WASHINGTON -- Dr. Judette Louis recalls a time when she treated a patient who was hemorrhaging from her pregnancy - and how she had to wait to obtain permission before she was allowed to terminate the pregnancy for the health of the mother.
"I was standing there watching her hemorrhage out, waiting for permission to do the termination. It is a disgusting feeling. It is a sad feeling. And you're sitting there literally watching her blood pressure going down while you're waiting for permission," the Chair of Obstetrics and Gynecology at the University of South Florida told CNN. "It's just sad to now know ... that that will be happening all over across the country where [terminating a pregnancy] won't even be a possibility for a lot of states."
Dr. Louis and other health care experts fear that with Roe v. Wade overturned, potential widespread abortion bans will deepen the United States' maternal mortality crisis. Health care experts told CNN they worry that reducing access to abortion - by closing clinics, setting early gestational limits or outlawing the procedure altogether - may lead to more pregnancy-related deaths in the United States.
Rates of pregnancy-related deaths in the US are the highest in the developed world and have risen steadily over time, with Black women three times more likely to die in pregnancy or childbirth than White women. The CDC recently reported that the rate of pregnancy-related deaths increased from 20.1 in 2019 to 23.8 in 2020, continuing a worrying trend of worsening maternal health outcomes for people in the United States.
Now that the Supreme Court has overturned Roe v. Wade, 26 states are poised to ban abortion through pre-existing bans or "trigger laws" that will now go into effect without the landmark ruling is no longer in place. As a result, more than 10 million people of reproductive age would have to cross state lines to access the procedure in the nearest state where it is legal, according to the Guttmacher Institute, a research and policy institute that supports legal abortion rights.
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"[People] may seek unsafe ways of terminating a pregnancy and could have harmful consequences," said Whitney Rice, the director of the Center for Reproductive Health Research in the Southeast at Emory University. "You also have people who may sort of be forced to continue pregnancies to term and could have a risk of infant health outcomes that include low birth weight, preterm birth, or may have a risk of maternal mortality."
Maternal mortality rates are already high in those states certain or likely to ban abortion - 47% higher than the national rate, according to a CNN analysis of 2018 data from the Centers for Disease Control and Prevention, the most recent available.
Overall, states with the most restrictive abortion laws had a 7% higher maternal mortality rate than states with fewer restrictions, according to a 2021 study in the American Journal of Public Health.
States that restricted abortion based on gestational limits saw a steep rise in the maternal mortality rate by 38%, according to a 2020 study in the American Journal of Preventive Medicine. A 20% reduction in Planned Parenthood clinics in a state between 2007-2015 resulted, on average, in an increase in the state's maternal mortality rates by 8%.
Black people are three times more likely to die of pregnancy-related causes than non-Hispanic White and Hispanic people, according to the CDC. With reduced access to abortion and other forms of reproductive healthcare, experts worry that these rates could rise in a post-Roe landscape.
These disparities are rooted in decades of structural disadvantages and well-documented discrimination in medical care, leading to persisting gaps across socioeconomic and educational levels.
"[Marginalized groups] really face barriers in every sense of the way," said Dr. Louis. "They face barriers in terms of getting care in a timely fashion, barriers in being able to see a health care provider, and then barriers to getting the appropriate treatment. And that's even if they're offered appropriate treatment."
Access to maternal care is also worse in the 26 states that the Guttmacher Institute expects will be certain or likely to ban abortion. More than half of all counties in these states are classified as having low access to maternal care or are maternity-care deserts, according to a CNN analysis of data from the March of Dimes, compared to 39% of counties in states that are not likely to ban abortion if Roe is overturned.
Nationwide, approximately 5.1 million women aged 15-44 live in areas with low access to maternal care - or "maternity care deserts," according to a 2020 report from the March of Dimes, a nonprofit that advocates for better health care outcomes for mothers and babies. The organization defines a maternity care desert as any county where there is no hospital offering obstetric care, no birth center and no obstetric provider. In these counties, people carrying a pregnancy to term may face significant barriers in receiving quality care for both the parent and child. The 2020 average annual median household income for these counties was $49,518, below the national median household income of $67,521.
"Those sorts of structural environments tend to go hand in hand," Rice said. "States with highly restrictive abortion environments also generally have fewer policies supporting health and well being of pregnant people, as well as their children and their families."
Negative health outcomes from receiving a legal abortion are rare - according to the CDC, the national death rate from 2013-2018 was 0.41 deaths per 100,000 abortions. In 2018, the CDC identified only two patients who died as a result of a legal abortion. The rate of abortion-related fatalities has remained stable over the past several decades, even as maternal mortality rates have crept upwards.
But people who seek to terminate their pregnancies and are unable to do so are more likely to face negative health outcomes, according to the Turnaway Study, a multi-year endeavor based at the University of California-San Francisco that tracked the health of people who were - and were not - able to receive a wanted abortion. The study found that women who were denied an abortion and gave birth reported more life-threatening conditions like eclampsia and postpartum hemorrhaging, in addition to higher levels of chronic conditions such as migraines and persistent joint pain, than women who were able to access the abortion. Two of the women in the study who were denied an abortion died from complications related to their pregnancy. Lauren Ralph, an epidemiologist who worked on the study at the University of California-San Francisco, described the deaths as "sobering."
"I think we can say with certainty that those deaths could have been avoided had these people had access to the abortion care that they had sought," Ralph added.
With Roe v. Wade overturned, Ralph and other experts have warned that the maternal mortality rate will likely continue to rise in the United States if pregnant people are unable to access the care they need.
"It's a wake up call that we should stop being so complacent and that we need to look at more proactive strategies," said Dr. Louis of the medical community's role in providing safe access to abortion.
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