In Louisiana, doctors will no longer be able to carry a lifesaving medication with them during pregnancy emergencies. In Texas, the infant mortality rate is soaring. In Idaho, pregnant people drive hours just to give birth. And in Oklahoma and Georgia, women are bleeding out in hospital parking lots and facing dangerous infections before they can find care – and sometimes, that care comes too late.
The limitations and outright bans on abortion that have taken hold in half of the US in the wake of the Dobbs decision have wreaked enormous changes to the reproductive health landscape.
The restrictions put a growing burden on the health and wellbeing of patients and providers, even as more Americans find it difficult to find and access care.
“The United States is, and has been for quite some time, in the midst of a maternal and infant mortality crisis,” said Dr Jamila Perritt, a board-certified obstetrician and gynecologist and president of Physicians for Reproductive Health.
Banning access to reproductive healthcare, including abortion care, is “directly causing an increase in morbidity and mortality in our community”, she said. “We have really robust evidence that shows us that when people have sought abortion care and are unable to obtain it, their psychological, social, physical and emotional health is harmed.”
Maternal and infant mortality will probably increase because of the restrictions – especially if national limitations, like enforcement of the Comstock Act, are put into place.
“I expect in the next few years, we’re going to start to see the infant mortality, pre-term birth, maternal mortality, and maternal morbidity numbers rise for everyone, and particularly for folks from racially marginalized and low-socioeconomic communities,” said Rachel Hardeman, professor of reproductive health and founding director of the Center for Antiracism Research for Health Equity at the University of Minnesota.
Calculating mortality is often a complicated and controversial endeavor. When maternal mortality dropped in 2022, anti-abortion advocates credited the success to the Dobbs decision.
But that’s not the case, according to new research in Jama Network Open.
Maternal deaths surged during the first two years of the pandemic, when Covid, a deadly illness during pregnancy, accounted for one-quarter of all maternal deaths. But in 2022, that rate dropped to levels similar to pre-pandemic levels, from 32.9 deaths per 100,000 live births in 2021 to 22.3 in 2022.
That rate is still higher than maternal mortality rates in peer nations, and research indicates it will increase if officials clamp down on abortion nationally – which, with the Comstock Act, would require no additional anti-abortion legislation or bans.
Right now, “people can still travel to other states, but once there’s a federal ban, that won’t be an option any more,” says Amanda Jean Stevenson, co-author of the new Jama research and a sociologist at the University of Colorado Boulder. “And there could be this very different set of outcomes when people’s options are gone.”
In the United States, more than 80% of pregnancy-related deaths and more than 60% of infant deaths in the first week are preventable – and those figures were estimated before the Dobbs decision.
Because of abortion restrictions, there are already significant challenges to accessing reproductive healthcare – and it’s not just abortion care.
In Louisiana, misoprostol – a drug used for medication abortion and other lifesaving purposes – will be labeled a controlled substance beginning on 1 October. One of its uses is keeping patients from bleeding out after childbirth, which is the No 1 cause of postpartum mortality.
Yet physicians cannot keep controlled substances in their emergency carts, and they fear they won’t have enough time to fill prescriptions for patients when minutes and even seconds make the difference between life and death.
In the year following Texas’s abortion ban, child mortality shot up by 12.9% – compared with a 1.8% increase in the rest of the country, according to a recent study. Congenital anomalies are the leading cause of infant death in the US – but while they went down by 3.1% in the rest of the country, they went up by 22.9% in Texas.
“That study was chilling. That is a huge change,” Stevenson said.
It echoed previous research finding that states with the most restrictive abortion laws saw 16% more infant deaths between 2014 and 2018.
The trauma and costs of carrying to term pregnancies that are incompatible with life inflict an incalculable toll on families and providers.
States are closing obstetric units and losing experienced providers who worry about not being able to offer lifesaving care as patients die on the table in front of them, and facing jail time if they provide care.
More than two-thirds (68%) of obstetricians and gynecologists say the Dobbs decision has made it harder for them to respond to pregnancy-related emergencies, according to the non-partisan health research organization KFF. They also believe it has worsened mortality in pregnancy while increasing racial and ethnic inequities, and fewer doctors are now interested in entering the field.
In 2022, soon after the Dobbs decision, medical residency applications dropped for states with bans.
More than half of doctors surveyed in states with bans and limitations said they were very concerned about legal repercussions to providing the standard of care in pregnancy.
“That can just exacerbate already pretty large gaps in the workforce,” said Usha Ranji, associate director for women’s health policy at KFF.
In the past two years, more than 100 hospitals have closed their obstetric units entirely, according to a new March of Dimes report. More than one-third of US counties are now maternity care deserts, with no obstetricians or places to give birth. North Dakota, South Dakota, Alaska, Oklahoma and Nebraska have the least access to maternity care.
The majority of rural hospitals (57%) no longer deliver babies, with more than 100 of the rural hospitals ending labor and delivery services in the past five years.
“We’ve created policy and legislation to limit access to abortions and also have closed the exact places that people need to go to get care if they are pregnant,” Hardeman said. That puts pressure on neighboring states that still provide care, she said.
“Where you live matters for your health. And I think that the Dobbs decision and the fall of Roe have demonstrated that in a very real and very obvious way, because there are literally places in this country where there is essentially no access to reproductive healthcare,” she said.
“It started out in rural spaces, but more and more, there’s reports popping up of labor and delivery units closing in, like, urban Chicago.”
In states with restrictions on abortion, women of color and pregnant people from low-income communities often suffer the most, said Hardeman. “Taking away access to reproductive healthcare is exacerbating those disparities.”
Black women die because of pregnancy at twice the national rate, and three times more than white women, according to the US Centers for Disease Control and Prevention.
“The fact that black women and birthing people are dying at three to four times greater risk than white women is shameful – and it’s preventable,” Perritt said.
It’s important to shore up protections for reproductive health for all Americans before health complications and mortality rise even more, she said. “One death is too much. One is too many.”
