The Impacts of Restricting Comprehensive Reproductive Healthcare

Comprehensive Reproductive Healthcare

The definition of comprehensive reproductive healthcare has varied, depending on the organization in question; however, most major healthcare organizations, including the Guttmacher Institute on Sexual and Reproductive Health Rights, note that comprehensive reproductive healthcare access includes the following:

• Inclusive sexual education
• Counseling and access to contraceptives
• Equitable access to prenatal, childbirth, and postnatal care
• Safe abortion services
• STI prevention and treatment
• Prevention, detection, and management of sexual assault situations
• Treatment of reproductive cancers
• Fertility and infertility counseling
• Sexual health counseling

The WHO acknowledges that health is nuanced, going far behind essential physical health and including mental and social wellness.

“Making health for all a reality, and moving toward the progressive realization of human rights, requires that all individuals have access to quality healthcare, including comprehensive abortion care services – which includes information, management of abortion, and post-abortion care. Lack of access to safe, timely, affordable, and respectful abortion care poses a risk to not only the physical but also the mental and social well-being of women and girls,” states the WHO.

Restrictive abortion laws in the US have left healthcare providers unable to provide complete and equitable reproductive care to American women and pregnant people. The detrimental impacts of abortion policies have contributed to worsened health outcomes and complicate the domestic healthcare system.

Pregnancy Outcomes

Understanding how abortion access impacts pregnancy outcomes is critical for understanding the effect of policy on healthcare outcomes.

Approximately 50% of all abortions do not follow the appropriate medical guidelines recommended by the WHO, causing 4.7–13.2% of all maternal deaths. In developed regions, including the US, 30 of every 100,000 unsafe abortions result in maternal mortality.

Experts project that the number of unsafe abortions and maternal deaths will continue to grow due to abortion restrictions implemented by state-level policymakers.

In addition to mortality, morbidities may include hemorrhage, infection, uterine perforation, and genital tract damage.

Data analyzed by the Commonwealth Fund determined that states that restrict abortions have higher rates of younger birth, with 57% of births in those states being for women under 30, 12% greater than abortion access states.

The ratio of obstetricians to births in abortion-restricted states is nearly 40% lower than in abortion-access states. Additionally, the proportion of certified nurse midwives to births is almost 60% lower. Many postulate that obstetricians’ and midwives’ extensive knowledge of pregnancy dangers and maternal health issues prompts them to advocate for more abortion providers. In states where abortion rights are restricted, these providers may not be as comfortable practicing.

These statistics indicate reduced access to reproductive and pregnancy care in states that have banned or restricted abortions, increasing the probability of pregnancy complications and maternal mortality.

In states with more restricted abortion access, maternal death rates are 62% higher than in abortion-access states. Although the Emergency Medical Treatment and Labor Act requires Medicare-participating facilities to provide abortions in cases of imminent danger to the pregnant individual, patients are still likely to suffer.

STI Transmission and Infection

Beyond worsened pregnancy outcomes, the Infectious Disease Society of America (IDSA) notes that banning safe abortions can have severe implications for spreading infectious diseases, including sexually transmitted infections like HIV.

The organization states that septic abortions in the US declined 89% between 1950 and 1979 when the US legalized abortion care. Based on this data and analyses of unsafe abortions, the IDSA predicts that banning legal abortions will contribute to a rising rate of septic emboli and septic pelvic thrombophlebitis.

The increasing infection rates will likely contribute to more antibiotic prescriptions, resulting in higher antibiotic resistance rates, which has widespread implications for infectious disease management.

Although patients are currently eligible to travel to a state where abortion is legal, in specific scenarios delaying an abortion may be linked to a higher incidence of septic abortion, infection, and complications. Furthermore, low-income patients seeking an abortion may be unable to afford travel, exacerbating existing inequities.

While some states that banned abortions have not restricted other reproductive health services, the bans have caused family planning clinics to close, fearing the repercussions of providing health services. In addition to the fatalities and morbidities associated with abortion restrictions, family planning and reproductive health clinic closures are associated with increased STI rates.

According to the IDSA, roughly 41% of women of reproductive age in the US can only seek reproductive health services at family planning clinics, including well-rounded STI prevention.

An article published in JAMA Network Open on October 14, 2022, analyzing the effects of family planning closures in Iowa on STI rates, found that clinic closures caused a significant increase in STI burden.

Data revealed that, in 2016, before a family planning clinic closure, there were 83 cases of gonorrhea per 100,000 individuals. Following clinic closers in 2018, cases nearly doubled, reaching 153.7 cases per 100,000 individuals. Additionally, statewide chlamydia cases increased from 414.6 to 466.3 per 100,000 individuals.

The outcomes of increased STI rates may impact more than sexual health. The IDSA notes, “Undiagnosed and untreated STIs can result in infertility and pelvic inflammatory disease, which also leads to increased morbidity and mortality and rapid progression of infections to sepsis, septic shock, acute respiratory distress syndrome, disseminated intravascular coagulation, acute renal injury, and death. Delayed treatment of STIs can require the prolonged use of antimicrobials and subsequent side effects such as C. difficile infection and acute kidney injury, among others, and the development of antimicrobial resistance, which also will affect the general population.”

Mental Health

In addition to physical health, the HHS Office on Women’s Health data suggests a strong link between reproductive and mental health. Hormonal changes throughout pregnancy can cause significant emotional and mental health complications for pregnant individuals.

Beyond that, postpartum depression affects a significant portion of the patient population. Individuals with existing mental health issues before pregnancy or a history of postpartum depression after a previous child are at a high risk of developing postpartum depression.

An article in the New England Journal of Medicine asserts that abortion is not detrimental to mental health, echoing the voices of multiple organizations, including the American Psychiatric Association (APA).

Among the studies analyzed in the journal is the Turnaway Study, a longitudinal evaluation of the impacts of abortion restrictions on patients and their children if they are denied care. The study's results emphasized that abortions do not increase the risk of PTSD, depression, anxiety, low self-esteem, or substance use issues.

The study also revealed that being denied an abortion was linked to higher stress, anxiety, and low self-esteem.

Pediatric Healthcare

Denying abortion access affects pediatric healthcare as well. An article by the Children’s Hospital of Philadelphia (CHOP) discusses the significance of access to comprehensive reproductive healthcare for adolescents, noting that it carries weight in improving adolescent health outcomes.

According to Sarah Wood, MD, MSHP, and Aletha Y. Akers, MD, MPH, FACOG, coauthors of the article, the rulings in the Dobbs case have had a significant impact on adolescent healthcare and health outcomes.

Wood and Akers outlined multiple legislative policies that improved access to well-rounded reproductive care and adolescent education.

Throughout the 1970s, multiple decisions by the US Supreme Court fortified access to reproductive care for adolescents. Among the many cases, the 1977 Carey v. Populations Services International case widened access to contraceptives by making it illegal to ban the sale of contraceptives to minors. Beyond that, the law established privacy guidelines for a minor’s reproductive decisions.

Other laws and programs, including the Title X Family Planning Program, gave minors the right to privacy when seeking testing for sexually transmitted infections (STIs), contraceptives, and pregnancy counseling.

Educational efforts, including the Sex Ed for Social Change initiative implemented in 1990, helped incorporate sexual and reproductive education in K–12 public schools. Although this program encouraged sexual education guidelines, many conservative locations adopted restrictive policies and programs to minimize or discourage access to care.

While historical laws and policies have worked to protect access to reproductive care for pediatric patients, recent legislation — including the Dobbs decision and the preliminary injunction issued by a Texas judge to reverse the approval of medication abortion pill — compromises pediatric health.

“Laws that restrict access to reproductive healthcare have a disproportionate impact on young people of color and those in rural and medically underserved areas, as well as other populations,” said Elizabeth Alderman, MD, FAAP, FSAHM, chair of the American Academy of Pediatrics (AAP) Committee on Adolescence, in an AAP statement. “People with resources, money, and transportation have the ability to travel to another state to receive the safe and legal care they need. For those who do not have those resources, including most adolescents, access to the healthcare they need is out of their reach. This reinforces the health disparities that exist across our country.”

LGBTQ+ Communities

According to GLAAD, LGBTQ+ people with female reproductive organs that have sex with individuals that have male reproductive anatomy are more likely to seek an abortion than cisgender heterosexual individuals.

Additional data determined that bisexual women were three times more likely than heterosexual women to have an abortion.

Data suggests that roughly 27% and 29% of heterosexual and bisexual individuals have unwanted pregnancies. By comparison, individuals who identify as lesbian have an undesired pregnancy rate of 39%.

According to an article by the University of California Los Angeles, members of the LGBTQ+ community are already more likely to receive less or lower quality healthcare. New restrictions on abortion access have led to the closure of many health clinics that provide quality healthcare to LGBTQ+. These closures will likely lower cancer and STI screening rates, jeopardizing this population’s health.

Beyond the harmful rhetoric surrounding abortion and LGBTQ+ people, many jurisdictions that enforce abortion bans have manipulated ideologies and used them to ban gender-affirming care despite it being deemed necessary healthcare by all major medical organizations.

Racial Minorities

In a blog post by the Economic Policy Institute, Bailey Nelson says that despite being painted as a race-neutral policy, abortion bans disproportionately impact marginalized communities, specifically non-Hispanic Black women and other minority groups who can get pregnant.

In addition to the direct health implications on childbearing individuals and their offspring, abortion bans contribute to worsening economic health, which, in turn, contributes to deteriorating health.

Furthermore, criminalizing pregnancy and termination will exacerbate racial disparities in incarceration rates. Under Roe protections, women could not be fined, jailed, or punished for making medically safe decisions regarding their pregnancy. Like other portions of the legal system, the criminalization of reproductive care will likely affect people of color more heavily than White women.

Overall, it is abundantly clear that abortion policies have dwindled access to many healthcare services beyond abortion. With the widespread implications of restricting abortion and the pleas of public health organizations, policymakers, healthcare professionals, and healthcare companies must consider how continued restriction will impact the nation.