An Update on the Consequences of Overturning Roe v. Wade

A year ago, I published “The Mental Health Consequences of Overturning Roe v. Wade." The post summarized the findings of the Turnaway Study, which examined the differences between women with unwanted pregnancies who had access to an abortion versus those who did not. The findings were clear: Abortion denial led to worse financial, health, and family outcomes. It not only affected the women themselves but also had significant impacts on their existing children.

Since the Supreme Court decision that overturned Roe v. Wade, a 50-year-old precedent, there have been significant changes. The decision to grant women access to reproductive health care, including abortion, has moved to a state-by-state jurisdiction. Some states, such as Alabama, have banned abortion outright, while several other mostly Southern states have dramatically limited abortion access and only allow it within the first six weeks of pregnancy, a time when many women may not even realize they are pregnant.

Research studies show that women who conceive unintentionally are more likely to have worse self-care, such as smoking cigarettes and abusing alcohol and illicit drugs. They are also less likely to engage in adequate pregnancy care, such as taking vitamins and attending prenatal care appointments.

According to a recent article in Nature, surveys now indicate that people who experience pregnancy complications in states where access to abortion is most restrictive have been placed in life-threatening situations because their physicians cannot properly treat them.

An article published in JAMA examined whether the SCOTUS decision was associated with mental distress among women of reproductive age, and how this association varied by barriers to accessing reproductive health care. It found that women residing in states restricting abortion rights experienced a higher prevalence of mental distress after the ruling. Additionally, there was an interaction between changes in access to legal abortion and mental distress.

Access to Care

In my previous post, I wrote, “Women who can travel and have financial means will be able to access abortions in states that allow abortion.” I wondered, however, what would happen to women without financial means or those who must travel a great distance to a state where abortion remains legal.

Although Justice Brett Kavanaugh assured us “Women in abortion-banning states would be free to travel elsewhere to obtain the procedure,” as of September 2023, only 12 states still have expanded access to abortion. Compare that to 25 in which abortion is either viewed in a hostile manner or is illegal. Most of those states are in the South, or the Dakotas. Guess where women who most need abortion reside?

According to Changing America, three-fourths of women who receive an abortion are considered poor or low-income, and they tend to live in states with the most restrictive abortion limits, or no access to care. A 2014 policy statement by the Guttmacher Institute predicted that, given that 75 percent of abortion patients were poor or low-income, “any additional barriers to abortion care—including travel and its associated costs, such as lost wages and expenses for childcare, transportation, and accommodations—may be significant for many women.”

Alabama began enforcing a total ban on abortion after Roe was overturned. One bordering state is Florida, which has its own restrictive ban, but guess what? Alabama’s Attorney General believes that “under state law, helping women travel to other states to obtain abortions could amount to a criminal conspiracy.” He believes such an act is equivalent to traveling out of state to obtain illegal drugs.

Middle-Aged Women

The abortion debate generally concerns younger women of childbearing age. But what about middle-aged women who can still conceive and find themselves with an unwanted pregnancy?

A 1995 survey revealed that 51 percent of pregnancies among women 40 and older are unintended. As we age, women are more likely to suffer from chronic health conditions. Many women in their 40s become pregnant because they incorrectly believe reduced fertility means they no longer need contraception. With little attention to midlife sexual health, contraceptive needs may go unaddressed, and unintended pregnancies will be more likely to occur and more likely to require ongoing medical care, especially because chronic health conditions raise the risk for pregnancy complications. A health-care workforce untrained in managing pregnancy and/or abortion complications may contribute to the health risks of women in midlife.

Pregnancy Essential Reads

What to Do When You Can’t Sleep When the Baby Sleeps

New Study Finds Sex Differences in Fetal Brain Development

Lack of Trained Providers

The overturn of Roe is influencing how medical students choose their specialty. Even those who choose OB-GYN are more likely to apply for training in states without abortion bans. An analysis of yearly resident applicant data from the Association of American Medical Colleges found a 7 percent drop in students who applied to OB-GYN residency programs. This was most significant in residency programs in states with the most restrictive abortion policies. Again, what does this mean for women who most need the procedure? There will be fewer providers trained in the states where demand is the greatest, but access is hardest to come by. In Texas alone, applications for residency training dropped by 20 percent between 2022 and 2023.

Implications for Psychiatric Care and Training

The Dobbs decision will likely lead to increased demand for psychiatric care both during and after pregnancy. Unwanted pregnancy is a risk factor for depression and anxiety in addition to postpartum depression. The U.S. mental health system is in crisis, unable to meet the existing demand for psychiatric care. Most psychiatrists and allied mental health professionals have limited training in managing mental health disorders during and after pregnancy. The number of reproductive psychiatry fellowships is growing but is still limited. Given the mental health workforce shortage and potential increase in demand for mental health providers since Dobbs, there will potentially remain inadequate access to mental health care. Filling the gap will increasingly fall on obstetrical, family medicine, and primary care providers.

The Dobbs decision has serious implications for all women of childbearing age as well as their children. It has overarching consequences for obstetric care providers, mental health professionals, and the patients we serve. It will increase demand for services already in short supply and will force many of us to practice in a reactive, not proactive mode. Most importantly, it will affect populations that are historically underserved. Until policy changes supporting abortion access are enacted, strategies that can be implemented immediately include the following:

• Strengthen sex education in schools to increase awareness of options for preventing unwanted pregnancy.
• Improve access to information about fertility and fertility management, including monitoring menstrual cycles and menopausal status and reliable and effective birth control approaches for all reproductive life stages, with attention to the specific needs of midlife women.
• Advocate for the inclusion of explicit coverage of effective and reliable contraception and other pregnancy prevention methods in health insurance plans.
• Provide readily accessible and affordable early pregnancy detection.
• Provide “morning after” contraception.
• Advocate for policies that ensure women’s right to agency over our bodies.