“The entirety of abortion rights history is a history of doctors appearing in court to represent their own interests and the interests of pregnant people,” said Elizabeth Sepper, a law professor at the University of Texas-Austin.

But in July, in a Texas courtroom, the case for abortion was made by women themselves who had been denied abortions and sued the state to clarify the exceptions to its ban, which makes it illegal to perform an abortion unless a patient is facing death or “substantial impairment of a major bodily function.” The aspiring mothers described in vivid, harrowing detail how the state’s abortion ban had endangered their health, traumatized them, and, in the case of Samantha Casiano, forced her to carry and give birth to a baby girl without a formed skull or brain only to watch her die a tortured death four hours later.

“She was gasping for air,” Casiano testified on the witness stand. She described how her baby turned purple and her eyeballs were bleeding. “I just kept telling myself and my baby that ‘I’m so sorry that this has happened to you.’ I felt so bad. She had no mercy. There was no mercy there for her.”

Casiano had been denied an abortion months earlier after she found out her baby had anencephaly, a fatal condition. She had wanted her daughter, whom she named Halo, to be spared from suffering and to “go to rest sooner.” She described abortion as an act of compassion, mercy, and love.

For decades, Christian anti-abortion groups have deployed ultrasound fetal images and grisly photos of what they say are aborted fetuses on highway billboards, protest signs, and online ads to garner sympathy for “unborn children” and advance their religious and political aims. But the Texas hearing, for the first time since the early 1970s, according to legal scholars and historians, trained the camera upward, away from the high-resolution fetal images to the faces of sympathetic women who say they suffered grievously under the state’s abortion ban.

Women have long shared abortion stories privately, and at public speak-outs, through #ShoutYourAbortion and the nonprofit group WeTestify. But the formality of the Austin courtroom focused unblinking attention on their experiences. The black-robed judge and court stenographer leaned in to hear plaintiffs as their testimony under oath was recorded for a national television audience. It put anti-abortion activists on the defensive.

“We’re in this moment where all of the stories are coming out and it’s raw,” said Greer Donley, an associate professor of law at the University of Pittsburgh School of Law. “All of these secrets — abortion, miscarriage, the blurring of miscarriage and abortion — that’s something people viscerally appreciate now.”

Before the Supreme Court’s conservative majority eliminated a federal right to abortion last June, polls showed that nationwide support for abortion care was “pathetically stagnant,” Donley said. Compare that stagnation, she said, to the support for same-sex marriage rights, which broadened as gay people and their families shared their stories publicly.

“Storytelling is the future,” Donley said. “That’s how you change hearts and minds.”

The pregnancy complications and medical emergencies described by the plaintiffs both “subvert ideas about motherhood” and “support ideas about motherhood,” said Mary Ziegler, a professor of law at the University of California-Davis who has written books about the history of abortion.

Soon after the Supreme Court held that women had the right to abortion in 1973, the anti-abortion movement began a concerted effort to narrow that newly established constitutional right. Movement leaders spoke in gruesome detail about abortions later in pregnancy, coining medically inaccurate phrases, such as “partial-birth abortion,” that infused the language of the abortion debate with emotional and provocative imagery.

“Usually, the story is women versus fetuses, and that people having abortions are selfish or don’t care,” Ziegler said. “But these women in court are saying, ‘What was best for my child was the abortion. I was denied that, but so was my child.’”

Some Catholics and conservative Christians who oppose abortion proffer the notion of “natural womanhood,” Ziegler said — the religious belief that God created women to complement men, and “that abortion is forcing women to be like men” and “disrupts nature.”

That belief was expressed by Ingrid Skop, a Texas OB-GYN who opposes abortion and testified last month as an expert witness for the state. When asked on the stand about Casiano’s description of watching her baby die, Skop said inducing a birth is “a much more holistic way to progress through the grieving process than to dismember your child and not have a way to grieve.”

Infant deaths have spiked in Texas since the government mandated births of nonviable pregnancies. In September 2021, Texas banned abortions after six weeks of pregnancy and then instituted a prohibition on all abortions from the moment of fertilization unless a woman was experiencing “a life-threatening physical condition aggravated by, caused by, or arising from a pregnancy.” The Texas law makes no exception for nonviable pregnancies.

In 2022, preliminary infant mortality data from the Texas Department of State Health Services, first obtained by CNN, showed a 21.6% increase in infant deaths caused by severe genetic and birth defects. That increase reversed a 15% decline in infant deaths from 2014 to 2021.

The case in Austin comes as abortion rights and civil liberties groups and state Democratic parties are mounting a series of legal and electoral challenges to the Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization, which overturned Roe last summer. In November, Ohio voters will take up a proposed constitutional amendment that would ensure “every individual has a right to make and carry out one’s reproductive decisions.” Litigation against abortion bans is ongoing in at least 17 states, according to KFF.

A new poll by the nonpartisan research firm PerryUndem that explored the impact of a “viability limit” on support for abortion ballot measures found that voters were 15 percentage points more likely to support ballot measures when they contained no government regulations on abortion over those that restricted abortion later in pregnancy.

The Texas lawsuit has highlighted the myriad reasons women and their families (at least two husbands were in the Austin courtroom) require abortion care throughout an entire pregnancy, Donley said.

In considering doing away with any limits on abortion, “we don’t have to trust that women are perfect, benevolent mothers,” Donley said. “We just have to believe they are rational actors.”

After 24 weeks, most abortions require induced birth, she added. “So, we’re imagining a person who, for no good reason, endured the burdens of pregnancy, watched her body change completely, and went through labor and delivery of a stillborn baby just because she couldn’t get around to an abortion earlier? People have abortions late because horrible things happen.”

Texas District Judge Jessica Mangrum on Aug. 4 ruled in favor of the plaintiffs, but the Texas attorney general has appealed the decision, blocking the order. The state’s assistant attorney general, Amy Pletscher, had asked the court to dismiss the case. She told Mangrum that the “plaintiffs sustained their alleged injuries as a direct result of their own medical providers failing them.”

But while the outcome of the case is uncertain, legal scholars said it marked the beginning of a new strategy for the abortion rights movement in the United States.

“We had a 50-year fight to get rid of Roe,” Ziegler said. “This is the beginning of the 50-year fight to get rid Dobbs.”

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“We didn’t even know germs caused disease back then,” said Kristin Lyerly, an obstetrician-gynecologist who lives in Green Bay.

Like undertakers and garbage haulers, obstetricians see the nitty-gritty of human existence that can be ghastly and grotesque. A fetus with organs growing outside its body. A woman forced to birth a baby with no skull to push open her cervix.

OB-GYN Anna Igler regularly performed abortions for medically indicated reasons before the Supreme Court overturned the right to abortion last year. She is beyond fed up.

“I’m at a different level with it now,” she said. “Part of me is so upset at people for sticking their head in the sand.” With her world inside a Green Bay hospital in turmoil, she said, she cannot fathom that people might be oblivious to the government’s incursion into their medical care. “So many people I’ve talked to have no idea what our laws are in our state.”

Even now, a year later, Igler said, expectant parents come into her office with the assumption that if their fetus has a lethal genetic disorder, like anencephaly or trisomy 13 or 18, they can end the pregnancy safely.

“They are shocked when I tell them they can’t,” Igler said, “and they are shocked when I tell them we are following the law from 1849.”

She was referring to the state’s original abortion law, which was passed before the Civil War, when women could not vote or own property. The law makes it a felony to perform an abortion at any stage of pregnancy, unless it would prevent the death of the pregnant person.

It had been some time since these women were together, and they were eager to compare notes. The certified midwife spoke on the condition of anonymity because she’s not authorized to talk to the media and is concerned about losing her job at a local health system. “My biggest issue right now is getting medication to end a pregnancy that has already passed,” she said. “I’m finding locally that pharmacists just won’t dispense the medication.”

She offered a rundown: One pharmacist told her patient that misoprostol, a drug that causes cramping to expel the pregnancy tissue, had expired. Another, at a Walgreens, simply canceled the order. A third said he needed preauthorization, noting, “It’s a $3 pill, and we’re not going to get preauthorization on a weekend.”

The midwife said she and physician colleagues in her practice have half-joked that they’d send a gift basket to one pharmacist in town she’d found who will fill their prescriptions for abortion pills.

Now, when a patient miscarries, the midwife said, “we warn patients that this might happen, and they are like, ‘But my baby is dead,’ and I tell them, ‘I’m sorry. I don’t know why, but a lot of pharmacists in Green Bay think it’s their job to police this.’”

A year into this new era of compulsory birth for most women with pregnancies, the dismay and disorientation of those first few months have settled into, if not acceptance or resignation, a kind of chronic fear. Obstetricians and gynecologists are fearful of practicing medicine as they were trained.

A recent survey by KFF pollsters of OB-GYNS in states with abortion bans found 40% felt constrained in treating patients for miscarriages or other pregnancy-related medical emergencies since the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision last summer. Nearly half of them said their ability to practice standard medical care has become worse.

The specter of felony charges and losing a medical license has led to futile exercises.

Under the Wisconsin abortion ban — and bans in at least 13 other states — physicians who cannot detect fetal cardiac activity should, in theory, not face criminal charges for prescribing pills for a medication abortion or performing abortions. But physicians here in Green Bay, and others interviewed in Madison, said they — and the litigation-averse hospitals they work for — are requiring patients whose pregnancies are no longer viable, or who have gestational sacs that do not contain an embryo, to return for multiple ultrasounds, forcing them to carry nonviable pregnancies for weeks.

Before Wisconsin’s abortion ban, Igler would typically use the ultrasound machine in her office to detect when a patient’s pregnancy had ceased. She would break the news to expectant parents there. In some cases, a patient wanted further ultrasounds and she would refer them to the fetal-imaging department. It might help with their grieving, and “I was happy to do that for them,” Igler said.

But her bedside ultrasound can’t record and save the images that Igler would now need to prove that her medical judgment was reasonable during a criminal prosecution, so she is compelled to send all her patients for additional imaging.

“It seems cruel to show a woman her nonviable, dead baby and then say, ‘Well, now I have to bring you over to fetal imaging so we can record a picture and you have to see it again,’” she said.

In March, Rep. Ron Tusler, a Republican who represents a rural swath of Wisconsin south of Green Bay, posted on Facebook, “Thank God for the Dobbs decision!” In response, a local resident asked, “If my non-verbal, non-ambulatory 14-year-old daughter is assaulted, should she be forced to carry?”

The exchange escalated into a confrontation. “Is her health jeopardized?” Tusler asked. “Is she unable to leave the state? Can she provide consent?”

In the torrent of vitriol, certain moments stand out. Igler was incensed at the callous response and jumped in, writing: “Are you a monster, Ron Tusler? Do you know what compassion is? Come the next election, you will feel the backlash of your inhumane and outdated views. Get your hands off women’s bodies and out of the exam room. I’m an obstetrician. I’m the expert, not you.”

Tusler shot back that Igler was “angry she can’t kill babies until and occasionally after birth” and asked whether “I’m a monster for stopping her.” He wrote, “Honestly, how many babies have you aborted? How much money have you made from it? Did your hospital harvest the bodies for stem cells?”

The lunchtime rush at the restaurant in Green Bay had eased, and the women stared at the Facebook post on Igler’s phone.

She shook her head in baffled amusement. “This doesn’t even make sense,” she said. “It’s a conspiracy theory. I make so much more money if people actually have their babies. And if I don’t give out birth control, I would make a lot more money.”

Those sitting at the table laughed at the absurdity.

The salad bowls were empty. Everyone had told their own abortion stories. Igler was forced to travel to Colorado after her baby, at 25 weeks, was ravaged by a viral infection; Lyerly had lost a pregnancy at 17 weeks and did not want to endure the trauma of a vaginal birth.

Some 22 million women living today have had an abortion. It doesn’t take much effort to find a few of them.

Igler has found a community of women to grieve with, in a Facebook group called “Ending a Wanted Pregnancy.” There are an untold number of other online groups.

“Politicians would like to believe we live in a perfect world where these things don’t happen,” she said.

The Wisconsin Legislature is one of the most gerrymandered in the country, according to Princeton University’s Gerrymandering Project. Republicans hold a majority in the state Senate and Assembly, and last month Senate Republicans voted unanimously to keep the 1849 abortion ban.

But a judicial alternative to restoring abortion rights has begun to unfold. In April, Janet Protasiewicz, an abortion rights supporter promoted by Democrats, won a seat on the Wisconsin Supreme Court, giving liberal justices a narrow majority and opening a path for a ruling on the legitimacy of the 1849 law. On July 7, a Circuit Court judge in Dane County, Diane Schlipper, appeared to doubt the validity of the pre-Civil War-era ban, allowing a lawsuit by Attorney General Josh Kaul, a Democrat, to proceed.

For now, Lyerly is driving across the border to work in rural Minnesota. “I want to practice medicine here,” she said, “but first we have to get rid of this law.”

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The travel ban, which took effect May 5, created the crime of “abortion trafficking,” punishable by a minimum of two years in prison. It forbids helping a person under 18 years old obtain abortion pills or leave the state for abortion care without parental permission.

The complaint, filed in federal court in Boise, Idaho, says the ban infringes on the right to interstate travel and on First Amendment rights to speak about abortion and “engage in expressive conduct, including providing monies and transportation (and other support) for pregnant minors traveling within and outside of Idaho.”

The suit also says the travel ban “lacks clarity” and “invites arbitrary enforcement,” raising the specter of traffic stops of girls of reproductive age, and infringes on the right of people to cross the border into neighboring states, including Washington, where minors can legally obtain abortion care without parental consent.

Wendy Heipt, senior reproductive health and justice counsel at Legal Voice, an advocacy group representing the plaintiffs, said Idaho’s law prohibits “recruiting or harboring a minor, but what constitutes recruiting? Giving information? You can’t stop [my clients] from providing information about conduct that is legal in another state.”

She added, “If we want to give money to a minor to go to another state, we should be able to do that.”

In a statement, Idaho’s Office of the Attorney General said, “While we don’t comment on pending litigation, our office is always prepared to vigorously defend the constitutionality of statutes duly passed by the legislature.”

Legal experts say the ban, based on a model bill written by National Right to Life, one of the country’s largest anti-abortion groups, is drafted to sidestep implied constitutional protections for interstate travel.

“This National Right to Life proposal was designed to chip away at travel in a way that is less politically and legally risky,” said Mary Ziegler, a professor of law at the University of California-Davis and an abortion historian. “It’s easier to package this as a Republican parental rights initiative, and it’s easier legally because courts have been willing to countenance limits on minor rights that they wouldn’t countenance on adults.”

She added, “The idea is to stop people from traveling to other states,” and teen travel bans “could be a steppingstone to limit an adult’s right to travel.”

The plaintiffs include the Indigenous Idaho Alliance, a nonprofit that has helped pregnant minors access abortion care outside the state; the Northwest Abortion Access Fund, which provided financial assistance to 166 Idahoans in 2022, including 18 minors; and Lourdes Matsumoto, an attorney who works with victims of domestic and sexual violence, many of whom are minors.

Domestic violence advocates “don’t know what advice they can give people,” Matsumoto said. “In the shelters, they are confused about what information they can and cannot give out without putting themselves in legal jeopardy.” She said the teen travel ban has had a chilling effect on her work with teenagers dealing with the trauma of sexual assault.

Idaho’s law, the first in the nation to describe “abortion trafficking,” requires a minimum two-year prison sentence for any adult who acts “with the intent to conceal an abortion from the parents or guardian of a pregnant, unemancipated minor.”

But Matsumoto, who has two teenage nieces, said the law fails to detail what constitutes parental consent. “If my niece comes to me and says, ‘My mom says this is OK; can you take me to Oregon?’ — is that enough that the mom consented? Am I going to have to come back, get arrested, lose my law license, then go to court and say, ‘The mom said it’s OK’? Is it a nod? A thumbs-up in a text message?”

Courts are usually suspicious of laws that are overbroad and vague, said I. Glenn Cohen, a Harvard Law School professor. But he said abortion bans around the country, including Idaho’s teen travel ban, have been written in a “fuzzy” way so that they “will deter ever more conduct because people don’t know where the line is.”

The lawsuit cites a legal opinion dated March 27 from Labrador that “stated that medical professionals who refer pregnant patients across state lines for either medical or chemical abortions violate Idaho’s Total Abortion Ban,” a separate law that went into effect after the Supreme Court overturned federal abortion rights last year in Dobbs v. Jackson Women’s Health Organization. Labrador withdrew the opinion on April 7, facing a legal challenge over constitutional rights of speech and movement.

“It is unconstitutional to forbid citizens from traveling because you disapprove of the reasons they are driving to another state,” Heipt said. “Idahoans, like all people, should be free to travel within and between states without the specter of prison, even if they are traveling for a reason other people disagree with.”

Idaho patients, including teenagers, have long crossed into Washington state to legally end their pregnancies. But fewer than 5% of patients at Planned Parenthood clinics in Washington who come for abortion care are minors, according to Karl Eastlund, CEO of Planned Parenthood of Greater Washington and North Idaho.

Most of those patients, he said, do involve their parents in the process, even though parental consent is not mandatory in Washington. Those who don’t, Eastlund said, have good reason not to. Some are in dangerous, abusive situations in which disclosing a pregnancy could put them at risk of further harm.

The lawsuit in Idaho cites Associate Justice Brett Kavanaugh’s concurring opinion in Dobbs, in which he claimed states could not bar residents from going to other states for abortions.

“May a State bar a resident of that State from traveling to another state to obtain an abortion?” Kavanaugh wrote. “In my view, the answer is no based on the constitutional right to interstate travel.”

But Kavanaugh represents only one vote on the court, Cohen said, and “it remains to be seen what the other justices have to say on the matter.”

Rather than settle the question of whether states can prohibit traveling for an abortion, Heipt said, “Dobbs unleashed chaos. What’s next?”

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Ho rebuffed attorneys for the Department of Justice and Danco Laboratories, a maker of mifepristone, urging a focus on “the facts of this case” rather than “this sort of ‘FDA can do no wrong’ theme.” He questioned whether the FDA erred in approving the medication through an expedited process typically reserved for treatments for serious illnesses. “Pregnancy is not a serious illness” he said. “When we celebrated Mother’s Day, were we celebrating illness?”

KFF Health News senior correspondent Sarah Varney joined PBS NewsHour’s Geoff Bennett and Stephen Vladeck, a professor at the University of Texas School of Law, to discuss the legal arguments that piqued the judges’ interest and how the case could affect the availability of mifepristone around the country.

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“This is embarrassing,” she said, sitting outside a café along a street thronged with students in this college town. “But I didn’t know that you had to have sex to have kids until I was 13 or 14.”

She’s a writer for the University of Idaho student newspaper, The Argonaut, and was asked recently to report on a new law. It’s now a crime to help a teen under 18 leave the state for an abortion or obtain medication abortion pills without parental consent — including when the girl has been sexually assaulted or raped by a family member or parent. Gov. Brad Little, a Republican, in signing the bill, wrote that the law does not “limit an adult woman from obtaining an abortion in another state.”

Davidson, 19, reached out to interview state Rep. Barbara Ehardt, a Republican co-sponsor of the bill, who touted her “Christian-based” attitude during her campaign.

“She kept saying that it was about parental rights,” Davidson said. But “the thing that really caught my attention was the fact that they were calling it ‘abortion trafficking.’”

The law creates a crime of “abortion trafficking” and criminalizes the “recruiting, harboring, or transporting” of minors without parental consent. In a floor speech before the Idaho Legislature voted on the bill, Ehardt said, “We are only looking to protect our children.”

Idaho’s “teen travel ban,” as it’s known here, took effect May 5, nearly 11 months after the U.S. Supreme Court eliminated the federal constitutional right to abortion. Any adult, including an aunt, grandparent, or sibling, convicted of violating the criminal statute faces up to five years in prison. Under a separate state law, family members of the pregnant minor and the sexual partner involved can sue any health care provider who helped terminate the pregnancy for financial damages.

“If you’re successful, you’re guaranteed $20,000 minimum, and that’s per claim per relative,” said Kelly O’Neill, an Idaho litigation attorney for Legal Voice, a progressive nonprofit.

“Idaho has a lot of big families,” she added.

Under the new law, even when a parent gives consent, the person accompanying the minor would need to provide an “affirmative defense” proving they were acting with the permission of a parent of the teen.

“You could still be charged, arrested, perhaps even have to go all the way to a jury trial and prove in a courtroom that your sister gave you permission,” O’Neill said.

Legal experts say Idaho’s travel ban, based on a model bill written by National Right to Life, one of the country’s largest anti-abortion groups, is designed to sidestep implied constitutional protections for interstate travel. The law targets travel assistance within and up to the state’s border, effectively criminalizing medical care legally obtained in neighboring states.

“This is one of the next frontiers of abortion litigation,” said David S. Cohen, a constitutional law professor at Drexel University. “They’re clearly pushing this kind of law with other states.”

In response to potential legal threats, on April 27, Washington Gov. Jay Inslee, a Democrat, signed a series of bills barring law enforcement from cooperating with other states’ abortion investigations. Those laws shield medical providers from lawsuits and protect their medical licenses from being revoked.

But in communities like Spokane, Washington, just 20 miles from the Idaho border, there is a sense of unease.

“We have staff who live in Idaho who commute,” said Karl Eastlund, CEO of Planned Parenthood of Greater Washington and North Idaho. “It’s one big economic region, when you think of the border communities here.”

When asked if he was concerned that medical staff members living in Idaho could be criminally charged for the abortion care they provide every day, he said, “We have told our providers we will handle all of your legal fees and we’ll provide lawyers to help you sort out anything that happens.”

He added, “It’s something we think about a lot.”

After Sunday morning Mass at St. Augustine’s Catholic Center in Moscow, Ryan Alexander tended to his 17-month-old daughter, Penelope, as she toddled about the church courtyard. Alexander, 25, a married law student at the university here, said ending any pregnancy violates his Catholic beliefs.

He has read the text of the bill, he said, “and the way it’s written is actually incredibly prudent.” No adult, he said, can act in place of a parent.

“That’s just kidnapping, by any means, if you take a girl away from her parents when she’s a minor and her parents have authority over her,” he said.

Alexander said he understands that some teenage girls are sexually abused at home or have dysfunctional relationships with their parents. Still, he supports the law.

“When we look at situations like that, my heart goes out to them. What can I do but pray from a distance and think, how can that be better?” he said. But “two wrongs do not make a right.”

Idaho patients, including teenagers, have long crossed into Washington state to legally end their pregnancies. Eastlund said fewer than 5% of the clinics’ patients who come for abortion care are minors.

Most of those patients, he said, do involve their parents in the process, even though parental consent is not mandatory in Washington. Those who don’t, Eastlund said, have good reason not to. Some are in dangerous, abusive situations in which disclosing a pregnancy could put them at risk of further harm.

“We’re talking about sexual abuse and incest,” said Eastlund, sitting upstairs at the clinic in Spokane. “It’s not stuff people want to talk about, but, unfortunately, it’s more common than people think.”

On the shores of Lake Pend Oreille, in Sandpoint, Idaho, Jen Jackson Quintano said she wants her daughter, Sylvia, 8, to have trusted adults around whom she can turn to when she’s a teenager.

“I think back to my teenage years when I was in high school, I had a boyfriend that I loved, and I was sexually active,” she said. At the time she thought, “If I get pregnant, I would rather just die, just end it, than have to figure this out and tell my parents.”

Quintano said that while growing up in the Roman Catholic Church, she was taught that sex, contraception, and abortion were shameful, and she is raising her daughter under a different set of beliefs.

“Shame as a woman — it’s a powerful form of control, and I don’t want her to walk that path of shame,” Quintano said. “I want her to feel comfortable in her body.”

Idaho’s teen abortion travel ban and the financial rewards for reporting citizens who obtain abortions are already dividing the tightknit fabric of Sandpoint’s community, she said.

“We don’t know who to trust,” Quintano said. “We don’t know who we can talk to.”

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Jen Quintano, the event’s organizer and a Sandpoint resident who runs a tree service, called to the crowd, packed shoulder to shoulder as children ran underfoot, “Raise your hand if you were born at Bonner General! Raise your hand if you gave birth at Bonner General!” Nearly everyone raised their hand.

Later this month, the hospital, founded in 1949 near the shores of Lake Pend Oreille, will stop providing services for expectant mothers, forcing patients across northern Idaho to travel at least an additional hour for care. In June, a second Idaho hospital, Valor Health, in the rural city of Emmett, will also halt labor and delivery services.

Those decisions came within months of Idaho’s abortion ban, one of the nation’s strictest, going into effect in August 2022. Physicians can now perform the medical procedure only to stop the death of a pregnant woman or in the case of rape or incest reported to the police.

In March, Bonner General Health officials said the law was a driving force in the closure, noting Idaho’s legal and political climate.

“Highly respected, talented physicians are leaving,” the hospital wrote in a statement. “Recruiting replacements will be extraordinarily difficult. In addition, the Idaho Legislature continues to introduce and pass bills that criminalize physicians for medical care nationally recognized as the standard of care.”

OB-GYNs Face Dangerous Dilemmas

Amelia Huntsberger, an OB-GYN, has delivered babies and treated miscarriages at Bonner General for more than a decade. Soon after abortion became illegal here, she saw a patient with a ruptured ectopic pregnancy — where a fertilized egg grows outside the uterus — and faced a dangerous dilemma. The state law did not allow physicians to terminate ectopic pregnancies, which are never viable.

“I went to the emergency room and evaluated the patient,” Huntsberger said. “Her vital signs were stable at the time of my evaluation, but I knew based on her imaging we needed to move quickly to stabilize her.”

Huntsberger said her duty as a doctor was clear — to prioritize the safety of her patient — but added that she “also knew that I was putting myself potentially at risk of felony charges, which would have a minimum of two years in jail, [and] loss of my medical license for six months.”

She added, “I took care of multiple cases of ruptured ectopic pregnancy in the first weeks following that law going into effect.”

The Idaho Supreme Court has since ruled that the law does not apply to ectopic or molar pregnancies, a rare complication caused by an unusual growth of cells. But physicians say that limited change does not account for many common pregnancy complications that can escalate rapidly.

That has led to deep frustration and turmoil in hospital emergency rooms.

“When is it OK for me to act?” Huntsberger said. “Do I wait until she bleeds out? Do I wait until we do CPR? When is it that I can intervene? How close to death does she need to be before I take care of her?”

State Rep. Mark Sauter, a Republican from this lakeside community 60 miles northeast of Spokane, Washington, said he hadn’t thought much about the state abortion ban.

“It really wasn’t high on my radar other than I’m a pro-life guy, and I ran that way,” he said during an interview at his home overlooking the lake and forested mountains. “I didn’t see it as having a real big community impact.”

Then in December, Sauter had dinner with Huntsberger, whose husband is an emergency physician at Bonner General. “They started explaining all the details of what’s going on and how it was uncomfortable for them,” Sauter said.

Those conversations proved revelatory. “You get exposed to something, all of a sudden you go, ‘Wow, there’s a different way to look at this,’” he said. “‘What are we going to do about all this?’”

With Sandpoint’s maternity ward closing, Sauter supported a bill that would have allowed doctors to terminate pregnancies to protect a woman’s health, not just prevent her death. But that effort was shot down by other Republicans during a committee hearing in late March.

“The list was endless when we began considering the conditions that could fall under that language,” said Rep. Julianne Young, a Republican from Blackfoot. “We want to make sure that health of the mother doesn’t become so broad that everything becomes an exception to take the life of a potential child.”

The effects of the ban are being felt statewide. In Boise, the state capital, Lauren Miller, an OB-GYN, resigned earlier this month from her position at one of the state’s largest hospitals, St. Luke’s Health System, further shrinking the state’s already minuscule corps of maternal fetal medicine specialists.

As a doctor who cares for complex and high-risk cases, Miller said, she’s had to send patients out of state to end dangerous pregnancies, including a woman with a serious kidney disease.

“I could very easily have taken care of that patient along with my partners,” she said, noting that the Boise-based medical center has kidney specialists and an intensive care unit. “Instead, she had to leave her family and fly several more hours away to receive care in an expeditious time frame. It’s just not what we signed up to do.”

Miller said the abortion ban and threat of prosecution were not the only factors that drove her to resign. She cited lawmakers’ failure to extend postpartum Medicaid coverage beyond two months and to renew the Maternal Mortality Review Committee. The state panel investigates deaths of pregnant patients and new mothers and whether they could have been prevented.

During a hearing before the House Health and Welfare Committee, Rep. Mike Kingsley, a Republican, said the maternal mortality reports “all seem to identify the same thing: substance abuse, mental health. So, I think this has served its purpose.”

The Start of an Exodus

Directors of women’s health care services at Idaho hospitals are bracing for what’s next: 75 of 117 Idaho OB-GYNs recently surveyed by the Idaho Coalition for Safe Reproductive Health Care said they were considering leaving the state. Of those, nearly 100% — 73 of 75 — cited Idaho’s restrictive abortion laws.

An exodus could affect broader medical coverage for women who rely on OB-GYNs for routine and urgent gynecological care unrelated to pregnancy, like menstrual disorders, endometriosis, and pelvic pain.

Idaho is one of 15 states that have implemented strict abortion laws since last year’s Supreme Court decision overturning Roe v. Wade. And while there is no official nationwide count yet, anecdotal evidence shows that women’s health specialists from states where abortion is criminalized are beginning to relocate to places like Washington state, which has strong abortion rights laws.

In Seattle, for example, about 270 miles west of Sandpoint, Sarah Villareal, an OB-GYN, is now practicing medicine without fear of prosecution after moving from Texas, where performing an abortion is a felony punishable by up to life in prison. In Texas, private citizens can file civil lawsuits against anyone who “aids or abets” an abortion, earning a minimum of $10,000 for cases prosecuted successfully.

The difference between Texas and Washington is stark, said Villareal, noting an atmosphere of fear and distrust at many Texas hospitals. She recalled caring for a patient in a Gulf Coast emergency room who was having a miscarriage, though the fetus still had a heartbeat. The patient, already in physical and emotional crisis, had to navigate a legal issue, too.

“She was trying to figure out if me as the provider was going to report her if she did decide that she wanted to do a procedure to save her life over the life of her fetus,” Villareal recalled. “And the worst part was I could assure her that I’m going to try to do everything that I can for her, but I could not assure her that someone else in the emergency room or someone else in the operating room was not going to report her.”

Sarah Prager, an obstetrics and gynecology professor at the University of Washington School of Medicine, who has been recruiting OB-GYNs from states with abortion bans, including Texas and Tennessee, says physicians believe deeply that they are failing their patients.

“There’s really a moral and an ethical injury that happens when you are unable to do the job that you want to do,” Prager said. “Being unable to take care of our patients is what makes doctors stressed out. And when you add that we are legally unable now to prevent harm to patients, it leads to incredible rates of burnout.”

Even medical students are beginning to change their plans.

Kathryn Tiger and Allie Ward, first-year medical students in Moscow, Idaho, are both planning to become surgeons, though both say they intend not to practice in Idaho.

“I wouldn’t feel safe here as a provider, and I wouldn’t feel safe here as a patient,” said Tiger, 25.

Ward said the new laws criminalizing abortion in the state are constricting the ability of physicians to provide comprehensive care.

“You have to be able to refer and collaborate with not only just your care team and nurses and everyone that’s involved there, but also with other physicians,” Ward said. “It’s terrifying to think that I wouldn’t be able to refer a patient who was seeking care or even just education to a colleague of mine that I trusted because of the laws in place.”

Back in Sandpoint, Huntsberger and her family are saying their goodbyes to Idaho, saddened by the idea that some patients left behind may be in medical peril.

“It’s heartbreaking to me to think about what it will mean for a woman experiencing a pregnancy crisis,” the doctor said.

But, she added, “This isn’t a safe place to practice medicine anymore.”

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In Washington state, U.S. District Judge Thomas Rice, appointed by former President Barack Obama, directed the FDA not to make any changes that would restrict access to the drug in 17 states and the District of Columbia, where Democrats sued to protect its availability.

The conflicting rulings are all but assured to wind up before the Supreme Court.

KHN senior correspondent Sarah Varney joined PBS NewsHour’s Ali Rogin to discuss the language in both decisions and what they portend for the future of abortion rights in the United States.

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Speaking from the bench in a courtroom in Amarillo, Texas, Kacsmaryk repeatedly used language that mimicked the vocabulary of anti-abortion activists. It also reflected the wording of the lawyers seeking to overturn the FDA’s two-decade-old approval of mifepristone, one of the drugs in the two-pill regimen approved for early pregnancy termination.

Each time a lawyer from the Department of Justice, representing the FDA, referred to “medication abortion,” Kacsmaryk returned to the language of conservative Christian activists, using monikers like “chemical abortion” and “mail-in abortion,” phrases at odds with conventional medical terminology.

The stakes in the case, Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration, are high: Abortion rights advocates fear that Kacsmaryk, an appointee of then-President Donald Trump and a former lawyer at the First Liberty Institute, a conservative Christian legal group, could rule within days to force manufacturers to pull mifepristone from the market nationwide. If that happens, clinics and obstetricians and gynecologists across the country will be able to prescribe only misoprostol, the second drug in the two-pill regimen, for miscarriages and early abortion care. Misoprostol is still extremely safe but less effective and comes with more side effects.

The ruling would be unprecedented in the history of approved drugs and could affect the health care of millions of women, even those in states where abortion is still legal.

“One conservative judge is impacting the rights of women in California and New York,” said Greer Donley, an associate professor of law at the University of Pittsburgh Law School and expert on reproductive health law. “The endgame is to stop as many abortions as possible by any means necessary.”

When the conservative majority on the Supreme Court eliminated the federal right to abortion, Justice Brett Kavanaugh, a Catholic, wrote that the court was not outlawing abortion throughout the United States. “On the contrary,” Kavanaugh wrote, “the Court’s decision properly leaves the question of abortion for the people and their elected representatives in the democratic process.”

But in the nine months since the announcement of the decision in Dobbs v. Jackson Women’s Health Organization, Christian legal groups have made their strategy clear: eliminate abortion nationwide by filing lawsuits in federal courts that make scientific claims, unsupported by mainstream medical organizations, to raise doubts about the safety of abortion pills and contraception.

These legal decisions, which conservatives might once have decried as “judicial activism,” are partially necessary because abortion rights continually poll positively, with voters even in solidly conservative states like Kansas and Kentucky refusing to enact bans.

“After Dobbs, there have been more and more efforts to move things away from the popular majority and into the hands of judges like Kacsmaryk,” said Mary Ziegler, a law professor and abortion historian at the University of California-Davis School of Law. “Because voters are not sold on fetal rights and because the only way to a national ban on abortion is likely to come from the conservative courts,” she said.

Ziegler added of anti-abortion campaigners, “They don’t want solutions that work only in Tennessee and Texas.”

The strategy of casting doubt on established and accepted science is not new in conservative circles, nor is it limited to abortion.

For decades, conservative Christian legal groups have introduced scientific uncertainty where there had been none: Claims that abortion causes breast cancer or infertility are unsupported by medical and scientific research but nevertheless made their way into state laws, requiring physicians in certain states to tell patients about risks from abortion that do not exist.

And in a recent opinion that ended birth control access for teens without parental consent in Texas, the same judge as in the mifepristone case — Kacsmaryk — exaggerated the health risks of prescription birth control in his decision, asserting that states have an interest in protecting the health of girls.

“Several popular methods of birth control carry serious side effects,” Kacsmaryk wrote, later quoting from Planned Parenthood educational material that read, “Complications are rare, but they can be serious. In very rare cases, they can lead to death.”

That case, Deanda v. Becerra, was filed by a Christian father who cited religious objections to a federal family planning program. And in the mifepristone case, fundamentalist Christian groups have argued that the drug is unsafe, despite ample research and decades of use testifying to the contrary.

Alliance Defending Freedom, which describes itself as the world’s largest legal organization committed to protecting “God’s design for marriage and family,” is pushing to outlaw abortion pills. Erik Baptist, an attorney for the group, said in a statement following the March 15 hearing that the “the FDA’s approval of chemical abortion drugs over 20 years ago has always stood on shaky legal and moral ground.”

He added, “It’s time for the government to do what it’s legally required to do: protect the health and safety of vulnerable women and girls.”

Conservative legal groups like ADF have been savvy about exploiting small wins in the courts and building on them, such as the 2007 decision Gonzales v. Carhart, which upheld a federal ban on a rarely used method of abortion.

The decision had minimal practical impact, as the procedure in question was rarely performed, but it established an important legal principle: When scientific uncertainty arises in legal disputes — is a medical procedure, device, or medication safe or not? — legislatures get to decide.

“The court said when there is scientific uncertainty the tiebreaker goes to the legislature,” said Ziegler.

But there is little question that mifepristone is safe: More than 5.6 million women have successfully used medication abortion since 2000, according to the FDA. In 2008, the Government Accountability Office investigated the FDA’s approval of mifepristone and concluded the process was consistent with FDA regulations.

In the courtroom, Baptist acknowledged that no court had ever ordered the FDA to remove a drug from the market over the agency’s objections, and legal observers say there remains a huge question whether the court can order the secretary of the Department of Health and Human Services, who oversees the FDA, to do so.

But Laurie Sobel, an associate director for women’s health policy at KFF, who listened to the hearing in a Dallas courtroom, said anti-abortion attorneys argued that the mailing of abortion medications strips states of their ability to protect women and children. (The hearing, which Kacsmaryk did not, initially, publicly announce, was not streamed to the public, and the court has yet to release a transcript.)

But Jessica Ellsworth, an attorney representing Danco Laboratories, a manufacturer of mifepristone, told the court that abortion remained legal in all states because it was allowed for preventing a patient’s death or serious bodily injury. Using mifepristone is the safest method of abortion, she argued, noting the judge’s decision in the case could ban it in every state.

“If Kavanaugh said, ‘We’re going to send it back to the states to be decided by their elected representatives,’ this is the exact opposite,” said Donley.

Kacsmaryk appeared ready to grant a preliminary injunction in favor of anti-abortion groups, asking ADF’s Baptist what kind of remedy he was seeking.

Baptist responded, “The court has an interest in preventing dangerous drugs from entering the marketplace.” He added, “Any relief you grant must be complete. The harm of chemical drugs knows no bound.”

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Como maestra de tercer grado en una escuela pública del condado de Miami-Dade, pasaba todo el día parada. Le pesaban las preocupaciones financieras, incluso teniendo seguro de salud y algo de licencia paga.

Y, como mujer negra, toda una vida de racismo la volvió desconfiada de las reacciones impredecibles en la vida diaria. Estaba agotada por el trato despectivo y desigual en el trabajo. Justamente el tipo de estrés que puede liberar cortisol, que, según estudios, aumenta el riesgo de parto prematuro.

“Lo experimento todo el tiempo, no camino sola, o lo hago con alguien a quien debo proteger. Sí, el nivel de cortisol en mi cuerpo es incontable”, expresó.

A los dos meses de embarazo, las náuseas implacables cesaron de repente. “Empecé a sentir que mis síntomas de embarazo estaban desapareciendo”, dijo. Entonces comenzó un extraño dolor de espalda.

Etienne y su esposo corrieron a la sala de emergencias, donde confirmaron que corría un grave riesgo de aborto espontáneo. Una cascada de intervenciones médicas —inyecciones de progesterona, monitoreo fetal en el hogar y reposo en cama— salvó a la niña, que nació a las 37 semanas.

Las mujeres en Estados Unidos tienen más probabilidades de dar a luz prematuramente que las de la mayoría de los países desarrollados. Esto coincide con tasas más altas de mortalidad materno infantil, miles de millones de gastos en cuidado intensivo y a menudo una vida de discapacidad para los prematuros que sobreviven.

Aproximadamente uno de cada 10 nacimientos vivos en 2021 ocurrió antes de las 37 semanas de gestación, según un informe de March of Dimes publicado en 2022. En comparación, investigaciones recientes citan tasas de nacimientos prematuros del 7,4% en Inglaterra y Gales, del 6% en Francia y del 5,8% en Suecia.

En su informe, March of Dimes encontró que las tasas de nacimientos prematuros aumentaron en casi todos los estados de 2020 a 2021. Vermont, con una tasa del 8%, tuvo la calificación más alta del país: una “A-”. Los resultados más sombríos se concentraron en los estados del sur, que obtuvieron calificaciones equivalentes a una “F”, con tasas de nacimientos prematuros del 11,5% o más.

Mississippi (15 %), Louisiana (13,5 %) y Alabama (13,1 %) fueron los estados con peor desempeño. El informe encontró que, en 2021, el 10,9% de los nacidos vivos en Florida fueron partos prematuros, por lo que obtuvo una “D”.

Desde que la Corte Suprema anulara Roe vs. Wade, muchos especialistas temen que la incidencia de nacimientos prematuros se dispare. El aborto ahora está prohibido en al menos 13 estados y estrictamente restringido en otros 12: los estados que restringen el aborto tienen menos proveedores de atención materna, según un reciente análisis de Commonwealth Fund.

Eso incluye Florida, donde los legisladores republicanos han promulgado leyes contra el aborto, incluida la prohibición de realizarlo después de las 15 semanas de gestación.

Florida es uno de los estados menos generosos cuando se trata de seguro médico público. Aproximadamente una de cada 6 mujeres en edad fértil no tiene seguro, lo que dificulta mantener un embarazo saludable. Las mujeres de Florida tienen el doble de probabilidades de morir por causas relacionadas con el embarazo y el parto que las de California.

“Me quita el sueño”, dijo la doctora Elvire Jacques, especialista en medicina materno-fetal del Memorial Hospital en Miramar, Florida.

Jacques explicó que las causas de los partos prematuros son variadas. Alrededor del 25% se inducen médicamente, por condiciones como la preeclampsia. Pero la investigación sugiere que muchos más tendrían sus raíces en una misteriosa constelación de condiciones fisiológicas.

“Es muy difícil identificar que una paciente tendrá un parto prematuro”, dijo Jacques. “Pero sí puedes identificar los factores estresantes en sus embarazos”.

Los médicos dicen que aproximadamente la mitad de todos los nacimientos prematuros debido a factores sociales, económicos y ambientales, y al acceso inadecuado a la atención médica prenatal, se pueden prevenir.

En el Memorial Hospital en Miramar, parte de un gran sistema de atención médica pública, Jacques recibe embarazos de alto riesgo referidos por otros obstetras del sur de Florida.

En la primera cita les pregunta: ¿Con quién vives? ¿Donde duermes? ¿Tienes adicciones? ¿Dónde trabajas? “Si no supiera que trabajan en una fábrica paradas cómo les podría recomendar que usaran medias de compresión para prevenir coágulos de sangre?”.

Jacques instó al gerente de una tienda a que permitiera a su empleada embarazada trabajar sentada. Persuadió a un imán para que le concediera a una futura mamá con diabetes un aplazamiento del ayuno religioso.

Debido a que la diabetes es un factor de riesgo importante, a menudo habla con los pacientes sobre cómo comer de manera saludable. Les pregunta: “De los alimentos que estamos discutiendo, ¿cuál crees que puedes pagar?”.

El acceso a una atención asequible separa a Florida de estados como California y Massachusetts, que tienen licencia familiar paga y bajas tasas de residentes sin seguro; y a Estados Unidos de otros países, dicen expertos en políticas de salud.

En países con atención médica socializada, “las mujeres no tienen que preocuparse por el costo financiero de la atención”, apuntó la doctora Delisa Skeete-Henry, jefa del departamento de obstetricia y ginecología de Broward Health en Fort Lauderdale. Y tienen licencias por maternidad pagas.

Sin embargo, a medida que aumentan los nacimientos prematuros en Estados Unidos, la riqueza no garantiza mejores resultados.

Nuevas investigaciones revelan que, sorprendentemente, en todos los niveles de ingresos, las mujeres negras y sus bebés experimentan resultados de parto mucho peores que sus contrapartes blancas. En otras palabras, todos los recursos que ofrece la riqueza no protegen a las mujeres negras ni a sus bebés de complicaciones prematuras, según el estudio, publicado por la Oficina Nacional de Investigación Económica.

Jamarah Amani es testigo de esto como directora ejecutiva de Southern Birth Justice Network y defensora de la atención de parteras y doulas en el sur de Florida. A medida que evalúa nuevos pacientes, busca pistas sobre los riesgos de nacimiento en los antecedentes familiares, análisis de laboratorio y ecografías. Y se centra en el estrés relacionado con el trabajo, las relaciones, la comida, la familia y el racismo.

“Las mujeres negras que trabajan en ambientes de alto estrés, incluso si no tienen problemas económicos, pueden enfrentar un parto prematuro”, dijo.

Recientemente, cuando una paciente mostró signos de trabajo de parto prematuro, Amani descubrió que su factura de electricidad estaba vencida, y que la empresa amenazaba con cortar el servicio. Amani encontró una organización que pagó la deuda.

De los seis embarazos de Tamara Etienne, dos terminaron en aborto espontáneo y cuatro fueron de riesgo de parto prematuro. Harta de la avalancha de intervenciones médicas, encontró una doula y una partera locales que la ayudaron en el nacimiento de sus dos hijos más pequeños.

“Pudieron guiarme a través de formas saludables y naturales para mitigar todas esas complicaciones”, dijo.

Sus propias experiencias con el embarazo dejaron un profundo impacto en Etienne. Desde entonces, ella misma se ha convertido en una doula.

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A third-grade teacher at an overcrowded Miami-Dade County public school, she spent harried days on her feet. Financial worries weighed heavy, even with health insurance and some paid time off through her job.

And as a Black woman, a lifetime of racism had left her wary of unpredictable reactions in daily life and drained by derogatory and unequal treatment at work. It’s the sort of stress that can release cortisol, which studies have shown heighten the risk for premature labor.

“I’m experiencing it every day, not walking alone, walking with someone I have to protect,” she said. “So the level of cortisol in my body when I’m pregnant? Immeasurable.”

Two months into the pregnancy, the unrelenting nausea suddenly stopped. “I started to feel like my pregnancy symptoms were going away,” she said. Then strange back pain started.

Etienne and her husband rushed to an emergency room, where a doctor confirmed she was at grave risk for a miscarriage. A cascade of medical interventions — progesterone injections, fetal monitoring at home, and bed rest while she took months off work — saved the child, who was born at 37 weeks.

Women in the U.S. are more likely to deliver their babies prematurely than those in most developed countries. It’s a distinction that coincides with high rates of maternal and infant death, billions of dollars in intensive care costs, and often lifelong disabilities for the children who survive.

About 1 in 10 live births in 2021 occurred before 37 weeks of gestation, according to a March of Dimes report released last year. By comparison, research in recent years has cited preterm birth rates of 7.4% in England and Wales, 6% in France, and 5.8% in Sweden.

In its 2022 report card, the March of Dimes found the preterm birth rates increased in nearly every U.S. state from 2020 to 2021. Vermont, with a rate of 8%, merited the nation’s highest grade: an “A-.” The grimmest outcomes were concentrated in the Southern states, which largely earned “F” ratings, with preterm birth rates of 11.5% or higher. Mississippi (15%), Louisiana (13.5%), and Alabama (13.1%) were the worst performers. The March of Dimes report found 10.9% of live births in Florida were delivered preterm in 2021, earning the state a “D” rating.

Since the U.S. Supreme Court overturned Roe v. Wade, many maternal-fetal specialists worry that the incidence of premature birth will soar. Abortion is now banned in at least 13 states and sharply restricted in 12 others — states that restrict abortion have fewer maternal care providers than states with abortion access, according to a recent analysis by the Commonwealth Fund.

That includes Florida, where Etienne lives, and where Republican lawmakers have enacted a series of anti-abortion laws, including a ban on abortion after 15 weeks of gestation. Florida is one of the least generous states when it comes to public health insurance. About 1 in 6 women of childbearing age in Florida are uninsured, making it more difficult to begin a healthy pregnancy. Women are twice as likely to die from pregnancy and childbirth-related causes in Florida than in California.

“I lose sleep over this,” said Dr. Elvire Jacques, a maternal-fetal medicine specialist at Memorial Hospital in Miramar, Florida. “It’s hard to say, I expect [better birth outcomes] when I’m not investing anything from the beginning.”

***

The causes of preterm births are varied. About 25% are medically induced, Jacques said, when the woman or fetus is in distress because of conditions like preeclampsia, a pregnancy-related hypertensive disorder. But research suggests that far more early births are thought to be rooted in a mysterious constellation of physiological conditions.

“It’s very hard to identify that a patient will automatically have a preterm birth,” Jacques said. “But you can definitely identify stressors for their pregnancies.”

Physicians say that roughly half of all preterm births are preventable, caused by social, economic, and environmental factors, as well as inadequate access to prenatal health care. Risk factors include conditions such as diabetes and obesity, as well as more-hidden issues like stress or even dehydration.

At Memorial Hospital in Miramar, part of a large public health care system, Jacques takes on high-risk pregnancies referred from other OB-GYNs in South Florida.

When meeting a patient for the first time she asks: Who else is in your household? Where do you sleep? Do you have substance abuse issues? Where do you work? “If you don’t know that your patient works in a factory [standing] on an assembly line,” she said, “then how are you going to tell her to wear compression socks because that may help her prevent blood clots?”

Jacques has urged a store manager to let her pregnant patient sit while working. She persuaded an imam to grant a mom-to-be with diabetes a reprieve from religious fasting.

Because diabetes is a major risk factor, she often talks with patients about eating healthfully. For those who eat fast food, she asks them to try cooking at home. Instead of, “Can you pay for food?” she asks, “Of the foods we’re discussing, which one do you think you can afford?”

Access to affordable care separates Florida from states like California and Massachusetts — which have paid family leave and low rates of uninsured residents — and separates the U.S. from other countries, health policy experts say.

In countries with socialized health care, “women don’t have to worry about the financial cost of care,” said Dr. Delisa Skeete-Henry, chair of the obstetrics and gynecology department at Broward Health in Fort Lauderdale. “A lot of places have paid leave, [and pregnant patients] don’t have to worry about not being at work.”

Yet, as preterm births rise in the U.S., wealth does not ensure better pregnancy outcomes.

Startling new research shows that at every U.S. income level, Black women and their infants experience far worse birth outcomes than their white counterparts. In other words, all the resources that come with wealth do not protect Black women or their babies from preterm complications, according to the study, published by the National Bureau of Economic Research.

Jamarah Amani has seen this firsthand as executive director of the Southern Birth Justice Network and an advocate for midwifery and doula care in South Florida. As she evaluates new clients, she looks for clues about birth risks in a patient’s family history, lab work, and ultrasounds. She homes in quickly on stress related to work, relationships, food, family, and racism.

“I find Black women working in high-stress environments, even if they are not financially struggling, can face preterm birth,” she said. She develops “wellness plans” that include breathing, meditation, stretching, and walking.

Recently, when a patient showed signs of preterm labor, Amani discovered that her electricity bill was overdue and the utility was threatening to cut service. Amani found an organization to pay off the debt.

Of Tamara Etienne’s six pregnancies, two ended in miscarriage and four were threatened by preterm labor. Fed up with the onslaught of medical interventions, she found a local doula and midwife who helped guide her through the birth of her two youngest children.

“They were able to walk me through healthy, natural ways to mitigate all of those complications,” she said.

Her own pregnancy experiences left a profound impact on Etienne. She has since become a fertility doula herself.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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