CHICAGO (AP) — The weeks after Kaniya Harris found out she was pregnant were among the hardest in her life.

Final exams were fast approaching for the college junior. Her doctors told her she had an ovarian cyst, and the risk of ectopic pregnancy was high. The wait times for abortion clinics near her city of Bethesda, Maryland, seemed impossibly long. And she couldn’t visit her family in Kentucky because of the state’s abortion ban.

Harris was having regular panic attacks. It all felt like too much, she said.

“My mental health was at the lowest point it’s ever been in my life,” said Harris, who had an abortion last May.

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As advocates push this year for ballot measure initiatives aiming to protect abortion rights, key differences have emerged in the language of proposed measures. Among them is the inclusion of mental health exceptions.

A Missouri proposal would allow lawmakers to restrict abortions after a fetus is considered viable, except if an abortion “is needed to protect the life or physical or mental health of the pregnant person.” A similar measure has been proposed in Arizona. In 2022, Michigan voters passed an abortion rights amendment with a mental health exception for viability limits.

Meanwhile, proposed ballot measure language in Arkansas only says “physical health,” excluding a mental health exception. Proposed abortion rights initiatives in other states, including Florida, Montana and Nebraska, don’t explicitly mention mental health.

“It’s heartbreaking to hear about these policies ignoring mental health,” said Harris, now 21. “An abortion can save someone’s life, including when they’re in a mental health emergency.”

Most states with abortion bans include exemptions for life-threatening emergencies, but only Alabama’s includes an exception for “serious mental illness” that could result in the death of the mother or fetus. Lawmakers added the provision after getting pressure from the state’s medical association, which was concerned about women at high risk for suicide.

The law, passed in 2019, was among the strictest abortion restrictions in the country at the time. It did not include exceptions in cases of rape or incest and considered performing an abortion to be a felony. Alabama began enforcing the ban in 2022 after the U.S. Supreme Court overturned Roe v. Wade, which once granted a federal right to abortion.

Abortion bans in at least 10 states — Florida, Georgia, Idaho, Iowa, Kentucky, Louisiana, Ohio, Tennessee, West Virginia and Wyoming — explicitly exclude mental health conditions as a possible exception. Others are murkier, allowing for exemptions for the “life and health” of the woman without defining if mental health is included.

Medical experts say even states that do allow mental health exceptions require patients to jump through hoops that may be inaccessible to some people, especially those with low incomes. Alabama, for example, requires a state-licensed psychiatrist with at least three years of clinical experience to certify the mental health condition as an emergency.

Some days, when Harris would get home from class, she would be “so overwhelmed that I’d have a breakdown on the floor,” she said. For two months, she cried every day. But facing an abortion ban in her home state and stigma from doctors, Harris said she didn’t feel comfortable speaking about her experience with a mental health professional.

“People shouldn’t have to jump through hoops and prove their pain to have access to the care they need,” she said.

Mental health conditions were the leading underlying cause of pregnancy-related deaths from 2017 to 2019 with nearly 23% of pregnancy-related deaths attributed to mental health conditions, including suicides and overdoses from substance use disorders, according to the U.S. Centers for Disease Control and Prevention.

About one in eight women experience postpartum depression, according to the CDC. But mental health struggles during pregnancy, especially the psychological trauma of those forced to carry unwanted pregnancies, are understudied, said Michelle Oberman, a Santa Clara University law professor researching the impact of abortion restrictions.

“These statistics, these stories of women’s suffering have been really haunting me,” Oberman said. “We don’t as a society have a great track record of treating mental health the same way we do physical health.”

Policies that dismiss mental health as less important than physical health put lives at risk, said Columbia University psychiatrist Paul Appelbaum. He said there is also growing evidence that being denied an abortion causes significant mental distress. This distress has been apparent in recent stories of women forced to flee their states or continue pregnancies despite serious risks to their health.

“I am extremely concerned by the exclusion of mental health exceptions in these ballot measures,” said Appelbaum, former president of the American Psychiatric Association. “It’s absolutely cruel and will lead to the suffering deaths of pregnant women in these states.”

Jayme Trevino, an OB-GYN in Missouri and fellow with Physicians for Reproductive Health, said she has seen first-hand how being denied abortion care can affect a patient’s well-being, including their mental health.

“It’s a devastating, regular reality for my patients,” she said, adding that she was grateful for the mental health exemption in the state’s proposed ballot measure language.

Mallory Schwarz, a spokesperson for Missourians for Constitutional Freedom, said the initiative’s language “is written to make sure that doctors — not politicians — are able to determine what’s best for their patients.”

Conversely, an Arkansas initiative only includes exemptions “to protect a pregnant female’s life or to protect a pregnant female from a physical disorder, physical illness, or physical injury.”

Previous versions of the proposal included broader exceptions, said Gennie Diaz, executive director of For AR People. Initially, she said, “We wanted to craft language for a constitutional amendment that would be as broad as possible and would hopefully account for something like mental health.”

But when handed a proposal with exceptions to “protect the life and health” of the mother, the state’s attorney general, a Republican, rejected the language, saying it must define “health.”

“That was a signal to us that we were going to have to make a choice,” Diaz said. “And another unfortunate factor is that the majority of Arkansas voters are unlikely to support mental health as a reason for an abortion after a particular timeframe. We felt it was unlikely for a version that explicitly names mental health to pass.”

Arkansas advocates were also worried the opposition campaign would target a mental health exception, Diaz said.

The National Right to Life Committee’s model state legislation for abortion bans explicitly excludes mental health exceptions. These exceptions allow pregnant women “to kind of bypass those laws and still abort pregnancies of children that were viable,” said Ingrid Duran, state legislative director of the NRLC.

“We specifically exclude mental health exemptions because we saw how that creates a loophole in a law and it leaves that unborn child at risk of dying for a sometimes treatable, sometimes temporary condition that the mother may be experiencing,” she said.

When asked if targeting mental health exceptions will be part of their strategy for campaigning against abortion ballot measures in 2024, she said, “I can’t necessarily say that would be part of the strategy.” Still, said Duran, “When I see mental health exceptions like this, my heart drops.”

Oberman from Santa Clara University said she expects to see the anti-abortion movement “employ a strategy of minimizing and dismissing the mental health consequences of forced pregnancy.”

“The mental health issues of pregnant people remain in the shadows and highly stigmatized,” she said. “And that clouds our judgment of what a medical emergency looks like during pregnancy.”

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