Note: This story was written and published in March 2019. HB 481 was signed by Governor Kemp in 2019 but was then blocked. The bill is currently pending in federal appeals court, and, following the June 24, 2022 overturning of Roe v. Wade, will likely be upheld but, as of June 24, has not yet been enacted into law.
Legislation that seeks to ban the majority of abortions in Georgia, HB 481, is up for a vote in the state Senate as early as this week. If it passes, which appears likely, it would proceed to the desk of Governor Brian Kemp, who has said it’s his mission for Georgia to pass the most restrictive abortion law in the country.
Georgia’s “heartbeat bill” proposes that the presence of an embryo’s heartbeat, rather than a fetus’s “viability outside of the womb,” should be the benchmark for outlawing abortions. Given the current state of heartbeat-detection technology, the bill would ban abortions about six weeks into a pregnancy (for a person with regular ovulation and menstrual cycles, that’s two weeks after the first day of a missed period). Currently, abortions are banned in Georgia at 20 weeks. A pregnancy is considered full-term at 40 weeks.
The bill passed the House 93-73 earlier this month. Of the yes votes, 80 were cast by men and one by a person of color.
At the Feminist Women’s Health Center in Atlanta, which provided care to 3,867 abortion patients in 2018, “almost all abortion procedures take place after six weeks,” says Anushka Gole, the center’s communications manager. “We have an early abortion protocol for procedures that take place before six weeks, but it’s nontypical.”
Most abortions take place after the six-week mark for a number of reasons, including not yet knowing you’re pregnant, the financial setback of paying for the procedure, and the time and cost to travel to a clinic, according to experts in the field.
The heartbeat bill makes exceptions for victims of rape or incest who filed a police report; pregnancies in which abortion is necessary to preserve the life of the mother; or “medically futile” pregnancies, in which “the unborn child has a profound and irremediable congenital or chromosomal anomaly that is incompatible with sustaining life after birth.”
Heartbeat bills have been proposed in 20 states, including Alabama, Florida, Mississippi, South Carolina, and Tennessee. Earlier this week, a federal judge temporarily blocked a newly passed law in Kentucky.
Similar laws in other states, such as North Dakota, have been overturned and ruled unconstitutional under federal law. Many of the bills, including Georgia’s, are designed to trigger a legal challenge to Roe v. Wade in the conservative-leaning U.S. Supreme Court, according to advocates on both sides of the issue.
Here are a few of the groups who would be disproportionately impacted by Georgia’s heartbeat bill if it becomes law and goes into effect:
- Low-income people, especially in rural areas
The average cost of a first-trimester abortion is $500 (second-trimester abortions, meaning after the 12th week of pregnancy, cost more), and for many people it will be next to impossible to come up with that much money on such short notice, according to Oriaku Njoku, co-founder and executive director of Access Reproductive Care Southeast. Then there’s the cost of getting to a clinic: 96 percent of Georgia counties have no abortion provider, and 58 percent of Georgia women of reproductive age live in those counties.
Njoku, whose organization helps facilitate funding, transportation, and lodging for abortion patients, says she often works with patients without cars who struggle to make cross-state journeys to reach the nearest clinic. She points to a recent ARC caller who lives in South Georgia and had to find someone to drive her an hour and a half to Macon in order to take a Greyhound bus to Atlanta for her abortion. That patient also had to line up childcare and miss a day’s worth of work—both of which would be more difficult on the heartbeat bill’s abbreviated timeline. “When you think about barriers to access, it’s not just paying for an abortion, and it’s not just having time to make the decision,” Njoku says. “The childcare, the lodging, the transportation . . . all of these compounding things are why this is disproportionately impacting lower-income and rural folks.”
According to Njoku, the cost of traveling out of state—potentially across the country, if enough states pass similar laws—could make an abortion out of the reach for all but the most privileged women.
- Patients who need to see an OB-GYN for any reason (there’s a statewide shortage, which the law stands to worsen)
Physicians have voiced concern that HB 481 would exacerbate the state’s shortage of OB-GYN providers by deterring physicians and medical residents from choosing to practice or train in the state. Currently, half of the counties in the state do not have an obstetrics provider at all.
Last week, obstetrics and gynecology providers testified before the Senate Committee on Science and Technology in opposition to the bill. John Walraven, a lobbyist representing obstetricians and gynecologists, shared the results of a survey in which 85 percent of medical residents said they would be less likely to practice medicine in Georgia after finishing their training if HB 481 were to become law.
Part of their concern is that the law would limit a physician’s ability to provide medical care and advice that’s in the best interest of the patient (see No. 5 below) and that the law’s subjective language could expose doctors to criminal prosecution for following what’s widely considered to be a medically acceptable standard of care.
“Nothing falls into a neat category, especially in medicine,” says Dr. Carrie Cwiak, professor of Gynecology and Obstetrics and Epidemiology and director of the Family Planning Division at Emory University. “That’s why, when you go to see your doctor and have a conversation, it’s typically not a black-and-white conversation. It goes back to shared decision-making.”
A worsening OB-GYN shortage could be devastating to Georgians in rural areas, where patients already are underserved by healthcare providers. “Rural hospitals are closing their OB wards,” says Cwiak. “You can’t even deliver anywhere close to you [in those places]. If we’re already talking about an OB-GYN shortage, all we have to do to tip the scales is to find some other reason for people not to come here, and we’ll have even more of a shortage.”
Georgia’s maternal death rate is the highest in the country, and women of color—particularly black women—die at the highest frequency. In data collected by the Yale Global Health Justice Partnership in 2017, black women in Georgia were more than twice as likely to die during or immediately after childbirth than their white counterparts—a disparity that persists across socioeconomic lines.
- Women who don’t have regular menstrual cycles
“The most common reason for patients to present for abortion in the second trimester, as opposed to the first trimester, is that they didn’t realize they were pregnant,” Cwiak says.
Irregular and unpredictable menstrual cycles are a common symptom of medical conditions such as polycystic ovary syndrome (PCOS), thyroid disease, some cancers, certain medications, and other chronic diseases. People who have low body fat and high levels of physical activity (such as elite athletes), who have or are recovering from eating disorders, or who suffer from severe chronic stress may not have periods at all. And those who are tapering off of hormonal contraceptives, such as Depo-Provera injections, may not resume their menstrual cycles for up to 18 months after their last dosage.
Most of them wouldn’t know they’re pregnant until well after six weeks.
Teenagers may not know enough about their bodies, their menstrual cycles, or the first signs of pregnancy to even realize that they’re pregnant within the bill’s proposed six-week timeline, let alone seek care, Cwiak says. “Let’s think about what Georgia allows as the standard for sex ed,” she says. “It’s not very good.” (Many sex ed programs in the state are purely abstinence-based.)
Teenagers in Georgia also are more likely to experience dating violence than in any other state, according to the state Department of Public Heath. While the bill includes a exclusion for victims of sexual violence, it only applies to those who filed a police report, even though the majority of sexual assaults are not reported.
Additionally, some pregnant adolescents have another hurdle to clear: navigating the legal system. In Georgia, minors are required to obtain parental consent before getting an abortion. “Young people under the age of 18, who can’t have that conversation with their parent [to ask for consent], have to go through the process of getting a judicial bypass to be able to have an abortion,” says Njoku. That process—on top of Georgia’s mandatory 24-hour waiting period—could prevent many minors from accessing abortion care within the bill’s proposed timeline. According to one study, the process of procuring a judicial bypass in Texas delayed abortions by two weeks on average.
- Anyone who wants to choose whether to give birth to a child with a debilitating chromosomal or genetic condition
The heartbeat bill allows for abortions if the fetus is diagnosed with a condition that is “medically futile,” meaning one that is incompatible with life. But there are a host of devastating conditions—spina bifida, skeletal dysplasia, hydrocephalus, and Budd-Chiari syndrome, to name a few—that, while not necessarily “medically futile,” would lead to such a low quality of life for the infant that the family may want to terminate the pregnancy for compassionate reasons, Cwiak says. None of those conditions can be detected at six weeks.
Though the risk of a conceiving a child with chromosomal abnormalities increases with age, pregnant women of all ages—including carriers of genetic mutations or ones without a family history of genetic disorders—often choose to do comprehensive screening for such abnormalities.
The most reliable tests for detecting genetic conditions, such as Tay-Sachs or cystic fibrosis, are a CVS, which is performed no earlier than 10 weeks, and an amniocentesis, typically done in the second trimester, according to Jamie Dokson, a genetic counselor at an IVF clinic in Atlanta.
Dokson also points out that the bill’s definition of “medically futile” is too vague for doctors or parents to interpret. “There are many conditions that are often ultimately lethal in infancy or childhood, but not with certainty at the time of birth,” she says, citing Trisomy 18, Tay-Sachs, anencephaly, and type-2 osteogenesis imperfecta as examples. “Individuals affected by genetic conditions that are ultimately lethal may still survive for a year or more. Are these medically futile? How would we possibly know which 10 percent of babies with Trisomy 18 might live for more than a year?”
HB 481 won’t stop physicians from equipping their patients with all of the knowledge available to them. “Because I follow standards of care, I’m still going to offer my patients all of the screening,” says Cwiak. But, under this legislation, if that screening shows abnormalities that don’t fit the bill’s definition of “medically futile,” and if out-of-state travel isn’t an option, then the patient would be forced to continue the pregnancy.
“That fetus might have a high chance of death before delivery, death after delivery, or death within the first year, and certainly it could have a considerable amount of suffering in the meantime,” Cwiak says. “So that’s why we say that it is, in essence, an abortion ban—because they’re not even giving women the chance to know that they’re pregnant, let alone the chance to initiate care.”