so it really wasn't until I was pregnant for the first time that I started reading and was like, Whoa, this is crazy.

But the people that put the bill together and then eventually passed it. How much did they know about women's bodies? Did you ask them any questions? Were you in with the various committees that this had to go through?

I remember I was an invited expert and in a hearing and we were discussing when people get their periods and when therefore they could become pregnant for the first time.

And there was a lot of misconception. about at what age people can get their period, and it occurred to me that it's the same body that decides what can be taught in sex ed, and most of those people are products of our sex education in this state, and so I raised the idea that then perhaps we need to revisit it.

What this looks like and from an education standpoint, because I feel like age, you know, 70 is a little late to be learning how old is a person when they can first get their period. And again, I try to remind people that we're just talking about women in this space. We're talking about young children.

That's just not going to happen for anyone who's been in that situation. Interestingly, also called an abortion, a spontaneous abortion or miscarriage in that early phase. That most health care providers will not see that early, so an effective total ban and at six weeks, that's just not reasonable for someone to a know that they're pregnant and be, be able to be seen and then see, have anything done, you're much more likely to have a spontaneous abortion or miscarriage at that phase.

When I was first pregnant, I called my doctor's office and they said, about what time do you think you got pregnant? And I gave them What I thought was around the right date.

And she said, okay, you need to wait until you're eight weeks before you come in, before we'll see you. So now with this bill passed, had there been, I wouldn't have even been able to see my doctor until eight weeks.

Another reason why in the realm of physicians and the people that they're caring for, this just is, it's really illogical or intentional.

It's hard to know which. I read something that was a statement by one of the doctors during the, the hearings. And it was that this bill isn't really about healthcare because you cannot perform informed medical consent if you cannot offer all of the legitimate options.

And I feel like it's really hurt doctors in a way to be able to perform. the best medical health care outcomes because they're limited and what they're able to relay to their patients about what their decision could be. It takes a really important and viable piece of medical care off the table completely.

Absolutely. And there are many implications of that inability to give informed consent. Different. People have different levels of bravery. Somebody near retirement is probably a little bit more likely to share what the options are, where they could find those options outside of this state, that kind of thing.

But you know that's not going to end up in the record. And then when somebody comes along, the next person to take care of this pregnant The story is not going to be fully there and it is true that many people won't feel comfortable sharing all the options and so people won't know that they could have a totally different health outcome in a different state.

That their underlying disease may not have been exacerbated or that their life may not have been threatened or their economic opportunity may not have been threatened just because of the zip code. Just because they're in this state.

So while you were there testifying. There were quite a few other, um, experts there testifying as well.

Who were the other quote unquote experts that were there, and what was their reasoning if they supported the bill?

When I was an invited expert in Senate Medical Affairs, I, it was curated to be five on each side of the issue, quote unquote. If you're sitting in the middle just listening as a lawmaker, you're hearing conflicting perspectives and that sort of thing.

But there were several OBGYNs, maternal fetal medicine specialists, a pediatric gynecology specialist, fertility folks, folks that were from ABLE SC, so in other words, people that are talking about the impact on a person's body who, they may have limited abilities, Our different abilities, even on the pro-choice side of things, there were different perspectives.

I was talking about the impacts on a child's body of pregnancy and the mortality risk for a child. And the fact that this also affects living children because of the health outcome of their mother and that sort of thing, whereas others were talking about the impact on IVF, which was a bit of a precursor to what we saw in Alabama.

So there were lots of different perspectives. It was a very rich discussion. However, despite the science, women do not maintain control of their bodies.

And were most of the doctors from South Carolina, because I feel like on so many of the other controversial legislation that has gone through the house and Senate, there have been outsized national groups that come in and they're pushing this throughout the country.

And those are the people that they tend to have talk about it versus on the abortion bill. It feels like it was mostly.

Yeah, I think I've definitely experienced that, and though we're all supposed to be constituents from the state, that does not always be the case for sure, but yes, on this issue, certainly all the pro-choice folks were, and as I recall, there were a number of anti-choice folks that were, you From in state as well.

There's a lot of expertise on this issue here, right here. And yet we have such a high maternal mortality rate. It's disturbing. We could be in a different place. Our women would have a different experience.

So this is sort of a theme of the legislature for this year. My counterpart, Caitlin Brewer interviewed the Sheriff from Richland County.

And one of his biggest points. Was that our legislature just completely ignored the testimony of all the experts on open carry. And I feel like that the same thing has been said about transgender care. The same thing has been said about abortion. And it's mind boggling to me to watch so many in our state legislature.

Talk their way out of the problem using national political messaging and also manipulating medical and legal language. And I think that should scare everyone in this state that our legislature doesn't seem to be taking the advice of experts.

Yeah, you know, it has been very disturbing and particularly talk about permitless open carry every single health care and law enforcement expert there.

Was in opposition and yet it moved forward became law. There was a ceremony and all the things and Having a subcommittee hearing with folks testifying is a bit performative, and, you know, that actually doesn't matter. There's an agenda, particularly in an election year. Right. And I will say, we have some real champions in our legislature.

They're just outnumbered. And the way to that is to, to vote and to fix our gerrymandered systems, but We have some real experts, and you make me think of a moment, uh, in the Permitless Open Carry debate, uh, when there was a amendment proposed, and I won't remember the exact wording, but essentially there was, there are obviously exceptions in terms of locations as to where you can openly carry without permit.

And one of the exceptions is, of course, the statehouse grounds. And so the amendment was proposed that that Yeah. And that was immediately shot down. No, we will, we will not have the Wild West in the state house weekend. We will only do that elsewhere. Just to really expose the hypocrisy there. I think we do have some beautiful champions and a shout out particularly to our sister senators who on this reproductive rights issue really banded together across party lines.

And I'm really grateful for the champions that we have.

So back to the care of women. In South Carolina, students fears about access to reproductive health education for their career. And abortion services for themselves have hampered the recruitment of medical residents and fellows that to me is saying that not only are we limited in abortion care, but we also aren't going to be training the best doctors here any longer, because you want to train on all of the services.

So, if you're in critical care, and you need. Some type of abortion care, you may be being treated by a doctor that trained in South Carolina or Mississippi or Alabama that didn't get any experience in abortion care, right? That's a real problem.

Let's just think about my own fellowship. So pediatric critical care.

I went to one of the busiest centers in the country. I knew that I wanted to go to a big place. I wanted to learn as many procedures and as many diagnoses and really get the full experience. If I went to a smaller place, I might be limiting my future job options. I wanted to go to a place that made me highly recruitable.

There's nothing political about that. It's just merely being able to take a job anywhere that does that full spectrum of services. Or smaller, so I could take a job at a big place, I could take a job at a small place, I could take a job that does a lot of the procedures or not. And so, same goes, uh, for OBGYN.

Folks that want to learn the full spectrum of care are gonna go to a place where that's local. They don't have to be farmed out to another state for a month to learn a skill, because by the way, this is still considered standard of care, whether it's our state law or not. But this does limit ability to recruit.

And not only that, it limits our access to all women's health care. So you think about our ability to recruit in our smallest, most rural towns or bigger academic centers that tend to pay less, but you might have limited access for pap smears. You might have limited access. for your regular pregnancy well care, because we will not be able to recruit for training or for employment, people that know that their options will be limited for the patients that they care for.

Because again, like you said, a premium no sarin, do no harm is what guides us. And we will go other places where we don't have to worry about. Having a conversation at 3 a. m. with our attorney on call about how we document that this woman is going to die if we don't do X, Y, or Z, or should we send her to North Carolina or some other place at 4 a.m. and then the lawyers have to convene and then we have to get a second position to document. I mean, that's just unnecessary headache and bureaucracy when we Should be able to take care of women based on the science.

And we already have a shortage of OBGYNs throughout the state. I mean, we have 15 counties that do not have an, so we don't have citizen referendums, so we can't do what Kansas or what Ohio did or what Florida is probably about to do Ohio, Kansas, very conservative states that enshrined abortion into their state constitution.

And we as a state do not have that option. It is very unlikely that the U. S. Congress is going to pass any legislation surrounding abortion with its current complete dysfunction and makeup. So what do we do as a state to go from here? What do we do as women to get this change? How do we do that?

You raised some really good points and I think even though it doesn't feel like we're heard all the time when we have opportunities to testify and share our voices.

at the legislature or other places. I think that's really important. I think it's important to make sure when you hear messaging that isn't inclusive of the whole picture to, to correct that. I think unfortunately, though we shouldn't have to bear our souls and tell our stories, it is important. You made the comment earlier, Grace, about Um, if somebody doesn't know somebody who's been through this, whether friend or loved one, family, that it's so easy to dehumanize the issue, to separate from it and just amplify the religious right messaging that you're hearing.

Those stories, unfortunately, as best we can, and when people are ready, we need to share, we need to connect as humans. And then of course, all the things, organizing, voting, exposing the issues with gerrymandering, supporting. All of the candidates that support women's health and rights, but unfortunately, our system is designed at the moment to deliver the results it's getting.

So we have to push back against that. Also, there are a lot of us that sit on the sidelines, meaning people that don't engage. I was one of those people for a long time and Then I realized, oh my gosh, this affects my patients, this affects me, all of these issues. And who thought healthcare was political? I don't say the term social determinants of health anymore. I say political determinants of health because that's what they are. They are perfectly designed to deliver the health outcomes we are experiencing.

Like you said earlier, being a good, moral human, we should want the best medical care with all of the options for every woman in this state.

No, I 100 percent agree. And I think, again, there is the ability to be a good human, if you choose to be certainly a religious human and the ability to hold science in this space and arguments, uh, just be a polite, nice Southerner and not engaged. Cause you know, we don't talk about religion and politics and all of that. When I start to see how this harms the people around me, and just words are free, messaging matters, and just really try to gently, with well-meaning folks, bring the facts, uh, to the surface, I think it matters.

Not everybody has these, uh, life experiences, or many people do, but don't talk about them. Yeah. Um, I think it's important to start conversations. Even in the spaces that are usually reserved for no politics, no religion conversation.

People don't talk about it because there's a shame associated with it.

There's a shame that you weren't able to do your job as a woman. And that's an old belief. And really, This has nothing to do with that. This is medical care. And it also ties into what your job is as a woman on this planet or as a child on this planet. Having a baby doesn't make you a better woman. It's just a part of womanhood. And I think that's the key difference for, in my head.

Yeah, I know. I think that shameful messaging is important to correct. And I spend a lot of my days with Patients and families really trying to build people up because they know deep in their heart that their health and their family's wellbeing is priority, but these external societally imposed messages get to people and just reminding people, you're putting your family first, your health first.

There's nothing shameful or wrong about that. And. That your actions will contribute to our reduction of maternal mortality and an increased opportunity for them and for their families.

I think that's a great place for us to end our conversation today, Elizabeth. You are so informative, and I think You're doing such important work and I think in the end we'll eventually win and you'll be a big part of that.

Well, you're too kind, Grace, and I appreciate you and Caitlin and this platform and TJ shout out to you. So thank you.

Thanks for being here. And that's all the stew for today.

The Frogmore Stew podcast is written and hosted. By Grace Cowan. Editing and IT support by Eric Johnson. Produced by T. J. Phillips with the Podcast Solutions Network.