Governing Reproduction: Institutional Determinants of Abortion Access and Reproductive Health

This dissertation investigates how institutional and societal structures shape reproductive rights and reproductive health outcomes, with a focus on abortion access and maternal and infant health. Grounded in the reproductive justice framework, it integrates political science, political psychology, public health policy, and representation theory to move beyond individualistic or biomedical explanations and instead foreground the role of institutional arrangements, public opinion, and political representation. The dissertation comprises four independent yet thematically connected studies. The first two studies examine the U.S. context in the aftermath of the Supreme Court's Dobbs decision, which removed abortion from the constitutionally protected rights. Drawing on original survey experiment data, the first study tests whether the Supreme Court ruling has influenced the perception of the orientation of public opinion and personal attitudes on the acceptability of abortion access. The Dobbs decision is arguably well positioned to study meaningful public opinion change because it is one of the few instances in mature democracies where a ruling went against prevailing public opinion and restricted rights. I show that priming respondents with information about the Dobbs decision did not alter either their perception of public opinion or their personal attitudes on the acceptability of abortion access. This finding goes against both the argument that restrictions to abortion access can foster “cultural change” (as has been historically advanced by anti-abortion access activists) and the claim that the Dobbs decision triggered some form of perception of backlash against the Supreme Court and the “pro-life” movement. The second study highlights the presence of a systematic underestimation of public support for abortion access (i.e., an instance of "conservative bias"), underscoring dynamics of pluralistic ignorance that may explain policy misalignment with majority preferences. The third study analyzes the diffusion of medical abortion in Italy using microlevel administrative data. The focus on medical abortion is motivated by its emphasis on the pregnant person's bodily autonomy in the process of terminating a pregnancy. This feature is particularly relevant in the Italian context, where abortion has been legal since 1978 but access remains contested in practice, especially because of the high prevalence of gynecologists opting out abortion service. Drawing on the comprehensive database of all certificates of first-trimester induced abortions performed in the Italian national healthcare system (N > 900,000 records), this study shows that access is stratified along socio-economic lines and shaped by systemic factors, especially at the healthcare provider level. It also highlights that medical abortion is significantly associated with lower waiting times but not with abortion-seeking out-of-region mobility. Finally, it documents the crucial effect of the Covid-19-related confinements measures on the diffusion of medical abortion in clinical practice. The fourth study adopts a comparative, global perspective to assess how the institutional context moderates the relationship between women's parliamentary representation and reproductive health outcomes, particular maternal and infant mortality. Using panel data from 164 countries (1990-2020) analyzed through two-way fixed effects models, it finds that representation is more impactful in centralized and civil law systems, while its effect is attenuated in decentralized and common law systems. In sum, it highlights that central state reach is a crucial scope condition for the effective translation of descriptive representation into substantive representation. Together, these studies contribute empirically to the advancements in the adoption of the reproductive justice framework in the study of reproductive choices and health outcomes.