South Carolina's governor has just signed a bill banning most abortions as early as six weeks into law.

South Carolina is the latest state to tighten its grip on abortion access since Roe v. Wade was overturned last June.

A new study has found that states blocking female reproductive rights are putting lives at risk.

The co-authors of the report joined me to discuss how these bans are endangering women.

Michel: Thank you both so much for joining us.

Dr. Grossman let me start with you.

What was the intention behind this study?

How did it get started?

What were you thinking about?

What did you want to know?

Dr. Grossman: I was really concerned.

These bans generally allow abortion in the pregnancy threatens the life of the pregnant person, but as a practicing physician for almost 30 years, what constitutes a life-threatening condition is not always as clear as it seems.

It is not black and white.

How severe does the condition need to be?

How immanent does the threat need to be?

Since these answers were someone clear, I was concerned that my colleagues in states with abortion bands were going to hesitate to provide the care that was medically necessary.

After the Dobbs decision, we did see some reports in the media about cases where patients had pregnancy complications but could not get the care they need, even though the condition threatened their life.

At the same time, we were hearing reports that doctors were being told by their hospitals and employers not to talk to reporters.

Their voices were being silenced.

That is why we started this project, to give doctors and nurses and midwives, nurse practitioners, pharmacists, anyone who cares for a patient an opportunity to be able to share these stories about quality care anonymously if they want to.

Michel: Dr. Grossman is a clinician, so you are interested in what is going on.

Katrina, you are a sociologist.

Were you interested in thinking about the patterns?

Katrina: absolutely.

My focus is on the patient experience, particularly with navigating reproductive health care.

This is something not generally recognized.

There are a heartbreakingly large number of ways that pregnancy can go wrong.

Generally we think of pregnancy as a positive thing.

People are excited about it.

We think of it as resulting in babies and family growth.

In actuality, there are a number of ways it can go wrong.

I was really interested in understanding what the patient experience is, what they are facing, what they learn about, and what the consequences of having a pregnancy in states that have banned abortion and therefore have taken that tool out of the toolkit of the prenatal care providers, of all the people who are supposed to take care of these patients.

What happens to the patient then?

That is why I joined this study.

Michel: You partnered with investigators at the University of Texas Austin, which started looking into the impact of the ban in Texas on abortions after six weeks.

Dr. Grossman but maybe you will start here, but were researchers seeing?

Dr. Grossman: My colleagues were already talking to doctors back in and they were seeing that patients could not always get the care they needed, because it was not always clear when a situation was life-threatening enough to provide lifesaving care.

So they started seeing some of these reports, essentially, Texas, because of the six-week ban, they got a web what the post op world was going to look like for the rest of the country.

Michel: Then the setting expanded out.

What were some of the other locations you looked at?

The purpose was to give people the opportunity to report without jeopardizing themselves professionally or legally.

But as broadly as you can, tell me who are some of the people you heard from in this story.

Prof. Kimport: We structured it to be fully anonymous, to allow people to submit cases even when their hospital system was discouraging them from speaking about it and even when they were concerned that maybe they potentially would be at risk of legal work criminalization.

We heard from doctors and nurses in states that have abortion bans about cases, patients who they took care of where they were not able to offer the standard of care.

We also heard from physicians and states that were receiving these patients.

When the patients were not able to get standard medical care, many times they would travel to a state that did not have an abortion ban in order to receive what they could have received for the Dobbs decision in their own hospital, from their own providers.

In our study, thankfully we did not get any reports of deaths.

Miraculously, all of the cases we heard about resulted in the patient ultimately getting the care they needed.

But I think the question is at what cost.

We have seen they have had to travel.

They had to experience both the physical extension and repercussions of the delay in receiving standard medical care, and they had to be away from family and friends and for some they had to fear that what they were doing was illegal.

We have had instances of people doing all these things that they need is basic medical care under an umbrella of fear that what they are doing could result in going to jail, being fined, and potentially long-term physical repercussions.

Michel: It is my understanding that you got submissions from about 50 providers across 14 states, but I take it you still feel the findings are important to highlight.

Why is that, for people who would argue or question that that is not a huge number, given how many practitioners there are, given how many pregnancies there are, what would you say?

Prof. Kimport: We believe this is the tip of the iceberg.

These are the cases where somebody observed that a patient did not receive standard medical care, new enough about our study today then be able to report it, and took the time to complete that form.

We can only imagine there are other cases -- and it is hard at this point estimate what that number would be, but there are going to be plenty of cases where somebody either did not know about the study or did not have time to report it.

Fundamentally, what these cases represent, and remember they happened immediately after these legal changes went into effect, and what we are looking at is just a six-month shot Michel: Dr. Grossman, walk me through some of the reports that stood out.

Dr. Grossman: There were many different scenarios.

No two were alike, but there were broad themes that allow us to break the cases.

Some were cases where there was a medical complication in pregnancy where it became necessary to terminate the pregnancy.

An example is the case of a person who was pregnant at about 16 weeks whose water breaks and because this puts a woman at a very high risk of infection or heavy bleeding, and it is also very unlikely that she will be able to continue the pregnancy to a point where the baby could survive outside of her, the standard care is to at least offer the woman adoption of having a termination.

But that was not the case in these scenarios, and many of them came back and had very serious infections, and some of them came.

Some came very close to dying.

And there were complications with the fetus.

There were women pregnant with a fetus that had anomalies that were generally incompatible with life.

Before Dobbs, patients had the option of having an abortion in these scenarios, but that is no longer possible now.

Women were faced with the very difficult decision to either travel to another state to obtain abortion care and all the logistical complexities and financial costs associated with that, or continue the pregnancy, carrying a baby that they knew was -- it was impossible for the baby to survive.

It was likely the baby would have a short and painful life.

The third category would be patients having a miscarriage.

There was one case of a woman who was prescribed medication by her doctor she could not get it at a pharmacy because the pharmacist was concerned that it was being used to induce an abortion.

There were a couple of patients who had symptoms and were concerned that they were having a miscarriage and they lived in a state with an abortion ban, but they were so scared to even go to a hospital or see a doctor because they were worried that they might be accused of possibly having done something on their own to end the pregnancy, and instead they traveled hundreds of miles to try to get care in another state.

Michel: I was interested in the fact that many of these physicians were going out of their way to coordinate with callings, some of them hundreds of miles away.

I was wondering whether that affected their ability to care for people with more routine medical concerns.

I am mindful of the fact that the maternal mortality rate in the United States is very high for a country as affluent as it is.

In fact, it ranks among one of the highest for a country as wealthy as the United States is, and particularly amongst certain groups.

Like women have a far higher rate of maternal mortality than other groups -- black women have a far higher rate of maternal mortality than other groups.

I wonder if this is part of the discussion.

Prof. Kimport: Absolutely, the United States has a crisis of maternal mortality, and it is particularly devastating for black and brown women.

It is across the United States, but there are also specific some states with even higher maternal mortality rates.

These are women dying in childbirth or within a short time after giving birth.

It is even more devastating in many of the states that have enacted these abortion bans.

These abortion bans are layered on top of a maternal mortality crisis.

The people who wrote in and shared their cases in our study described going to extreme lengths, spending a huge amount of time and resources.

It follows that that meant were taking away time and effort toward other patients.

The other piece that is important to underscore about the effort that these physicians were taking on behalf of their patients to ensure that they could get the standard of care, many of them were relying on their personal social networks.

They were contacting their colleagues and friends in other states that did not have an abortion ban.

What that means from a patient perspective is that your care and your ability to have standard medical care may actually depend on the social networks of your physician.

This is something that suddenly now, whether or not you are able to have standard of care, depends on who your physician is friends with.

Michel: Did the clinicians talk at all about the toll on themselves?

Did they talk about wanting to leave medicine, for example?

Did they talk about the fear of criminal prosecution?

Did they talk about the toll on themselves in the study?

Dr. Grossman: They did.

These laws are scary.

There was a risk that they could go to jail, and in some of these narratives, they talked about that fear.

And the moral distress they were experiencing, because they felt like their hands were tied, that they had been trained for so long to provide high quality medical care, and now they were unable to do that.

They had to watch their patients essentially suffer or find a way to get them care in another state.

Prof. Kimport: One of the things we saw too, while not many reported they were intending to leave medicine altogether, there were several that said they were planning to relocate to a state that would not tie their hands.

And there were others who were committed to their community and their patients and had no intention to leave, but said they would discourage a future resident physician or a nurse from moving to the area and starting a practice.

I think we are going to see, maybe not immediately, but down the line we are going to start to see a shift in the work force , and that is going to have even more consequences for patient care.

Michel: I have to ask both of you a question that clearly there are medical providers who do think, who do agree that abortion should be illegal, or at least illegal in many cases, so I am going to ask each of you, did any of your respondents take that view?

Dr. Grossman: No, no one took that view.

We were specifically asking doctors and nurses to tell us about the cases where the care was different from the standard.

Really, in all the submissions, they talked about how care was different, it was worse quality, and this is a serious problem.

They were all very critical of the laws.

Michel: There are clearly significant numbers of people in this country, including some medical practitioners, who do believe abortion should not be permitted.

I am going to ask you that there are those that would say you found what you are looking for.

How would you respond?

Prof. Kimport: 21 of these findings show is the disconnect between how we think in a public setting, politicians in administration, and what it actually means in a medical setting.

This idea between law and on the ground medical care.

This idea in law and often in our public discussion about abortion, is that there is a black-and-white setting, this is an abortion ban this is not.

What we get into, in actual medical care, is a lot more gray and becomes a lot more difficult to draw a really firm line.

What we see in this study is that over and over again, when people try to draw a line through the law, what ended up happening was that patients got sicker, patients were denied the care that they needed, that their physicians, doctors, and nurses knew was the best care.

There really is no bright line where you can just segment off abortion and say that this is never necessary or is not a part of reproductive health care.

Instead, what we find is that abortion and the procedures related to abortion are fundamentally important tools in keeping patients safe.

And doing things like insuring their future fertility, insuring that they have reduced risk of complications and mortality.

Dr. Grossman: I recognize that people have different belief systems and may feel differently about abortion bans and these laws restricting abortion, but I want people to know that these laws are having an additional effect.

They are causing real harm to the very pregnant women that I think we all care about and want to protect.

It just feels really important to me now to share this information about the harms we are seeing so that people are aware of this as they are having discussions and thinking about what kinds of laws and policies they want in their state.

Clinicians like myself just want to provide the best high-quality care weekend to patients.

That is no longer possible in some of these states.

I want people to hear about this, learn about this, and be as concerned as I am.

Michel: Professor Kimport, what do you hope people will take away from this conversation?

Prof. Kimport: I hope this helps recognize the way these abortion bans are creating dangerous situations for pregnant patients , and it means that they are being denied standard medical care.

I think that was in every way people talked about abortion bans or understood what their effects could be, but it is what we are seeing, and it needs to be part of the conversation.

Michel: Thank you both for talking so much about this.