Missouri’s ban on abortion has had sweeping effects on health care, abortion rights advocates say — even though restrictions were already so severe many deemed the state “post-Roe” long before the landmark case was overturned.
Saturday marks one year since the Supreme Court overturned the constitutional protections for the right to access abortion in the decision Dobbs v. Jackson, which left it up to states to determine abortion regulations.
Missouri, just minutes after the decision, was the first state to ban abortion.
“Even under Roe, abortion was largely inaccessible in Missouri and Missourians were already forced to flee the state to access this basic essential health care,” said Mallory Schwarz, executive director of Abortion Action Missouri (formerly Pro-Choice Missouri). “The game has definitely changed.”
In the years before the Dobbs decision, Missouri lawmakers and the state health department made it more difficult to access abortion, including by instituting waiting periods, parental consent laws, requiring patients receive a pelvic exam for a medication abortion and challenging abortion providers’ licenses.
“As a lobbyist for a number of decades, part of the legislation we would try to pass would be to attempt to chip away at Roe v. Wade,” said Sam Lee of Campaign Life Missouri, who has lobbied against abortion for decades.
“There weren’t a whole lot of abortions being done before the Dobbs decision,” Lee said. “Those women were going to Illinois or Kansas beforehand.”
The clinics in bordering states that Missourians had long traveled to for abortions have recently been flooded with patients from across the country, delaying care even as the clinics have raced to expand hours and keep up.
Advocates for abortion access also say the decision has had spillover effects on other parts of health care, sowing confusion over the legality of contraception and concern over doctors’ discretion to provide emergency abortions.
“It’s not just folks who need abortion that are impacted. It is pregnancy care more broadly. It is folks who need medication…to treat their chronic non-pregnancy related medical conditions,” said Colleen McNicholas, chief medical officer at Planned Parenthood in the St. Louis Region and Southwest Missouri.
“And this is in a state that is at the bottom of the list for maternal mortality and morbidity,” she added.
In the last year in Missouri, a hospital was cited for violating federal law by denying a patient an emergency abortion.
And the fight over putting abortion rights on the ballot continues to drag through the courts, with opposition from the state’s attorney general.
“While we believe that if Missourians had a chance to vote at the ballot box for abortion access that abortion access would win,” Schwarz said, “right now, there is so much remaining to be seen in what happens in the process that is underway.
“In the meantime, we are prepared to, and are using, every tool that we can to continue to build back that access.”Diminishing access
In 1982 Missouri had 29 abortion providers and they performed 19,226 abortions, the most in any year since the Roe decision.
By the time Roe fell, there was just one remaining abortion provider in Missouri and fewer than 100 abortions in the first half of 2022. Most Missourians – more than 3,000 – seeking abortions in 2020 did so outside of Missouri.
The Dobbs decision brought more and more patients to the clinics Missourians had come to rely on.
The Planned Parenthood clinic in Fairview, Illinois, just miles from St. Louis, reported a 700% increase in patients from outside the bistate region of Missouri and Illinois in the 11 months after June 24, 2022.
“Before, we were able to get a patient in for abortion care within two to three days,” McNicholas said. “And now our wait times fluctuate between two and three weeks.”
Long wait times can cause patients to delay care beyond when they’d like for a procedure in which time is of the essence, sometimes causing higher-riskabortions.
The spillover effects, advocates say, extend to pregnancy care and other realms of health care.
Some advocates in Missouri and nationally have pointed to situations where doctors deny pregnant patients abortion-related care for fear of violating their states’ laws — potentially endangering the patient.
Medical uncertainty
Under Missouri’s “trigger law” law, passed in 2019, abortions are only permitted in cases of a medical emergency to prevent the death of the pregnant woman or when “a delay will create a serious risk of substantial and irreversible physical impairment of a major bodily function.”
Health care providers who violate the law can be found guilty of a class B felony, which can result in five to 15 years in prison, and have their medical license suspended or revoked — it’s up to local prosecutors and the attorney general to enforce that, and so far no doctor has been prosecuted under the Missouri law. People who receive abortions cannot be prosecuted in violation of the law.
The first confirmed federal investigation of an alleged denial of abortion to a woman in a medical emergency was in Missouri last year.
Mylissa Farmer first visited Freeman Health in August of last year, according to a federal report, when her water broke after almost 18 weeks of pregnancy.
She was allegedly told her pregnancy was no longer viable but that the hospital could not terminate it because it was not immediately life-threatening for her and Missouri law prohibits abortions if a fetal heartbeat is detectable.
The Missouri hospital was cited for denying an emergency abortion by federal regulators.
Regarding the prospect of pregnant patients being denied emergency care, Lee, the anti-abortion lobbyist, said “I don’t have any data to suggest that that’s true.”
“So many women were leaving the state anyway, I don’t know if this is making a difference,” he said. “Literally just handfuls of women were having abortions in Missouri before the Dobbs decision, so I don’t know if there’s a difference now anyway.”
Since the Dobbs decision, Lisa Cox, spokesperson of the Department of Health and Senior Services, said, there have been 35 abortions reported to the state, which were under the medical emergency exemption.
There is not yet national data to provide a comparison with other states and prior years’ state abortion data does not identify abortions that were performed because of emergency.
Contraceptive confusion
Another consequence of Dobbs, said Michelle Trupiano, executive director of Missouri Family Health Council Inc., has been confusion around the legality of contraception.
Soon after Dobbs, a group of hospitals in Kansas City briefly stopped providing emergency contraception, which remains legal, and Trupiano said she fielded questions from providers and patients about contraception.
“And that was immediately, within the first few hours,” Trupiano said at a roundtable event in St. Louis on Friday, “and we still see that confusion across the state when it comes to emergency contraception.”
A poll conducted by the health policy research nonprofit KFF this year found that one-third of American adults said they are “unsure” if emergency contraception is legal in their state, though it is legal in all 50 states. Confusion about its legality is more pronounced in states where abortion is banned, the poll found. (That does not, however, show a difference in change over time — whether people are more confused now than pre-Dobbs.)
The emergency contraception pill works similarly to birth control pills, generally to prevent ovulation, but most adults incorrectly believe it can end early pregnancy, KFF found.
“Patients are scared. They’re confused. They don’t know who to trust for accurate information,” Trupiano said. “Providers feel that they’re on very shaky ground, some even choosing to leave the state in order to fully practice without repercussions. And we’ve spent so much time combating that misinformation.”
Political clash ahead
A central goal of many abortion rights advocates in Missouri is to put abortion on the ballot — reversing Missouri’s abortion ban by enshrining reproductive rights in the constitution.
Advocates have submitted 11 different versions of a ballot proposal to protect the right to reproductive freedom.
Abortion rights won broad support in states where the issue was on the ballot last year, including neighboring Kansas.
The legislature this year failed to pass a bill seeking to make it harder to amend the state constitution through the initiative petition process. Republicans pushing the bill argued initiative petition measures allow laws to be easily changed by big-money out of state interests.
Legislative leaders made it clear the effort to increase the majority needed to pass a constitutional amendment was intended to block an abortion initiative.
“If the Senate fails to take action on (initiative petition) reform, the Senate should be held accountable for allowing abortion to return to Missouri,” House Speaker Dean Plocher, R-Des Peres said hours before session adjourned.
House Minority Leader Crystal Quade, D-Springfield, thanked Plocher for saying “the quiet part out loud.”
Though the legislature did not succeed in changing the initiative petition process, Attorney General Andrew Bailey is doing everything he can to prevent it from making the ballot. He is currently arguing he can refuse to certify a fiscal note summary on the cost of an abortion amendment in a case now in the state Supreme Court.
Lee said one focus of anti-abortion groups in the state is defeating any ballot measure that arises.
He added that the anti-abortion movement needs to adjust to the reality of people ordering medication abortion by mail — that Dobbs “didn’t end the battle. It just changed the battleground,” he said.
“That just changes our emphasis,” Lee said, “and particularly, an emphasis on making sure that Missouri’s pregnancy centers and maternity homes and other safety net programs are even more available to women who are considering having an abortion.”
Legislation sponsored by Sen. Mike Moon, R-Ash Grove, to impose criminal penalties on women seeking abortion, did not advance very far. Both Lee and Susan Klein, who directs Missouri Right to Life, opposed the bill.
Abortion rights advocates, Schwarz said, are working on several fronts: providing information about and access to contraception, canvassing and involving themselves in local municipal elections “to build in protections for people at the local level, even while the state continues its attacks.”
McNicholas said the effects of Dobbs are, after just one year, still unknown and emerging.
“It will take probably decades before we see the full impact of abortion bans,” McNicholas said. “…This singular issue of abortion bans has impacted health care much more broadly than just abortion alone.”
This story was originally published on the Missouri Independent.
