Abortion access could continue to change in year 2 after the overturn of Roe v. Wade

From the moment the Supreme Court decision overturning the right to an abortion was leaked last spring, researchers and pundits began to predict the consequences.

A year later, data is beginning to bring the real-life effects into focus. Over a dozen states have near total abortion bans, with several more state bans in the works. At least 26 clinics have closed. In Texas, nearly 10,000 more babies were born in the state since its 2021 "heartbeat bill" took effect.

The number of abortions that happened nationally declined, though not as much as many anticipated. Health care workers provided 25,000 fewer abortions through March 2023. For context, there were around 930,000 abortions in 2020 according to the Guttmacher Institute.

As the U.S. enters its second year without the abortion access provided by Roe v. Wade, NPR asked abortion researchers and clinicians what they expect will change in the year to come.

1. The entire Southeast could become an abortion desert

A growing number of states are taking steps to ban or severely restrict abortion. Researchers think as many as 25 states could ultimately do so.

"There are several states in the Southeast that are really essential to abortion access – Florida, North Carolina, Virginia, South Carolina as well," says Ushma Upadhyay, a professor and public health scientist at University of California San Francisco. She analyzed abortion data from providers for #WeCount, a project of the Society of Family Planning. She explains that there has been a surge of people traveling to those states for abortion in this first year, from places like Texas, Alabama, and Oklahoma.

But those states are either considering or beginning to implement new bans of their own. If and when those bans take effect, "it will cut off access for people in the entire Southeast," she says, from west Texas to halfway up the Atlantic coast.

What happens in Florida could have an especially big impact. It's a huge, populous state, with 21 million residents. Currently, abortion is legal there through 15 weeks, but governor and Republican presidential candidate Ron DeSantis is eager to change that. A six-week ban is on hold, pending a decision in a case challenging the current abortion law.

At a national convention of anti-abortion rights activists last month, attendees made clear their goal is to ban abortion in all states.

2. Doctors may start pushing legal boundaries more

Doctors who violate abortion laws can face the possibility of prison time, fines, and the loss of their medical license. There are a lot of unanswered legal questions about what exactly would violate these laws and what the consequences would be. Those questions remain unanswered because so far in the first year post-Roe, there have been no reported charges against physicians for providing illegal abortions.

"Doctors and institutions have been very careful," says Dr. Nisha Verma, an OB-GYN working in Atlanta who consults with the American College of Obstetrician Gynecologists. In Georgia, where she practices, abortion is illegal after six weeks of gestation, before many people know they are pregnant.

In places with abortion bans, health care providers often face situations where they must balance worrisome health risks to pregnant patients with compliance with the law.

For example, when a patient's water breaks too early, before 22 weeks or so, the pregnancy can't continue and the patient is at high risk of developing an infection. Many doctors and hospitals in states that ban abortion won't provide an abortion procedure unless the fetal heart has stopped or the pregnant patient's condition is severe enough that it's an emergency.

For cases like this, says Verma, "a lot of institutions have said ... even though [the patient's] risk of getting sick is super high, we can't provide care until they get sick."

This approach is called "expectant management" and the results may not be good for patients. Verma points to a study of 28 Texas patients who were only offered expectant management instead of immediate care after their water broke early. Most of these patients developed a serious condition, including 10 who developed infections, five who needed blood transfusions, and one who required a hysterectomy.

Bioethicists have argued that doctors and hospitals have a moral duty to err on the side of early intervention, and Verma thinks that may be starting to happen, including at her own hospital. "Now we're figuring out, how much can we push the envelope?" she says. "But it's scary – no one wants to be the test case."

She thinks, as doctors and hospitals get bolder, eventually a physician will get charged for providing an abortion – perhaps in the coming year. The questions are who, where, and what will the ensuing legal case change about abortion access.

3. A key abortion medication is in jeopardy

There's a lot of legal activity happening around one of the two medications used for at-home abortions: mifepristone. Since more than half of abortions in the U.S. are medication abortions, this could have huge ripple effects.

There are two conflicting federal cases at play. One judge in Texas ruled that the Food and Drug Administration improperly approved mifepristone; another judge in Washington ruled that FDA must preserve access to mifepristone.

For now, mifepristone is still available in states where abortion is legal, and nothing is expected to change until the Supreme Court hears arguments on the Texas case and issues a decision, which won't happen for many months.

"If medication abortion were meaningfully limited as a result of this [Texas] case – and that's a big 'if' – it would dramatically reduce abortion access, most especially actually in states right now that have the highest levels of access," says Middlebury College economics professor Caitlin Myers, who manages an abortion facilities database.

Many abortion facilities only provide medication abortions, not procedural abortions she says, so the decision could lead to many clinics shuttering. "California stands to lose more facilities than any other state if medication abortion were actually not available anymore.

"I don't know what will happen, but it could be bigger than Dobbs," in terms of its impact on reproductive health access, Myers says. "I think that's important for people to understand."

4. Some funding to protect abortion access may fizzle out

One reason abortions didn't decline as much as expected in the first year after Dobbs is because of a swell of support for abortion access that emerged in response, say Diana Greene Foster, the author of The Turnaway Study, a landmark research project documenting the long-term medical and social impacts of abortion on women's lives.

This support included abortion funds and online guides that provided women help finding appointments, raising money to cross state lines, and navigating the confusing legal landscape. "New funds popped up, people were generous," Greene Foster says. "There was a sense of emergency and funds came in."

But that might not last, she says. "I am worried about the resources drying up," she says. "On the other hand, the very first year is the year when the most resources are needed to set up the systems and get the word out."

5. A clearer view of what just happened will develop

It's actually not yet clear how many people who sought abortions couldn't get them in 2022, notes Upadhyay. Of the 25,000 fewer people who got abortions with health care providers, "we don't know how many of those 25,000 ended up self-managing their abortions [with abortion medication at home] and how many ended up continuing with their pregnancies," she explains. "We won't know until the birth data are released in about a year from now."

The true effect of abortion bans on the number of children born takes a long time to gather and analyze, in part because full-term pregnancies take nearly a year. Once the CDC releases 2022 birth data in the coming year, the number of people denied abortions will be easier to calculate.

6. Contraception access may increase but it won't change demand for abortion

The FDA appears likely to approve over-the-counter birth control pills this summer. But both Greene Foster and Upadhyay doubt that will have a big impact on the need for abortion.

"People want to hear that there's some silver lining and contraceptive use is going to go up," Greene Foster says. "But most people who become pregnant and seek abortion were already using a contraceptive method." Every birth control method has failure rates.

Upadhyay agrees. "There will always be a need for abortion," she says. "No matter how careful people are or how responsible they are trying to be, people always need abortions."

7. 'Sanctuary' states might go further to protect patients and doctors

As patients have to travel farther and raise more money to access abortion out-of-state, their care may be delayed until further along in pregnancy. Upadhyay did an analysis that found that abortion providers have increased their use of telehealth and begun offering care later in pregnancy to meet the needs of patients.

Many states have passed "shield" laws to protect out-of-state patients and the doctors who treat them. But Upadhyay notes, some of the same states that are spending millions to increase access to abortion, have their own abortion restrictions.

"So many states that proclaim to be protective of abortion rights actually have gestational limits at viability," Upadhyay says. In rare cases, these limits could present obstacles to parents in difficult and tragic circumstances. States with these limits include California, Illinois, New Mexico, Massachusetts, New York, and others.

Upadhyay says she hopes that these states will do more to increase access to abortion, especially since residents in states with no access have farther to travel.

Edited by Carmel Wroth.