Abortion Restrictions Worsen Racial Inequities in Maternal Care

Aziza Ahmed

Sept. 23, 2024, 3:30 AM CDT

Shifts in abortion law, with some states banning abortions altogether, have had a wide impact on maternal and child health. This generalized crisis heightens an already acute issue for racial minorities accessing health care.

Almost immediately after the Dobbs v. Jackson Women’s Health decision, patients of all backgrounds began reporting an inability to access necessary abortion procedures due to delayed medical interventions and inability to access care. Many of the laws that restricted abortion did so by penalizing doctors through threatening medical licenses and sanctions, fees, and even jail time.

The result was predictable. Physicians are hesitant to work in jurisdictions where they can’t provide complete and necessary care, and medical education fails to adequately prepare medical students to provide maternal health care.

Black and Indigenous individuals are more likely to live in jurisdictions where there are abortion restrictions. This is a crisis based on explicit and implicit racism as well as race-based medicine built into the technologies that physicians use.

Racial bias, both explicit and built into the medical care infrastructure, is the only rationale for many ongoing crises of care. This is particularly in the context of morbidity—the maternal mortality for Black patients whose maternal mortality rate is three times that of Whites, according to 2021 research from the Population Reference Bureau, even when controlling for class. Racism is a difficult phenomenon to measure, but some health outcomes seem to point to it as a controlling force in health disparities.

While racism typically is understood to be invidious and intentional, it’s often built into the technologies used for medical care. A doctor can act with the best intentions and still hurt patients.

In many instances, race appears as an adjustment or variable in a diagnostic or predictive tool. Knowing race is an arbitrary categorization of people means, it’s necessary to ask what the race category might be masking regarding social and economic inequalities structuring health outcomes.

In the maternal health context, one example stands out: a device built to understand success of vaginal birth after caesarean section—the VBAC calculator. It has a race adjustment that shows Black women are less likely to have a successful vaginal birth after caesarean.

In recent years, researchers have questioned the use of race in the VBAC calculator. The American College of Obstetrics and Gynecologists noted that race adjustment could reflect the “impact of systemic racism, social determinants of health, and clinician bias” rather than biological differences between the races.

Racism and structural factors such as poor housing, exposure to environmental toxins, and food deserts are being masked by using a race adjustment in clinical tools. For racial minorities, structural, clinical, and technological biases then compound an existing problem of unequal outcomes.

One intervention to alleviate the compounded harms in the maternal and child health space is ensuring quality medical education that addresses both racial inequalities and the full range of obstetric and gynecological interventions. This would include ensuring that providers are trained to recognize racial bias and question the assumptions built into clinical calculators to predict outcomes.

But medical education itself is being attacked. In some jurisdictions, after Dobbs, medical student residents aren’t getting the necessary education to provide abortions. The American College of Obstetricians and Gynecologists has been sounding the alarm about the failure to provide robust training on abortion and its impact on patient care and the skills of future providers.

While maternal care has always been hard to reach in certain parts of the US, such as the Midwest and South, maternity care deserts are growing. There is a link between states with abortion restrictions and poor maternal health care. This makes sense, as physicians are less likely to practice where they face prosecution and can’t make the best decisions for and with their patients.

A lack of training, furthered by attacks on diversity, equity, and inclusion in universities, is now affecting medical schools. Given that a history of racial subordination affects health in countless ways, banning the ability to discuss race will limit understanding of how racial bias operates in medical training and practice.

When the US Supreme Court overturned the federal right to abortion, it justified the decision in part on the fact that states could enact laws on abortion that were closer to the will of the people in those jurisdictions. In a sharp rebuke, the dissenting justices pointed to the crisis that now has emanated from the decision and certainly harmed maternal health.

The crisis is here and will continue without strong action from federal and state governments to protect the right to abortion access and ensure a robust understanding of the role of race in health.

This article was originally published by Bloomberg Law.