Medical exceptions to abortion bans often exclude mental health conditions
More than a dozen states now have near-total abortion bans following the overturning of Roe v. Wade, with limited medical exceptions meant to protect the patient’s health or life.
But among those states, only Alabama explicitly includes “serious mental illness” as an allowable exception. Meanwhile, 10 states with near-total abortion bans (Florida, Georgia, Idaho, Iowa, Kentucky, Louisiana, Ohio, Tennessee, West Virginia and Wyoming) explicitly exclude mental health conditions as legal exceptions, according to an analysis from KFF, a health policy research organization.
Abortion rights advocates and mental health experts say those laws could put women’s lives at risk. A report released last year by the federal Centers for Disease Control and Prevention analyzing maternal deaths between 2017 and 2019 found that that pregnant women and new mothers were more likely to die from mental health-related issues, including suicides and overdoses from substance use disorders, than any other cause. Mental health conditions in total accounted for 23% of maternal deaths with an identified cause.
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Even before the U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization last year overturning the federal right to abortion, women with mental health problems faced disproportionate barriers to getting an abortion, said Sarah Roberts, a researcher with the University of California, San Francisco’s Advancing New Standards in Reproductive Health program.
Fewer than 20 states have state-funded perinatal psychiatry access programs. Thirty-eight states and Washington, D.C., have extended Medicaid coverage for 12 months postpartum, but fewer mental health practitioners accept Medicaid or private insurance compared with other specialties, making it harder for patients to get care.
“People who reported using more substances or having more mental health conditions were more likely to report a policy-related barrier to obtaining an abortion,” Roberts said. In the aftermath of Dobbs, she said, “There’s no reason to believe that things would have become easier.”
Low-income women are disproportionately affected by bans, making cost and travel burdens to get abortions elsewhere. Additionally, the Hyde Amendment, a federal rule renewed annually since 1976, restricts use of federal dollars, including federal Medicaid funds, for most abortions. While 17 states have state-only abortion funds, Hyde affects about 7.8 million reproductive-aged women across more than 30 states where it has effect, according to reproductive health research organization the Guttmacher Institute. Half of those affected are women of color.
Joy Burkhard, the founder and executive director of the Policy Center for Maternal Mental Health, a California-based national nonprofit and think tank where Herrick is a project manager, said the issue should be a bipartisan opportunity to “put systems in place to support women’s mental health delivery.”
Burkhard also stressed that an already taxed health care workforce will be further stressed as more women give birth post-Roe and need care. A report by inequities research organization Mathematica estimated untreated maternal mental health conditions cost $14.2 billion for births in 2017, or $32,000 on average for every untreated mother and her child.
“Everyone’s going to be waiting longer, struggling to access care — and no one’s talking about that,” she said.
Already, an estimated three-quarters of women with mental health conditions are untreated, according to the nonprofit advocacy group Maternal Mental Health Leadership Alliance.
“They need to be offered (mental health care) in a way that a birthing person doesn’t have to scramble to find those services,” said Isha Weerasinghe, a senior mental health policy analyst at the Center for Law and Social Policy, a national nonprofit based in Washington, D.C., focused on addressing poverty barriers.
She said policymakers need to define “medical necessity” for abortions more broadly, by considering what a pregnancy and birth will mean for a woman’s mental health.
Many of the states with strict abortion bans have large communities of color, and Black women are three times as likely and Indigenous women twice as likely as white women to die of pregnancy-related causes.
The CDC’s analysis found mental health-related conditions were the top cause of maternal deaths among Hispanic, white, and American Indian and Alaska Native mothers.
Black women also face disproportionate risk — twice as likely as white moms to suffer from a maternal mental health condition but half as likely to get treatment, according to the Maternal Mental Health Leadership Alliance.
The CDC’s analysis also included a specific report on maternal deaths for American Indian and Alaska Native people, who are more than twice as likely as white mothers to die of pregnancy-related causes but often undercounted in health data due to misclassification. More than 90% of these mothers’ deaths were preventable, the CDC analysis found, with most of their total deaths due to mental health conditions, followed by hemorrhage.
Dr. Allison Kelliher, who is Koyukon Athabascan, Dena, from Nome, Alaska, is a family medicine physician and a researcher at Johns Hopkins School of Nursing and Bloomberg School of Public Health Center for Indigenous Health. She’s practiced and taught medical students in North Dakota, and said the strict abortion bans ignore the disproportionate illnesses and lack of access to care Indigenous people in rural areas already face. Indian Health Service-run clinics are allowed to provide abortions only in rare circumstances, and patients are often forced to cross state lines or drive hours for care.
But, Kelliher said, many young Indigenous people may not have “the privilege of money, of a vehicle, of a provider who knows them.” In addition to disproportionate poverty rates, tribal women are at higher risk of violence and assault, all of which contribute to increased risk of mental health burdens, she added.
“When you couple that with the very stressful experience of pregnancy … you can see why we’re so vulnerable during that time, when we might be suffering from increased risk of mental illness,” she said.
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Some medications to treat psychosis or bipolar disorder, particularly lithium and valproic acid, may cause severe birth defects, especially during the first trimester, she said. Women on these medications are strictly placed on contraception.
But unexpected pregnancies may still occur.
“Say you do have a pregnancy that is unexpected, and you end up having a fetus that has a severe defect that for some may not result in a viable pregnancy, or if it does, can be extremely challenging and devastating,” Smalls-Mantey said. “A lot of options are restricted, and then the child, the mom, have a lot of challenges in their life going forward.”
“I just really fear for the people that don’t even have the resources, what options they’re turning to, and if even more women are becoming suicidal or attempting suicide as a result of this very sentinel event in their lives that they’re not ready for,” she said. “How desperate they could become that they would try to end their life.”