When most people no longer can seek safe abortion care in their home regions and states, there will be an increase in maternal deaths and injuries, both from unsafe abortions and from unsafe pregnancies that should have been ended because they risked the woman’s health, several reproductive health advocates and researchers say.

“It’s clear in countries where abortion is illegal or criminalized that women suffer more complications of pregnancy and higher mortality rates from unsafe abortions,” says Mimi Zieman, MD, author of Managing Contraception and president of SageMed LLC in Atlanta. “In this country, the most unfortunate and unjust consequence of restricting abortion is that women of lower income and women of color will suffer more than women who have the means to travel to other states and countries to get care.”

Abortions will continue in a post-Roe America, but women’s safety will be jeopardized, says Eva Lathrop, MD, MPH, global medical director of Population Services International (PSI).

“It’s crucial to provide safe abortion services,” Lathrop says. “The global data show us that in highly restricted places, abortion does not go away.”

When nations eliminate legal access, abortion numbers do not necessarily go down, but complications from abortions and deaths from abortions go up. “That’s what we’re looking at if abortion is overturned,” Lathrop says.

A 2018 Guttmacher Institute report revealed that the abortion rate is 37 per 1,000 women in countries where abortion is prohibited or permitted only to save a pregnant woman’s life. The rate is 34 per 1,000 women in countries where abortion is not as restricted.1

States have passed hundreds of abortion restrictions in recent decades, and access to safe and legal abortions already is limited for many people — particularly those from communities of color and indigenous communities.

“Removal of Roe v. Wade will make abortion care more challenging for everybody. It’s devastating to think about,” Lathrop says. “It’s cruel and inhumane, and it’s devastating for people who are carrying these pregnancies to term against their will. It’s a complete violation of human rights to do that.”

Vulnerable communities and people will suffer the most, says Bhavik Kumar, MD, staff physician at Planned Parenthood Center for Choice in Houston.

“Banning abortion uniquely harms the people who cannot travel out of state or find the means to end their pregnancies on their own,” he says. “Disproportionately, those are the same communities who are already the most marginalized.”

People of color, people in rural communities, and people who are struggling to make ends meet and care for their families are the ones who will suffer most under state abortion bans because they usually are the ones who can least afford the cost and time of traveling out of state, Kumar adds.

States and nations that ban abortions also put pregnant women at risk, even with intended pregnancy. One consequence of abortion bans is that young OB/GYNs will choose not to practice in a state where they could suffer legal consequences if they perform an abortion to save a patient’s life or health.

“What Texas did [with its six-week abortion ban] is make [it likely some] OB/GYNs will leave the state,” Zieman says. “When we were fighting the six-week anti-abortion law in Georgia, we did a survey of new OB/GYNs and how the law would impact them. They said they wouldn’t want to practice there.”

Many reproductive health providers likely will avoid Texas because of its abortion ban. “They may not want to be in a position where someone is going to target them and take them to court, so they won’t practice in that state at all,” Zieman says. “That will affect all women because there will be a shortage of those providers.”

The United States already has one of the highest maternal mortality rates in the industrialized world, and deaths during pregnancy likely will increase post-Roe.1

Recently, researchers found pregnancy-related deaths would increase by 7% soon after a nationwide abortion ban, and would increase by a further 21% in subsequent years. The researchers also noted pregnancy-related deaths would increase even if only some states banned abortions.2

Under the Texas abortion ban (SB 8), which began Sept. 1, 2021, women have been refused potentially life-saving care by practitioners in the state, according to media reports.

A woman in a rural area of south Texas called the National Abortion Federation (NAF) hotline after her doctor refused to help her end an ectopic pregnancy because of SB 8. NAF told the woman to go to the closest emergency department. But when the woman contacted the closest hospital, she was told she would have to go out of state to seek immediate medical care. The woman drove more than 12 hours to New Mexico to terminate her ectopic pregnancy.3

Ectopic pregnancies, which mainly occur in the fallopian tube, cannot be moved to the uterus. These pregnancies can cause a rupture with major internal bleeding, creating a life-threatening emergency that needs immediate surgery, according to the American College of Obstetricians and Gynecologists.4

“While some ectopic pregnancies end on their own, the vast majority are treated with medicine or surgery, which are necessary because it’s life-threatening,” Zieman says.

Laws that ban abortions, such as SB 8, force physicians and nurses to violate their medical practice and ethics. “They’re not doing their best work, but they’re doing what the state ordered them to do,” Zieman says.

The United States is moving backward, Lathrop says. “We already have the highest maternal mortality rate among highly developed countries. That is shameful, and this will only increase it,” she says.

Since SB 8 bans all abortions after six weeks, with no exception for rape or incest, this will have an immeasurable toll on women who become pregnant and are forced to continue the pregnancy.

Adolescents who become pregnant experience more complications in pregnancy and a higher risk for most complications, including preterm birth, pre-eclampsia, and risks from the physical trauma of carrying the pregnancy. They also could suffer from greater emotional trauma for being forced to become pregnant and bear the child of the person who assaulted them, Lathrop says.

States like California and New York, where state laws ensure abortion access, will see more people from out of state seeking abortion services. Early reports from late 2021 suggest that many Texans already have sought abortion care in other states.

“In California, abortion will be legal,” says Julie Rabinovitz, MPH, president and chief executive officer of Essential Access Health in Berkeley, CA. “Governor Gavin Newsom has created the Future of Abortion Council.”

The council will help the state prepare for an expected influx of out-of-state patients from Texas and also from other states in the event the Supreme Court overturns Roe v. Wade. An estimated 1.4 million women — a nearly 3,000% increase — may travel to California for abortions if Roe ends, according to the council’s December 2021 report.5

The Future of Abortion Council recommended that the state ensure cost is not a barrier to care and ensure timely reimbursement for abortion-related services, including an uncompensated care program that would provide abortion care reimbursement for out-of-state patients.

The report also recommends an expansion of abortion training and reproductive health education programs for primary care providers. The state should enact legal protections from civil and criminal liability for clinicians who provide abortions, including for patients from states with hostile abortion laws, the council noted.

“My hope is the government and legislature will adopt the recommendations and fully fund whatever is necessary to ensure access to people who want and need an abortion — not only in California, but also for those who come to California from other states where they do not have access,” Rabinovitz says.

REFERENCES

  1. Guttmacher Institute. New report highlights worldwide variations in abortion incidence and safety. March 20, 2018.
  2. 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.
  3. Kitchener C. The Texas abortion ban has a medical exception. But some doctors worry it’s too narrow to use. The Lily. Oct. 22, 2021.
  4. The American College of Obstetricians and Gynecologists. FAQs: Ectopic pregnancy. February 2018.
  5. California Future of Abortion Council. Recommendations to protect, strengthen, and expand abortion care in California. December 2021.