Women’s Mental Health: Implications of Restricting Access to Reproductive Care
Behavioral Health Insights
By Micah Hoffman, MD, DABPN, FAPA, QME, CIME, CHCQM
AllMed Behavioral Health Medical Director
Last year, in Dobbs v. Jackson Women’s Health Organization, the Supreme Court returned decisions about the legality of abortion to the states. Though the dust from the ruling is far from settled, at least two outcomes have since become clear: women face new barriers to essential reproductive care while they, their providers, and health plans must contend with new legal risks and uncertainties. For plans, navigating successfully in this environment calls for pairing clinical expertise about reproductive health options with up-to-date knowledge of abortion’s shifting legal status in specific states.
The U.S. Maternal Mortality Rate, Already High, Could Get Worse
Research shows that being unable to obtain an abortion can profoundly impact a person’s long-term health and well-being.1 At a population level, these impacts can have serious social and economic consequences for the wider society. Understanding the clinical implications of laws restricting access to this component of reproductive care is vital to providing comprehensive health care for women today.
Quantifying risk can help bring perspective. The United States has long lagged its peers in maternal health care. A 2020 analysis found that the U.S. had the highest maternal mortality rate by far among developed countries with 23.8 maternal deaths per 100,000 births. (By comparison, France, with the second-highest rate, has 7.6 per 100,000.)2 Restricting access to abortion is likely to make the situation worse—especially for Black women, who die of pregnancy-related causes at nearly three times the rate of White women.3 Centers for Disease Control (CDC) data supports this premise, showing that already the states with the most restrictive abortion laws tend to have the highest maternal mortality rates.4 Notably, in the U.S., a woman’s risk of dying from childbirth is approximately 14 times higher than her risk of dying from a legal induced abortion.5
A 2021 University of Colorado study estimating the potential impact of a total abortion ban in the U.S. arrived at a similar conclusion. The study projected that a ban would result in a 21-percent overall increase in pregnancy-related deaths (33-percent for Black women).6 These estimates do not account for additional deaths due to unsafe abortions or attempted abortions.
Deepening Inequities with Consequences for Future Generations
As significant as an increase in maternal deaths undeniably would be, it’s just one likely consequence of laws banning or restricting abortion. The landmark Turnaway study documented that denying abortion to women who seek it also leads to higher rates of household poverty and instability, particularly among marginalized communities.7 These issues have trickle-down effects on future generations.
The Turnaway Study was designed to analyze the impact of abortion denial on women over time. The study followed nearly 1,000 women for five years. While the Turnaway study has limitations, it offers the most comprehensive data available to date and has been published in numerous peer-reviewed journals. Over the extended period of the study, researchers found that women who were denied an abortion had more psychological issues in the short term than those who received one and experienced more long-term physical and financial difficulties. These long-term difficulties included frequently cited risk factors for depression such as economic hardship, a higher likelihood of staying in contact with a violent partner, and increased odds of raising a child alone.
A subsequent study, published in 2020, focused on the mental health impact of being denied an abortion. Based on the experiences of 784 people seeking abortion in three U.S. states, the study found that those who encountered logistical problems finding, scheduling, or traveling to care and those who felt forced to wait to have the abortion or to tell other people about their pregnancy were more likely to have symptoms of stress, anxiety, and depression8, conditions that can have negative effects on maternal-infant attachment and on fetal development.
From a macro perspective, these findings have implications for U.S. society and for the economy. The legal status of reproductive care influences whether girls will be able to complete their educations and to what extent women will be able to participate in the workforce. In turn, women who are better educated, have better access to comprehensive health care, and are employed and paid fairly, will be better positioned to avoid an unwanted pregnancy, reducing the need for termination.
Putting Patients and Doctors at Risk
The shift in the Supreme Court’s position puts providers and health plans in a difficult position, particularly in cases where a pregnant patient is sick or has complications. Legal labyrinths in some states limit a physician’s ability to provide the highest-quality evidence-based care using their informed judgment and knowledge of patients’ preferences. Instead, they often must first consider the potential legal ramifications at the possible expense of the patient’s physical and mental well-being. While most states that ban abortion make exceptions to protect the life or health of the woman, the exceptions are so vaguely worded or narrow that providers may hesitate to invoke them for fear they could be charged with a crime. Complicating matters further, the laws are continually in flux, requiring constant vigilance and diverting resources from caring for patients.
How AllMed Can Help
AllMed is staying abreast of the latest developments, at both the medical and legislative levels, to help plans navigate this complex issue. Our board-certified obstetrician/gynecologists and behavioral health specialists can provide the knowledge and sensitivity needed to help your team ensure members receive high-quality care that aligns with plan policy.
- University of California San Francisco. The Turnaway Study. https://www.ansirh.org/research/ongoing/turnaway-study. Accessed January 30, 2023.
- Gunja M, Seervai, S, et al. Health and Health Care for Women of Reproductive Age. The Commonwealth Fund. Apr 5, 2022. https://www.commonwealthfund.org/publications/issue-briefs/2022/apr/health-and-health-care-women-reproductive-age. Accessed January 20, 2023.
- https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm Accessed January 24, 2023
- Centers for Disease Control. Maternal deaths and mortality rates by state for 2018-2020. https://www.cdc.gov/nchs/maternal-mortality/mmr-2018-2020-state-data.pdf. Accessed January 24, 2023.
- Raymond EG, Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol. 2012 Feb;119(2 Pt 1):215-9. Doi: 10.1097/AOG.0b013e31823fe923. PMID: 22270271.
- Amanda Jean Stevenson; The Pregnancy-Related Mortality Impact of a Total Abortion Ban in the United States: A Research Note on Increased Deaths Due to Remaining Pregnant. Demography 1 December 2021; 58 (6): 2019–2028. Doi: https://doi.org/10.1215/00703370-9585908
- University of California San Francisco. The Turnaway Study. https://www.ansirh.org/research/ongoing/turnaway-study. Accessed January 30, 2023.
- Biggs MA, Neilands TB, Kaller S, Wingo E, Ralph LJ (2020) Developing and validating the Psychosocial Burden among people Seeking Abortion Scale (PB-SAS). PloS ONE 15(12): e0242463. https://doi.org/10.1371/journal.pone.0242463. Accessed January 30, 2023.