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Medical News & Perspectives

How Caring for Patients Could Change in a Post–Roe v Wade US

Rita Rubin, MA; Jennifer Abbasi; Melissa Suran, PhD, MSJ

T
he driving distance between Dallas or
Houston and Baltimore, Maryland, is
roughly 1400 miles. And yet, since
Texas’ Senate Bill 8 (SB 8) banned abortion
of fetuses with a detectable heartbeat last
September, a couple of individuals each
week, on average, travel from that state to
one of Planned Parenthood of Maryland’s 7
clinics for an abortion.
Kyle Bukowski, MD, medical director of
Planned Parenthood of Maryland—1 of 16
states and the District of Columbia that have
laws protecting the right to abortion—is
preparing for a substantial increase in the
number of people seeking abortion care in
his state.
A recently leaked draft opinion from
Justice Samuel Alito suggests that the US
Supreme Court will soon overturn Roe v
Wade, the 1973 ruling that legalized abor-
tion nationwide, leaving the decision about
whether to keep abortion legal up to each
individual state. The final ruling in Dobbs v
Jackson Women’s Health Organization is
expected in late June or early July.
In an analysis last updated April 22,
2022, the Guttmacher Institute, a research
and policy organization, reported that a
total of 26 states are certain or likely to
ban abortion if Roe is overturned: 9 states
have a pre-Roe abortion ban still on the
books, 13 have a “trigger ban” that will go
into effect if Roe is overturned, and 4 have
constitutions that specifically ban a right
to abortion.
The ripple effects for both patients and
physicians are expected to be far-reaching.
“Abortion has been in the background,
available for most practicing doctors for
almost 50 years in this country,” Lisa Harris,
MD, professor and associate chair of
obstetrics and gynecology at the University
of Michigan and professor of women’s and
gender studies, said in an interview with
JAMA. “If it’s not anymore, it’s going to
change the way that we provide all kinds
of care.”
provide 2 very different types of services:
calm reassurance after unsupervised medi-
cation abortions—which evidence suggests
are safe and effective—and critical lifesav-
ing treatment after unsafe abortions.
Then there are the effects of poten-
tially tens of thousands of additional births
each year.
“There will be increased deaths,”
Daniel Grossman, MD, a professor of ob-
stetrics and gynecology at the University
of California San Francisco, said in an inter-
view. Most of the increase in maternal
mortality, Grossman said, will result from
the increased numbers of additional preg-
nancies carried to term. Although some
deaths related to unsafe abortions may
occur, safe and effective medication abor-
tion, which has been available since 2000,
may result in fewer of these deaths than
during the pre-Roe era.
In states like Michigan, where a 1931 law
still on the books allows abortion only to pre-
serve the life of the pregnant person, Harris
noted that neonatal intensive care unit cli-
nicians, pediatric surgeons, pediatricians,
and family physicians should prepare for the
care of infants and children with significant
medical and surgical needs whose families
may have decided to end the pregnancy if it
was legal to do so, often to spare a future
child from what may be a short or painful life
full of medical interventions. Michigan’s law
makes no exceptions for families that learn
their future infants have serious illnesses or
anomalies, even ones that are incompat-
ible with life. Unless Michigan’s Supreme
Court or a ballot initiative decides that abor-
tion is protected under the state’s constitu-
tion, Harris said, “those babies may be born
and will need critical care.”
Physicians who provide abortion care
in such states may have to weigh difficult
new considerations: how much risk to the
birthing person is enough to legally justify
terminating a pregnancy, and how immedi-
ate must the risk be? Although the answer
sometimes will be straightforward—in cases
of severe, life-threatening preeclampsia, for
example—“those are not the majority of
cases,” Harris said.
In more common scenarios, a pregnant
person with cardiac disease perhaps might
have an increased risk of dying or a patient
diagnosed with cancer during pregnancy
might need immediate chemotherapy to
prevent disease progression and death
down the line. Physicians typically termi-
nate pregnancies in these situations, Harris
said, but they could face legal sanctions

Preparing for Potential Challenges

Emergency physicians and primary care phy-
Pablo Martinez Monsivais/AP Images
sicians, Harris said, should be prepared to

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for doing so in the future. Some of these
patients will have to travel to other states
to get an abortion, whereas others will con-
tinue the pregnancy and may experience
the health consequences.
Harris also warned that mental health
professionals will need to prepare for more
individuals carrying unwanted pregnancies,
including those resulting from sexual
assault, and that maternity care profession-
als should be ready to adopt a trauma-
informed approach for these patients.
Meanwhile, clinics in states where abor-
tion remains legal will be asked to meet in-
creased demand from out of state. “We’ve
recognized that we need to respond to this
moment,” Bukowski said in an interview.
Sean Mehl, associate director of clini-
cal services at Whole Woman’s Health
(WWH)—an organization that provides
abortion care and was the lead plaintiff in
abortion cases reviewed by the Supreme
Court in 2016 and 2021—said that the group
is working to ensure that patients receive the
care they need, even if that means getting
them to other states.
“In many cases, it means working with
both state and national organizations that
can help with funding and travel logistics
in order to get patients seen elsewhere,
including our Minnesota clinic,” Mehl said
in an interview. WWH recently launched
the Abortion Wayfinder Program to assist
people with logistics and finances if they
need to travel for abortion care.
Going to Greater Lengths
Approximately 862 000 abortions occurred
in 2017, the most recent year for which data
are available from the Guttmacher Institute.
The expected Supreme Court ruling
would leave behind a patchwork of states
where individuals who want an abortion os-
tensibly could travel to have one. But re-
search by Middlebury College economist
Caitlin Myers, PhD, suggests that many
people seeking abortions out of state won’t
be able to get them.
In a 2019 study published in Contracep-
tion, modeling by Myers and colleagues sug-
gested that increased distances to abortion
facilities could prevent an estimated 93 546
to 143 561 people per year from reaching one
if the Court overturned Roe. Some of these
people may “self-manage” an abortion with
medication abortion or unsafe means, while
many of the individuals likely will give birth,
according to Myers.
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“That’s a lot more maternity care re-
sources and infrastructure that are needed,”
Harris said. “All birthing people will feel it
when labor and delivery units are full and
overflowing.”
Myers, who wrote an amicus brief
signed by 154 economists and researchers in
support of the respondents in Dobbs v
Jackson Women’s Health Organization,
noted that better access to mail-order medi-
cation abortion could reduce the estimated
number of births. “That’s a big question
mark,” she said.
Her modeling study, however, didn’t ac-
count for longer appointment wait times due
to increased demand in states where abor-
tion remains legal.
For example, by March 2022, about 6
months after SB 8 went into effect in Texas,
wait times for abortions in 8 bordering and
nearby states were commonly 2 or 3 weeks,
according to research by Myers’ team and the
Texas Policy Evaluation Project at The Uni-
versity of Texas at Austin published in con-
junction with the website FiveThirtyEight.
“[T]hey already can’t absorb that,”
Myers said of the 8 states. “When clinics in
Oklahoma were called, not a single one could
offer any appointment at all.” That was be-
fore May 3, when Oklahoma Governor Kevin
Stitt signed the Texas-style Senate Bill 1503,
which immediately banned abortions once
a fetal heartbeat can be detected.
At Planned Parenthood of Maryland, the
preparations for additional patients include
making sure that clinic waiting rooms are
child-friendly—most people seeking an abor-
tion already have children, Bukowski noted—
and that clinics are set up to accept cash pay-
ments. Some patients don’t have a credit
card or checking account or, if they do, pre-
fer not to use them.
One way to accommodate the ex-
pected influx of patients from states that ban
abortion to those that allow abortion care is
by training additional types of clinicians to
provide the care.
Eighteen states and the District of
Columbia allow some or all advanced prac-
tice clinicians—nurse practitioners, certified
nurse midwives and certified midwives, phy-
sician assistants—to independently provide
medication or surgical abortion care or both,
according to the Abortion Provider Toolkit,
a resource for advanced practice clinicians.
Some other states may allow them to pro-
vide abortion care under the oversight of
a physician, according to the Toolkit.
(Reprinted) JAMA June 7, 2022 Volume 327, Number 21
News & Analysis
Maryland Governor Larry Hogan, a Re-
publican, had vetoed House Bill (HB) 937,
which authorizes abortions by these other
health professionals, saying it would endan-
ger lives, but the state legislature’s Demo-
cratic super majority overrode him. The law
becomes effective July 1. However, Hogan
has refused Democrats’ request to release
early $3.5 million in funds for training ad-
vanced practice clinicians in abortion care.
The funding isn’t required until fiscal year
2023, which begins July 1, 2023.
Even so, Planned Parenthood of
Maryland this year started training its nurse
practitioners to provide procedural abor-
tions, Bukowski said. As a result of a January
2020 opinion by Maryland Attorney Gen-
eral Brian Frosh, they already are able pro-
vide medication abortions.
Medication Abortion Steps In
Many observers expect that an increasing
number of people will turn to medication to
manage an abortion in a post-Roe US. The
most common regimen is a combination of
the drugs mifepristone and misoprostol.
In 2019, the most recent year for which
the Centers for Disease Control and Preven-
tion (CDC) has information, 43.7% of all US
abortions were performed with medica-
tion. Preliminary data from the Guttmacher
Institute’s census of US health care facilities
that provide abortion care show that in
2020, medication abortion for the first time
represented the majority of pregnancy ter-
minations. Based on information from 75%
of US abortion clinics, medication abortion
accounted for 54% of US abortions in 2020,
Guttmacher found.
While abortion medication “can miti-
gate some of the harm” caused by overturn-
ing Roe, Grossman said, “pills are not a solu-
tion” for every person seeking to terminate
a pregnancy.
One reason: the US Food and Drug Ad-
ministration(FDA)hasapprovedmifepristone
for use only through 10 weeks’ gestation. Past
that point, medication abortions are more
likely to be incomplete, necessitating a sur-
gical abortion, Grossman said.
Plus, as the Kaiser Family Foundation
pointed out in April, medication abortion “is
subject to many of the same restrictions as
other abortion methods, at both the state
and federal levels.”
The FDA only this past December per-
manently removed the requirement that
people seeking a medication abortion
2061
 News & Analysis
obtain mifepristone in person at a clinic,
medical office, or hospital. The change gave
rise to several US-based websites that use
telemedicine to connect patients with pre-
scribers. Clinicians ask clients about their
last menstrual period to confirm that they
are early enough in their pregnancy to ter-
minate it with medication, and, if so, pre-
scribe the pills, which are then shipped
from US mail-order pharmacies.
However, 19 states still require clini-
cians who provide medication abortion to
be physically present when the drugs are
administered, according to the Guttmacher
Institute, thus prohibiting the telemed-
icine companies from serving people who
live in those states. Even in states that
allow medical abortions via telemedicine,
the lack of an internet connection, a credit
card, or a reliable mailing address might
prevent some people from accessing them,
Harris noted.
Since its launch in 2018, Aid Access
has shipped mifepristone and misoprostol
to tens of thousands of people in the US, re-
gardless of their address, for self-managed
abortions. Clients fill out an online consul-
tation form; if there are no contraindica-
tions and the patient reports a gestation
of 10 weeks or less, a clinician prescribes
the drugs, which are mailed from a phar-
macy in India.
Aid Access, founded by a physician in
Amsterdam, has no plans to stop shipping
abortion medication to the US should
the Supreme Court overturn Roe, according
to its website.
The organization has continued to
send pills to women in Texas, even though
that state’s law—and now Oklahoma’s,
too—authorizes private citizens to sue any-
one involved in facilitating abortions after 6
weeks’ gestation. In fact, the demand in
Texas for pills from Aid Access increased
substantially after SB 8 went into effect,
according to a recent study published in
JAMA Network Open.
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People at a Disadvantage
A 2021 study published in Demography
estimated that a total abortion ban in the
US—something Senate Majority Leader
Mitch McConnell recently said isn’t off the
table—would result in a nearly 21% increase
in estimated annual pregnancy-related
deaths, from 675 to 815 deaths, in subse-
quent years. But those extra deaths would
not be distributed equally. The study pro-
jected that an estimated additional 78 non-
Hispanic Black pregnant people would die
annually in this scenario—an approximate
33% increase, the highest among all racial
and ethnic groups.
The study also illustrated what experts
say are the realities of restricting abortion ac-
cess: people from historically marginalized
communities will be among those most
affected by denial of abortion care.
“Taking away the basic right to decide if,
when, and how to be pregnant is asking
pregnant people to take on medical risks,”
Liza Fuentes, DrPH, MPH, a senior research
scientist at the Guttmacher Institute, said in
an interview. “And for Black women, that de-
nial is more likely to be to be deadly.”
The Pew Research Center reports that
more than half of the US Black population
lives in the South—where most states
would enact trigger laws if Roe v Wade is
overturned. Even now, according to the
most recent CDC report on disparities in
pregnancy-related death, compared with
White women, Black women are 3.2 times
more likely to die from a pregnancy-related
cause, with absolute death rates of 12.7 vs
40.8 per 100 000 live births, respectively.
American Indian and Alaska Native women
have a death rate of 29.7 per 100 000 live
births, a 2.3 times greater risk of death than
White women.
“Abortion restrictions are racist and clas-
sist at their core,” Bukowski said.
He pointed out that the US has the
highest maternal mortality rate compared
with 10 other high-income countries. Many
states that could pass abortion trigger laws
have some of the highest poverty rates in
the country.
Bhavik Kumar, MD, MPH, a staff physi-
cian at the Planned Parenthood Center for
Choice in Houston, Texas, said he’s already
witnessed a “post-Roe world” since SB 8
passed. Further restricting abortions will dis-
proportionately affect Hispanic individu-
als, especially those who are undocu-
mented and live near the US-Mexico border,
he said.
When he worked at a clinic that pro-
vides abortions in the Rio Grande Valley,
Kumar said, patients often told him they
went to Mexico and obtained medication
he’d never heard of to terminate their preg-
nancy. If Roe is overturned, “I think we’ll con-
tinue to see that,” he said.
With more babies being born, espe-
cially in underserved communities, the de-
mands on society will increase. It’s not clear
how those needs will be met in “a country
that doesn’t have robust safety nets for
people,” Harris said, like paid family and ma-
ternity leave and child care including spe-
cialized care for children with disabilities.
Kumar urged physicians to prepare:
“This is not a drill. It is not hyperbole to say
that Roe is likely to be overturned—the writ-
ing is on the wall.”
Published Online: May 18, 2022.
doi:10.1001/jama.2022.8526
Conflict of Interest Disclosures: Dr Fuentes
reporting receiving honoraria from the Society of
Family Planning to mentor fellows and review grant
applications. Dr Harris reported receiving honoraria
for speaking on abortion care and works with the
Planned Parenthood Federation of America and the
Society of Family Planning without direct
compensation. Dr Kumar reported that he is a
national medical spokesperson for Planned
Parenthood Federation of America and an advocacy
campaign consultant for The People’s Lawsuit. Dr
Myers reported having served as an expert witness
and consultant for the Center for Reproductive
Rights and Planned Parenthood Federation of
America. No other disclosures were reported.
Note: Source references are available through
embedded hyperlinks in the article text online.
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