TYPE Perspective

PUBLISHED 05 December 2023

DOI 10.3389/fpubh.2023.1291668

The impact of hostile abortion

OPEN ACCESS legislation on the United States
maternal mortality crisis: a call for
EDITED BY
Cheryl Healton,
New York University, United States

REVIEWED BY
Polychronis Voultsos,
increased abortion education
Aristotle University of Thessaloniki, Greece

*CORRESPONDENCE Anna Kheyfets 1,2*, Shubhecchha Dhaurali 2, Paige Feyock 2,3,

Anna Kheyfets
anna.kheyfets@tufts.edu
Farinaz Khan 4, April Lockley 4, Brenna Miller 2, Lauren Cohen 2,
RECEIVED 09 September 2023 Eimaan Anwar 2 and Ndidiamaka Amutah-Onukagha 1,2
ACCEPTED 15 November 2023 1
Tufts University School of Medicine, Boston, MA, United States, 2 Center for Black Maternal Health and
PUBLISHED 05 December 2023
Reproductive Justice, Tufts University School of Medicine, Boston, MA, United States, 3 University of
CITATION Michigan School of Medicine, Ann Arbor, MI, United States, 4 Collective Energy for Nurturing Training in
Kheyfets A, Dhaurali S, Feyock P, Khan F, Reproductive and Sexual Health (CENTRS Health), Albuquerque, NM, United States
Lockley A, Miller B, Cohen L, Anwar E and
Amutah-Onukagha N (2023) The impact of
hostile abortion legislation on the United States The growing restrictive abortion policies nationwide and the Supreme
maternal mortality crisis: a call for increased
abortion education.
Court decision on Dobbs v. Jackson Women’s Health Organization place
Front. Public Health 11:1291668. increasing barriers to abortion access in the United States. These restrictions
doi: 10.3389/fpubh.2023.1291668 disproportionately affect low-income people of color, immigrants, and non-
COPYRIGHT English speakers, and have the potential to exacerbate already existing racial
© 2023 Kheyfets, Dhaurali, Feyock, Khan, inequities in maternal and neonatal outcomes. The United States is facing a
Lockley, Miller, Cohen, Anwar and Amutah-
Onukagha. This is an open-access article Black maternal health crisis where Black birthing people are more than twice as
distributed under the terms of the Creative likely to experience maternal mortality and severe maternal morbidity compared
Commons Attribution License (CC BY). The to White birthing people. Restrictions creating geographic, transportation, and
use, distribution or reproduction in other
forums is permitted, provided the original financial barriers to obtaining an abortion can result in increased rates of maternal
author(s) and the copyright owner(s) are death and adverse outcomes across all groups but especially among Black
credited and that the original publication in this birthing people. Restrictive abortion laws in certain states will decrease already
journal is cited, in accordance with accepted
academic practice. No use, distribution or limited training opportunities in abortion care for medical professionals, despite
reproduction is permitted which does not the existing abortion provider shortage. There is an immediate need for federal
comply with these terms. legislation codifying broad abortion care access into law and expanding access
to abortion training across medical education. This commentary explores the
impact of restrictive abortion laws on the Black maternal health crisis through
multiple pathways in a logic model. By identifying current barriers to abortion
education in medical school and residency, we created a list of action items to
expand abortion education and access.

KEYWORDS

abortion, health policy, abortion restrictions, maternal health, abortion education, racial
disparities

Introduction
In 2021, over 90 restrictive abortion policies had been enacted in the United States (US);
more than any other year on record since the Roe v. Wade Supreme Court ruling in 1973 (1).
The Roe v. Wade decision reduced maternal mortality rates by 30–40% for people of color by
securing access to safe and legal abortions (2). The Supreme Court’s decision on Dobbs v. Jackson
Women’s Health Organization has overturned the 50 years precedent set by Roe v. Wade, resulting
in an immediate impact on abortion access (3). This decision overturned the rulings of Roe v.

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Kheyfets et al. 10.3389/fpubh.2023.1291668

Wade and Planned Parenthood v. Casey, removing federal protection Looking forward: abortion education
for abortion access and allowing states to regulate, limit, or ban
abortion. As of September 2019, the majority of reproductive-age Abortion education and training for medical students and
people living in the US live in abortion-hostile states (4). The Supreme residents, as well as related reproductive care, will become even more
Court’s decision to overturn Roe v. Wade in the Dobbs v. Jackson limited than it was prior to Dobbs v. Jackson Women’s Health
Women’s Health Organization decision has paved the way for 28 states Organization (22). These limitations on education will exacerbate racial
with laws in place or proposed to ban abortion almost entirely through inequities in maternal health by further limiting the quality of routine
new legislation or preceding trigger laws that previously could not obstetric care in certain geographic regions that are already devastated
be enforced following the Roe v. Wade ruling (5–7). by poor maternal health outcomes and by reducing opportunities to
Currently, 11.3 million individuals have to travel over an hour improve abortion provider diversity and provider concordance that
to reach the nearest abortion clinic (8). The repercussions of each was lacking prior to the Dobbs decision. In overturning Roe v. Wade, a
clinic closing ripple out as more pregnant people seek services at a distinction between essential healthcare and abortion has been made.
smaller number of centers, impacting not only the distance patients However, routine obstetrical care includes abortion (23). It is
have to travel but also the congestion of each center, as they serve imperative that future physicians have access to training on essential
both local patients and patients from nearby states (9). A 25-mile healthcare such as abortion. Similarly, abortion providers who have
increase in travel distance has been associated with a 5% reduction academic appointments in hostile states may be limited in what they
in abortions; as abortion clinics close, the remaining clinics can teach, and the number of clinical learning opportunities for
experience an influx of patients that results in a decrease in abortion during the final 2 years of medical school will likely decrease
abortions in their community (9). The increase of patients at (21, 22). The decision to overturn Roe v. Wade will not only make it
facilities that provide abortions as other nearby facilities close more difficult for providers to perform abortions, but could also affect
negatively impacts the delivery of other care offered at reproductive training in and care for patients requiring lifesaving miscarriage and
health care clinics, such as preventative breast exams, mammograms, ectopic pregnancy care (21, 24). Across various specialties, such as
and pap smears (10). emergency medicine, residents find themselves weighing the options
Low-income and birthing people of color have increased rates of between facing criminal charges for performing an abortion, or losing
abortion compared to White and high-income birthing people (11). their patient whose survival depends on access to an abortion (25).
The abortion rate among White individuals in the US is 10 per 1,000, Lack of abortion training access will decrease the quality of care
while it is 27.1 per 1,000 among Black individuals (12). Approximately physicians provide and the quantity of physicians able to provide this
70% of pregnancies that were documented in 2014 were reported as care in abortion hostile states. Thus, we sought to explore the current
unintended among Black people, while the rates were 57 and 42% atmosphere of abortion training and how it will impact the Black
among Hispanic and White people, respectively (13). Increased maternal health crisis in our logic model and narrative review.
hostility toward accessing abortion creates an even more dangerous
climate for Black people, who are already 2–4 times as likely to
experience maternal mortality and morbidity than their White Abortion education in medical schools
counterparts (14). Socioeconomic status, racial discrimination, and
disproportionate access to health care, including more effective forms By the age of 40, one in four American birthing people have
of contraception, are pivotal determinants in experiencing undergone at least one abortion procedure in their lives, making
unintended pregnancies and similarly limit abortion access. Black abortion one of the most common healthcare procedures in the US (4,
people live in states with the most restrictive policies regarding 26, 27). Professional organizations such as the American College of
abortion (15). Obstetricians and Gynecologists (ACOG) recognize abortion as an
Hostile restrictions to abortion access coupled with the important and core topic for medical education (28). Despite being one
pre-existing Black maternal health crisis will result in increased rates of the most widely utilized maternal health care services and recognized
of mortality and morbidity among Black birthing people. One study as an essential topic for medical education, the majority of US medical
estimates a total abortion ban in the United States would result in an schools lack sufficient abortion education (27). While competing
additional 140 maternal deaths annually (16). This would be a 21% priorities and the breadth of information necessary to provide are causes
increase in maternal death and a 33% increase for non-Hispanic Black of limitations in all preclinical education, one cause for the insufficient
individuals (16). One study estimated that the closure of abortion attention given to abortion during preclinical years lies includes the
clinics and early gestational age limits increase maternal mortality by underlying sexism and racism present in medical education (29).
6–15 and 38%, respectively. Worldwide, unsafe abortion results in the Medical practice inadequately considers gender in the areas of diagnosis,
loss of 68,000 lives annually (17). Restrictions on legal and safe treatment, and disease management for men, women, and gender
abortion can force individuals to resort to unsafe abortions performed minorities (30). Gender minorities have been systematically excluded
by untrained individuals in unsafe settings, using methods that fail to from medical and scientific knowledge. As a consequence, the
meet healthcare standards (18). healthcare system has been shaped by and catered to men. This bias in
This commentary showcases the impact of restrictive abortion healthcare and clinical research has far-reaching implications for
laws on the Black maternal health crisis through multiple pathways in obstetric health and medical practices compromising the quality of care
a logic model. The logic model in Figure 1 explores the connections provided to birthing persons (31, 32). The logic model in Figure 1
between abortion restrictions and the worsening Black maternal showcases the medical bias is worse for racial and ethnic minorities
health crisis further, using abortion education and training as both a demonstrated by the current Black maternal mortality crisis rooted in
determinant and strategy (19–21). the history of obstetric racism present in the US.

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Kheyfets et al. 10.3389/fpubh.2023.1291668

FIGURE 1
The impact of abortion restrictions on the US Black maternal health crisis logic model.

There is very limited data on abortion curricula in US medical obstetrics and gynecology residency programs in the US provide
schools (33). One of the few studies published on this topic access to abortion training and routinely teach abortion care to their
demonstrated that abortion education is not thoroughly incorporated residents (33). A study published in 2019 surveying OB/GYN Program
into medical schools’ curricula: 17% of medical schools in the US did Directors found that out of 190 respondents, 10 programs do not offer
not formally teach abortion, and less than 50% of schools dedicated at any abortion training at all (5%), 59 offer optional abortion training
least one lecture on abortion (26). Of the schools that offered clinical (31%), and 121 programs routinely schedule training for their
abortion care experience, it was included in the third year of medical residents (64%) (37). This is concerning as contraception, miscarriage
school as an elective course that interested students had to actively management, medication and surgical abortion methods are highly
seek out (26). Another study requesting information from the 126 necessary and routine health procedures for a large part of the US
accredited US medical schools’ OB/GYN clerkship directors found population (4).
that nearly a quarter of schools offered no formal abortion education Recent years have demonstrated increased integration and
in their clinical and preclinical program years, and a majority of abortion care training among family medicine physicians. Family
schools only offered one abortion-care lecture elective course (34). An medicine physicians are the most common specialty in medicine
updated preliminary 2020 study reported that since 2005, there have practicing in abortion-care deserts, places with a lack of abortion-
been increases in abortion education availability in American medical care/abortion-care access limitations (38). In a nationally
schools, but compared to the national demand, the increases are representative sample of family medicine physicians, over 80%
insufficient (35). This is only set to progressively worsen with abortion described having treated early pregnancy loss and 73% agreed that
education being limited in nearly half of the country. abortion was within their scope of practice, whereas only about 15%
In the year following the Dobbs decision (2022–2023), states with of family medicine providers in this survey reported offering early
the most severe abortion restrictions found a 3.0% decrease in all abortion care. This discrepancy may be explained by the fact that only
applicants into residency programs, with a 10.5% decrease in OB/ 7% of all nationally accredited family medicine residencies offer
GYN applicants compared to previous application cycles (36). In a abortion-care training (38). All medical practitioners who serve
single application cycle, the impact of the Dobbs decision and reproductive-aged birthing people must understand and be able to
subsequent abortion bans and restrictions has been made clear by adequately facilitate abortion care and comprehensive family planning
these graduating medical students choosing to practice in other states. counseling, even if they do not perform the abortions themselves (33).
This change foreshadows a decrease in the number of physicians in Following the Dobbs decision overturning Roe v. Wade,
states with abortion restriction, in OB/GYN as well as other specialties. approximately 44% of residents in OB/GYN programs will no longer
have access to in-state abortion training (39). Before Dobbs, residents
in Missouri had to go to Illinois to be fully trained in abortion, now
Abortion training in residency traveling elsewhere to practice these skills will become a reality for
residents in Texas and other states that are hostile to abortion, though
The Accreditation Council for Graduate Medical Education coordinating this effort will be difficult (21). Physicians in Louisiana
(ACGME) and ACOG require and recommend all 267 accredited are concerned that they will not be able to recruit the best physicians

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Kheyfets et al. 10.3389/fpubh.2023.1291668

to the state due to the new laws limiting abortion training and Provider concordance
provision opportunities, impacting the quality of care for its
residents (24). Abortion hostility and restrictive legislation throughout
institutions is not the only problem in accessing abortion and
reproductive health care services, or training abortion provider. The
Barriers for providers abortion provider and abortion care workforce does not reflect the
communities it serves. After centuries of canceled and compromised
Over the past several years, the number of abortion providers in reproductive autonomy, Black birthing people once again find their
most states has significantly declined. As of 2017, 89% of all US health and rights in the hands of people who do not share their lived
counties do not have an abortion provider available for their residents experiences. The majority of abortion care providers are White and
(4). The abortion provider decline is associated with the increasingly serve largely non-White, immigrant, low-income, and non-English
restrictive and hostile abortion legislation taking hold in the US (4, speaking populations (46, 47). This is a result of the systematic
40). Over the last decade, there have been 479 abortion restrictions exclusion of people of color from the medical profession and results
enacted in 33 states, even though abortion is one of the safest medical in the exclusion and stigmatization of patients (48). Nearly half of all
procedures (40). abortions obtained in the US are by those whose incomes are below
States with abortion bans or restrictions experience adverse the federal poverty level (46). Despite this, wealthy, White individuals
outcomes including limited maternity care providers, maternity care still hold the greatest power and leverage over the legislative decisions
deserts, higher rates of maternal mortality and infant death, especially being made, the pathways created for education, pathways for
among people of color, elevated death rates for birthing individuals of employment and work, and education curricula surrounding abortion
reproductive age, and greater racial disparities in healthcare (41, 42). and reproductive health care. As training opportunities for abortion
Maternal death rates in abortion-restriction states were 62% higher care become more limited across the country, there is further
than in states with greater abortion access states (28.8 vs. 17.8 per limitation to training culturally concordant providers.
100,000 births) (43). Abortion-restrictive states have a 32% lower ratio Diverse physicians, healthcare specialists, and administrators are
of obstetricians to births and a 59% lower ratio of certified nurse associated with improved health outcomes for underserved,
midwives to births compared to states with abortion access (41). The vulnerable, underrepresented, and underprivileged patient
recent Dobbs decision could exacerbate this disparity as it may deter populations (49). Not only are there improved health outcomes but
some maternity care providers from practicing in states where their a more diverse physician workforce is also associated with White
work faces legal challenges, as seen in the recent residency application doctors being more culturally competent and better serving minority
cycle (36). Insufficient maternity resources not only restrict access to patients (50). There must be increased workforce diversity in the
birthing services, but also make it harder for pregnant individuals to physician and medical care workforce as a whole, and in abortion
access early and continuous prenatal care. In 2020, states with abortion provision in particular, as cultural humility, competence, and respect
restrictions had a 62% higher proportion of individuals giving birth are essential in creating an unbiased, quality healthcare system
who either received no prenatal care or received it late when compared rooted in justice and equity (51). As opportunities for training
to states with abortion access (44). become more limited with the elimination and severe restriction of
Surveyed Maternal-Fetal Medicine (MFM) providers stated that abortion access, increasing provider concordance will become even
individual, institutional, and state-level factors impact their ability to more difficult, and should remain a focus of programs seeking to
provide abortion care in their practices (40). Limitations such as improve health equity.
abortion public funding, cost, state mandates, waiting periods, and
institutional policies impact their ability to provide abortion care
(40). MFM physicians practicing in supportive abortion legislation Call to action
states reported higher abortion provisions than those physicians
practicing in abortion-hostile states, resulting in an unequal In recent years, with advocacy efforts from Medical Students for
geographic distribution and representation of abortion providers and Choice, the Kenneth J. Ryan Program, and Reproductive Health
abortion clinics across the US and reduced access to reproductive Education in Family Medicine (RHEDI) programs, the availability
health services (40). The disproportionate distribution of physicians of abortion education in some US medical schools has improved (4,
is especially dangerous for high-risk patients whose pregnancies pose 27, 52). The overturn of Roe v. Wade will undoubtedly impose limits
impending physical threats to their lives and who are located in areas on education related to miscarriages and other OBGYN health
with reduced or no access to family planning counseling services issues (21). To combat this, abortion education must be embedded
(Figure 1). All these factors readily contribute to the rising US into the overall medical school curriculum for all US medical
maternal mortality rates, especially for Black birthing people who schools (27). The healthcare field should be intentional in training
face more deadly birth inequities that are slated to worsen as states the next generation of clinicians. This can be accomplished by
further eliminate access and support for abortion (15, 40). Abortion requirements set forth by the American Medical Association,
providers and clinicians standing up to these injustices are facing Association of American Medical Colleges, and the American
immense backlash. For example, a physician in Indiana publicly Association of Colleges of Osteopathic Medicine, for all medical
shared a story of her 10-year-old patient who was raped and could schools to include evidence-based abortion education in their
not obtain an abortion in their home state; subsequently she was preclinical curricula, and as possible in their clinical years. For
humiliated by state attorneys, called a liar, and is now facing legal schools in states with limited training to abortion, efforts should
troubles (45). be made to offer abortion training experiences or dedicated time to

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Kheyfets et al. 10.3389/fpubh.2023.1291668

establish them in other states during clinical years. Further, Author contributions
standardized exams can demonstrate the ubiquity of and normalize
abortion by including the topic as an unstigmatized procedure on AK: Conceptualization, Data curation, Investigation,
the United States Medical Licensing Exams and Comprehensive Methodology, Project administration, Visualization, Writing –
Osteopathic Medical Licensing Examinations. It is crucial to original draft, Writing – review & editing. SD: Conceptualization,
incorporate abortion training into the medical school curriculum, Data curation, Investigation, Visualization, Writing – original draft,
similar to any other surgical or medical procedure, to diminish its Writing – review & editing. PF: Conceptualization, Data curation,
associated stigma (28). Investigation, Writing – original draft, Writing – review & editing. FK:
Both residents and medical students should be supported by their Conceptualization, Data curation, Supervision, Writing – review &
respective institutions for advocacy work being done to improve editing. AL: Conceptualization, Data curation, Supervision, Writing
access to abortion care. Residents in specialties adjacent to abortion – review & editing. BM: Investigation, Writing – original draft. LC:
care including pediatrics, anesthesia, and emergency medicine, should Writing – original draft, Writing – review & editing. EA: Writing –
be trained on counseling for abortion care options and where to refer original draft, Writing – review & editing. NA-O: Conceptualization,
patients. Programs that offer abortion training must also be intentional Supervision, Writing – review & editing.
in recruitment of trainees. Not only should the number of abortion
providers in training increase, but also the racial concordance between
physician and patient should be considered as a determinant of patient Funding
experience and outcomes.
Attention should be focused on improving access to abortion The author(s) declare that no financial support was received for
medication outside the clinic setting. Self-managed abortions are as the research, authorship, and/or publication of this article.
safe as those in the clinic and online telemedicine can be highly
effective (53, 54). Most importantly, physicians of any specialty should
not report individuals who seek care following a self-managed Acknowledgments
abortion. Legislative action is necessary to secure reproductive rights
long-term. The healthcare field should advocate for establishing We would like to thank the CENTRS Health organization
federal law securing access, in particular, to abortion and reproductive physicians for their mentorship in this project.
healthcare, including federally enacting the Women’s Health
Protection Act (55). Given the fact that nearly one-quarter of birthing Conflict of interest
people in the US will have an abortion in their lifetimes and that
abortion restrictions disproportionately impact already vulnerable The authors declare that the research was conducted in the
populations, the medical community must leverage its power to absence of any commercial or financial relationships that could
protect the right to abortion and provide appropriate resources be construed as a potential conflict of interest.
through advocacy.
Publisher’s note
Data availability statement All claims expressed in this article are solely those of the authors
and do not necessarily represent those of their affiliated organizations,
The original contributions presented in the study are included in or those of the publisher, the editors and the reviewers. Any product
the article/supplementary material, further inquiries can be directed that may be evaluated in this article, or claim that may be made by its
to the corresponding author. manufacturer, is not guaranteed or endorsed by the publisher.

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