With National Abortion Rights Gone, What Is Next for Providers?

Editor's Note

Family planning providers and OB/GYNs will have little time to prepare for the dark curtain that separates states with abortion bans from those that have passed laws to protect reproductive rights and access to abortion care. As this issue of Contraceptive Technology Update went to press, the U.S. Supreme Court had not issued a final decision in the Dobbs v. Jackson Women’s Health Organization case — a case that will decide the future of Roe v. Wade, possibly for decades to come. But the Supreme Court’s earlier decision, allowing a six-week abortion ban in Texas to continue, effectively ended national protection of abortion access. By July 1, more than 20 states are expected to begin enforcing abortion bans. In this special report, we are shedding some light on what the end of Roe may look like for reproductive health providers and their patients.

Reproductive health providers have seen abortion rights being attacked and eroded for years. But the harshest threats occurred in September 2021, when the U.S. Supreme Court allowed the Texas six-week abortion ban to proceed — effectively ending a nationwide right to abortion care in the first trimester and beyond.¹ Following this, five justices signaled in the Dobbs v. Jackson Women’s Health Organization oral arguments they were ready to overturn the 1973 Roe v. Wade decision, despite nearly five decades of precedent upholding abortion care as a constitutional right.²

When Supreme Court Justice Samuel Alito’s 98-page draft decision was leaked in May, it seemed certain that national abortion rights would end this year. “We hold that Roe and Casey must be overruled,” Alito wrote. “The Constitution makes no reference to abortion, and no such right is implicitly protected by any constitutional provision, including the one on which the defenders of Roe and Casey now chiefly rely — the Due Process Clause of the Fourteenth Amendment.”³

“It’s shocking that this is where we’re at,” says Daniel Grossman, MD, FACOG, professor in department of obstetrics, gynecology and reproductive sciences and the director of Advancing New Standards in Reproductive Health at the University of California, San Francisco (UCSF).

Pregnancy Risks Will Increase

Pregnancy will become more dangerous if abortion care is banned across half of the United States. “We know the risks associated with continuing a pregnancy to term are higher compared to having an abortion,” Grossman says. “Dr. Amanda Stevenson at the University of Colorado has estimated that there would be a 21% increase in maternal mortality because more people would be continuing pregnancy to term. That increase is even greater for Black people, who have a higher maternal mortality rate in the United States.”⁴

Stevenson and colleagues found that additional pregnancy-related deaths would increase by 7% in the first year of a nationwide abortion ban, followed by a 21% increase in subsequent years. Black women would see the greatest increase in pregnancy-related deaths, with an increase of 33%.

“The impact of the Supreme Court decision will be swift and painful,” says Danika Severino Wynn, CNM, vice president of abortion access of Planned Parenthood Federation of America. “Millions will be immediately harmed if the court decides to overturn our constitutional right to abortion. We also know that this is not the end: Anti-abortion groups have made it crystal clear that their ultimate plan is a nationwide abortion ban. Planned Parenthood will be in all 50 states and Washington, DC, fighting tooth and nail to keep states from banning abortion and enacting more abortion restrictions.”

This unprecedented crisis will require abortion rights organizations to work together, Wynn adds. (For more information, see related story in this issue.)

The end to national abortion rights will have an immediate, drastic, and dire effect, says Amy Moy, chief external affairs officer at Essential Access Health in Berkeley, CA. Essential Access Health is a steering committee member of the California Future of Abortion Council.

“We are in an abortion access crisis in this country, and we’ll need all hands on deck along with a robust, bold, and comprehensive response to meet the needs of patients who will have to travel to get the care they want and need,” Moy says.

Black Americans may be disproportionately affected by abortion bans because of healthcare and economic inequities and systemic racism in the U.S. criminal justice system. “Unfortunately, I think Black people are going to be harmed more,” says Katherine Brown, MD, MAS, assistant professor in obstetrics, gynecology, gynecological surgery, and gynecologic subspecialties at UCSF. “In states where abortion is criminalized, I worry that Black people will more likely be seen as guilty of doing a self-managed abortion or committing a crime when they have a miscarriage or loss in their pregnancy. Who will help Black people and people of color?”

Police and prosecutors already have criminalized Black women during pregnancy for drug use. “We see it as parents where Black families are more likely to be reported to child services,” Brown says. “I think these new laws will continue to find new ways to criminalize pregnancy, and that will disproportionately harm Black people and other people of color.”

At the same time, abortion advocacy groups and providers need to push for a national solution to return the fundamental right to privacy and access to abortion care to everyone in the nation. California is leading the way.

“We are doing everything we can to move as quickly as possible to enhance our capacity in California to be able to meet the needs of anyone in need of care for abortion services in our state,” Moy says. “This includes people who will be forced to travel long distances to get the essential care they need.”

For months, reproductive health leaders in California have been working to identify what resources they will need once the state receives an influx of people seeking abortion care. (For more information, see the story on abortion care capacity challenges in this issue.)

What Will Happen to Miscarriage Care?

Providers in states where abortions will be fully or mostly banned also are preparing for the future. What has happened in Texas after Senate Bill 8 took effect provides a troubling look at what lies ahead.

Anecdotal evidence shows Texas physicians and hospitals are weighing their legal risks against the health risks to pregnant patients, and the chilling effect has left women with few safe options. To say Texas’ abortion ban is difficult is to use a minimizing term, says Kari White, PhD, lead investigator at Texas Policy Evaluation Project at the University of Texas at Austin.

“Right after the law went into effect, there were people who were surprised to hear about it and were very concerned about whether or not they would be able to get care in Texas,” White says. “We have done dozens of interviews with people who obtained abortion care out of state, and it’s been very challenging. They’ve had to call multiple clinics to find a place where they can get an abortion soon.”

Other states have been overwhelmed with taking care of Texas patients seeking abortion care. Patients often had to wait weeks to find an appointment. Texas patients traveled across the country when border states were unable to help them.

OB/GYNs also face challenges keeping patients safe during pregnancy and miscarriage emergencies, says Lisa H. Harris, MD, PhD, professor and associate chair in the departments of obstetrics and gynecology at the University of Michigan. Harris also is a professor of women’s and gender studies at the university.

“Certainly, the maternal death rate will increase,” Harris predicts. “There may be deaths associated with unsafe self-managed abortion, and there may be deaths when no one could perform a life-saving abortion when someone needs it.”

Each year, Harris’ team sees a few pregnant patients facing emergencies in which they are hours away from a life-threatening outcome if they could not end their pregnancy. (For more information, see the case study in this issue.)

“My team has the skills to do that because we developed that skill set over years,” Harris explains. “To develop the skills required to provide expert abortion care, it’s likely we’d have to send our learners out of state for that training.”

Many hospitals could face a shortage of physicians who know how to perform abortions because their states’ medical schools can no longer teach it.

Texas OB/GYNs, family planning centers, and patients already are experiencing the hardships of being forced to take extraordinary trips to obtain abortion care, or having to continue with a pregnancy they wished to end.

“A lot of people seeking abortions are people who live on low incomes, and the economic hardships they’re encountering are incredible,” White says. “People are putting off paying routine expenses like utility bills, buying groceries for their family, and they’re borrowing money. Or, they’re looking around their house for any kind of extra dollars stuck in a drawer to just come up with funding to cover the costs of their travel and care.”

The Texas law, like many other new laws passed by states in the South and Midwest, does not allow any exceptions for medical emergencies, rape, incest, and fetal anomalies. Even the wording for “medical emergency” creates barriers to life-saving care, since is difficult for providers to agree on what that means.

“Patients are surprised when experiencing a complication in their pregnancy that they are not able to get care from a provider in Texas,” White says. “The providers are even worried about providing information on where someone can get care outside of Texas because of their fear of aiding and abetting.”

After speaking with providers and patients, White learned how even pregnant patients who are at risk of membrane rupture are told to travel out of state or wait until they develop signs of sepsis.

“Providers know they need to give patients the best care, but they don’t feel like they [can] until it reaches a true medical emergency,” White explains. “Patients feel abandoned by providers when they’re in the most difficult health circumstances of their lives.”

It does not matter that only a handful of lawsuits have been filed in Texas since the bill went into effect.

“The law has really had a chilling effect,” White says. “People are not providing care, or they’re not getting services because they’re afraid of civil suits.”

REFERENCES

1. American College of Obstetricians and Gynecologists. ACOG responds to SB 8. 2022.
2. Supreme Court of the United States. Oral argument: Dobbs v. Jackson Women’s Health. Dec. 1, 2021.
3. Politico Staff. Supreme Court: Read Justice Alito’s initial draft abortion opinion which would overturn Roe v. Wade. Politico. May 2, 2022.
4. Stevenson AJ. The pregnancy-related mortality impact of a total abortion ban in the United States: A research note on increased deaths due to remaining pregnant. Demography 2021;58:2019-2028.