On June 24, 2022, The Supreme Court announced a 6-3 ruling on the Dobbs v. Jackson Women’s Health Organization case that overturned the 1973 Roe v. Wade decision and ended the constitutional right to obtain an abortion. As a result of this ruling, individual states can now decide whether or not abortion access will remain legal, and what restrictions can be placed on abortion care within their state.
Following the news of this decision, GW health leaders and experts released statements and responses that expressed deep concern for the implications this decision will have on medicine and public health. Barbara Bass (Dean of the GW School of Medicine and Health Sciences and CEO of the GW Medical Faculty Associates), Lynn Goldman (Dean of the GW Milken Institute School of Public Health), and Pamela Slaven-Lee (Interim Dean of the GW School of Nursing) released a joint statement in response to this decision. The statement highlighted the health ramifications of carrying an unintended pregnancy to term, including “a higher risk of maternal death, preterm birth, and other serious health problems” (Bass et al., 2022). The statement went on to assert that the decision “disrupts the oath of physicians and health care providers to provide care that, first and foremost, honors personal autonomy and the unwavering commitment to provide care with safe and effective therapies” (Bass et al., 2022).
Amita Vyas, Director of the GW Maternal and Child Health Center told GW Today that “every single adult and child in this country will be affected by this decision” (GW Today, 2022). Vyas went on to express concern based on evidence-based studies that have shown that abortion restrictions lead to higher maternal mortality rates.
These statements from GW experts are grounded in evidence-based research. This post will examine what the evidence-based research says about abortion-related morbidity and mortality rates, and how restrictive abortion laws affect health disparities and health outcomes. This post will also explore what the evidence shows about whether or not restrictive abortion laws prevent or reduce abortion rates, the impacts of restrictive abortion laws on patient care, and how health care providers can prepare for the consequences of this ruling in their practices.
Abortion and Morbidity and Mortality
Numerous studies have examined the rates of morbidity (an illness or disease) and mortality (death) related to abortion. Stevenson’s 2021 study investigated the impact of a total abortion ban in the United States on pregnancy-related mortality. This study estimated that a total abortion ban would result in a 7% increase in pregnancy-related deaths during the first year of the ban, and a 21% increase in subsequent years (Stevenson, 2021). Black, Indigenous, and people of color populations would likely experience even higher rates of mortality: an estimated first-year pregnancy-related death increase of 12% among Non-Hispanic Black people and a 6% increase among Hispanic people, followed by subsequent year increases of 33% among Non-Hispanic Black people and 18% among Hispanic people (Stevenson, 2021).
Despite the 1973 Roe decision, access to abortion care has steadily become more restrictive in the United States since the mid-1990s. Addante et al. published a retrospective study examining maternal mortality rates in the United States between 1995 and 2017, during which time, the number of states with restrictive abortion laws rose from 13 states to 29 states. (Addante et al., 2021). States with neutral abortion laws decreased from 32 states to only 12 states, while states with protective abortion laws rose slightly from 5 states to 9 states during this time period (Addante et al., 2021). The mean maternal mortality rates in 1995 were similar across states with restrictive, neutral, and protective abortion laws, but by 2017, maternal mortality rates in states with restrictive abortion laws were 70% higher than in states with protective abortion laws (Addante et al., 2021).
Restrictive abortion laws can contribute to increased maternal mortality rates in a variety of ways. Women who have high-risk pregnancies, which increase the risk of poor obstetrical outcomes, may be less able to terminate a pregnancy for medical reasons in states with restrictive abortion laws (Addante et al., 2021). Additionally, there is often a reduction in sexual and reproductive healthcare services, such as access to contraception, that are provided by abortion clinics when clinics are forced to close due to restrictive abortion laws (Addante et al., 2021). Verma and Shainker’s 2020 study found that a 20% reduction in Planned Parenthood clinics resulted in an 8% increase in the maternal mortality rate (Verma & Shainker, 2020).
Karletsos et al.’s 2021 study explored whether states with gestational age limit abortion laws experienced changes in infant mortality rates. Between 2005 and 2017, 13 states passed gestational age limit laws (Karletsos et al., 2021). The study found that infants born as a result of gestational age laws had a 3.6% increased infant mortality rate (Karletsos et al., 2021). The Turnaway Study by Foster and Kimport in 2013 found that people who sought an abortion after the gestational age of 20 weeks experienced difficulty in finding a provider, as well as financial hardships associated with the cost of the procedure and travel-related costs (Foster & Kimport, 2013).
Abortion Access and Health Disparities
Studies have shown that limiting access to abortions has a disproportionally negative impact on underserved groups, thus exacerbating already existing health disparities. Low-income populations and those experiencing poverty are the most at risk of being impacted by the negative effects of anti-abortion laws. Many people who seek abortions cite not being able to afford a child (or another child), negative impacts on work, school, and/or the ability to care for other children among the factors influencing their decision (Boonstra, 2016). In addition, low-income individuals seeking an abortion may “delay or forgo paying utility bills or rent, or buying food for themselves and their children” in order to afford the procedure (Boonstra, 2016).
According to 2014 data from the Guttmacher Institute, 75% of patients who seek abortions were poor or low-income (Verma & Shainker, 2020). The 1976 Hyde Amendment, which restricted access to reproductive healthcare by banning federal funding for abortions under Medicaid, the Indian Health Service, and the Children’s Health Insurance Program, had a disproportionately negative impact on Black women (Salganicoff et al., 2020). 30% of black women and 24% of Hispanic women between the ages of 15 and 44 have Medicaid coverage, compared to only 14% of their white counterparts (Boonstra, 2016).
States-level gestational age laws also tend to negatively impact lower-income people who “were unable to obtain earlier care owing to a lack of financial resources, transportation, child care, and other constraints” (Karletsos et al., 2021, p.788). Forced maternity only enhances these hardships as low-income individuals often experience barriers to “adequate prenatal, postpartum, and other health care for themselves and their infants” in addition to the barriers experienced in affording living expenses and access to resources to keep their newborns healthy (Karletsos et al., 2021, p.791).
According to Verma and Shainker, “unintended pregnancy rates remain highest among Black women, Hispanic women, and women of lower socioeconomic status, comprising the same groups with the highest abortion rates” (Verma & Shainker, 2020, p. 4). The article goes on to point out that these are also the groups facing the greatest risk of maternal mortality since they tend to be less likely to have health insurance, further limiting access to family planning and preventive health care services (Verma & Shainker, 2020).
Increased Rates of Abortion
While anti-abortion advocates often seek abortion bans in an effort to deter abortions, evidence shows that legal restrictions on abortions do not eliminate abortions or result in decreased abortion rates. Instead, legal restrictions simply “increase the likelihood that abortions will be performed unsafely, as they compel women to seek clandestine procedures” (Fathalla, 2020, p. 8). Latin American countries have the world’s strictest abortion bans but have the highest rates of abortion in the world at 32 abortions for every 1,000 women (Oberman, 2022). In contrast, Western Europe has the world’s lowest abortion rates (12 abortions per 1,000 women), with some of the world's most liberal abortion laws that provide easy access to safe abortions (Oberman, 2022).
The largest predictor of abortion rates is the percentage of unwanted or unintended pregnancies - not the legal status of abortion (Oberman, 2022). Western Europe not only provides easy and legal access to safe abortions, but modern contraception use is high, thus diminishing unintended and unwanted pregnancies and the need for abortions (Fathalla, 2020). “Public health experience has demonstrated that women’s need for abortion can be reduced by making contraceptive information and services available, accessible, and affordable” (Fathalla, 2020, p. 6). When the Affordable Care Act was passed mandating health insurance coverage for contraception in 2010, unintended pregnancy rates dropped by 15% (Obermann, 2022).
Complications of Unsafe and Unmanaged Abortions
“When abortion is legally restricted or otherwise inaccessible, girls, women, and those who care about them look outside formal medical care to end pregnancies” (Harris & Grossman, 2020, p. 1,029). This can often end in unsafe or self-managed abortions, often through medication.
According to the World Health Organization (WHO), abortion is considered safe when it is “done with a method recommended by the WHO that is appropriate to the pregnancy duration and if the person providing or supporting the abortion is trained” (Fathalla, 2020, p. 3). Abortions are considered less safe if it meets one of the criteria (method or trained provider), but not both (Fathalla, 2020). WHO estimates that between 4.7% and 13.2% of maternal deaths each year are a result of unsafe abortions worldwide (WHO, 2021). The health risks resulting from unsafe abortions can include incomplete abortion, hemorrhage, infection, uterine perforation, and genital tract and/or internal organ damage (WHO, 2021). Unsafe abortions are a leading cause of maternal morbidity resulting in almost 300,000 maternal deaths per year worldwide (Rodgers et al., 2021).
Aside from the very real health risks associated with unsafe abortions, there is also a significant financial cost. A 2020 systematic review found that the annual cost of abortion care in the United States was $134 million (Soleimani et al., 2020, p. 63). WHO estimated that the financial burden on health care systems from complications of unsafe abortions in developing countries was $553 million per year not including a loss of $922 million in household income that is lost due to long-term disability resulting from unsafe abortions (WHO, 2021). By comparison, for patients requiring post-abortion care for unsafe abortions, the yearly cost of contraception supplies and services amounts to just 3% to 12% of the cost of providing post-abortion care (Rogers et al., 2021).
One response to the increase in restrictive abortion laws has been self-induced or self-managed abortions, often through medications obtained outside of a medical setting (Conti, & Cahill, 2019). Medication-based abortions have made finding an abortion both easier and safer (Oberman, 2022, p. 6). Misoprostol is the most common and most widely available abortion medicine and is classified as an “essential medicine” by WHO for its “vital role in reducing deaths from postpartum hemorrhages, miscarriages, and illegal abortions” (Oberman, 2022, p. 7). Patients managing abortion through medications such as mifepristone and misoprostol can experience bleeding, cramping, and expulsion of pregnancy tissue at home (Harris & Grossman, 2020).
Pregnancies ended through medications are often “clinically indistinguishable from those who have had uncomplicated spontaneous pregnancy loss” (Harris & Grossman, 2020, p. 1,029). Telemedicine could be an essential tool in enabling patients experiencing financial or geographical difficulties when seeking an abortion to receive medication abortions (Verma & Shainker, 2020). Unfortunately, “abortion pill” bans have also become a target for states that seek to pass restrictive abortion laws.
Physician Preparedness for Restricted Abortion Access
As states pass more restrictive abortion laws following the recent Supreme Court decision, health care providers are faced with helping patients navigate the new abortion landscape and “must become familiar with the normal course of self-managed abortion with medications and its rare complications, as well as complications of unsafe abortions” (Harris & Grossman, 2020, p. 1,029).
In Harris and Grossman’s 2020 review article, they explore potential circumstances physicians and health care providers may be facing as abortion laws become more restrictive. While many patients who seek care will only require confirmation that a medication-induced abortion is complete, others will require outpatient interventions for incomplete abortions (Harris & Grossman, 2020). “In contrast, those using unsafe methods may need lifesaving critical care for sepsis, hemorrhage, pelvic-organ injury, or toxic exposures” (Harris & Grossman, 2020, p. 1,029). Patients managing abortion through a clinically supervised combination of mifepristone and misoprostol rarely experience major complications that require hospitalization, surgery, or blood transfusions, which occur in only 0.3% of cases (Harris & Grossman, 2020). However, physicians should be aware of other ineffective and less safe methods of self-managed abortions, such as herbal remedies that are not only ineffective but can cause toxic reactions and even death (Harris & Grossman, 2020).
Physicians and healthcare professionals need to be increasingly prepared to provide “prompt, nonjudgmental, evidence-based care” when patients present after self-managed abortions or following unsafe abortions (Harris & Grossman, 2020, p. 1,037). Additionally, health care facilities need to develop policies and care protocols that prioritize the safety of pregnant patients (Harris & Grossman, 2020).
Summary
The evidence shows that restrictive abortion laws not only fail to eliminate abortions or decrease the number of abortions taking place but instead increase the rate of abortions. In addition, the evidence demonstrates that morbidity and mortality rates related to abortion increase as a result of more restrictive abortion laws, having a disproportionate effect on Black, Indigenous, and people of color communities, including a 33% increase in pregnancy-related death among Black people. Limits on abortion access disproportionately negatively impact low-income groups by increasing barriers to necessary healthcare services, thus exacerbating already existing health disparities.
References:
Addante, A. N., Eisenberg, D. L., Valentine, M. C., Leonard, J., Maddox, K., & Hoofnagle, M. H. (2021). The association between state-level abortion restrictions and maternal mortality in the United States, 1995-2017. Contraception, 104(5), 496–501. https://doi.org/10.1016/j.contraception.2021.03.018
Bass, B. Goldman, L., Slaven-Lee, P. (June 24, 2022). GW health leaders issue statement on Supreme Court decision to overturn Roe v. Wade. GW Media Relations. https://mediarelations.gwu.edu/gw-health-leaders-issue-statement-supreme-court-decision-overturn-roe-v-wade
Boonstra, H. D. (2016). Abortion in the lives of women struggling financially: Why insurance coverage matters. Guttmacher Policy Review, 19(7). https://www.guttmacher.org/sites/default/files/article_files/gpr1904616_0.pdf
Conti, J., & Cahill, E. P. (2019). Self-managed abortion. Current Opinion in Obstetrics & Gynecology, 31(6), 435–440. https://doi.org/10.1097/GCO.0000000000000585
Council on Community Pediatrics (2016). Poverty and Child Health in the United States. Pediatrics, 137(4), e20160339. https://doi.org/10.1542/peds.2016-0339
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Foster, D. G., & Kimport, K. (2013). Who seeks abortions at or after 20 weeks?. Perspectives on Sexual and Reproductive Health, 45(4), 210–218. https://doi.org/10.1363/4521013
GW Today. (June 24, 2022). Q&A: How the Supreme Court’s abortion ruling impacts public health. GW Today. https://gwtoday.gwu.edu/q-how-supreme-court%E2%80%99s-abortion-ruling-impacts-public-health
Harris, L. H., & Grossman, D. (2020). Complications of unsafe and self-managed abortion. The New England Journal of Medicine, 382(11), 1029–1040. https://doi.org/10.1056/NEJMra1908412
Karletsos, D., Stoecker, C., Vilda, D., Theall, K. P., & Wallace, M. E. (2021). Association of state gestational age limit abortion laws with infant mortality. American Journal of Preventive Medicine, 61(6), 787–794. https://doi.org/10.1016/j.amepre.2021.05.022
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Salganicoff, A., Sobel, L., & Ramaswamy, A. (2020). The Hyde Amendment and coverage for abortion services. Kaiser Family Foundation. https://www.kff.org/womens-health-policy/issue-brief/the-hyde-amendment-and-coverage-for-abortion-services/
Soleimani Movahed, M., Husseini Barghazan, S., Askari, F., & Arab Zozani, M. (2020). The Economic Burden of Abortion and Its Complication Treatment Cares: A Systematic Review. Journal of Family & Reproductive Health, 14(2), 60–67. https://doi.org/10.18502/jfrh.v14i2.4354
Stevenson A. J. (2021). 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, 58(6), 2019–2028. https://doi.org/10.1215/00703370-9585908
Supreme Court of the United States. (2022). Dobbs, State Health Officer of the Mississippi Department of Health, et al. v. Jackson Women’s Health Organization et al. https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf
Verma, N., & Shainker, S. A. (2020). Maternal mortality, abortion access, and optimizing care in an increasingly restrictive United States: A review of the current climate. Seminars in Perinatology, 44(5), 151269. https://doi.org/10.1016/j.semperi.2020.151269
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