By Michael Ollove
Stateline

The 17 states that ban abortion after 20 weeks make exceptions to protect the life or health of the woman. But doctors and reproductive health advocates worry such exceptions are so vague or narrow that abortion providers are unlikely to invoke them—especially if they fear they could be charged with a crime. 

In a country that has long lagged its peers in maternal mortality, many reproductive health providers warn that stricter abortion laws are likely to make the situation worse—especially for Black women, who die of pregnancy-related causes at nearly three times the rate of White women.

“Doctors have said it puts them in an untenable position where they have to base decisions on their legal liability, which shouldn’t be a consideration at all,” said Shaina Goodman, director for reproductive health and rights at the National Partnership for Women and Families. “At what point is the life of the mother at risk, when she’s coding on the table?”

Several scientific studies in the past two years have noted that abortion bans will likely increase maternal mortality. A University of Colorado study in 2021, for example, found that a total ban on the procedure could increase pregnancy-related deaths up to 21% overall and up to 33% for Black women.

Already, some doctors say the inflammatory nature of the abortion issue has compelled them to provide care they regard as less than optimal.

Dr. Alice Mark, a Massachusetts OB-GYN and medical adviser to the National Abortion Federation, which represents providers of abortion services, said exceptions in state abortion bans are not designed to provide patients with the best medical care. 

“These laws are not meant to be clinical guidance about what I can or can’t do,” she said. “They are meant to prevent women from having an abortion.”

In Wisconsin, for example, some clinics already are refusing to use mifepristone to help women pass an early miscarriage because the drug also can be used in medical abortions, said Dr. Amy Domeyer-Klenske, an OB-GYN in Milwaukee who is vice chair of the Wisconsin chapter of the American College of Obstetricians and Gynecologists. 

Without mifepristone, Domeyer-Klenske said, doctors must either wait to see whether a patient passes the miscarriage on her own, or use less effective medications or perform a riskier surgical procedure.

“We are already telling pregnant patients who are suffering a miscarriage: ‘You can’t have the best level of care because of the politics around abortion,’” she said.

Domeyer-Klenske cited the hypothetical example of a woman whose water broke during the first trimester in her pregnancy. The fetus would likely be unviable, but the woman could develop a life-threatening infection unless a doctor performed an abortion quickly, Domeyer-Klenske said.

But many doctors, fearful of criminal prosecution, might hesitate to act. “Am I going to have to wait until you are in the ICU and septic before I invoke the life is at risk exception?” she asked.

Kentucky state Rep. Nancy Tate, a Republican who authored a recently approved law that bans abortions after 15 weeks of pregnancy, pointed out that in 2020 there was only one confirmed case of an abortion being performed after 20 weeks in Kentucky to spare the life of the patient, out of 4,104 total procedures performed, according to the state’s Department of Public Health. 

“Typically, women do not visit abortion clinics when their lives are in danger—we see doctors in hospitals who view saving the lives of both patients as critical,” Tate wrote in an email to Stateline.

The law, which has been temporarily stayed by a federal judge, contains language permitting the abortion if it “was necessary to prevent the death of the pregnant woman or to avoid a serious risk of the substantial and irreversible impairment of a major bodily function of the pregnant woman.”

Dr. Donna Harrison, an OB-GYN and CEO of the American Association of Pro-Life Obstetricians and Gynecologists, said doctors shouldn’t have to perform an abortion to save a patient’s life. “The problem isn’t that we have too few abortions, it is that abortion is not necessary for good OB-GYN care. If it was, all OB-GYNs would do it.”

Falling Behind

The United States has the highest maternal mortality rate among comparable nations. In 2020, the U.S. ranked last among developed countries analyzed by the Commonwealth Fund, a private foundation that promotes improvements in health care and health equity. According to the Commonwealth analysis, the U.S. recorded 23.8 maternal deaths per every 100,000 births (the rate was 55.3 for the nation’s Black women). Second among the developed countries examined was France with 7.6 deaths per 100,000. 

Many reproductive health care providers worry that tighter abortion laws will cause the U.S. to fall further behind. 

“There’s no question there is a real concern that mortality and morbidity will be affected as we see further restrictions and bans in half the states,” said Andrea Miller, president of the National Institute for Reproductive Health, an advocacy group.

Dorianne Mason, director of health equity at the National Women’s Law Center, said the effects are likely to be most dire for women of color.

“We have already been at a crisis point,” Mason said. “If you add on top of that a system that restricts access to abortion care and increases unwanted pregnancies, you are potentially cycling more Black and brown women into a system that is already failing them.”

Non-Hispanic Black women receive abortions at a higher rate and account for a greater percentage of abortions than non-Hispanic White women or Hispanic women, according to the federal Centers for Disease Control and Prevention. 

Already, the states with the most restrictive abortion laws tend to have the highest maternal mortality rates, according to the CDC. These include Alabama, Arkansas, Kentucky, Louisiana, Mississippi and Tennessee, all of which, the CDC reports, recorded more than 30 maternal deaths per 100,000 births between 2018 and 2020. The CDC analysis used slightly different numbers from the Commonwealth Fund. (Arkansas had the highest, with more than 40 deaths per 100,000 births.) 

By contrast, states with more permissive laws on abortion had much lower rates: Illinois, for example, recorded fewer than 13 maternal deaths per 100,000, and California had 10.

Some research suggests a connection between the denial of abortion services and maternal health.

One well-known national 2020 study by the University of California-San Francisco found that women who were denied requested abortions were more likely to die or experience serious complications, such as eclampsia, after their pregnancies. They also were more likely to experience poor physical health for years after the pregnancy, including chronic pain and gestational hypertension. And they were more likely to stay with abusive partners and suffer anxiety and loss of self-esteem in the short term.

The National Right to Life Committee argues that the University of California study is not credible, because “these researchers and their institution have a vested interest, a clear and definite agenda, and it affects the research they choose to do and how they do it,” Randall K. O’Bannon, the committee’s director of education and research, wrote in an email to Stateline.

Policies to Reduce Mortality

Amelia Cobb, who works in health equity for the California Health Care Foundation, said another concern is the continued closure of health clinics, such as Planned Parenthood, that provide comprehensive maternal health services, which has already occurred in states that targeted clinics providing abortion services.

Already, according to the organization Power To Decide, which helps guide people to available birth control, more than 19 million women who are of reproductive age and have low incomes, and who need publicly funded birth control, live in areas without easy access to health centers offering comprehensive reproductive health services.

With further abortion restrictions, the situation will get worse, especially for lower-income women and women of color, Cobb said. 

Maternal health experts say that aside from allowing abortions, states can take further actions to reduce maternal mortality and morbidity. 

Expanding Medicaid eligibility to lower-income women under the Affordable Care Act, they say, is one of the most effective measures. Of the 12 states that have not yet expanded Medicaid, the nine that reported maternal mortality deaths to the CDC all recorded more than 20 deaths per 100,000 births. With the exception of North Carolina, all also have relatively restrictive abortion laws.

Another policy change maternal health advocates have pushed for is extending postpartum Medicaid benefits from the minimum two months to 12 months as many states have done. But other states with high maternal death rates and restrictive abortion laws, such as Missouri, Oklahoma and Texas, have not.

Many states, predominately but not exclusively Democratic-leaning states, also have extended Medicaid benefits to cover the services of doulas, who provide emotional, physical and educational support to women during and after pregnancy.

To reduce racial disparities in maternal health outcomes, a handful of states—California, Maryland, Minnesota and Michigan—have adopted requirements for implicit bias training, at least for those who work in perinatal care. The CDC recorded fewer than 20 maternal deaths per 100,000 for California, Maryland and Michigan. Minnesota, citing confidentiality, didn’t report results.

Stateline, an initiative of The Pew Charitable Trusts.