Reproductive Health Providers Prepare for Increased Capacity

EXECUTIVE SUMMARY

Before voters in Ireland overturned a constitutional abortion ban, people had to travel to England and other places to obtain a safe and legal abortion. Soon, a large proportion of pregnant Americans will face the same choice.

• For those with enough money to obtain an out-of-state abortion, flights to New York City and Las Vegas may be an option.
• The number of self-managed abortions likely will increase as people obtain medication abortion pills via online sources.
• The California Future of Abortion Council, which includes researchers, healthcare providers, legal experts, advocates, and legislative leadership, recently released a report with more than 45 policy recommendations for protecting and expanding abortion access in California.

The future of safe and legal abortion care in the United States could be similar to what Ireland experienced before their nation voted to change its constitution and overturn the severe abortion ban.¹

For decades after 1983, when Ireland enshrined in its constitution that the mother’s life and the fetus’ life were equal, Irish women had to travel far to obtain safe and legal abortions.²

“People would take the abortion trail from Ireland to England to get surgical abortions because it was the closest place,” says Gretchen E. Ely, PhD, MSW, professor and director of the PhD program in the College of Social Work at the University of Tennessee, Knoxville.

A similarly long and difficult trail has been in place in the United States, since many people live in areas that are hundreds of miles from an abortion clinic. But these distances will be much worse in a future without Roe v. Wade.

“Huge swaths of the U.S. will be without a provider, meaning many more people will have to travel long distances by car or get on a plane,” Ely says. “It’s going to get worse, but it’s already bad because of hundreds of state restrictions since 2010.”

For those who can afford even a cheap flight, cities like New York City and Las Vegas may see big increases in abortion travel. “Las Vegas is a good example because a lot of places have flights to Las Vegas,” Ely explains. “Cheaper airlines fly to Las Vegas as a destination city, so it’s a [lower] cost for people who have the means and resources to do that.”

Self-managed abortions likely will increase once abortion clinics close across the South and Midwest. Women in those states may obtain pills through Aid Access and other international abortion organizations.

Underground abortion networks will work to educate women on how to obtain medication abortion pills so they do not have to resort to the coat hanger days, Ely says. “There is great research that medication abortion, self-managed at home, is safe,” she explains. “There will be people who need to give [patients] the information they need to make that choice.”

But medication abortion is not the best option for every pregnant person. Many still will need to travel to an abortion clinic for a surgical procedure. That is where capacity problems could occur after the Supreme Court issues its decision on Dobbs v. Jackson Women’s Health.

States Seek to Protect Access

Legal abortion havens will include California, Colorado, Connecticut, Illinois, New York, Washington, DC, Nevada, New Jersey, Oregon, Vermont, Maine, Massachusetts, Maryland, and Washington. Additional states are working on legislation to codify legal abortion care.³

California Gov. Gavin Newsom has advocated for the state to become a reproductive freedom state. He also has pushed for state laws that will help abortion providers with the economic and capacity challenges of taking care of hundreds to thousands of women from other states, 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.

More than 40 organizations joined the Future of Abortion Council, which includes researchers, healthcare providers, legal experts, advocates, and legislative leadership. “In December, we released a report⁴ that has over 45 policy recommendations to protect, strengthen, and expand abortion access in California,” Moy explains. “We anticipate this could be a model and potential beacon of help for the rest of the nation.”

States like California and Massachusetts are including legal protections in their legislative measures because of the threat of lawsuits from Texas and other states.⁵ “We have to enact legal protections from criminal and civil liability, including patients who reside in other states with hostile abortion laws,” Moy says.

California’s AB-2134 bill would establish a reproductive equity fund to provide grants to abortion providers for uncompensated care.⁶ “The governor’s May budget revision included a $40 million investment for reproductive equity fund. We’re hopeful that when the new budget period starts, new funds will be available in short order,” Moy says.

But for women living in the Southeastern United States, there are no states with laws legalizing abortion care — and most of these states are passing even more restrictive bans. Pregnant people in the South would have to drive or fly 500 to more than 1,000 miles to obtain a legal in-person abortion.

Michigan Advocates Fight Old Laws

There also are states like Michigan and Wisconsin, with no post-Roe laws banning abortion. But reversing Roe v. Wade would bring back old laws. “What felt most acute to us is to be ready for enforcement of an abortion ban because of a 1931 law banning abortion except to preserve the life of the woman,” says Lisa H. Harris, MD, PhD, professor and associate chair in the departments of obstetrics and gynecology at the University of Michigan.

Michigan health coalitions and leaders might succeed in creating a ballot initiative to change Michigan’s constitution and protect abortion rights. There also are lawsuits pending to challenge the 1931 ban. “If any of those legal efforts have the [desired] outcome, we could be a state that would see more patients,” Harris says.

In May, a Michigan judge suspended the 1931 abortion ban as part of a lawsuit by Planned Parenthood of Michigan. The plaintiffs argued the ban violates the state constitution. The injunction will mean the 1931 ban will not go into effect until the lawsuit is resolved.⁷ But Michigan reproductive health providers also must prepare for the possibility the abortion ban goes into effect.

“Multiple prosecutors, including where the University of Michigan is, said they would not prosecute doctors for abortion care,” Harris says. “It’s somewhat comforting to know that, but it’s not a reason where we’d feel legally safe to provide abortion care if it was illegal in the state.”

One prosecutor might not charge doctors who provide abortions. But the next prosecutor could reverse that practice and even press charges for past abortions. “We are parents and sisters and daughters and have other responsibilities we don’t want to jeopardize,” Harris explains. “We commit to following the law in licensure and contracts with insurers, so there are many reasons people are law-abiding.”

If Michigan’s abortion ban takes effect, physicians should prepare to send patients to Illinois and to decide when an abortion is life-saving and allowable under the state law. “Those things need to be in place on day one,” Harris adds.

If Michigan courts rule the state can continue to provide abortion care, providers will need to prepare for an influx of patients from Ohio, Kentucky, Indiana, West Virginia, and other nearby states.

“The easiest part will be to increase medication abortion capacity and office procedures,” Harris says. “The hardest part will be caring for people with underlying illnesses, including serious ones where they’ll need hospital-level care.”

Although there are not enough data to predict how many new patients would travel to Michigan for an abortion, anecdotal evidence suggests there will be significant increases. “Someone on our team has cared for someone from Texas every week, and the patients will travel far for an abortion,” Harris says. “Routinely, we’ve seen patients from Ohio when it was hard for them to get care there.”

Abortion bans in half of the nation take many different forms. Some criminalize abortions provided by doctors or other people. Others follow Texas’ lead and allow anyone, anywhere to sue someone who helps a person obtain an abortion. Some impose penalties for self-managed. Most prohibit mail-order abortion pills. The most restrictive laws ban abortion from the moment of fertilization. Old and new laws would have women arrested for miscarriage if local police and prosecutors think it was caused by a woman’s behavior.

States Anticipate Increases in Capacity

As emerging research shows, the only certainty is that people will continue to obtain abortions, and they will travel great distances and spend a lot of money to make it happen.⁸

“Our concern with multiple states prohibiting abortion is the travel distances,” says Kari White, PhD, lead investigator at Texas Policy Evaluation Project at the University of Texas at Austin.

Travel costs will increase, and financial assistance may not keep up with costs for Texas residents. “The financial assistance people will need will be greater, and funding now is directed at Texas,” White says. “When multiple states prohibit abortion, will the funding multiply to the same extent, or will it be the same amount of funding spread over a broader basis with less funding [per individual]?”

This means that abortion care providers in haven states will see huge influxes to their patient populations, and many will need financial help.

California facilities are exploring ways to enhance capacity, including increasing the number of abortion providers in the state, Moy notes. One way is to expand pathways to care for medication abortion by integrating it in more diverse health settings.

“We’re also working to help enhance legal protections for existing abortion providers to provide care to anyone who comes to our state for the services they want and need,” Moy says.

Reproductive healthcare advocates are focusing on logistics, such as providing practical support like patient navigation, transportation, hotels, and other things that make procedural care possible for people who travel for care.

“Provider training is going to be more critical than ever before to ensure that providers can work to the ceiling of their license,” Moy says. “In California, nurse practitioners can provide first-trimester abortion services. SB 1375 will seek to allow greater autonomy for nurse practitioners to provide a full range of reproductive health services.”

Enhanced training will be necessary for emergency department providers, pharmacists, and first responders, who may encounter patients with medical emergencies where abortion care is needed.

“I think comprehensive training is going to be necessary to ensure that patients feel safe, and their privacy is protected,” Moy says.

All abortion care providers will need training on how to provide trauma-informed care and how to ensure their services are as client-centered as possible.

“If patients are traveling far distances to get critical and potentially life-changing care, they’ll have already gone through a lot to get the care they need,” Moy explains. “We should make sure patients get the care they want and need in a way that meets them where they are and protects their privacy and their health.”

Robert A. Hatcher, MD, MPH, chairman of the Contraceptive Technology Update editorial board, suggests “greater familiarity and availability of self-managed approaches to abortion may become extremely important.”

“The lead article in the June 2 issue of The New England Journal of Medicine⁹ further describes a framework for preparation for the loss of abortion services in Michigan, a state where abortion will become illegal,” Hatcher explains. “Self-managed abortions using mifepristone and misoprostol, and use of misoprostol alone, are described. These nonsurgical approaches will need to be understood by healthcare providers.”

REFERENCES

1. Green M. Ireland changes constitution in abortion referendum. Ireland Information Blog. May 2018.
2. Ely GE. Abortion: The story of suffering and death behind Ireland’s ban and subsequent legalization. The Conversation. May 16, 2022.
3. Lonas L. Here are the states that have passed laws restricting and enshrining abortion access. The Hill. April 16, 2022.
4. California Future of Abortion Council. Recommendations to protect, strengthen, and expand abortion care in California. December 2021.
5. Bebinger M. Mass. Senate moves to protect abortion providers from out-of-state court judgments and investigations. WBUR. May 27, 2022.
6. AB-2134 Reproductive health care. California Legislative Information. April 28, 2022.
7. Ploeg LV. Michigan judge suspends an abortion ban from 1931. The New York Times. May 17, 2022.
8. White K, Dane’el A, Vizcarra E, et al. Out-of-state travel for abortion following implementation of Texas Senate Bill 8. Texas Policy Evaluation Project. March 2022.
9. Harris LH. Navigating loss of abortion services — a large academic medical center prepares for the overturn of Roe v. Wade. N Engl J Med 2022;386:2061-2064.