By Delesiya Davis, Rolonda Donelson, Shaina Goodman and Jessica Mason

Introduction

Every person should have the freedom to decide if, when and how to raise a family, no matter who they are, where they live, or how much money they make. Over the two years since the U.S. Supreme Court overturned Roe v. Wade, in states where people have more power to participate in democracy, voters have used ballot initiatives and responsive legislatures to win on policies that help women and their families access reproductive health care, become economically stable and navigate work-family conflicts. But in other states, extremist policymakers have threatened or enacted restrictive abortion bans which force patients into pregnancy and parenthood, costly out-of-state travel, devastating medical outcomes or death. These same states have made the least progress on other policies vital for maternal health, and on economic policies such as paid family leave that enable people to get timely health care and provide for their families. These least supportive states are home to a disproportionate number of Black and Native women, disabledOverall, the disability community has reclaimed identity-first language (i.e., “disabled”) to acknowledge disability as a critical part of identity in which to take pride. However, not all members of the disability community prefer identity-first language. Others may prefer person-first language (i.e., “person with a disability”). Preferences may also vary by disability. This report uses identity-first and person-first language interchangeably. However, the Partnership will always honor the language a disabled person chooses for themselves. women, women veterans, and women who are economically insecure.

With the election of Donald Trump to a second term and a critical mass of anti-abortion zealots heading to Congress and the White House, women’s freedom and health are under threat nationally. And advancements made in the states could be undermined by federal efforts to prevent access to reproductive health care, to dismantle programs that provide affordable health care and to block progress on economic and work-family supports for all. While we all fight against these attacks on the national stage, it is even more urgent for states to take action now to support and empower women and families.

This report analyzes how well states are doing to support women’s freedom to make decisions about their lives and care for themselves and those they love. We still find that states that have banned or are likely to ban abortion also overwhelmingly fail women on a range of key work and care policies. Yet, we also find that many states have taken key steps to advance women’s health and economic freedom, and point to opportunities to do more.

In many states, the threats women currently face are all too real. But a better life is within our reach, one in which women and all people have the power and resources they need – including both economic support and the full range of reproductive health care – to achieve the futures they want.

Abortion Bans Undermine People’s Bodily Autonomy, Health and Economic Security

The Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization has fundamentally altered the landscape of care in the United States by denying millions of people the right to abortion and obstructing access to this care for millions more.There is a critical difference between having the right to an abortion and having access to abortion care. Having the right to an abortion means that there are legal protections which allow a person to have an abortion without legal consequences or interference. But legal availability alone does not guarantee meaningful access. Abortion access is influenced by proximity to an abortion clinic, cost of abortion care, availability of abortion providers, ability to take time off of work or have child care in order to get care, and many other factors. As a result of this decision, 20 statesIncluded in this list are Missouri and Arizona, which both passed ballot measures enshrining a right to abortion in their state constitutions in November 2024. More work, including litigation, will be necessary to ensure that the constitutional protections offered by these ballot measures are implemented and that state laws that are in conflict with these new protections are repealed. have banned abortion outright. Many other states have restrictive policies that make care difficult to access, erecting barriers that are impossible for many to overcome. The ensuing chaos, confusion and unavailability of care has had myriad negative consequences – disproportionately hurting people of color, LGBTQ people, young people, immigrants, people with low incomes, and disabled people. For example, for people forced to travel out of state or long distances or navigate other barriers to receive care, the costs – economic and otherwise – are highly burdensome or even insurmountable. The risk of criminalization – for patients and especially for providers – has driven some providers to flee states hostile to reproductive health. Some hospitals have even closed their maternity wards, resulting in an increase in the number of maternity care deserts and higher maternal mortality and morbidity rates.

Learn more about these intersections.

Download the fact sheets for each state:

Alabama | Alaska | Arizona | Arkansas | California | Colorado | Connecticut | Delaware | District of Columbia | Florida | Georgia | Hawaii | Idaho | Illinois | Indiana | Iowa | Kansas | Kentucky | Louisiana | Maine | Maryland | Massachusetts | Michigan | Minnesota | Mississippi | Missouri | Montana | Nebraska | Nevada | New Hampshire | New Jersey | New Mexico | New York | North Carolina | North Dakota | Ohio | Oklahoma | Oregon | Pennsylvania | Rhode Island | South Carolina | South Dakota | Tennessee | Texas | Utah | Vermont | Virginia | Washington | West Virginia | Wisconsin | Wyoming

Abortion Access and Other Key Health and Economic Policies That Enable Parenting People and Their Families to Thrive

This report looks at a range of health and economic policies that, when coupled with abortion access, create a foundation that enables people to create and sustain healthy families if and when it makes sense for them. On the health care side, access to Medicaid coverage, state recognition of midwifery credentials and Medicaid coverage of doula services support safer and healthier pregnancies and births. On the economic side, paid family and medical leave, paid sick days, fair pay and raising the minimum wage enable workers to financially provide for their families and still care for them, as well as themselves. Each of these policies is necessary for women and their families to thrive, but no single one is a silver bullet. Instead, they are mutually reinforcing, and we need a comprehensive strategy to improve women’s health and ensure they can support and care for themselves and their loved ones. None of these policies are substitutes for legally protected access to abortion – but losing the right to abortion and simultaneously not having these additional policies to support them compounds harms. Fundamentally, these are issues of dignity and equality for people of all genders.It is critical to note that bans on abortion care disproportionately harm LGBTQ+ people – and these bans are part of a larger playbook to undermine the autonomy of women, LGBTQ+ people, people of color, disabled people, and people living at the intersection of these identities. An estimated 1.3 million transgender adults and 1.2 million LGBTQ nonbinary adults live in the United States, many of whom have or will become pregnant. LGBTQ+ people experience high rates of discrimination on the job and in the labor market, as well as elevated rates of poverty, making supportive and inclusive policies especially important.

Medicaid Expansion Improves Health Outcomes and Economic Security

Bans on abortion care are egregious enough on their own, but they are especially problematic in a context where access to health care overall is inadequate. Medicaid expansion, a policy that allows states to expand Medicaid coverage to adults with incomes up to 138% of the federal poverty level ($25,820, for a family of three in 2024), plays an essential role in addressing disparities in health care coverage and access to care. However, 10 states have yet to adopt Medicaid expansion under the Affordable Care Act (ACA), leaving 1.5 million adults uninsured. In 2019, over 800,000 women of reproductive age with incomes below the poverty line – 29 percent of whom were Black and 33 percent Latina – were uninsured without any pathway to affordable health coverage.

Accessing health care may be impossible for those who fall in this coverage gap, and uninsured people are less likely to obtain preventive care and needed health services. Additionally, even people who have insurance may have coverage that requires paying out-of-pocket costs that they can’t afford, so they delay or forgo care. This is particularly true for Black women. Importantly, these barriers to health care often result in worse health outcomes.

Learn more about Medicaid expansion.

Midwifery Care Improves Birth Outcomes

Midwives are health care professionals dedicated to providing high-quality maternity care that prioritizes meeting the holistic needs of the childbearing individual and their family and building a trusting relationship. Research indicates that, compared to obstetrician-led care, midwifery-led care results in key outcomes that are either similar or better. This includes lower rates of cesarean births, lower risks of adverse newborn outcomes (such as preterm birth, low birth weight and infant mortality), and overall lower care costs. In addition, midwifery education is typically shorter and less costly than physician training, enabling a more diverse pool of maternity care providers that can be deployed more rapidly. This is especially critical in maternity care deserts and where culturally congruent care is inaccessible or unavailable.

There are three nationally recognized midwifery credentials in the U.S. with accredited educational programs: Certified Nurse-Midwives (CNMs), who are licensed and covered by Medicaid throughout the U.S., as well as Certified Midwives (CMs) and Certified Professional Midwives (CPMs), whose legal recognition varies significantly by state. States that recognize more of the midwifery credentials and have fewer unnecessarily restrictive regulations have approximately double the number of midwives per 1,000 live births. This means women and birthing people in those states have a 60 percent greater chance of having a midwife attend their birth.

Expanding access to midwifery care is a priority for enhancing access to quality, respectful, and equitable maternity care.

Learn more about midwifery care.

Covering Doulas in Medicaid Supports Better Birth Outcomes

Birth doulas are trained, non-clinical health workers who provide emotional, physical and informational support for pregnant people and their families, often throughout the pregnancy and perinatal period. Doulas have a proven track record of improving maternal and infant birth outcomes and experiences of care. Community-based doulas in particular are recognized as important resources in enhancing cultural congruence and language accessibility for birthing families from communities who frequently face deep inequities in outcomes.

Despite this, only 19 states reimburse doula support through their state Medicaid programs. Even then, these reimbursement rates are often too low to make doulas affordable for pregnant people or to adequately support doulas as a profession. Reimbursement for doula support is a priority issue in improving the health outcomes of pregnant people and their families.

Learn more about doula support.

The Roles of Paid Family and Medical Leave and Paid Sick and Safe Days in Economic Security and Health Care Access and Outcomes

Nobody should ever have to risk their job or their paycheck in order to manage their health and caregiving needs. With a statewide paid family and medical leave program, workers can take time to bond with a new child or care for their own or a loved one’s serious health condition. Yet, about 73 percent of workers do not have paid family leave through their employer to do so, and about 60 percent lack employer-provided temporary disability leave to recover from birth or address other serious health conditions they or their loved ones have. Nearly 1 in 4 private sector workers do not even have short-term paid sick days for needs such as recovery from an illness, prenatal care, well-child check-ups or abortion care. Survivors of domestic and sexual violence, and those caring for them, also need paid safe leave. Women, workers of color and people with disabilities are especially likely to lack paid family and medical leave and paid sick days, contributing to health inequities and economic insecurity.

When combined with access to comprehensive health care, including abortion care, paid sick days and paid family and medical leave help enable people to have the resources and autonomy to decide whether and in what circumstances they want to become parents, as well as care for their own health and for other loved ones. Fourteen states, including Washington, D.C., have paid family and medical leave programs for workers in those states. But nearly 75 percent of states do not yet offer this protection. Nineteen states, including D.C., have paid sick days laws in place, and 18 of those states offer safe leave too. The newest states to join this growing category are Alaska, Missouri, and Nebraska, after a majority of voters in each state approved ballot initiatives in November. Notably, not a single one of the 27 states with restrictive, very restrictive or the most restrictive laws on abortion guarantees paid leave, and 24 do not guarantee statewide paid sick days, creating an impossible bind for pregnant people who need to travel to seek abortion care as well as for new parents.

Learn more about paid family and medical leave.

Learn more about paid sick days.

The Roles of Fair Pay and a Higher Minimum Wage in Economic Security and Health Outcomes

As of 2024, only 31 states have minimum wages higher than the federal minimum wage, which has been stuck at $7.25 per hour since 2009. Of those 31 states, only eight states, including D.C., have a minimum wage at or above $15, even while rent alone rose 67 percent from 2009 to 2023.National median rent rose from $842 in 2009 to $1,163 in 2023 according to American Community Survey data. Kresin, M., & Schwartz, M. (2010, October). Rental Housing Market Condition Measures: 2009. Retrieved 6 December 2024, from U.S. Census Bureau website: https://www2.census.gov/library/publications/2010/acs/acsbr09-07.pdf; U.S. Census Bureau. (2024). American Community Survey 1-Year Estimates (DP04: Selected Housing Characteristics). Retrieved 6 December 2024, from: https://data.census.gov/table/ACSDP1Y2010.DP04?q=dp04 By raising the minimum wage and enacting strong fair pay policies – including pay transparency, salary history bans and more – not only would women’s wages be raised, but it would help close pay gaps. For example, if the minimum wage were raised to $15 nationwide, nearly 19 million women would see their wages rise, including 3.4 million Black women and 4 million Latinas. For the lowest wage workers, increasing the minimum wage to at least $15 could mean an extra $8,000 annually which could go a long way toward paying high grocery and housing costs.

Further, if the wage gap closed, women on average would be able to afford an additional 17 months of food, 15 months of child care, make an additional seven months of mortgage payments, or even help pay the costs of restrictions on reproductive healthcare, such as needing to travel out-of-state to access abortion care. These costs disproportionately fall on women who already face the greatest harms from low wages and pay discrimination, including women of color and disabled women. Raising the minimum wage and implementing additional policies to close the gender pay gap would not only put more money in their pockets, but also improve the quality of their lives.

Learn more about fair pay.

Learn more about the minimum wage.

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Methodological note

State laws and policies were evaluated as follows:

• Abortion access: Rated on a seven-category scale from Most Protective to Most Restrictive, as of November 26, 2024, using Guttmacher’s Interactive Map: US Abortion Policies and Access After Roe. States were assessed on approximately 20 types of abortion restrictions and approximately 10 protective policies and then rated based on policies currently in effect and the cumulative impact of those policies on abortion rights and access.
• Medicaid expansion: Rated Adopted or Not Adopted based on whether the state had adopted Medicaid expansion as of November 2024, according to Kaiser Family Foundation’s Status of State Action on the Medicaid Expansion Decision.
• Doula Medicaid coverage: Rated Actively Reimbursing, Implementation in Progress, or No Coverage as of November 2024, according to the National Health Law Program’s Doula Medicaid Project. States were rated Actively Reimbursing if Medicaid plans were actively reimbursing doula’s for their support services. States were rated Implementation in Progress, if the state is in the process of implementing reimbursement for doula support services such as if the state has passed a bill that will require reimbursement for doula support at a later date. A state was rated No Coverage, if they do not actively reimburse for doula support services and are not in the process of implementing reimbursement for doula support services.
• Midwife coverage: States were evaluated for their recognition of licenses for Certified Nurse Midwives (CNMs), Certified Professional Midwives (CPMs), and Certified Midwives (CMs), as of November 2024 based on the American College of Nurse-Midwives Comparison of Certified Nurse Midwives, Certified Midwives, and Certified Professional Midwives and the National Association of Certified Professional Midwives. States were rated Legally Recognized or No State Licensure based on their recognition of the specified midwifery credential.
• Paid family and medical leave: Rated Yes or No based on whether a statewide paid family and medical leave program had been enacted as of December 4, 2024, based on a National Partnership analysis of state laws. See State Paid Family & Medical Leave Insurance Laws.
• Paid sick days: Rated Statewide if the state had enacted a statewide paid sick days law; Local Only if a city or county, but not the state, had enacted a paid sick days law; and No if no jurisdiction had enacted a paid sick days law, by December 4, 2024, based on a National Partnership analysis of state and local laws. See Current Paid Sick Days Laws.
• Fair pay: States were evaluated based on whether they had enacted laws requiring salary transparency (employee protection when discussing salary and mandated salary range posting in job descriptions), banning the use of salary history, requiring the collection of pay data, and/or expanding on federal civil rights standards for protected characteristics. States were rated Strong if they had four or more of the measures in place; Moderate if they had three of the measures in place; and Weak if they had two or less measures in place by November 18, 2024, based on a National Partnership analysis of state laws.
• Minimum wage: States were evaluated on the statewide minimum wage that will be in effect as of January 1, 2025; states with multiple wage levels depending on employment type, business size or other characteristics were rated based on the highest wage level. States were rated No Higher than Federal if they had no minimum wage or a mandated was less than or equal to the federal rate of $7.25 per hour, or Above Federal if their minimum wage was higher than the federal rate of $7.25 per hour. State infographics were color-coded on the following scale, from Least Supportive to Most Supportive: Red: $0.00-$7.25; Magenta: $7.25-$10.99; Orange: $11.00-$11.99; Gold: $12.00-$12.99; Lime: $13.00-$13.99; Green: $14.00-$14.99; Blue: $15.00 or higher. Data was based on the Economic Policy Institute’s Minimum Wage Tracker.

The authors would like to thank Anna Derrick, Sharita Gruberg, Sinsi Hernandez-Cancio, Llenda Jackson-Leslie, Mettabel Law, Erin Mackay, Nan Strauss, Brittany Williams and Gail Zuagar for their contributions to this report.

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