How new abortion laws could spell more deaths for Black women

It has become a common television and movie cliché, although it happens to just 10 percent of women as their due date approaches: Suddenly their water breaks, signaling the birth is near.

Before 20 weeks of pregnancy, the breaking of the amniotic sac signals dire peril to mother and child and the need for urgent medical intervention.

In the face of Florida's new abortion restrictions, however, physicians find themselves in a desperate quandary. They can either face possible prosecution for terminating the pregnancy or put their medical training aside and wait until the onset of blood poisoning indicates a woman's life is in immediate danger.

While rare, it is one of many problems that can make a pregnancy suddenly dangerous, For reasons spanning social barriers to health and health care, it happens most frequently to women who are Black.

It also is one of many situations in which, physicians say, two new laws — the 15-week ban and 24-hour delay — can keep them from providing established standards of care to pregnant patients.

A Palm Beach Post investigation has found that Florida's new laws compromise access not only to abortion care but to routine and emergency care, endangering the lives and health of women and children across the state.

The implications are gravest for Black women, who have the highest death rates related to pregnancy in the nation and in any industrialized country.

At the same time, the state pays loosely monitored faith-based centers focused solely on persuading women with limited resources to carry pregnancies to term.

2 Florida abortion laws complicate care for most vulnerable patients

Together, the two laws that went into effect this year have the power to put abortion access out of reach for the most fragile people seeking to end pregnancies, including young women and those living in poverty. The laws threaten Black women, whether they live in poverty or affluence.

A week after the U.S. Supreme Court's June decision overturning Roe v. Wade, Florida's abortion ban went into effect, barring women whose pregnancies are 15 weeks or more from obtaining abortions unless two doctors certify the woman will die or that the fetus has an immediately fatal condition.

Planned Parenthood sued to stop the ban, saying it would harm women.

The state countered that the ban would protect women from the risks of the procedure at a later stage of pregnancy than when most abortions take place and would protect fetuses from pain.

Dr. Shelly Tien, who specializes in maternal fetal medicine, testified for Planned Parenthood that abortion in a medical setting at 15 weeks was generally safe and markedly safer than the three alternatives: an abortion outside a medical setting, an abortion delayed by travel to a state where a post-15 week procedure is legal, and childbirth. She also explained that at 15 weeks, fetuses lack the neurological development to feel pain.

Dr. Maureen Condic, who identified herself as "an animal biologist" who "does not work on humans" testified for the state. She said that pain "has many different dimensions" and estimated that human fetuses can experience pain as early as 12 weeks.

Finding the state witnesses' testimony "runs counter to credible and scientifically supported evidence," Leon County Circuit Court Judge John Cooper ordered an immediate stop to enforcement of the ban. An immediate appeal by the state kept it in effect.

The ban includes no exception for rape or incest.

A physician who terminates a pregnancy that is 15 weeks or longer, outside of the exceptions, could be charged with a third-degree felony, punishable by up to five years in prison.

Of more than 50,000 abortions in Florida so far this year, about 90% were in the first three months of pregnancy. Women who decide to or must have an abortion later may be in the greatest jeopardy if not able to get one.

Since April, the state's 24-hour delay law has added a potentially insurmountable obstacle to both abortions and emergency health care.

Legislators who wrote the law argued that requiring women to pay one visit to the abortion provider to discuss the procedure and the option to cancel it, and one at least 24 hours later for the procedure itself gives women time to consider their decision.

Sen. Anitere Flores, a Miami Republican and sponsor of the bill in 2015, called the law "an opportunity to reflect on a major decision . . . a major medical procedure that will have lifelong effects, not just physically but mentally as well."

Legal abortion is not considered a major medical procedure and, according to the National Academies of Sciences, it's not nearly as risky as other outpatient procedures such as colonoscopies, dental work, plastic surgery and tonsillectomies. It also is significantly safer than childbirth.

No data support the claim that having an abortion results in lifelong emotional effects. In fact, stability in their lives and meeting their goals improved for women who obtained wanted abortions, a five-year Turnaway study found.

"It is wrong in its premise that women who desire to have an abortion have not already spent more than 24 hours considering their decision," said then-Rep. Lori Berman, a Democrat representing Delray Beach and now a state senator.

More than 60% of women obtaining abortions in Florida, as across the country, have one or more children.

The 24-hour delay poses challenges that include additional time off work and childcare and explaining the additional absence from home or work.

After Roe, Black women's maternal deaths dropped by a third

Last year, as the Supreme Court prepared to rule on Dobbs v. Jackson Women's Health Organization — with the constitutional right to abortion at stake — a group of economists weighed in with a court brief, showing the effect of the 1973 Roe decision in the lives of women since.

The right to safe, legal abortions had led to increased achievement in educational and career goals as well as steep drops in maternal deaths. Black women had benefited the most in all areas, and their maternal deaths dropped by roughly a third.

A 2003 National Academies of Sciences paper, however, showed that equal access to quality health care continued to elude Black Americans regardless of income. Unacknowledged biases and stereotypes and insurance reimbursement that incentivizes short patient visits are among the factors.

Studies since have explored the possible causes of health conditions that affect Black women more than white.

One is the premature rupturing of the amniotic sac, and another is benign uterine fibroid tumors that can complicate childbirth and occur in four times as many Black women as white women. Stress caused by routine exposure to discrimination and bias contribute to pregnancy risks even among affluent Black women, research suggests.

Four out of five maternal deaths are preventable, according to the most recent data released in September from the Centers for Disease Control and Prevention.

Back men and women make up 13% of the U.S. population, yet Black women account for 30% of maternal deaths, with cardiac conditions leading the underlying cause of those deaths.

On a patient survey used to identify at-risk pregnancies, the accumulation of six points indicates possible risk. Smoking cigarettes gets one point. So does drinking alcohol. Not wanting to be pregnant just before becoming pregnant also counts for one point.

Six points highlight a risk on a survey given to prenatal care providers in Florida. Smoking cigarettes gets one point. So does drinking alcohol.

Being Black counts for three points. Only previously having had a child born three weeks or more premature, underweight or stillborn — counts for as many points.

Statewide, from 2018 to 2020, Black women's maternal death rate was more than twice that of white women.

University of Colorado researchers estimated in a study recently that a national ban on abortion could increase maternal deaths overall by 24% and by 39% for Black women. Florida would see the biggest leap with 13 more women dying each year — a 29% increase.

ER staff worried they'd be prosecuted for treating woman who was hemorrhaging

Florida overturned its abortion ban a year before the 1973 Roe v. Wade decision legalized abortion nationally. In 1997, state legislators passed the "Right to Know" law that required health providers to give specific information to women seeking abortions. Counseling any patient on the risks of medical care was already standard medical practice.

Now, the 24-hour delay along with the 15-week abortion ban have begun to change standards of routine and emergency medical practice, physicians say.

A young South Florida woman, who was 17 weeks' pregnant, was hemorrhaging when she appeared at a local emergency room on a Saturday evening. She had learned a week or two earlier that she was pregnant. Concerned about prosecution without an immediate threat to her life, emergency room staff did not treat her and referred her to an abortion provider. None would open until Monday.

By Monday, she had to be wheeled from the car to the clinic's doors. The doctors there then had to address the infection that had ensued.

In Broward County, a physician told Planned Parenthood about a woman who was 20 weeks pregnant on June 29 when the fetus was diagnosed with a genetic condition that causes seizures, intellectual disability and a range of physical and medical challenges. Due to the15-week ban set to go into effect July 1, she had less than 48 hours to decide. The next day, she chose to end her pregnancy.

At her 16-week visit, her doctor had seen nothing of concern. This syndrome is not detected prior to 18 weeks. Today, she would have had to leave the state to carry out the choice she made at week 20.

Are doctors too afraid to treat? Enforcement of new laws is strict

Providers' caution has been reinforced by rigorous monitoring and enforcement of Florida's new rules as well as by the interpretation of laws in other states.

In April, the Florida Agency for Health Care Administration, which monitors abortion providers, has filed with the state three complaints against three clinics they said violated the 24-hour delay.

Potential fines against one clinic totaled $193,000. At another clinic, inspectors said three procedures had taken place 21 to 22 hours after counseling with a $1,000 fine for each.

The potential for unpredictable enforcement of more ambiguously worded laws has confounded physicians outside of abortion facilities.

An example, says Dr. Shelly Holmström, past president of the Florida Obstetric and Gynecologic Society, could occur when a pregnant woman's amniotic sac ruptures before 24 weeks, a time that an when a prematurely born infant's chances of surviving is doubtful. With a risk of infection for the woman, a doctor would normally counsel the patient of the risks and potential need to end the pregnancy.

Now, the new restriction is chilling. "If you're not familiar with the law, there's a lot of fear."

The confusion has already spurred a demand from doctors for guidance.

A committee at the University of South Florida in Tampa, where Holmstrom teaches medicine, is developing a list of medical situations potentially affected by the new restriction and advice on how to respond.

The fear remains, said Holmström, who is not a member of the committee, that a condition not included on the list could leave a physician vulnerable to prosecution for too wide an interpretation of "life-saving."

"To legislate how to provide care when it's in direct conflict with science is not evidence-based, it's not patient focused," she said. "Regardless of what you think, it's in direct conflict with science."

Limiting emergency care for pregnant women also conflicts with federal law.

The 1983 Emergency Medical Treatment and Labor Act required all hospitals with Medicare provider agreements to provide stabilizing care in their emergency departments, regardless of ability to pay. Seeking to put an end to patient dumping, the act is widely considered a landmark civil rights advance.

The June overturn of Roe set off state "trigger laws," criminalizing abortion even when a woman's life is threatened. The Centers for Medicare & Medicaid Services responded by reiterating that the right to stabilizing emergency medical treatment under federal law overrides state abortion bans.

Texas Attorney General Ken Paxton sued the administration. Following a Texas judge's ruling in the state's favor, the centers now say the federal law can't be enforced in Texas. There, a doctor can be prosecuted for providing rather than withholding care from a pregnant woman.

Florida Attorney General Ashley Moody did not join her colleagues from 20 states and the District of Columbia in a court brief challenging Texas' suit.

Essential needs, services far away for some

By car from Mar-a-Lago, former President Donald Trump's Palm Beach estate that hosts lavish galas attended by billionaires, to one of the most impoverished towns in the nation takes under an hour without a single turn.

By bus, the trip to Belle Glade takes twice as long with luck making connections to routes that zigzag across Palm Beach County.

Evidence persists in Belle Glade of abysmal work and living conditions first highlighted there more than 60 years ago in the television documentary "Harvest of Shame."

More than 60% of residents are Black, and more than 40% of females live below the poverty line.

Residents of Belle Glade seeking to end an unintended or unwanted pregnancy – because of a high-risk health condition or because their circumstances are precarious — may need to take the bus.

Lakeside Medical Center serves Belle Glade and produces an annual report assessing the community's health that showed more than 1 in 4 people there had no access to a vehicle. Consistent sources of fresh produce and dietary choices considered essential to sound health are hard to find.

Nearly half of Belle Glade women who gave birth in 2020 were overweight when they became pregnant, a condition associated with multiple birth complications, including dangerously high blood pressure, gestational diabetes, pre-term delivery and infant death, according to the report.

Mental health conditions leading to suicide and overdose or poisoning related to substance use disorder were the leading underlying cause of pregnancy-related deaths in the CDC data. Florida's 15-week abortion ban, however, excludes "psychological conditions" as threats to a woman's life.

Most of the pregnant women treated for substance use disorders at the Family Treatment Center in Lantana are not in a relationship. Most are homeless. Mental illnesses — bipolar and other mood disorders, schizophrenia and post-traumatic stress syndrome — exacerbate the challenges many of the patients there face.

Pregnancy can restrict some medicines that treat some mental illnesses. An untreated mental illness leading to a manic episode, however, also can harm the fetus.

Substance use disorders are dominant drivers of behavior, Family Center founder and owner Dr. Robert Moran says. For a person whose disorder is not treated, nutrition, health and safety can be impossible to attain.

Recently a woman in her 30s discovered she was in her third month of pregnancy. She planned to continue the pregnancy. When a doctor told her the psychiatric medication she was taking would harm the fetus, she switched to another. It didn't work.

As she descended into a deepening depression, she began to fear she would take her own life. As she considered an abortion, she discussed her decision in group therapy and with Moran, who advised her that the depression might be adding to her feeling of hopelessness about her pregnancy.

She had little time to decide. The 15-week abortion ban was in effect, and she had underestimated the duration of her pregnancy at her one and only prenatal visit.

"She made the difficult decision to abort," he said. She is back on her effective medication and proceeding with her recovery.

A patient who came to the Presidential Women's Center in West Palm Beach recently was not as fortunate. Because she was more than 15 weeks pregnant, the law dictated that she leave the state to terminate her pregnancy, so she traveled to North Carolina to have her procedure. There, on her own, she succumbed to her addiction. The procedure, which would have required sedation, was cancelled. The center has not heard from her since.

Misinformation from state-financed 'pregnancy resource centers'

The primary purpose of a woman's first visit to a clinic is to receive the state-sponsored pamphlet depicting and describing fetal development and what the title calls "Alternatives to Abortion."

Those include places offering nonmedical and often faith-based services that the state began to fund in 2006.

The centers endanger women and girls by diverting them from needed services and information, with the greatest effects on those most in need of support – impoverished and Black women and girls, research by top universities. and medical associations concluded.

In 2018, Florida made the funding permanent with $4 million annually going to centers that are part of the "Florida Pregnancy Care Network." Contracts overseen by the state's Health Department require the centers provide their services "in a noncoercive manner" and "not include any religious content."

Antigone Barton is a journalist at The Palm Beach Post, part of the USA TODAY Florida Network. You can reach her at [email protected]. Help support our journalism. Subscribe today.