Intended for healthcare professionals

Feature Obstetrics and Gynecology

US doctors worry about rise in unsafe abortions

BMJ 2019; 365 doi: (Published 21 May 2019) Cite this as: BMJ 2019;365:l2267


The cost of new efforts to restrict abortion in the US

  1. Kim Painter, freelance journalist
  1. McLean, VA, USA
  1. kimpainters{at}

Many women already lack access to legal, safe abortion services, and a flurry of new state laws will do nothing to improve women’s health, doctors tell Kim Painter

On May 8, the morning after the governor of Georgia signed a law that would ban most abortions after six weeks of pregnancy, the phones at Planned Parenthood Southeast’s offices rang nonstop, says its executive director, Staci Fox.

“We were inundated with calls from people who were worried abortion was already illegal,” she says. Some women with abortion appointments in Georgia, she says, wondered whether to cancel them.

For now, abortion remains legal throughout the US despite extremely restrictive laws passed by state legislatures and signed by governors in five states so far in 2019. It’s legal even in Alabama, where this month the governor signed the most extreme of these bills: one that bans nearly all abortions, at all stages of pregnancy, with no exceptions in cases of rape or incest.

The reprieve could be temporary. Although these laws are not expected to go into effect soon because of legal challenges, they are part of a strategy to challenge the legal foundation of abortion in the US—the 1973 Roe v Wade decision by the US Supreme Court that found abortion to be a constitutional right. That decision made abortion legal and limited the restraints that states could apply.

Advocates on both sides, however, say that the legal debate is just part of their battle: they’re also engaged in an information war. And they’re planning for a future in which access to abortion from state to state is even more uneven than now.

The definition of a “heartbeat”

New laws signed in Ohio, Georgia, Kentucky, and Mississippi this year (and previously in Iowa and North Dakota) share a central provision: banning most abortions after doctors can detect what proponents call a “fetal heartbeat.” That could be as early as six weeks after a woman’s latest menstrual period—a time when many women don’t even realize that they’re pregnant.

“The heartbeat has been the universal hallmark of life since man’s very beginning,” said Mississippi’s governor, Phil Bryant, when he signed his state’s version. But early cardiac activity in an embryo is “an arbitrary point in pregnancy,” says Jennifer Villavicencio, a Michigan physician who performs abortions and is a fellow at the American College of Obstetricians and Gynecologists. The term heartbeat “implies the entire organ of the heart has been formed, and that is actually not the case,” she says.

Rebecca Cohen, a Colorado obstetrician-gynecologist who provides abortions, agrees: “It really lends credence to the idea that this is a baby, and it is not.” Such language can stigmatize women who seek abortions and their medical providers, say supporters of abortion rights.

But opponents of abortion see it differently. The heartbeat bills are “a really powerful educational tool,” says Jamieson Gordon, director of communications and marketing at Ohio Right to Life. The antiabortion group is affiliated with the US’s largest such group, National Right to Life.

“I don’t think that people realize . . . that a heartbeat is detectable so early,” says Gordon. “We’ve been having a lot of interesting conversations.” Those conversations are happening in a country where 29% of adults said that abortion should be legal under any circumstance and 50% said that it should be legal under certain circumstances, in a 2018 poll by Gallup.1

Despite this, people such as Zemmie Fleck, executive director of Georgia Right to Life (unaffiliated with the national group), says that the heartbeat law passed in her state doesn’t go far enough, as it allows exceptions for rape or incest.

“We want to promote a culture of life,” she says, based on the idea that “life begins at conception” and that it always deserves protection. The ban in Alabama is closer to her ideal.

Access now and in the future

Any high court decision on these new laws is probably at least two years away, says Elizabeth Nash, senior state issues manager at the Guttmacher Institute, a nonprofit research group that supports abortion rights. In the meantime, women in states threatened with bans already face hurdles, say abortion rights advocates.

For example, Alabama requires women to wait 48 hours after an initial clinic visit before returning for an abortion at one of three clinics statewide, while Mississippi has a 72 hour waiting period—and just one clinic, says Fox. Her Planned Parenthood affiliate serves those states, as well as Georgia.

These states, she says, have poor records on women’s health overall and high rates of pregnancy related death. They have also declined to expand Medicaid to provide health insurance to poor adults and children.

Lawmakers concerned about the health of families “could have expanded Medicaid; they could have done something about rural hospitals,” says Fox. Some 75 of Georgia’s 159 counties had no obstetrician-gynecologist in 2017, says the Georgia Board for Physician Workforce.2 This means that rural residents often face long drives for any sort of reproductive healthcare, including abortion, says Antoinette Nguyen, an Atlanta obstetrician-gynecologist who is a member of the advocacy group Physicians for Reproductive Health. Poor women of color are disproportionately affected, she says.

Under current laws, 43 states prohibit abortion at some point in pregnancy, 27 impose waiting periods, and 24 regulate abortion facilities and providers in ways that Guttmacher says “go beyond what is necessary to ensure patients’ safety.”3

Such restrictions already drive some women to cross state lines, say abortion providers. “When Texas put new restrictions in place, they put out stats saying they decreased abortion,” says Cohen, the Colorado provider. “But the numbers in New Mexico and Colorado went up.”

The number of abortion facilities in Texas fell from 41 in 2012 to 17 in 2016, after the adoption of restrictive clinic regulations, said a study published in JAMA in 2017.4 Abortions among state residents fell from 66 098 to 53 882 in 2012-14, and reported procedures out of state rose from 97 to 754—which was probably an underestimate, said the study authors.

Other data, says Cohen, suggest that the need to travel can delay women in getting an abortion. And that could happen more often in a future where some states ban almost all abortions and others keep it legal, as some states have vowed to do.

Providers are now planning for that possibility, with discussions about transportation, funding, and other logistics, says Cohen. She worries most about the women who will not find their way to legal providers: “Making abortion illegal doesn’t make it stop—it just makes it unsafe.”

The prospect that physicians could be jailed for performing abortions is “demoralizing” and a wake-up call, says Nguyen.

“Criminalizing healthcare should not be tolerated by the medical community,” she says. “This becomes a slippery slope of what legislators think they can impose on how all of us practice medicine.”

Restrictive abortion laws

Over half of US state legislatures introduced restrictive abortion laws in the first quarter of 2019, says the Guttmacher Institute.5 Below are the states with the most restrictive new laws signed by governors but not yet enacted because of legal challenges or delayed start dates:

  • Ohio, Mississippi, and Kentucky: To ban abortion after a detectable heartbeat, with exceptions for serious health threats to the pregnant woman.

  • Georgia: To ban abortion after a detectable heartbeat, with exceptions for rape, incest, and serious health threats to the pregnant woman. It defines an embryo or fetus as a “natural person.”

  • Alabama: To ban abortion at every stage of pregnancy, with exceptions for serious health threats to the pregnant woman. It sets a maximum prison term of 99 years for doctors who perform abortions.

  • Arkansas and Utah: To ban abortions at 18 weeks, before viability.

Legislative actions in other states are as follows:

  • Missouri: Legislators voted to ban most abortions after eight weeks. The bill is awaiting review by the governor.

  • Tennessee and South Carolina: Legislators are considering similar early abortion bans.


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Correction: We amended this article on 22 May 2019 to clarify Antoinette Nguyen’s role.


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