Longer travel time, more requests for pills

Following the Supreme Court’s decision to overturn the federal right to abortion, the practice is now banned in 13 states and restricted in Arizona, Florida and Georgia.
More than a dozen studies, reports and editorials published Tuesday in JAMA investigate the effects of that decision and highlight the many ways in which state-level changes are jeopardizing pregnant people’s health.
The findings, a compilation from a total of around 60 researchers and doctors, come a week before the midterm elections, when abortion rights are expected to be a motivating issue for many voters.
One of the newly published studies showed that it took people 100 minutes, on average, to travel to abortion facilities in September, compared to an average of 30 minutes before the Dobbs decision. The share of women of reproductive age who lived more than an hour away from an abortion facility rose from 15% to 33%.
Another study found that unintended pregnancies — which are expected to rise — put mothers at increased risk of depression and interpersonal violence. Infants born as a result of an unintended pregnancy, meanwhile, face a higher risk of low birth weight or preterm birth.
The risks are particularly stark for young adolescents, according to the research. A third study found that pregnant adolescents ages 10 to 13 had a significantly higher risk of preterm delivery and C-section compared with older teens. Around 19% of 10- to 13-year-olds in the study delivered preterm compared with 12% of 14- to 17-year-olds.
As abortion clinics have become harder to reach, a fourth study revealed that Aid Access — a physician-run telehealth service based in Europe that provides abortion pills through the mail — saw a surge in requests for self-managed abortions after the Dobbs decision. The service received around 214 daily requests from June to August, compared to 83 from September 2021 to May 2022.
“It becomes an issue of who is stopped from accessing this care and who isn’t? It is always going to be the most privileged in our society who are still going to be able to access an abortion,” said Asha Hassan, the author of one of the new editorials and a scholar at the National Birth Equity Collaborative.
Hassan’s article suggests that some Black pregnant people can have an especially hard time seeking abortion services, since they’re less likely to have paid time off, access to a car or stable child care.
Even after pregnancy, Hassan’s past research has shown, Black and brown people are disproportionately prosecuted for pregnancy loss. Other research has shown the same for self-managed abortions.
What’s more, Hassan added, Black, brown and Indigenous people are disproportionately likely to need a surgical abortion, since they have higher rates of chronic diseases, which are in turn made more likely by structural racism.
These patients face a higher risk of ending up in emergency situations and experiencing delayed care, according to Dr. Deepshikha Charan Ashana, the author of another newly published editorial.
“If we wait until people develop critical illness, that is a tacit acknowledgment that it’s OK for some people to die,” said Ashana, an assistant professor of medicine at Duke University.
“Survival is not the only goal here,” she added. “We know that those survivors of critical illness experience tremendous physical and psychological disability.”
Ashana’s article asserts that every hour of delayed care increases a patient’s risk of adverse outcomes or death. But in some cases, abortion restrictions require waiting until a person is hemorrhaging or develops sepsis before performing a lifesaving abortion.
“This is the new, despicable normal,” said Dr. Linda Brubaker, a clinical professor of obstetrics and gynecology at The University of California San Diego who wrote an editorial summary of JAMA’s special issue. “It’s really going to lead to story after story of heartbreaking maternal and child loss.”
Ashana said researchers haven’t yet determined how many pregnancy-related deaths have occurred post-Dobbs, since the decision was so recent. But it was previously understood that around two-thirds of pregnancy-related deaths are preventable.
Medical experts anticipate a rise in maternal deaths as a result of abortion bans. A 2021 study estimated that if the U.S. banned abortion everywhere, pregnancy-related deaths might rise 7% in the first year. That number would be even higher for Black people: 12%.
Although researchers are still examining the ripple effects of the Dobbs decision, it’s already clear that the number of abortions provided by clinicians has decreased. A report published Friday by the Society of Family Planning showed a 6% drop in August compared to April, before the Supreme Court’s ruling.
But that doesn’t count people who’ve obtained abortion pills from services like Aid Access. Hassan said medication abortion presents “a lot of opportunity to be able to expand into places that are geographically difficult for people to access abortion.”
Ashana, meanwhile, hopes that doctors who are worried about the legal repercussions of performing abortions will help patients find facilities where they can still get that care. Perhaps, her editorial suggests, health care providers could even cover the costs of transporting patients across state lines.
“There are a lot of things within the health care system environment that could change, including the way we think about where abortion care can be accessed,” Hassan said.