Does Maryland expect to see an influx of out-of-state patients seeking an abortion and how is the state preparing to intake them? Does the University intend to advocate for the training of abortion providers? How does overturning Roe v. Wade affect in-vitro fertilization, medication abortion, and access to contraception?
These are just three of dozens of questions posed by the virtual audience of Virtual Face to Face with President Bruce Jarrell. The host, University of Maryland, Baltimore (UMB) President Bruce E. Jarrell, MD, FACS, enlisted the expertise of four faculty members to help explain the impact that the Supreme Court’s recent ruling that overturned the landmark Roe v. Wade decision, returning control of abortion rights back to state legislatures after 49 years, will have on women's health.
Existing laws and so-called “trigger laws” made abortion illegal in seven states almost immediately. That number will jump to 16 soon, although legal challenges might slow things down a bit. Six more states will implement laws that impose restrictions, banning abortion in some cases after just six weeks of pregnancy. And a handful of others are already becoming battlegrounds for state legislatures, including Michigan and Pennsylvania. All told, in the near future, 26 of the 50 states may impose strong restrictions or outright bans on abortion.
Of course, we can’t know the full impact yet, but there’s plenty of evidence that the impact is going to be widespread and manifold and will disproportionately affect women of color — Black women in particular who already often suffer from an array of issues stemming from long-term, structural racism, such as poorer health conditions, lower incomes, and a lack of health insurance and access to good health care, including prenatal health care.
The Centers for Disease Control and Prevention says Black women are four times as likely to seek an abortion as white women, and Black people are a larger part of the population of most of the states that have banned or are set to ban abortions. The Kaiser Family Foundation points out that in Mississippi, for example, Black residents make up 38 percent of the population, compared with 13 percent of the national population. As a result, Black women account for about three-quarters of the abortions in that state.
Many of the states moving to ban abortion also have the fewest social services available for mothers in poverty. The Census Bureau says Texas has the largest percentage of women who receive no prenatal care in their first trimester and Mississippi has the highest percentage of children living in poverty and lowest birthweights.
“Jessica, if you are a practicing OB [obstetrician] in a state like Mississippi, which has banned abortion, what are the one or two medical situations that would pose a high risk to the pregnant woman that you might encounter?” Jarrell asked panelist Jessica Lee, MD, assistant professor, the University of Maryland School of Medicine, and director of the Ryan Residency Program in Abortion and Family Planning. “And how would you deal with that situation today in Mississippi as opposed to two weeks ago? Give us some insight into your medical thinking.”
Lee explained that several life-threatening conditions might occur that would cause a physician and patient to consider abortion to protect the health of a pregnant woman.
“Another common condition that can affect patients early in pregnancy is preeclampsia, which is a blood pressure disorder of pregnancy,” Lee explained. “The cure for that is also removal of the pregnancy or delivery of that pregnancy. And I’ve seen patients even here in Maryland who developed the life-threatening version of preeclampsia, in which they actually lose their ability even to clot their blood. And at that point, we definitely recommend delivery or termination to save their life.”
“I would see my colleagues being faced with a very difficult decision on when they can intervene,” she added. “I know my colleagues are struggling with worrying about being sued or being prosecuted if they intervene too early. Did they not show that the maternal health was at risk enough to perform this abortion? I see it becoming very sticky to uphold our duty to take care of our patients if we’re worried about the law hanging over our heads.”
Accessing an abortion for most reasons — depending on each state’s law — may soon become a practical impossibility for millions of disadvantaged women. A recent study by Middlebury College found that if all the states expected to ban abortion do so, about one-fourth of all American women of reproductive age would live at least 200 miles from a legal clinic, imposing possibly insurmountable obstacles, such as cost, access to transportation and child care, and the need to take time away from work. What’s more, just being able to get to a clinic doesn’t guarantee you can get an appointment, because demand in adjoining states where clinics can legally operate is expected to grow.
The University of California, San Francisco’s Turnaway Study followed more than a thousand women across the country who were denied abortions, mostly because they sought care beyond their facility’s gestational limit. The study found the women were less able to pay basic living expenses, more likely to experience bankruptcies and evictions, and more likely to stay with a violent partner. They also experienced more mental health issues, often impairing maternal bonding.
The challenges are particularly prevalent in inner cities and other disadvantaged communities and often lead to higher infant mortality rates. Baltimore’s Upton/Druid Heights community, one of its least wealthy and almost entirely Black, experienced those challenges and along with them an infant mortality rate comparable to many impoverished developing countries. But after 12 years of investment in outreach, education, and services for expectant mothers, UMB’s Promise Heights-led B’more for Healthy Babies program helped reduce the infant mortality rate by 75 percent, making it one of the healthiest for babies in the city.
“I had the great pleasure of presenting the B’more for Healthy Babies results in West Baltimore with the mayor about a year ago. And they were fabulous results, showing that infant mortality can really be influenced by an extensive program of building trust and a network and a number of other things,” Jarrell said, turning to Stacey Stephens, LCSW-C, director of B’more for Healthy Babies. “So, what would you tell us about your success in Baltimore, but then extend that to a disadvantaged community, say in Mississippi or Kentucky, where they banned abortion? What do you predict will happen for these young mothers who want to carry their baby to term or for those who want to terminate their pregnancy?”
“It takes a concentrated effort at looking at all levels of systems for women and applying a life course perspective,” Stephens explained. ”We’re really fortunate here in Maryland to have adequate funding to support women through medical assistance, expansion of medical assistance, options, Title X funding, to make sure that folks have access to fantastic family planning. But what I’m saying is that it takes this concentrated collective impact model across systems over a period of time that includes not just the medical providers, it includes community health workers, it includes doulas, it includes public health workers, everyone who’s on the call, pharmacists and what have you, in supporting that woman in making the decisions about her health care options.”
Even with strong abortion rights laws, accessing reproductive health care in Maryland can be problematic, offered Nadine Finigan-Carr, PhD, MS, research associate professor and director of the Prevention of Adolescent Risks Initiative at the University of Maryland School of Social Work. “In our state, even with good access — and ‘good’ being in air quotes — I’m also concerned because we have less than half of the clinics that offer contraception as well as abortion in our state than we had in 1982. In 1982, we had 52 clinics across the state that offered broad-spectrum contraception and abortion, and we're down to 25. Sixty-seven percent of our counties in Maryland don’t have an abortion clinic. So even though we have good laws, we don't have good access as it is,” she said.
One area of health care access that has improved in Maryland, the panel agreed, is a new law taking effect July 1 that allows nurse practitioners, nurse midwives, and trained physician assistants to perform abortions. The law also requires most insurance providers to cover the cost.
Maryland pharmacists also are empowered to prescribe contraceptives under collaborative practice agreements with physicians.
“As the most accessible of health care providers, we can really be at the center of this fight for reproductive justice,” said Danya Qato, PhD, PharmD, MPH, assistant professor and director of the Pharmaceutical Health Services Research Graduate Program at the University of Maryland School of Pharmacy. “In previous surveys, one-third of U.S. adults reported trouble accessing contraception, and these rates are even higher among Black women and other women of color. To help enhance access, in 2017, the state of Maryland passed legislation that broadens the scope of pharmacist practice to include hormonal contraceptive prescribing, thus broadening access to contraceptive therapy.”
Qato also expressed concern that abortion bans in some states may be used to limit or prohibit medication abortion, in vitro fertilization, and certain contraceptives. “We know this now that medical legal experts are very worried and anticipate that states, counties, or even individual prosecutors who want to ban Plan B, also known colloquially as the morning-after pill, may now believe they have this tailwind of support from the Supreme Court and may begin prosecuting that,” Qato said.
To watch the entire discussion, including the question-and-answer period with the audience, access the link to the video at the top of this page.