As abortion is now intensely politicized in the United States, public discourse obscures its nature as an issue of health and health care. Preparation for the wide impact of criminalized abortion is paramount. This perspective offers a framework for preparation in states in which abortion is likely-or is already-illegal. This article reports on the perspective of a single institution in Michigan. It is important to note that preparations for the potential activation of the strict 1931 Michigan law criminalizing abortion raise more questions than they answer. A diverse set of people involved in these preparations is essential. In Michigan, the 1931 law renders only "life-preserving" abortions as legal to perform. Although it is often understood which medically necessary abortions these are, such as those performed for critically ill patients in the intensive care units (ICUs), the term "life-saving" is actually vague. How imminent must a death be to warrant an abortion? Would a patient with pulmonary hypertension and a 30%-to-50% chance of death be qualified to receive one? Or does the percentage need to be 100%? Would abortion be permitted to allow a newly diagnosed cancer patient to begin chemotherapy and radiation treatments immediately? Immediate treatment of cancer could possibly prevent future recurrence and risk of death that would otherwise be present. In states that outlaw abortion, individuals with necessary resources will opt to seek out-of-state care, but many, including teens, will lack such resources. The average travel distance for an abortion inMichiganwill increase fromless than 20miles to greater than 260 miles, childcare needs for previous children, and the difficulty of losing wages or taking time off work are all obstacles facing those seeking abortions but lacking the ability to access legal ones. Health care systems can assist patients in need, even in states where abortion is illegal. Referrals and pretravel "teeing up" may be options, which might include blood work, ultrasounds, and "fast track" consultations with specialists. Hospital systems need to arrange for the capacity in neighboring states' facilities. Insurers will have to decide on what type of coverage for travel expenses will be provided. As another option, some will choose self-managed abortion. Receiving the Food and Drug Administration-approved regimen of mifepristone and misoprostol in a medical office allows for patients to safely have abortions at home. Patients unaware of these medications, or without access to them, might use ineffective or dangerous methods to induce abortion, including poisons, intentional trauma, and insertion of implements or caustic substances into the cervix or vagina. Health care providers (especially in emergency departments and primary care settings) need to familiarize themselves with medications used for self-managed abortions. The use of unsafe methods may require critical lifesaving care for hemorrhage, sepsis, pelvic-organ injury, or toxic exposures. In addition, patients mayworry about legal recourse: reporting, detention, and arrest. Notably, there are currently no requirements in any state for reporting of self-managed abortions. Finally, those who cannot travel to receive care or manage their own abortion will give birth. It is projected that the illegalization of abortion in Michigan will result in a 5% to 17% increase in births in Michigan, which already faces maternity care deserts. This could limit care for patients, children in neonatal ICUs, and stretch medical professionals to see more patients and therefore possibly give lower quality care. In addition, maternal mortality will increase simply due to the difficult nature of childbirth in comparison to abortion. It is estimated that maternal mortalities will increase by 21% under a ban, along disparate lines of our current society: a 13% increase among White and 33% among Black birthing people. Doctors may also hesitate to treat ectopic pregnancies, inevitable miscarriage, or ruptured membranes with remaining fetal cardiac activity. They may also consider whether or not to even stock mifepristone and misoprostol in their offices, which are the best evidence-based medication treatments used in abortion care. Infertility clinics may need to halt provision of selective reduction for multifetal pregnancies produced by in vitro fertilization (IVF), thereby raising the possibility of premature delivery with higher rates of neonatal death. Also, IVF clinics may opt to halt treatment altogether to avoid the potential embryo losses that are common in the procedure. Overturning Roe will also affect medical education, as abortion training opportunities are required for accreditation of obstetrics residencies and are integral parts of nursing and other medical professions. Institutions will need to require out-of-state training, resulting in licensing and logistical issues. If trainees cannot learn to safely perform abortions, the number of professionals capable of performing "lifesaving" abortions will dwindle. Finally, given the large percentage of women in the medical workforce, these new restrictions will have a large impact on the system through their pregnancies, parental leaves, and travel for abortion care. Avoiding the issue of abortion is impossible, as it is a health care and health equity issue. Those who attempt to avoid the issue will quickly determine that the only means to avoid it is simply to abandon care and equity missions for abortion altogether.
