A clinician and two public health experts at Tufts University School of Medicine reflect on what the overturning of Roe v. Wade means for the future of maternal health
More than two months after the Supreme Court overturned Roe v. Wade, abortion is now banned in 12 states, with additional bans expected to take effect soon. Some state supreme courts will decide the legality of abortion in places where bans were blocked by lawsuits and appeals.
In Massachusetts, abortion is legal, and Governor Charlie Baker recently signed legislation further protecting providers, patients, and people who need to travel to the state for care from legal repercussions. Still, despite local protection, maternal health care providers and advocates at Tufts University School of Medicine say that the overturning of Roe v. Wade is extremely problematic.
“No part of this overturn is positive,” says Ndidiamaka Amutah-Onukagha, the Julia A. Okoro Professor in Black Maternal Health at Tufts University School of Medicine and director of the Center for Black Maternal Health and Reproductive Justice (CBMHRJ) at Tufts University. “For women of color who were already in a pandemic of racism prior to the COVID-19 pandemic, this is another layer that further exacerbates underlying disparities and that will leave them disproportionately impacted."
She notes that red states and rural states already have a lack of women’s health care providers—a problem that will worsen because of the court’s ruling.
“When you're talking about health, you’re talking about politics. They're very much intertwined, especially in this country,” says Vanessa Nicholson, assistant professor of public health and community medicine at Tufts University School of Medicine. Additionally, Nicholson is the MOTHER Lab Unit Lead within the CBMHRJ and the Chief Report Editor of the Report of the Special Commission on Racial Inequities in Maternal Health for the Commonwealth of Massachusetts. “Many of the people who put the laws in place are not health professionals. That’s not to say health professionals should be the only professional community to make the decisions, but they definitely can help inform policy makers as they're making these decisions, because there's an intersection.”
Tufts Now recently spoke with Amutah-Onukagha, Nicholson, and physician Erika Werner, chair of the obstetrics and gynecology department and the Louis E. Phaneuf Teaching and Research Professor of Gynecology at the School of Medicine, and chief of obstetrics and gynecology at Tufts Medical Center, about what the abortion ruling means for the future of women’s reproductive health.
Tufts Now: What will the ramifications be from overturning Roe v. Wade?
Erika Werner: Nationally, what we expect to see is that pregnant people will not have access to evidence-based medicine. They will present with health conditions and not be able to end their pregnancy and optimize their health. Women will die because they cannot access abortion in the short term, and in the long term, we'll see a decrease in the number of providers that have the skills needed to perform particularly dilation and evacuation, but also dilation and curettage.
We're also going to see huge inequities in care. The middle and upper class can access care, and those who can't afford to travel, who don't have the resources to get out of state, will not be able to access that care.
Ndidiamaka Amutah-Onukagha: The people who suffer due to a lack of infrastructure and support in the health care system, which is racist in nature and racist in its development, are going to continue to be disadvantaged. People will have to travel further to get abortions. They will have to spend more resources—that they may or may not have—to get the care they need. This may require flights and logistics such as childcare for other children.
People are going to carry a pregnancy longer while they figure these things out. Maybe they would have done an earlier-stage abortion, but now they have to do a later-stage abortion, which brings more potential complications and risks.
Also, Black women are more likely to have preexisting conditions, such as high blood pressure or diabetes, which complicates the underlying health landscape for the patient. These are social determinants of health that will be severely impacted.
Vanessa Nicholson: Many people are involved in a woman's birth: her partner, care providers like doulas or midwives, nurses, doctors. Everyone involved in her care must adhere to the regulations in the state where they're located, because there may be legal ramifications if they don't.
After more of the anticipated bans are in place, about 40 million women of childbearing age will live in states where abortion will be more difficult to access. Especially in trigger-ban states like Kentucky, Louisiana, Tennessee, Mississippi, and Missouri, I would expect that we will see more maternal illness and maternal mortality as a result. There also may be an increase in teenage pregnancy.
There is ongoing conversation as to what is to come and how best to prepare for that. What we can do is look at states where abortion is banned to see what the effects are there, and those effects can inform next steps.
How is access to contraception affected?
Werner: There are laws being considered in some states that would limit contraception. But also, pregnant women are experiencing limited access to other medications. For example, my colleagues in New Jersey and Pennsylvania have shared that their patients with rheumatoid arthritis can't get access to methotrexate because it can be used as a termination drug.
Also, many Planned Parenthood and other clinics that historically have prescribed birth control are now being closed. There's a domino effect where we will see less and less access to reproductive choice, not just in the form of abortion, but in the form of access to everything related to family planning.
Nicholson: Some pharmacies in trigger-ban states removed Plan B medication from their shelves after Roe v. Wade was overturned.
How is abortion used to save lives?
Werner: Particularly as a maternal fetal medicine (MFM) physician, there are times when a woman's life is at risk because of her pregnancy, and she is not far enough along where the fetus can survive outside her body. In that case, if we do not end her pregnancy in the near term, she will end up in the intensive care unit or maybe not survive. In those settings, a physician can either induce pregnancy or do a surgical procedure to end the pregnancy. That's when abortion is a life-saving tool.
If they are in a place where they can't do a surgical procedure, and their only option is to induce the patient, that takes longer. So, for example, a patient whose lungs are filling with fluid or whose kidneys are shutting down may have to wait a few days for their body to spontaneously get rid of the pregnancy, and that delay is life-threatening. Performing a surgical termination of dilation and evacuation is safer for the patient, and there's ample medical evidence to demonstrate that.
Amutah-Onukagha: Abortion saves lives because it gives women and birthing people who need to have an abortion the ability to live the life that they want and deserve to live. It saves their financial life, emotional life, and mental-health life. If someone is forced to carry a child for which they are not prepared, or that comes from a rape or domestic violence situation, abortion can offer a new lease on life. Their physical health may not be in danger, but their mental health is at stake.
What are your colleagues around the country reporting as they grapple with the changing legality of abortion?
Amutah-Onukagha: I am hearing burnout. I am hearing fear. I recently had a call with an OB-GYN having what she called an existential career crisis. People are thinking about changing careers because they don't want to work under this ridiculous system. These people got into obstetrics and gynecology to deliver reproductive health care. And if they’re in a place where that is no longer an option or they fear for their life, they start to think critically about making career changes. Most of us don't go to work every day worrying about our safety and what that means for our families.
Werner: My MFM colleagues in other states are having a hard time. I'll give an example. They see a patient for a routine anatomy ultrasound at 18 to 28 weeks where they diagnose that fetus with a major brain abnormality, not consistent with long-term life—and they cannot offer that woman a termination or even use the word abortion. They have to allow that woman to go home and do research on her own about abortion options in other states or carry that pregnancy to term and have a baby who passes away shortly after birth.
Some maternal fetal medicine physicians in restrictive states are being asked to consult their hospital’s lawyer before they counsel a patient. Each hospital lawyer may have a different interpretation of the state law, leading to inconsistency between hospitals. And it means that before a doctor can provide care, they have to seek legal consultation.
How does this change what medical students and residents learn?
Werner: Abortion means many things. It’s not just used to end an elective pregnancy. Abortion is any procedure that empties the uterus because the pregnancy is no longer viable, whether for a medical reason or an elective reason.
Knowing how to facilitate an abortion is a required skill that every medical resident must learn and that is tested on the exam for the American Board of Obstetrics and Gynecology. Residents don't have to learn to do it in elective settings; they can choose to learn on only non-viable pregnancies. But it is a required surgical skill.
Amutah-Onukagha: As far as what medical students learn, we need to infuse actively anti-racist practices into the curriculum. We're still dancing around racism a little too much for me. We still operate in systems of oppression and racism and have not drilled down enough to make long-term, systemic change.
We have to have that level of candid conversation, because we're putting people out in the world who are well-trained and brilliant, but we're not fully maximizing their potential impact on the field.
What can people do to protect access to reproductive choices?
Werner: In Massachusetts, we don't have a gag order on the topic of abortion. Sharing our experiences has enormous power.
Amutah-Onukagha: We have to vote in the midterm elections. We also need people to hold their legislative representatives accountable because they are beholden to us as constituents.
Sometimes we have a really short memory as a country. We forget things and we're easily distracted by the next big story. We move on too quickly to hold people accountable. This is not one of those topics for which we have the luxury of doing that.
I spoke at the Bans Off Our Bodies rally right before Roe v. Wade was overturned. It was incredible. There’s real magic in those types of gatherings where like-minded people come together. Strategy can happen. Resources, ideas, and tactics are shared. I believe in the power of community organizing, as we would not have half the rights we have as a country, as women, if we didn't rally. That's how we got here.