When we observe the 40th anniversary of Roe v. Wade on January 22, we are celebrating a major milestone in women’s health, equality, and status as citizens. At its core, Roe stands for women’s right to make important decisions about our own lives.

This momentous Supreme Court decision protects both women’s right to have an abortion and women’s right to continue a pregnancy. And yet, the reality of women’s lived experience often falls short of the rights pronounced 40 years ago.

Roe built on a series of decisions throughout the 20th century dealing with marriage, procreation, and childrearing, including a 1972 case about the right to use contraception which said that if the right to privacy means anything, it is the right “to be free from unwarranted governmental intrusion into matters so fundamentally affecting a person as the decision whether to bear or beget a child.”

In political circles, the meaning of Roe v. Wade is usually talked about as “the right to choose” or reduced to the shorthand of “choice.” This simplistic rhetoric not only diminishes the profound and fundamental nature of decisions about parenthood, it begs the question whether it make sense to talk about “choices” unless women have alternatives to choose from. For example:

• to get pregnant or prevent pregnancy
• to continue or terminate a pregnancy
• to raise a child or make arrangements for someone else to do so

Forty years after Roe, the reality for too many women is that these possibilities are severely constrained

Constraints on abortion

One of the biggest constraints is money. For the millions of women of women who use Medicaid for their health care, for example, the Hyde Amendment bans federal funding of abortion. Although the Hyde Amendment initially targeted women who use Medicaid, its reach has extended over the years to virtually every woman whose health insurance is part of the federal budget.

Women who serve in the military or Peace Corps or work for the federal government – out of luck. Women who rely on the Indian Health Service – out of luck. Women who are sentenced to federal prison or immigration detention – out of luck. Women who qualify for Medicare because of disabilities – out of luck.

(So, too, are women who live in the District of Columbia, because Congress has say over D.C. policy, even over how the District spends its own tax revenues.)

All these groups of women, no matter how few resources they may have, must figure out how to pay for an abortion on their own, even when their very poverty is what qualifies them for government health assistance in the first place.

(The official definition of poverty is living on less than $12,000/year for an individual and less than $18,000 for a family of three.)

Because of the racial distribution of poverty, women of color are disproportionately likely to be low-income and rely on government sources of health insurance. Women who are young typically have few resources of their own, and women who live in rural areas, on reservations or in small towns, face the added difficulty of getting to an abortion provider whose office may be many miles away.

It would be bad enough if money were the only significant barrier women had to deal with. But thanks to decisions in which the Court backtracked from Roe, states have enacted a slew of restrictions that turn the path to abortion care into an obstacle course littered with hurdles like biased “counseling” and mandatory waiting periods designed to dissuade women from going through with their decision.

Constraints on parenthood

Despite how difficult politicians have made it to get an abortion, they haven’t made it particularly easy to raise children. Consider some of the challenges:

• ongoing discrimination against pregnant students

• ongoing discrimination against pregnant women on the job

• no federal policy guaranteeing paid parental leave

• the worst conditions for single mothers

• high rates of maternal mortality

Race and economics matter here, too. The maternal mortality rate for African American women is three times higher than it is for white women, for example. Discrimination and policy failures take an especially heavy toll on women of color, young women, rural women, and all women working low-wage jobs.

Among the groups for whom motherhood poses the biggest challenge are women in jail, prison, and immigration detention. Misguided drug policy and harsh sentencing rules have fueled a dramatic rise in the imprisonment of women since 1973. Increasingly, women risk arrest and imprisonment because they are pregnant.

A majority of incarcerated women have children with whom they struggle to maintain relationships, both in terms of preserving their emotional bond and in terms of preserving their legal rights as parents. If they are pregnant, they face medical neglect and the prospect of being shackled when they are in labor and giving birth.

Moving forward: supporting women’s decisions

Women go to school, work, have sex, form families. One in three women has an abortion at some point in her life. Six in ten women having an abortion have at least one child.

Because of Roe, abortion is one of the safest medical procedures. This is one of the most important benefits of legalization.

After 40 years, the availability of safe medical care is the minimum we should expect. To fulfill the promise of Roe, we still need public policies that truly promote women’s right to decide whether and when to become mothers, including policies that ensure access to abortion and policies that support raising children.