June 22, 2023 – Since the Supreme Court overturned Roe v. Wade one year ago, abortion has been banned or is unavailable in 14 states and many others have enacted restrictions. Beyond even the loss of access to abortion care, these new laws have had a wide range of negative impacts on obstetric and gynecological care. Pregnant people living in a state that banned abortion after Dobbs were up to three times more likely to die during their pregnancy, in childbirth, or soon after giving birth, compared to those living in states without bans, according to The State of Reproductive Health in the United States: The End of Roe and the Perilous Road Ahead for Women in the Dobbs Era, a January report from the Gender Equity Policy Institute, a research and public policy organization.

In Care Post-Roe: Documenting Cases of Poor-Quality Care Since the Dobbs Decision, a preliminary report from Advancing New Standards in Reproductive Health, health care providers describe being forced to deviate from the usual standard of care in order to comply with the new abortion bans and restrictions. The cases in the report include delayed treatment for ectopic pregnancies, which are never viable and can become life-threatening if left untreated; delays and inabilities to properly treat obstetric complications in the second trimester; and delayed care for patients who have underlying medical conditions that made continuing their pregnancy dangerous. With dilation and evacuation (D&E) — the most commonly used method of abortion in the second trimester — banned in 33 states, patients experiencing preterm prelabor rupture of membranes in the second trimester, for which they previously would have been offered the option of a D&E, were instead sent home and told to return when they went into labor or had signs of an infection.

“The findings were exactly what we were worried would happen” after Dobbs, said Dr. Daniel Grossman, director of Advancing New Standards in Reproductive Health, a research program at the University of California, San Francisco, focused on abortion and reproductive health. “Abortion care is a critical component to comprehensive health care. These stories are really shocking. We had heard that doctors were being forbidden from speaking to the media, and that’s why we wanted to do this study. Two-thirds of the reports were anonymous. Institutions are probably concerned about these stories getting out because they are providing poor-quality care and they might be liable from a medical malpractice perspective.”

Half of the cases in the study involved patients who were Black or Latina/Latinx. “That is a higher percentage than the general population,” said Grossman. “It suggests that people of color are disproportionately impacted. It could mean even worse outcomes for people of color who already have higher rates of maternal mortality.”

The landscape is constantly changing because of legal challenges and ongoing litigation, making it difficult for health care providers and institutions to keep track of what is or isn’t legal. “It’s been devastating; there is a state of confusion and health care providers have to look past the patient in front of them to consider what they are allowed to do,” said Dr. Amna Dermish, chief operating and medical services officer at Planned Parenthood of Greater Texas. “It’s especially hard coming out of a global pandemic — health care providers have been under enormous stress, and now they are forced to make medical decisions based on state laws, not based on standards of care and what is best for their patient. Having to put people in danger before we treat them is a moral injury and against what we signed up to do. Over the past decade, Texans who need abortions have had to jump through so many hoops just to get to us, and then we have to enforce a law that harms them — it’s traumatizing to our patients who come to us for help and it’s traumatizing to us as health care providers. And we don’t even know if we are collecting the right data on this — we may never know the true impact.”

The language in the bans and restrictions is vague, which has a “chilling effect on providers because they fear prosecution,” said Elena Sarver, senior legal advisor at the Global Justice Center, an international legal advocacy organization focused on gender-based violence and access to abortion, and one of several co-authors of the report Human Rights Crisis: Abortion in the United States After Dobbs“It’s an untenable situation — there is already a power dynamic between a patient and a physician. It damages the relationship if they feel like their hands are tied and [they] can’t provide the optimum health care or have to tell patients to wait until their lives are in danger before they can treat them. It discourages engagement with the health care system in general. And the lack of privacy protection in the laws is harmful and disproportionately impacts marginalized populations, who are surveilled at higher rates in other areas of their lives. These laws are intentionally vague and without a way to work around them. It creates a situation for physicians to have to provide substandard care, which goes against what the profession is.”

Having an unwanted pregnancy and birth means that a patient’s “physical health is worse for years,” said Diana Greene Foster, professor and demographer at the University of California, San Francisco and Advancing New Standards in Reproductive Health, and lead author of The Turnaway Study, which documented the consequences for people who are denied an abortion in terms of overall health and well-being as well as the financial impacts. “I suspect that the people now who aren’t able to access abortion care are those who already have the least resources — undocumented immigrants, minors, people who are incarcerated — and their outcomes will be much worse from having an unwanted pregnancy. Because there are legal threats in some of these new abortion bans, I am very concerned that people won’t seek health care when they need it because of fears about the legal consequences. How will this extra level of threat impact health outcomes?”

No One Could Say: Accessing Emergency Obstetrics Information as a Prospective Prenatal Patient in Post-Roe Oklahoma, a report from Physicians for Human Rights, the Oklahoma Call for Reproductive Justice, and the Center for Reproductive Rights, looked at how Oklahoma’s abortion bans are forcing health professionals “to balance their obligation to provide ethical, high-quality medical care against the threat of legal and professional sanctions.” The research, conducted in November and December 2022, found that hospitals in Oklahoma were providing opaque, contradictory, and incorrect information about when an abortion is available. “You can’t create a comprehensive list of exceptions; even the provision of someone’s life being in danger isn’t clear — what is the degree of danger that will hold up to a legal challenge?” said Dr. Michele Heisler, medical director at Physicians for Human Rights and co-author of the report. “How close to death does the patient have to be? Already there are maternal care deserts that are only worsening because physicians are referring patients for care outside of their geographic region for treatment options in cases of medical emergencies that they used to provide themselves, but are now too scared to offer.”

Already, the United States has the highest maternal mortality rate among high-income countries, with Black women experiencing a higher rate of death than any other demographic group. “What we found is that, even before Dobbs, maternal mortality rates were higher in states where it is harder for people to obtain abortion or contraception, and we expect to see this trend continue,” said Natalia Vega Varela, senior researcher at the Gender Equity Policy Institute and the lead author of The State of Reproductive Health in the United States. “There’s a reason someone needs an abortion — financial reasons, health reasons, etc. If they can’t get one, there’s a higher chance for bad outcomes, the research shows. Some states with bans also haven’t expanded access to Medicaid, so low-income people can’t get prenatal or postpartum care. They already don’t have access to comprehensive health care, so they are starting out on an unequal field, and if they can’t get an abortion that they want, they are facing so many possible bad outcomes for both the mother and the newborn.”

Abortion bans and restrictions are also impacting where medical students choose to do their training. According to a recent survey from the American College of Obstetricians and Gynecologists, almost 58% of medical students said they were unlikely or very unlikely to apply to a residency program in a state with abortion restrictions. “I have a lot of concerns about the workforce and the ability of new medical students and nurses to train as abortion becomes more stigmatized,” said Kwajelyn J. Jackson, executive director of the Feminist Women’s Health Center in Atlanta. “As more and more clinics close and family planning programs make training for abortion care optional, it puts it all on the students to find places to be trained. Treating miscarriage is exactly the same as abortion care, so how will people learn if they don’t know how to perform a D&C? If they can’t come to a place like the Feminist Women’s Health Center, where will they get these skills? Is there a scenario where in a few years, the entire Southeast won’t have health care providers who have comprehensive reproductive health training?”

In the nine months following the Dobbs decision, more than 25,000 people were unable to get an abortion from a provider, according to #WeCount, a national abortion reporting survey by the Society of Family Planning along with providers and researchers. The largest declines in abortion were in states that also tend to have high rates of poverty and maternal mortality and morbidity. “The states with laws that restrict abortion access also tend to provide fewer resources to pregnant people and underinvest in education and family support,” said Dr. Alison Norris, co-chair of #WeCount research steering committee and professor at the Ohio State University’s College of Public Health. “The premise of reproductive justice — to be able to choose when to have a birth and to parent — those main tenets are undermined at every point.”

In addition to the current harms the abortion bans are causing, how will these laws impact the quality of health care in the future? “Physicians are being put in an impossible situation where they aren’t making medical decisions, they are making legal decisions,” said Payal Shah, a human rights lawyer and the director of the program on sexual violence in conflict zones at Physicians for Human Rights and co-author of No One Could Say. “The dual loyalty situation — that is, the quandary where providers are prevented by the law from fulfilling their medical ethical obligations and standards of care — that physicians have been put in and the health risks to patients is all entirely preventable. The U.S. is moving backwards compared to the majority of other countries on reproductive rights. This raises the question of whether a certain standard of medical care in this country can be maintained under these laws.”

Susan Buttenwieser writes frequently about reproductive health care, immigration, and the criminal justice system. Her writing has been nominated for a Pushcart Prize, and she teaches creative writing in New York City public schools and with incarcerated women. Her short story collection, We Were Lucky With the Rain, was published by Four Way Books in September 2020.

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