Roe was reversed one year ago. Missouri’s abortion ban has left patients in crisis

A year into Missouri’s abortion ban, residents who want to end their pregnancies are sometimes told that instead of traveling to neighboring Kansas, where the state constitution protects abortion, they need to look to other states such as Colorado that are hours away because clinics are inundated with patients.

The closest abortion clinics to Missouri – on the Kansas side of the Kansas City metro and on the Illinois side of the St. Louis metro – are flooded with patients from states with bans on the procedure, according to representatives from Planned Parenthood on both sides of the state.

Saturday marks one year since the U.S. Supreme Court overturned Roe v. Wade, which guaranteed a federal right to abortion, in a decision called Dobbs. Minutes after the ruling, a 2019 trigger law took effect in Missouri, making it the first state to ban nearly all abortions. Roughly a third of states now have bans.

Today, Missouri residents who want an abortion, and can travel out of state to have one, are now waiting in line behind women from Texas and Arkansas. Patients have been forced to figure out how to take off work, pack up their bags and travel hours to receive care – or, in some instances, keep an unwanted pregnancy.

“There are people who are going to either attempt to terminate a pregnancy without medical support, which should never ever have to happen, or they’re going to continue with pregnancies that they had not wanted,” said Emily Wales, president and CEO of Planned Parenthood Great Plains. “It’s going to be years of us uncovering what happens when you take away access to a fundamental right and critical type of care.”

The Missouri ban has ushered in a chaotic and uncertain era for women and doctors in a state where anti-abortion activists and officials for years worked to limit abortion access.

Even though Missouri had just one abortion clinic – in St. Louis – before the Supreme Court decision, medical providers have still spent the past year grappling with fallout from the ban. They say a provision allowing abortion in medical emergencies is poorly defined and has caused hospitals to deny life-saving care.

Some abortion rights advocates worry the ban has sown confusion among health care providers and pharmacists, as some patients struggle to get access to non-abortion-related medication over fears that it may hurt a pregnancy. Others have fallen through the cracks as the number of women who have been forced to carry an unwanted pregnancy to term as a result of the ban remains unknown, advocates say.

“One year ago, as the decision came down, we were very clear that this was going to send off a public health crisis in the context of already having a maternal mortality and morbidity crisis,” said Colleen McNicholas, the chief medical officer for Planned Parenthood of the St. Louis Region and Southwest Missouri. “We have absolutely seen that come to fruition.”

Far from settling the matter, the past year has revealed just how deep the divide over abortion is in Missouri. The aftermath of the ban has made clear that the end of Roe was only the start of a new chapter in the state’s decades-long fight over how and when women can legally terminate their pregnancies.

Even some who oppose abortion argue there are still unresolved issues a year into the ban.

“It is pretty clear that there are outstanding questions as to how we are going to close the door on mail order abortifacients, prescriptions or drugs that are delivered via mail to assist in taking the life of the unborn,” said state Rep. Doug Richey, an Excelsior Springs Republican.

“I think that that is an ongoing concern for those who have been in the pro-life community for decades upon decades. So I think that’s gonna be an ongoing effort, trying to determine how best to close the door on that industry. And I think that’s probably the chief focus.”

But the next major fight will likely be at the ballot box. Abortion rights supporters have filed a flurry of ballot initiatives to try to force a statewide vote on legalizing the procedure in 2024. Republican lawmakers, in turn, have vowed to put a proposal on a statewide ballot that would raise the threshold for ballot measures to pass.

Any vote on an amendment enshrining abortion rights in the Missouri Constitution would be a pivotal moment. Both abortion rights supporters and opponents have suggested voters may be more likely than not to approve such a measure as they look to Kansas and other states where the electorate has backed abortion rights.

Missouri would potentially be the first state with an abortion ban overturned by voters since the Dobbs decision.

“There is some irony there because on paper it looks like we’re better off politically but now we have an increased and greater threat than we had under Roe vs. Wade,” said Samuel Lee, a longtime anti-abortion lobbyist in Missouri.

“But I wouldn’t trade the situation for anything else because it was important that the states have the right to regulate abortion and things surrounding that.”

Effect of Missouri’s abortion ban

Missouri’s nearly-instantaneous ban was made possible by a small provision in a 2019 anti-abortion law signed by Republican Gov. Mike Parson. At the time, it was initially overshadowed by the legislation’s ban on abortion after the eighth week of pregnancy, which reflected the anti-abortion movement’s long-time strategy of chipping away at access.

Missouri already had stringent requirements surrounding abortion that over time had whittled away the number of clinics in the state to one. State law required women seeking an abortion to wait 72 hours and blocked the use of telemedicine in abortion.

The year-old ban is in some ways a return to the state’s roots. Prior to Roe v. Wade in 1973, Missouri had prohibited abortion in laws dating back to at least 1825.

But the 2022 Supreme Court decision, which was preceded by a leak of a draft opinion earlier in the spring, came as a shock to some. Lee said that some had expected the trigger wouldn’t become operative for a decade or longer.

“Am I grateful for the Supreme Court’s decision to overturn Roe? Absolutely. Was I surprised? Yes,” Lee said.

Within days, the ban began sowing confusion across the state. In one of the first indications of uncertainty over how far the law went, Saint Luke’s Health System temporarily stopped offering emergency contraceptives in the days after the Dobbs decision.

The move by the Kansas City health system received national attention and criticism from both sides of the abortion debate. Saint Luke’s reversed course after then-Missouri Attorney General Eric Schmitt and Parson gave assurances that the ban doesn’t affect contraception.

Concerns have also persisted that medical providers, fearful of the ban, won’t perform abortions that remain legal. Abortion is still allowed for medical emergencies, but the law includes no other exceptions.

Missouri’s previous abortion bans prior to Roe v. Wade also included medical exceptions, but courts then mostly deferred to the judgment of physicians, said Evan Hart, an associate professor of history at Missouri Western State University who has studied the history of abortion in Missouri.

“What’s come now is … doctors are concerned because the definitions aren’t very clear because medical emergencies aren’t always clear,” Hart said.

Last month, the U.S. Department of Health and Human Services found that the Freeman Health System in Joplin and the University of Kansas Hospital in Kansas City, Kansas violated federal law when they denied emergency abortion care to Mylissa Farmer, a Joplin woman, in August 2022.

After the abortion ban, Farmer went into labor just before 18 weeks of pregnancy, and doctors told her the fetus would not survive and she was at risk of infection. She was unable to get an abortion despite her condition, and eventually went to a clinic in Illinois to receive the care.

The first-of-its-kind federal investigation offered renewed scrutiny of the vagueness in Missouri’s abortion ban.

Abortion access was already a burden before the Dobbs decision, but now clinics in southern Illinois and on the Kansas side of the Kansas City metro are filling up with patients coming from states with abortion bans such as Arkansas, Florida and Louisiana.

On Friday, Kansas released official abortion statistics for 2022. The report shows that the number of Missouri residents receiving abortions in Kansas declined over the past year, falling from from 3,458 in 2021 to 2,883 in 2022, even as the total number of out-of-state abortion patients in Kansas jumped by 117%.

“Missourians who used to rely on that somewhat regional care are seeing wait times through the roof. And we know that pregnancy is time-sensitive care,” said Mallory Schwarz, executive director of Abortion Action Missouri, formerly known as Pro Choice Missouri.

The abortion rights advocacy group rebranded on Friday before the anniversary of the Dobbs decision.

Kansas in particular has become a beacon of abortion access in the Great Plains after voters in August overwhelmingly rejected an amendment to the state constitution that would have allowed legislators to ban the procedure. Abortion providers are now suing to overturn some remaining Kansas restrictions, including a 24-hour waiting period.

On Friday, U.S. Rep. Sharice Davids, a Kansas Democrat, reintroduced legislation that would expand access to birth control and reproductive health care services. The measure doesn’t fund abortions, however.

McNicholas said that prior to the Dobbs decision, only about 7% of the patients visiting the Planned Parenthood clinic in Illinois were from outside of Illinois or Missouri. Now, nearly half of the patients are coming from outside of the bi-state area.

And, including Missouri, nearly 85% of the clinic’s patients are from outside of Illinois, she said.

Maggie Olivia, the policy manager for Abortion Action Missouri, was one of those patients. Olivia, a 27-year-old from St. Louis, became pregnant this winter. It took her four weeks to make the final decision to end her pregnancy, she said. Olivia previously had an abortion before the state’s abortion ban.

Olivia crossed the Mississippi River into Illinois for an abortion, where she was harassed by anti-abortion protesters. She’s thankful that she was able to access the care and views her abortion provider as one of the only providers she trusts.

Months later, Olivia had a difficult time picking up her antidepressant prescriptions. After taking off work, she discovered that there was a medical record of her pregnancy and that her medications were being denied because of an assumption that she was pregnant, she said.

“That situation was devastating and horrifying,” she said. “These bans on abortion care are not only devastating to folks actively seeking abortion care, but they really are impacting every facet of our medical care.”

McNicholas said that restricted access to other medications has been one of the consequences of Missouri’s abortion ban.

“We know that folks are having difficulty accessing, for example, their basic pregnancy care for miscarriage management. Some folks struggling to get their medications that they use for non-pregnancy-related medical conditions because they might somehow impact a developing pregnancy,” she said.

Abortion rights supporters consider statewide vote

Concerns over the state’s ban have bolstered efforts by abortion rights supporters to restore access through a statewide vote.

“It’s unfortunate that we’ve taken a step backwards,” said state Sen. Lauren Arthur, a Kansas City Democrat. “But my hope is that this has awakened many of us who have taken our rights for granted.”

U.S. Sen. Josh Hawley, a Missouri Republican, painted the Dobbs decision as a way for states to decide how to address the legalization of abortion.

“Missouri voters will do what they think is best. I mean, listen, we’re a pro-life state. I’d be shocked if voters imposed abortion on demand. I’d just be shocked,” he said.

Hawley is married to Erin Morrow Hawley, an attorney who is on a team of lawyers suing in federal court in Texas to overturn the Food and Drug Administration’s decades-old approval of a common abortion medication.

Some Republicans, partly in response to a possible abortion rights ballot measure, are pushing legislation to make it harder for voters to amend the state constitution. Missouri House Speaker Dean Plocher, St. Louis Republican, last month acknowledged to reporters that voters would likely approve a measure if given the chance.

Polling by Saint Louis University and YouGov of nearly 450 voters in August 2022 found that 48% support reversing the ban, while 40% would vote to continue the ban. The question had a margin of error of plus or minus 5.93%.

The poll appears to show Missourians support some restrictions on abortion, even if a plurality also support overturning the state’s ban. While 58% of voters said abortion should be legal during the first eight weeks of pregnancy (a period during which many women don’t know they’re pregnant), only 40% said it should be legal through the first 15 weeks compared to 46% who said it shouldn’t.

Just 32% said abortion should be legal when a woman wants one for any reason. The poll didn’t ask about support for legal abortion up to the point of viability (around 24 weeks).

Missouri Attorney General Andrew Bailey, a Republican who has been accused of attempting to delay the abortion rights petition from reaching the ballot, championed the state’s abortion ban and vowed to continue fighting against the procedure.

“From getting Walgreens to back off of shipping unsafe, abortion-inducing drugs illegally in the mail to defending our pro-life law against abortion activists in court, my office is just getting started,” he said in a statement.

Earlier this week, a Cole County judge ruled that Bailey overstepped his authority when he tried to inflate the estimated cost of a proposed ballot measure to restore abortion rights. The judge ruled that Bailey had 24 hours to approve fiscal notes filed by Republican Auditor Scott saying that the ballot measure would have no cost to the state.

Bailey has since appealed the decision and missed the 24-hour deadline.

As the one-year anniversary of the Dobbs decision approaches, Wales, from Planned Parenthood, wants lawmakers to think about the effect Missouri’s abortion ban has had on patients.

“We, as providers of this care, are thinking about the people who come to us every day and are still asking why care is legal here and not back at home or why they had access to rights that they no longer have,” she said. “We wish that people who make the laws in this country would trust the people they’re elected to serve.”