Experts warn of harmful public health consequences in Georgia if Roe is overturned

Enacting severe restrictions on abortion access—as Georgia will likely do if Roe v. Wade is overturned—could increase maternal mortality rates, worsen the existing crisis of a lack of OB-GYNs in the state, increase economic strain on families, and more

634
The harmful public health consequences of a post-Roe Georgia
Pro-choice activists protest during a May 3 rally in front of the U.S. Supreme Court in response to the leaked Supreme Court draft decision to overturn Roe v. Wade.

According to a leaked draft opinion published by Politico on Monday, the Supreme Court may soon vote to overturn Roe v. Wade—the fifty-year-old legal precedent that established the constitutional right to abortion, and one that the majority of Americans (including two-thirds of Georgians) support. Currently, Roe is still in place, but overturning it would upend the protections the case established in 1973 and instead leave abortion legislation up to the individual states. Twenty-two states already have laws in place to either ban or severely restrict abortion, with Georgia among them.

Lawmakers here laid the groundwork in 2019, when HB 481, also known as “the heartbeat bill,” was signed into law. The six-week ban would outlaw abortion before most people even know they’re pregnant, and would put the average Georgian past the 6-week gestational limit more than 200 miles away from the closest legal abortion provider. After the ACLU, Planned Parenthood, and the Center for Reproductive Rights sued the state over the law, a federal district court struck it down as unconstitutional. The state appealed to the Eleventh District Court, which issued a stay on the case until the Supreme Court’s upcoming summer decision on Mississippi’s Dobbs v. Jackson Women’s Health Organization case. According to the Center for Reproductive Rights, as well as Republican lawmakers, Georgia will most likely move forward with enforcing HB 481 if Roe is overturned.

Georgia has one of the worst maternal mortality rates in the nation, in a country where maternal health outcomes are among the worst of all developed nations and have been worsening since 2000. This public health crisis is exacerbated for Black women, who are two to three times more likely to die from pregnancy or childbirth than their white counterparts.

Today, the states with the most restrictive abortion laws are also those with the highest maternal mortality rates. One study estimated that a nationwide abortion ban would increase the number of pregnancy-related deaths overall by 21 percent, and for Black women, by 33 percent.

Following the oral arguments in Dobbs this past December, we began asking public health and women’s health experts from Emory, the University of Georgia, and Morehouse School of Medicine to weigh in on the broader ramifications of a Roe reversal in the state. Here are some of the concerns they shared:

Maternal mortality rates could worsen under an abortion ban
Public health experts think this is likely: in terms of health outcomes, abortion is inherently safer than pregnancy and birth, especially in Georgia. “There’s so much evidence and research that shows that maternal mortality and abortion [restrictions] go hand-in-hand,” says Dr. Natalie Hernandez, who serves as the interim director for Morehouse School of Medicine’s Center for Maternal Health Equity and sits on the state of Georgia’s Maternal Mortality Review Committee. “Research has shown that the more abortion restrictions a state has, the worse women and children’s health outcomes in the state are.”

Dr. Andrea Swartzendruber, researcher and assistant professor at the University of Georgia’s College of Public Health, adds that those who’d ordinarily choose abortion but are instead forced to carry an unwanted pregnancy will probably be predisposed to poor outcomes, including mortality and morbidity: “With people carrying unwanted pregnancies, [including] those who may not be in optimal health because of a lack of access to healthcare, it would seem predictable that maternal mortality may get worse.” She adds that this could have implications for the state’s infant mortality rate, too—also among the worst in the nation.

If Georgia’s maternal mortality crisis continues to worsen, Black families will suffer the most. Hernandez points out that, for Black women, maternal mortality and morbidity transcends factors like income, health, and college education. “Black mothers who are college-educated fare worse [in maternal mortality outcomes] than all other races who never finished high school,” she says. “Black women in the wealthiest neighborhoods still do worse than the white women in the poorest ones. The ways in which women of color are discriminated against and excluded from the healthcare system really contributes to poor health outcomes for women related to maternal mortality and abortion care.”

The already-severe, statewide OB-GYN shortage could reach a crisis level
In 2019, opponents of the “heartbeat bill” included physicians and medical students, who cited the state’s healthcare provider shortage, especially among OB-GYNs. Currently, half of the counties in the state do not have an obstetrics provider at all.

“We have a severe OB-GYN shortage that seems like it’s only going to get worse,” Swartzendruber says. She adds that Georgia already struggles with retaining its medical school students and resident trainees. Legislative restrictions that limit a provider’s ability to care for their patients would only exacerbate that shortage, she believes. “And that will be felt probably most heavily in rural areas and among communities that already have limited or harder access to healthcare services.”

Economic strains on Georgia families could worsen
In 2020, researchers at the University of California, San Francisco, published the results of a ten-year longitudinal study that examined the effects of being denied a wanted abortion. Over years of interviews with 1,000 patients, the researchers compiled experiences and trajectories of people who were turned away from an abortion because they were just barely past their state’s legal gestational limits, and compared them with the experiences and trajectories of people who were just under that limit and received care. The Turnaway Study found that the economic impact of being denied a wanted abortion was severe and long-term, both for the pregnant person and for their families. (In America, the majority of people who get abortions are already parents.)

“We know that people who are denied wanted abortions, compared to people who are given the care they wanted, have worse economic outcomes,” Swartzendruber says, including higher likelihood of household poverty, unemployment, lower credit scores, higher debt, and an inability to cover basic living expenses for their household. In 2017, more than a third of Georgia households were headed by single mothers.

“Many people who get abortions already have children,” Swartzendruber adds. “They’re choosing abortion because it isn’t the right time, or they’re seeking to better care for the children they already have, or because of their economic situation. So, thinking about the implications for those children and households as well . . . I think that is an often overlooked point.”

Dr. Danielle Lambert, a UGA College of Public Health researcher and assistant professor, points out another critical missing safety net: Georgia has not expanded Medicaid, creating a coverage gap that makes it difficult and expensive for thousands of people to access healthcare. “We have pretty high rates of uninsured individuals in Georgia, so thinking about how people are going to get access to healthcare . . . there are a lot of obstacles,” she says. (Earlier this year, lawmakers did extend the window of pregnancy Medicaid coverage from six months postpartum to twelve.)

The overall wellbeing of parents and children could suffer
In addition to socioeconomic consequences and poorer long-term physical health, the Turnaway Study also found that being denied a wanted abortion was associated with adverse mental health outcomes (as opposed to having a wanted abortion, which was not associated with any adverse mental health outcomes). Participants in the study who were denied an abortion suffered from higher anxiety than their counterparts who received an abortion, and had poorer maternal-infant bonds with the resulting children. Those experiencing intimate partner violence were more likely to stay in contact with violent partners after giving birth than their counterparts who received abortions. Their other children suffered, too: kids of a parent denied an abortion were less likely to achieve developmental milestones than the existing children of parents who received abortions. Most tragically, two of the study’s participants who were denied an abortion died after their delivery.

Complications from high-risk pregnancies could increase
As currently written, Georgia’s abortion bill (HB 481) allows for pregnancy termination if the parent’s life is in danger or if the fetus is deemed “medically futile,” but providers worry about the legal gray areas in the law, as well as the idea of lawmakers without medical degrees deciding which medical conditions fit into those categories. For fetal anomalies, conditions like spina bifida, skeletal dysplasia, and hydrocephalus may not be “incompatible with life,” as the bill’s language puts it, but would still lead to such a low quality of life that a family may wish to terminate the pregnancy out of compassion. (None of these conditions can be detected at six weeks.) Likewise, in caring for patients with pregnancy complications, it’s possible providers could be restricted by the law’s ambiguities: at what moment does a potentially lethal condition like pre-eclampsia, for example, become “life-threatening” in the eyes of the law?

Dr. Carrie Cwiak, an associate professor of obstetrics and gynecology at Emory’s School of Medicine and a director at Emory’s Center for Reproductive Health Research in the Southeast, says she expects to see more complicated pregnancies across the board. Some people choosing abortion may do so because they’re living in poverty, have substance abuse issues, have little access to healthcare, or are victims of inter-personal violence in their own household—all of which are considered risk factors in a pregnancy. “If you have no access to abortion, and therefore the only option is to carry your pregnancy, then we are going to see higher rates of complications,” she says.

And so could complications from unsafe self-managed abortions
Self-managed medication abortion, in which a person takes a combination of prescription drugs (mifepristone and misoprostol) to induce an abortion, is safe and effective. But in a scenario where that medication might be harder to access, and where providers are unable to assist and counsel their patients through the process, Cwiak says, some complications can be expected. (Earlier this year, Georgia lawmakers introduced a bill that would have added more restrictions to obtaining this type of medication, including banning obtaining the pills by mail; it didn’t pass.)

In her practice, Cwiak says she’s seen patients turn to folk remedies, self-inflicted trauma, and other methods.

“My colleagues and I know that part of our practice is going to change because we’re going to be taking care of people who are having those complications,” she says. “Because this is not going to stop abortion. This is going to stop early access to safe, legal abortion in our state.”

A loss of human potential
For Swartzendruber, one possible consequence of an abortion ban isn’t as quantifiable as other socioeconomic or public health factors, but is just as devastating: the loss of people’s futures. “I’m really scared about the loss of potential . . .  of people not being able to direct their lives in the way they want to direct them, of decisions being made outside of their own autonomy, of what they want to do with their lives,” she says. “I don’t just mean about making a pregnancy decision, but all of the ways that this affects people’s education, job opportunities, the reward that they find in life. Of course that has implications for individuals, but that has implications for us as a society and community . . . these are our friends and neighbors and community members.”

Advertisement