In South Dakota, too, official records show zero abortions that year.

And in Idaho, home to abortion battles that have recently made their way to the U.S. Supreme Court, the official number of recorded abortions was just five.

In nearly a dozen states with total or near-total abortion bans, government officials claimed that zero or very few abortions occurred in 2023, the first full year after the Supreme Court eliminated federal abortion rights.

Those statistics, the most recent available and published in government records, have been celebrated by anti-abortion activists. Medical professionals say such accounts are not only untrue but fundamentally dishonest.

“To say there are no abortions going on in South Dakota is ludicrous,” said Amy Kelley, an OB-GYN in Sioux Falls, South Dakota, citing female patients who have come to her hospital after taking abortion pills or to have medical procedures meant to prevent death or end nonviable pregnancies. “I can think of five off the top of my head that I dealt with,” she said, “and I have 15 partners.”

For some data scientists, these statistics also suggest a troubling trend: the potential politicization of vital statistics.

“It’s so clinically dishonest,” said Ushma Upadhyay, a public health scientist at the University of California-San Francisco, who co-chairs WeCount, an academic research effort that has kept a tally of the number of abortions nationwide since April 2022.

The zeroing out is statistically unlikely, Upadhyay said, and also runs counter to the reality that pregnancy “comes with many risks and in many cases emergency abortion care will be needed.”

“We know they are sometimes necessary to save the pregnant person’s life,” she said, “so I do hope there are abortions occurring in South Dakota.”

State officials reported a sharp decline in the official number of abortions after the Supreme Court overturned Roe v. Wade in June 2022.

• Arkansas reported zero abortions in 2023, compared with 1,621 in 2022.
• Texas reported 60 in 2023, after reporting 50,783 abortions in the state in 2021.
• Idaho reported five in 2023 compared with 1,553 in 2021.
• South Dakota, which had severely restricted abortions years ahead of the Dobbs ruling, reported zero in 2023 compared with 192 abortions in 2021.

Anti-abortion politicians and activists have cited these statistics to bolster their claims that their decades-long crusade to end abortion is a success.

“Undoubtedly, many Arkansas pregnant mothers were spared from the lifelong regrets and physical complications abortion can cause and babies are alive today in Arkansas,” Rose Mimms, executive director of Arkansas Right to Life, . “That’s a win-win for them and our state.”

A spokesperson for the Arkansas Department of Health, Ashley Whitlow, said in an email that the department “is not able to track abortions that take place out of the state or outside of a healthcare facility.” State officials, she said, collect data from “in-state providers and facilities for the Induced Abortion data reports as required by Arkansas law.”

WeCount’s tallies of observed telehealth abortions do not appear in the official state numbers. For instance, from April to June 2024 it counted an average of 240 telehealth abortions a month in Arkansas.

Groups that oppose abortion rights acknowledge that state surveillance reports do not tell the full story of abortion care occurring in their states. Mimms, of Arkansas Right to Life, said she would not expect abortions to be reported in the state, since the procedure is illegal except to prevent a patient’s death.

“Women are still seeking out abortions in Arkansas, whether it’s illegally or going out of state for illegal abortion,” Mimms told Â鶹ŮÓÅ Health News. “We’re not naive.”

The South Dakota Department of Health “compiles information it receives from health care organizations around the state and reports it accordingly,” Tia Kafka, its marketing and outreach director, said in an email responding to questions about the statistics. Kafka declined to comment on specific questions about abortions being performed in the state or characterizations that South Dakota’s report is flawed.

Kim Floren, who serves as director of the Justice Empowerment Network, which provides funds and practical support to help South Dakota patients receive abortion care, expressed disbelief in the state’s official figures.

“In 2023, we served over 500 patients,” she said. “Most of them were from South Dakota.”

“For better or worse, government data is the official record,” said Ishan Mehta, director for media and democracy at Common Cause, the nonpartisan public interest group. “You are not just reporting data. You are feeding into an ecosystem that is going to have much larger ramifications.”

When there is a mismatch in the data reported by state governments and credible researchers, including WeCount and the Guttmacher Institute, a reproductive health research group that supports abortion rights, state researchers need to dig deeper, Mehta said.

“This is going to create a historical record for archivists and researchers and people who are going to look at the decades-long trend and try to understand how big public policy changes affected maternal health care,” Mehta said. And now, the recordkeepers “don’t seem to be fully thinking through the ramifications of their actions.”

A Culture of Fear

Abortion rights supporters agree that there has been a steep drop in the number of abortions in every state that enacted laws criminalizing abortion. In states with total bans, 63 clinics have stopped providing abortions. And doctors and medical providers face criminal charges for providing or assisting in abortion care in at least a dozen states.

Practitioners find themselves working in a culture of confusion and fear, which could contribute to a hesitancy to report abortions — despite some state efforts to make clear when abortion is allowed.

For instance, South Dakota Department of Health Secretary Melissa Magstadt to clarify when an abortion is legal under the state’s strict ban.

The procedure is legal in South Dakota only when a pregnant woman is facing death. Magstadt said doctors should use “reasonable medical judgment” and “document their thought process.”

Any doctor convicted of performing an unlawful abortion faces up to two years in prison.

In the place of reliable statistics, academic researchers at WeCount use symbols like dashes to indicate they can’t accurately capture the reality on the ground.

“We try to make an effort to make clear that it’s not zero. That’s the approach these departments of health should take,” said WeCount’s Upadhyay, adding that health departments “should acknowledge that abortions are happening in their states but they can’t count them because they have created a culture of fear, a fear of lawsuits, having licenses revoked.”

“Maybe that’s what they should say,” she said, “instead of putting a zero in their reports.”

Mixed Mandates for Abortion Data

For decades, dozens of states have required abortion providers to collect detailed demographic information on the women who have abortions, including race, age, city, and county — and, in some cases, marital status and the reason for ending the pregnancy.

Researchers who compile data on abortion say there can be sound public health reasons for monitoring the statistics surrounding medical care, namely to evaluate the impact of policy changes. That has become particularly important in the wake of the Supreme Court’s 2022 Dobbs decision, which ended the federal right to an abortion and opened the door to laws in Republican-led states restricting and sometimes outlawing abortion care.

Isaac Maddow-Zimet, a Guttmacher data scientist, said data collection has been used by abortion opponents to overburden clinics with paperwork and force patients to answer intrusive questions. “It’s part of a pretty long history of those tools being used to stigmatize abortion,” he said.

In South Dakota, clinic staff members were required to report the weight of the contents of the uterus, including the woman’s blood, a requirement that had no medical purpose and had the effect of exaggerating the weight of pregnancy tissue, said Floren, who worked at a clinic that provided abortion care before the state’s ban.

“If it was a procedural abortion, you had to weigh everything that came out and write that down on the report,” Floren said.

The Centers for Disease Control and Prevention does not mandate abortion reporting, and some Democratic-led states, including California, do not require clinics or health care providers to collect data. Each year, the CDC requests abortion data from the central health agencies for every state, the District of Columbia, and New York City, and these states and jurisdictions voluntarily report aggregated data for inclusion in the CDC’s annual “.

In states that mandate public abortion tracking, hospitals, clinics, and physicians report the number of abortions to state health departments in what are typically called “induced termination of pregnancy” reports, or ITOPs.

Before Dobbs, such reports recorded procedural and medication abortions. But following the elimination of federal abortion rights, clinics shuttered in states with criminal abortion bans. More patients began accessing abortion medication through online organizations, including Aid Access, that do not fall under mandatory state reporting laws.

At least six states have enacted what are called “shield laws” to protect providers who send pills to patients in states with abortion bans. That includes New York, where Linda Prine, a family physician employed by Aid Access, prescribes and sends abortion pills to patients across the country.

Asked about states reporting zero or very few abortions in 2023, Prine said she was certain those statistics were wrong. Texas, for example, reported 50,783 abortions in the state in 2021. Now the state reports on average five a month. WeCount reported an average of 2,800 telehealth abortions a month in Texas from April to June 2024.

“In 2023, Aid Access absolutely mailed pills to all three states in question — South Dakota, Arkansas, and Texas,” Prine said.

Texas Attorney General Ken Paxton filed a lawsuit in January against a New York-based physician, Maggie Carpenter, co-founder of the Abortion Coalition for Telemedicine, for prescribing abortion pills to a Texas patient in violation of Texas’ near-total abortion ban. It’s the first legal challenge to New York’s shield law and threatens to derail access to medication abortion.

Still, some state officials in states with abortion bans have sought to choke off the supply of medication that induces abortion. In May, Arkansas Attorney General Tim Griffin wrote cease and desist letters to in the Netherlands and in New York City, stating that “abortion pills may not legally be shipped to Arkansas” and accusing the medical organizations of potentially “false, deceptive, and unconscionable trade practices” that carry up to $10,000 per violation.

Good-government groups like Common Cause say that the dangers of officials relying on misleading statistics are myriad, including a disintegration of public trust as well as ill-informed legislation.

These concerns have been heightened by misinformation surrounding health care, including an entrenched and vocal anti-vaccine movement and the objections of some conservative politicians to mandates related to covid-19, including masks, physical distancing, and school and business closures.

“If the state is not going to put in a little more than the bare minimum to just find out if their data is accurate or not,” Mehta said, “we are in a very dangerous place.”

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Their testimony is scheduled to lead off the second week of a closely watched trial concerning one of the nation’s strictest abortion bans. The case, brought by four women, two physicians, and a group of medical professionals, seeks to limit the extent of the state’s ban, which prohibits abortion in almost all circumstances except to prevent a pregnant woman’s death, to stave off “substantial and irreversible impairment of a major bodily function,” or if the pregnancy was a result of a woman or girl being raped.

Over three days in district court last week, the women who brought the case shared emotional testimony about serious pregnancy complications that forced them out of state for medical care. That testimony drew objections from , an attorney with Idaho’s Office of the Attorney General, who interrupted the women frequently arguing that the details of their stories were not relevant.

Craig pushed back on assertions that Idaho’s criminal abortion laws are endangering women’s health care, while also casting abortion procedures in a negative light. Craig called abortion “barbaric and gruesome” in an opening statement.

“Abortion laws prevent unborn children from being exposed to pain,” he said.

At one point in the trial, Craig suggested that women could use any medical condition to sidestep the law, describing a scenario in which a pregnant woman who stepped on a rusty nail could claim she was at risk of infection and thus entitled to an abortion.

If the court finds in favor of the women, Craig said, “women [would] have a right to kill their unborn baby anytime it’s disabled, anytime they have an infection.”

During the plaintiffs’ testimony, as the women described what happened to their bodies during their pregnancies, Craig’s repeated objections drew reprimands from the 4th Judicial District Court judge overseeing the case, .

The patient plaintiffs’ testimony drew a warmer response from Scott, who said the women’s “circumstances are very worthy of sympathy.”

The case has drawn national attention to Idaho’s ban, one of the first enacted after the U.S. Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization. As it proceeds, abortion rights advocates are watching to see whether court challenges — including in other Republican-led states, such as Tennessee, where a similar case is ongoing — will be successful.

The plaintiffs in the case are not seeking to overturn the Idaho ban but rather to enact medical exceptions to the law. Their prospects are unclear, though a similar challenge in Texas did not fare well.

As the trial played out in a Boise courtroom, Jillaine St. Michel sat with her husband as they tended to their 10-month-old son. St. Michel had faced a pregnancy in which her fetus developed in devastating ways — a lack of leg and arm bones, a missing bladder, fused kidneys. She was barred from ending her pregnancy.

“We were told in the state of Idaho an abortion was not legal, and my case was no exception,” she said. 

Instead, the family drove to Seattle for an abortion, she said, to spare the fetus she carried from further torment.

“The state talks about how barbaric it is, they keep using that term,” St. Michel said. “The idea of allowing your child to experience suffering beyond what is necessary, to me that feels barbaric. To put myself through that when that is not something I desired, that feels barbaric. To have that ripple down into my ability to parent my existing child, that feels barbaric.”

Earlier this year, the Texas Supreme Court ruled against 20 women and two OB-GYNs, upholding that state’s criminal law that allows abortion only to prevent a pregnant patient’s death. The court added one clarification ruling that abortions would be considered a crime when the amniotic sac breaks before 37 weeks of pregnancy, known as preterm premature rupture of membranes, because the condition can cause rapid and irreversible infection. That exception is not currently allowed in Idaho, and physicians who testified in the first week of the trial said they’d been forced to put their pregnant patients into cars and planes to receive abortions out of state.

In Idaho, a previous legal challenge to the state’s near-total abortion ban was rejected by the Idaho Supreme Court. In the case brought by Planned Parenthood, the justices wrote in a January 2023 ruling that the Idaho Constitution contains no right to an abortion, and that Idaho’s laws criminalizing abortion are constitutional.

This latest challenge, Adkins v. State of Idaho, comes on the heels of Donald Trump’s presidential victory. His Supreme Court appointments made way for the anti-abortion movement’s most vaunted goal of eliminating a woman’s constitutional right to abortion. 

Advocates for abortion rights say that a loss in the case would close off options for challenging bans.

“If this isn’t successful, it’s not really clear if there are really additional places to go for help,” said Gail Deady, a senior staff attorney at the Center for Reproductive Rights, a legal advocacy organization representing the plaintiffs.

Kayla Smith, one of the plaintiffs, sobbed during her testimony as she recalled suffering from preeclampsia during her pregnancy with her first child. When medication could not control the condition, physicians were concerned that the blood pressure disorder could cause Smith to have a stroke or seizure, so they induced birth early, and Smith delivered a daughter, who is now 4 years old.

She told the court her second pregnancy seemed normal until a routine anatomy scan showed her son had multiple lethal heart defects. She and her husband had named him Brooks.

Idaho’s abortion ban had taken effect two days earlier and no longer allowed a physician to allow women such as Smith to end a pregnancy involving lethal fetal anomalies.

Her husband recalled the moment when their doctor, Kylie Cooper, delivered the diagnosis. “I remember finally asking just her if Brooks was going to be able to survive, and Dr. Cooper, she broke down. And the three of us just cried. And I understood that we were helpless in Idaho at that point,” James Smith said.

Despite a frantic search, the Smiths could not find a fetal surgeon who would operate on Brooks. His heart could not be fixed.

“My son wasn’t going to survive,” Kayla said in an interview. “We wouldn’t bring a baby home. And we also didn’t want him to suffer, so we just decided to do the most compassionate thing for him and also for me.”

Idaho’s criminal abortion laws required either that Kayla stay pregnant until her condition deteriorated and an abortion would be needed to prevent her death, or that she give birth to Brooks, who would not survive.

“I was not willing to watch my son suffer and gasp for air,” she said about the couple’s decision to end the pregnancy.

The Smiths drove with their toddler to Seattle, where physicians induced labor at about 20 weeks into her pregnancy, and Kayla and James were able to hold Brooks, who did not survive.

Attorneys for the state of Idaho are expected to call one witness this week, Ingrid Skop, an OB-GYN anti-abortion advocate.

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“I didn’t really have a lot of knowledge about abortion care,” she said.

After Roe v. Wade was overturned, she watched state after state ban abortion, and Marsee decided to take part in the first class of a new training program offered by the University of Maryland School of Medicine and the University of Maryland-Baltimore.

Marsee learned how to administer medication abortion pills, procedural abortions, and highly effective birth control methods, including hormonal implants and intrauterine devices.

She cares for patients with all sorts of everyday ailments and health conditions, including pregnancy. “I do have patients who come in for confirmation of pregnancies and then disclose they don’t want to continue with the pregnancy for whatever reason,” Marsee said.

Now, with her new training, she can help.

Expanding the pool of health care providers with reproductive health care skills outside of the state’s urban centers is vital, said Mary Jo Bondy, associate dean of the School of Graduate Studies at the University of Maryland-Baltimore. She helped create the new training program.

In 2022, Maryland lawmakers passed the Abortion Care Access Act, expanding the type of medical care nurse practitioners, physician assistants, and certified nurse-midwives could offer, including abortion, and the training program “prioritized that group,” Bondy said.

Those types of professionals have long provided abortions to rural patients in other states, Bondy said, and “we have proof that receiving this care from an advanced practice clinician is safe.”

As many as 120 health care providers will be trained over the next two years. Some participants have said they are returning to communities that are hostile to abortion rights.

On Nov. 5, voters approved a ballot measure to protect reproductive rights in the Maryland Constitution, by an overwhelming margin, preliminary results show. The state is widely considered a safe haven for patients who live in states with abortion bans. The number of abortions in Maryland from 2019 to 2023, driven largely by out-of-state residents. But one training participant, a family physician from the Eastern Shore, said providing abortions makes her concerned for her physical safety and asked not to be identified.

“The rural catchment and politics really drive it either out or at least into the quiet,” she said of abortion availability where she lives. She worries that her employer will question the prescriptions she writes for medication abortion pills and said pharmacists often refuse to give the medication to her patients.

Even in Maryland, pharmacists are allowed to refuse to dispense medication abortion pills.

As more health care providers are trained in abortion care, they need help from the state’s medical schools and health officials to overcome these barriers, the family physician said. She wants help with “access to medication and pushing in some ways the hand of our employers, or normalizing, ‘This is just health care.’”

For Marsee, the next step is to figure out how to let her patients know she can provide abortions. She plans to tell her current patients and hopes they’ll tell others.

“I’m working on a way to let people know that I’m here and can provide it,” Marsee said. “This is a conservative area, so it’s walking that line. I want people to know I’m here, but I don’t want to cause too much outrage and attention.”

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It’s a conundrum for Democrats, who expected ballot initiatives on abortion rights in those states to boost the prospects of their candidates, including Vice President Kamala Harris. But data from VoteCast, a large survey of U.S. voters conducted by The Associated Press and partners including Â鶹ŮÓÅ, found that about 3 in 10 voters in Arizona, Missouri, and Nevada who supported the abortion rights measures also voted for Trump.

“We saw lots of people who voted in favor of abortion access and still voted for Donald Trump,” said Liz Hamel, director of Public Opinion and Survey Research for Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

VoteCast is a survey of in all 50 states conducted between Oct. 28 and Nov. 5. It’s intended to be “the most accurate picture possible of who has voted, and why,” .

About 1 in 4 of the polled voters said abortion was the “single most important” factor to their vote, though that number was higher among Democrats, young women, Black adults, and Hispanic adults.

Abortion rights referendums passed in seven states on Tuesday, including Missouri and Arizona, where state bans were overturned. Vice President Kamala Harris made reproductive rights a cornerstone of her campaign, but the VoteCast results reinforce earlier surveys that indicated economic concerns were the foremost issue in the election.

Tuesday’s was the first presidential election since the U.S. Supreme Court’s conservative majority overturned Roe v. Wade. During Trump’s first term as president, he nominated three Supreme Court justices who later joined the 2022 ruling that eliminated women’s constitutional right to abortion care.

Mike Islami, 20, voted for Trump in Madison, Wisconsin, where he’s a full-time student. He said abortion is “a woman’s right” that “was definitely in the back of my mind” when he cast his ballot.

“I don’t think much is going to change” about abortion access during Trump’s second term, he said. “I believe his policy is that he’s just going to give it back to the states and from there they could decide how important it was.”

The survey found that the percentage of voters who said abortion was the most important factor in their vote was similar in states that had abortion measures on the ballot and states without them.

When voters cast their ballots, they were more motivated by economic anxiety and the cost of filling up their gas tanks, housing, and food, according to the survey results. Trump won those voters as much in hotly contested states such as Pennsylvania and Wisconsin as in reliably red states.

Glen Bolger, a Republican campaign strategist, said the 2022 election results demonstrated that Republican candidates are better off talking about the economy and the cost of living than they are about abortion.

This year, Trump voters who supported abortion rights amendments may have decided to take Trump “at his word that he was not going to support a national ban,” Bolger said. In casting their vote for Trump, he said, those supporters may have thought, “Let’s elect him to deal with the cost of living and health care and gasoline and everything else.”

The VoteCast survey found stronger support for abortion ballot initiatives from female voters: 72% of women in Nevada, 69% in Arizona, 62% in Missouri.

Erica Wallace, 39, of Miami, voted for Harris and in favor of an abortion rights ballot measure in Florida, which fell just short of the 60% threshold needed to amend the state constitution.

“As a grown woman, you’re out and you’re working, living your life,” said Wallace, an executive secretary who lives in Miami. She said the state’s ban, which criminalizes abortion care before many women know they’re pregnant, amounts to unequal treatment for women.

“I pay my taxes. I live good,” she said. “I’m doing everything every other citizen does.”

Men were more likely to vote against protecting abortion rights. Men voted 67% in Nevada, 64% in Arizona, and 55% in Missouri for the abortion rights ballot initiatives.

The VoteCast survey found that, overall, voters believed Harris was better able to handle health care. That is consistent with the long-standing view that “Democrats traditionally have the advantage on health care,” Hamel said. Still, Trump outperformed Harris among more than half of voters who said they were very concerned about health care costs.

Family premiums for employer-sponsored health insurance rose 7% in 2024 to an average of $25,572 annually, according to Â鶹ŮÓÅ’s . On average, workers contribute $6,296 annually to the cost of family coverage.

“Everybody is impacted by high health-care costs, and nobody has a solution to it,” Bolger said. “That’s something voters are very frustrated about.”

Florence Robbins in Madison, Wisconsin, and Denise Hruby in Miami contributed to this report.

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In Maryland, where abortion is legal, a proposed amendment is much broader than many abortion-related ballot questions in other states. Called the Right to Reproductive Freedom amendment, it would enshrine in the state constitution a right “to make and effectuate decisions to prevent, continue, or end one’s own pregnancy.”

“What we’re saying with this amendment is that the right to reproductive freedom is central to an individual’s liberty and equality,” said Joseline Peña-Melnyk, a Democrat who chairs the Health and Government Operations Committee in the Maryland House of Delegates. She helped draft the amendment.

Reproductive freedom, Peña-Melnyk said, includes birth control, fertility treatment, tubal ligation, abortion care, and vasectomies. “It’s not just for women; it’s for everyone,” she said.

Maryland already has some of the strongest protections for reproductive health care in the country. In 1998, it became the first state to mandate that insurance companies cover birth control, more than a decade before the Affordable Care Act did so nationwide. And, in 2016, it became one of the first states to require insurance companies and Medicaid to pay for the entire cost of male sterilization procedures and over-the-counter emergency contraception.

The state’s agencies are prohibited from providing information to other states for investigations of “legally protected health care,” including reproductive health care services, provided by Maryland-based physicians.

Democratic lawmakers, who control the state legislature and now hold the governor’s mansion, have methodically passed laws to bolster reproductive health rights. Enshrining those rights in the state constitution will protect Marylanders regardless of which party is in power, Peña-Melnyk said.

“The measure guarantees that future changes — for example, in state politics — will not easily overturn these rights,” she said.

Putting an abortion rights amendment on the state ballot could also boost turnout for the Nov. 5 election — a potential lift for Democratic U.S. Senate candidate Angela Alsobrooks, who is in a competitive race against former Gov. Larry Hogan, a Republican.

Jeffrey Trimbath, president of the , an anti-abortion group that describes its work, in part, as protecting life and parental rights, said the amendment is unnecessary because there is no serious discussion of rolling back abortion rights in the state capital.

The measure “uses this undefined term ‘reproductive freedom’ and it says ‘including but not limited to,’” Trimbath said. And, he said, the reproductive freedom amendment would undermine parents’ rights.

“The first two words, ‘Every person’ — there is no constraint on who that is. Every single person, whether you’re 6 months old, 6 years old, 16 years old, or 100 years old,” Trimbath said. “Every person is entitled to this right. We think that includes children.”

Maryland law does require that one parent or guardian be notified before a person under 18 can receive abortion care, although the law provides several exceptions, including if a doctor determines that the notification could harm the patient. State lawmakers who drafted the amendment and legal experts say it will not alter existing abortion laws in Maryland, including requirements for minors.

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En Maryland, donde el aborto es legal, una enmienda propuesta es mucho más amplia que muchas de las cuestiones electorales relacionadas con el aborto en otros estados. Llamada enmienda del Derecho a la Libertad Reproductiva, consagraría en la constitución estatal un derecho “a tomar y hacer efectivas decisiones para prevenir, continuar o terminar el propio embarazo”.

“Lo que estamos diciendo con esta enmienda es que el derecho a la libertad reproductiva es central para la libertad y la igualdad de un individuo”, dijo Joseline Peña-Melnyk, demócrata que preside el Comité de Salud y Operaciones Gubernamentales en la Cámara de Delegados de Maryland, quien ayudó a redactar la enmienda.

La libertad reproductiva, dijo Peña-Melnyk, incluye el control de la natalidad, el tratamiento de fertilidad, la ligadura de trompas, la atención del aborto y las vasectomías. “No es sólo para las mujeres; es para todos”, dijo.

Maryland ya cuenta con algunas de las protecciones más sólidas para la atención de salud reproductiva en el país. En 1998, se convirtió en el primer estado en obligar a las compañías de seguros a cubrir los métodos anticonceptivos, más de una década antes de que la Ley de Cuidado de Salud a Bajo Precio (ACA) lo hiciera a nivel nacional. Y, en 2016, se convirtió en uno de los primeros estados en exigir a las aseguradoras y a Medicaid que pagaran el costo total de los procedimientos de esterilización masculina, y los anticonceptivos de emergencia de venta libre.

Las agencias del estado tienen prohibido proporcionar información a otros estados para investigaciones de “atención médica protegida legalmente”, incluidos los servicios de atención médica reproductiva, proporcionados por médicos con sede en Maryland.

Los legisladores demócratas, que controlan la Legislatura estatal y ahora tienen la mansión del gobernador, han aprobado metódicamente leyes para reforzar los derechos de salud reproductiva. Consagrar esos derechos en la constitución estatal protegerá a los habitantes de Maryland independientemente del partido que esté en el poder, dijo Peña-Melnyk.

“La medida garantiza que los cambios futuros, por ejemplo, en la política estatal, no anularán fácilmente estos derechos”, dijo.

La inclusión de una enmienda sobre el derecho al aborto en la boleta electoral estatal también podría impulsar la participación en las elecciones del 5 de noviembre, un posible impulso para la candidata demócrata al Senado de Estados Unidos, Angela Alsobrooks, que se encuentra en una carrera competitiva contra el ex gobernador, el republicano Larry Hogan.

Jeffrey Trimbath, presidente del , un grupo antiabortista que describe su trabajo, en parte, como la protección de la vida y los derechos de los padres, dijo que la enmienda es innecesaria porque no hay una discusión seria sobre la eliminación del derecho al aborto en la capital del estado.

La medida “usa este término indefinido ‘libertad reproductiva’ y dice ‘incluyendo, pero no limitado a’”, dijo Trimbath. Y, agregó, la enmienda sobre la libertad reproductiva socavaría los derechos de los padres.

“Las primeras dos palabras, ‘Toda persona’, no hay ninguna restricción sobre quién es. Cada persona, ya sea que tenga 6 meses, 6 años, 16 años o 100 años”, dijo Trimbath. “Toda persona tiene derecho a este derecho. Creemos que eso incluye a los niños”.

La ley de Maryland exige que se notifique a uno de los padres o tutores antes de que una persona menor de 18 años pueda recibir atención para un aborto. Aunque la ley prevé varias excepciones, por ejemplo, si un médico determinara que la notificación podría perjudicar a la paciente.

Los legisladores estatales que redactaron la enmienda y los expertos legales dicen que no alterará las leyes de aborto existentes en Maryland, incluidos los requisitos para menores de edad.

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“The pharmacy told me I didn’t have insurance,” Gobara said.

Arkansas is the that has not taken the step to expand what’s called postpartum Medicaid coverage, an option for states paid for almost entirely by the federal government that ensures poor women have uninterrupted health insurance for a year after they give birth. Forty-six states now have the provision, encouraged by the Biden administration, and Idaho, Iowa, and Wisconsin either have plans in place to enact legislation or have bills pending in their legislatures.

Federal law requires states to provide pregnancy-related Medicaid coverage through 60 days after delivery. But maternal health advocates say Arkansas often begins the process of moving women out of the program after six weeks, or 42 days.

Gobara said she thinks that’s what happened to her: She was transferred to another health plan with a different slate of doctors, and she didn’t receive notice of the change.

Gobara, who is 38 and a freelance copywriter, said the health plan switch happened to her just as a cascade of previous health problems — an autoimmune disorder, postpartum depression, and rheumatoid arthritis — flared up.

“Everything that I had before hit me like a ton of bricks at once after I had the boys,” she said.

Maternal health advocates say many lower-income women in Arkansas have fallen into that familiar health care gap.

Arkansas has one of the highest rates of maternal mortality in the nation, a grim tally of women who die from any cause related to pregnancy or childbirth, including weeks after delivery. In Arkansas, 20% to 29% of women are uninsured at some point over the period before they conceive to after they give birth. 

In March, Arkansas Gov. Sarah Huckabee Sanders, a Republican, signed an executive order creating a committee of experts charged with improving the state’s dismal maternal health outcomes and better educating women about their health insurance options.

At a press conference announcing the initiative, Gov. Huckabee Sanders said, “This specific group that we’re establishing through the executive order, they’re going to look at every option on the table.”

When asked by reporters at the press conference about whether she would support expanding postpartum Medicaid to 12 months of coverage as other states have done, the answer was a firm “no.”

“I don’t believe creating a duplicative program just for the sake of creating a program is actually going to fix the issue,” she said. “We already have so many women who aren’t taking advantage of the coverage that exists. Creating more coverage doesn’t get more women to the doctor.”

Huckabee Sanders, 42, is the youngest governor currently serving, and she is the parent of three school-age children.

In Arkansas, postpartum women can apply for other insurance coverage in Arkansas six weeks after delivery, but they must send in a paper application, said Zenobia Harris, executive director of the Arkansas Birthing Project, a mentor program that works with pregnant and postpartum women.

“Women get told things like their paperwork got misplaced or lost or they have to resubmit paperwork. They get put on hold when they make phone calls in trying to connect with people,” Harris said. “So, some people, they quit trying.”

Lower-income women, like Maya Gobara, are shifted into touted by Huckabee Sanders, that uses Medicaid funding to buy private health insurance.

The shift to new health coverage happened to Gobara while her twins, Amir and Bryson, were on breathing tubes and needed multiple brain surgeries and she required urgent gallbladder surgery.

“I was supposed to have my gallbladder taken out in one week, but with this new plan I needed a referral for that surgery, but I no longer could see my primary care doctor because she wasn’t under that plan that they put me under,” she said.

Seized with gallbladder pain, Gobara spent days sorting out what had happened to her postpartum Medicaid coverage.

“It felt like the system was set up so I would give up,” Gobara said. “And, honestly, if it was not for my mother sitting next to me and helping me go through step by step by step, I probably would have given up.”

New mothers shouldn’t be shuttled from plan to plan or uninsured when they are dealing with their own health and their newborns, said Camille Richoux, health policy director for , a nonprofit advocacy and policy group. Richoux is part of the , a committee tasked with developing recommendations to improve maternal health and increase access to maternal health services. 

Richoux said the switch to a new health plan can disrupt the continuity of care when health care is vital. “Especially when so many pregnancy-related deaths occur after that 60-days-postpartum coverage,” she said.

The committees tasked with making recommendations to Gov. Huckabee Sanders have been meeting this summer and recently prepared draft recommendations.

But missing from the list is an expansion of postpartum Medicaid coverage, despite widespread agreement by health organizations and the state’s Maternal Mortality Review Committee that doing so would reduce pregnancy-related deaths.

One of the tasks of the maternal health initiative is “making sure Medicaid does a better job of educating women postpartum on their health insurance options that already exist today, to ensure they get enrolled and have the coverage they need,” said Alexa Henning, communications director for Gov. Huckabee Sanders in an emailed statement last month.

“The data indicates that most women have continuous coverage, they just need to access it,” Henning said. “But if we identify gaps, the Governor is open to all options to help moms and babies.”

The final recommendations are expected to be released this month.

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The couple’s heartbreak came a few weeks after the U.S. Supreme Court overturned the federal right to abortion. In Wisconsin, their home state, an 1849 law had sprung back into effect, halting abortion care except when a pregnant woman faced death.

Insurance coverage for abortion care in the U.S. is a hodgepodge. Patients often don’t know when or if a procedure or abortion pills are covered, and the proliferation of abortion bans has exacerbated the confusion. Ashley said she got caught in that tangle of uncertainties.

Ashley’s life wasn’t in danger during the miscarriage, but the state’s abortion ban meant doctors in Wisconsin could not perform a D&E — dilation and evacuation — even during a miscarriage until the embryo died. She drove back and forth to the hospital, bleeding and taking sick time from work, until doctors could confirm that the pregnancy had ended. Only then did doctors remove the pregnancy tissue.

“The first pregnancy was the first time I had realized that something like that could affect me,” said Ashley, who asked to be identified by her middle name and her husband by his first name only. She works in a government agency alongside conservative co-workers and fears retribution for discussing her abortion care.

A year later, the 1849 abortion ban still in place in Wisconsin, Ashley was pregnant again.

“Everything was perfect. I was starting to feel kicking and movement,” she said. “It was the day I turned 20 weeks, which was a Monday. I went to work, and then I picked Kyle up from work, and I got up off the driver’s seat and there was fluid on the seat.”

The amniotic sac had broken, a condition called previable PPROM. The couple drove straight to the obstetrics triage at UnityPoint Health-Meriter Hospital, billed as the largest birthing hospital in Wisconsin. The fetus was deemed too underdeveloped to survive, and the ruptured membranes posed a serious threat of infection.

Obstetrician-gynecologists from across Wisconsin had decided that “in cases of previable PPROM, every patient should be offered termination of pregnancy due to the significant risk of ascending infection and potential sepsis and death,” said Eliza Bennett, the OB-GYN who treated Ashley.

Ashley needed an abortion to save her life.

The couple called their parents; Ashley’s mom arrived at the hospital to console them. Under the 1849 Wisconsin abortion ban, Bennett, an associate clinical professor at the University of Wisconsin School of Medicine, needed two other physicians to attest that Ashley was facing death.

But even with an arsenal of medical documentation, Ashley’s health insurer, the Federal Employees Health Benefits Program, did not cover the abortion procedure. Months later, Ashley logged in to her medical billing portal and was surprised to see that the insurer had paid for her three-night hospital stay but not the abortion.

“Every time I called insurance about my bill, I was sobbing on the phone because it was so frustrating to have to explain the situation and why I think it should be covered,” she said. “It’s making me feel like it was my fault, and I should be ashamed of it,” Ashley said.

Eventually, Ashley talked to a woman in the hospital billing department who relayed what the insurance company had said.

“She told me,” Ashley said, “quote, ‘FEP Blue does not cover any abortions whatsoever. Period. Doesn’t matter what it is. We don’t cover abortions.’”

University of Wisconsin Health, which administers billing for UnityPoint Health-Meriter hospital, confirmed this exchange.

The Federal Employees Health Benefits Program contracts with , or the BlueCross BlueShield Federal Employee Program, to provide health plans to federal employees. In response to an interview request, FEP Blue emailed a statement saying it “is required to comply with federal legislation which prohibits Federal Employees Health Benefits Plans from covering procedures, services, drugs, and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest.”

Those restrictions, known as the Hyde Amendment, have been passed each year since 1976 by Congress and prohibit federal funds from covering abortion services.

In Ashley’s case, physicians had said her life was in danger, and her bill should have immediately been paid, said Alina Salganicoff, director of Women’s Health Policy at Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

What tripped up Ashley’s bill was the word “abortion” and a billing code that is insurance kryptonite, said Salganicoff.

“Right now, we’re in a situation where there is really heightened sensitivity about what is a life-threatening emergency, and when is it a life-threatening emergency,” Salganicoff said. The same chilling effect that has spooked doctors and hospitals from providing legal abortion care, she said, may also be affecting insurance coverage.

In Wisconsin, Bennett said, lack of coverage for abortion care is widespread.

“Many patients I take care of who have a pregnancy complication or, more commonly, a severe fetal anomaly, they don’t have any coverage,” Bennett said.

Recently, the bill for $1,700 disappeared from Ashley’s online bill portal. The hospital confirmed that eight months later, after multiple appeals, the insurer paid the claim. When contacted again on Aug. 7, FEP Blue responded that it would “not comment on the specifics of the health care received by individual members.”

Ashley said tangling with her insurance company and experiencing the impact of abortion restrictions on her health care, similar to other women around the country, has emboldened her.

“I’m in this now with all these people,” she said. “I feel a lot more connected to them, in a way that I didn’t as much before.”

Ashley is pregnant again, and she and her husband hope that this time their insurance will cover whatever medical care her doctor says she needs.

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Esto ocurrió unas semanas después que la Corte Suprema de Estados Unidos anulara el derecho federal al aborto. En Wisconsin, su estado natal, volvió a entrar en vigencia una ley de 1849, que permite el procedimiento solo cuando la embarazada corre peligro de muerte.

En el país, la cobertura para la atención del aborto es laberíntica. A menudo, los pacientes no saben cuándo un procedimiento, o las píldoras abortivas, están cubiertas, si es que lo están; y la proliferación de prohibiciones ha exacerbado la confusión.

Ashley dijo que se encontró atrapada en esa maraña de incertidumbres.

La vida de Ashley no estuvo en peligro durante el aborto espontáneo, pero la prohibición del aborto en el estado significaba que los médicos en Wisconsin no podían realizar un D&E —dilatación y evacuación— incluso durante un aborto espontáneo hasta que el embrión no muriera. Condujo ida y vuelta del hospital, sangrando y tomando días por enfermedad en el trabajo, hasta que los médicos pudieron confirmar que el embarazo había terminado.

Solo entonces los médicos eliminaron el tejido del embarazo.

“Con el primer embarazo fue la primera vez que me di cuenta de que algo así podría afectarme”, dijo Ashley, quien pidió ser identificada por su segundo nombre y que su esposo solo fuera mencionado por su primer nombre. Ella trabaja en una agencia gubernamental con compañeros conservadores, y teme represalias por hablar sobre su atención de aborto.

Un año después, con la prohibición del aborto de 1849 aún vigente en Wisconsin, Ashley quedó embarazada de nuevo.

“Todo era perfecto. Empecé a sentir pataditas y movimientos”, dijo. “Fue el día en que cumplí 20 semanas, un lunes. Fui a trabajar, luego recogí a Kyle en el trabajo, y cuando me levanté del asiento del conductor, había líquido en el asiento”.

El saco amniótico se había roto, una condición llamada PPROM no viable. La pareja condujo directamente al triaje obstétrico en UnityPoint Health-Meriter Hospital, conocido como el hospital de maternidad más grande de Wisconsin. Se consideró que el feto estaba demasiado subdesarrollado para sobrevivir, y las membranas rotas representaban una grave amenaza de infección.

Los obstetras y ginecólogos de todo Wisconsin habían decidido que “en casos de PPROM no viable, se debería ofrecer a cada paciente la terminación del embarazo debido al riesgo significativo de infección creciente, y la posible sepsis y muerte”, dijo Eliza Bennett, la gineco-obstetra que trató a Ashley.

Ashley necesitaba un aborto para salvar su vida.

La pareja llamó a sus padres; la madre de Ashley llegó al hospital para consolarlos. Bajo la prohibición del aborto de 1849 en Wisconsin, Bennett, profesora clínica asociada en la Facultad de Medicina de la Universidad de Wisconsin, necesitaba que otros dos médicos atestiguaran que Ashley corría peligro de muerte.

Pero incluso con un arsenal de documentación médica, el seguro de salud de Ashley, el Programa de Beneficios de Salud para Empleados Federales (FEP), no cubría el procedimiento de aborto. Meses después, Ashley entró al portal de facturación médica y se sorprendió al ver que la aseguradora había pagado su estadía de tres noches en el hospital, pero no el aborto.

“Cada vez que llamaba al seguro sobre mi factura, estaba llorando por teléfono porque era muy frustrante tener que explicar la situación y porque creo que debería estar cubierto”, dijo. “Me hacía sentir que era mi culpa, y que debería sentir vergüenza”, dijo Ashley.

Finalmente, habló con una mujer del departamento de facturación del hospital que le transmitió lo que la compañía de seguros había dicho.

“Ella me dijo, textual, ‘FEP Blue no cubre ningún aborto, en absoluto. Punto. No importa lo que sea. No cubrimos abortos’”.

University of Wisconsin Health, que administra la facturación para el hospital UnityPoint Health-Meriter, confirmó este diálogo.

El Programa de Beneficios de Salud para Empleados Federales contrata a , o FEP de BlueCross BlueShield, para proporcionar planes de salud a empleados federales. En respuesta a una solicitud de entrevista, FEP Blue envió un comunicado diciendo que “está obligado a cumplir con la legislación federal que prohíbe a los planes de Beneficios de Salud para Empleados Federales cubrir procedimientos, servicios, medicamentos y suministros relacionados con abortos, excepto cuando la vida de la madre esté en peligro si se lleva el feto a término, o cuando el embarazo sea el resultado de un acto de violación o incesto”.

Desde 1976, el Congreso aprueba cada año esas restricciones, conocidas como la Enmienda Hyde, que prohíben que los fondos federales cubran servicios de aborto.

En el caso de Ashley, los médicos habían dicho que su vida estaba en peligro, y su factura debería haber sido pagada de inmediato, dijo Alina Salganicoff, directora de Políticas de Salud para la Mujer en Â鶹ŮÓÅ, una organización sin fines de lucro de información de salud que incluye la redacción de Â鶹ŮÓÅ Health News.

Lo que hizo trastabillar la factura de Ashley fue la palabra “aborto” y un código de facturación que es criptonita para los seguros, dijo Salganicoff.

“En este momento, estamos en una situación donde hay una sensibilidad muy alta sobre lo que es una emergencia que amenaza la vida, y cuándo es una emergencia que amenaza la vida”, dijo Salganicoff. El mismo efecto paralizante que ha asustado a médicos y hospitales para no proporcionar atención de aborto legal también puede estar afectando la cobertura, agregó.

En Wisconsin, la falta de cobertura para la atención del aborto es generalizada, dijo Bennett.

“Muchos pacientes que atiendo y que tienen una complicación del embarazo o, más comúnmente, una anomalía fetal grave, no tienen ninguna cobertura”, expresó Bennett.

Recientemente, la factura de $1,700 desapareció del portal de facturación de Ashley. El hospital confirmó que ocho meses después, tras múltiples apelaciones, la aseguradora pagó el reclamo. Cuando se le contactó nuevamente el 7 de agosto, FEP Blue respondió que “no comentará sobre los detalles de la atención médica recibida por miembros individuales”.

Ashley dijo que enfrentarse a su aseguradora y experimentar el impacto de las restricciones al aborto en su atención médica, similar a otras mujeres en todo el país, la ha fortalecido.

“Estoy en esto ahora con todas estas personas”, dijo. “Me siento mucho más conectada con ellas, de una manera que no lo estaba tanto antes”.

Ashley está embarazada de nuevo, y ella y su esposo esperan que esta vez su seguro cubra cualquier atención médica que su médico diga que necesita.

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Tia Freeman, a reproductive health organizer, leads workshops for Tennesseans on how to safely take medication abortion pills outside of medical settings.

Abortion is almost entirely illegal in Tennessee. Freeman, who lives near Nashville, said people planning to stop pregnancies have all sorts of reasons for wanting to do so without help from the formal health care system — including the cost of traveling to another state, challenge of finding child care, and fear of lost wages.

“Some people, it’s that they don’t have the support networks in their families where they would need to have someone drive them to a clinic and then sit with them,” said Freeman, who works for , a U.S.-based project of Women Help Women, an international nonprofit that advocates for abortion access.

“Maybe their family is superconservative and they would rather get the pills in their home and do it by themselves,” she said.

The new study is from Advancing New Standards in Reproductive Health, a research group based at the University of California-San Francisco. The researchers surveyed more than 7,000 people ages 15 to 49 from December 2021 to January 2022 and another 7,000-plus from June 2023 to July 2023.

Of the respondents who had attempted self-managed abortions, they found the percentage who used the abortion pill mifepristone was 11 in 2023 — up from 6.6 before the Supreme Court ended federal abortion rights in 2022.

One of the most common reasons for seeking a self-administered abortion was privacy concerns, said a study co-author, epidemiologist Lauren Ralph.

“So not wanting others to know that they were seeking or in need of an abortion or wanted to maintain autonomy in the decision,” Ralph said. “They liked it was something under their control that they could do on their own.”

, vice president of media and policy at Students for Life Action, a national anti-abortion group, said she doesn’t believe the study findings, which she said benefit people who provide abortion pills.

“It should surprise no one that the abortion lobby reports their business is doing well, without problems,” Hamrick said in an emailed statement.

Ralph said in addition to privacy concerns, state laws criminalizing abortion also weighed heavily on women’s minds.

“We found 6% of people said the reason they self-managed was because abortion was illegal where they lived,” Ralph said.

In the JAMA study, women who self-managed abortion attempts reported using a range of methods, including using drugs or alcohol, lifting heavy objects, and taking a hot bath. In addition, about 22% reported hitting themselves in the stomach. Nearly 4% reported inserting an object in their body.

The term “self-managed abortion” may conjure images of back-alley procedures from the 1950s and ’60s. But OB-GYN Laura Laursen, a family planning physician in Chicago, said self-managed abortions using medication abortion — the drugs mifepristone and misoprostol — are far safer, whether done inside or outside the health care system.

“They’re equally safe no matter which way you do it,” Laursen said. “It involves passing a pregnancy and bleeding, which is what happens when you have a miscarriage. If your body doesn’t have a miscarriage on its own, these are actually the medications we give women to pass the miscarriage.”

Since Roe’s end, more than 20 states have banned or further restricted abortion.

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