US doctors worry about rise in unsafe abortions

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.”