The election has been widely recognized as a referendum on the Trump presidency, but for many voters, it’s also the last front for protecting human rights and access to health care and key resources. The midterms had a substantial impact on reproductive rights, with state-wide initiatives involving abortion laws on the ballot in Alabama, West Virginia, and Oregon, and key elections for state and federal offices that could decide the future of abortion access across the country.

In West Virginia and Alabama, voters ultimately voted in favor of measures that could ban or severely prohibit abortion in the event that Roe v. Wade is overturned by the conservative-majority Supreme Court. Oregon voters defeated a ballot measure that would have reversed a law covering the costs of abortion and reproductive health care. And across the country, numerous Republican and anti-choice controlled state legislative bodies flipped, while other contentious and influential races between pro-choice and anti-choice candidates saw mixed results.

In the US, the last seven years account for 34 percent of the roughly 1,200 abortion restrictions enacted by states since Roe v. Wade was decided in 1973; about 90 percent of all US counties lack an abortion provider. Rising US maternal death rates are the highest in the industrialized world, with disproportionately higher rates in states with more restrictions on abortion access.

And while abortion measures were on the ballot in three states this year, in most cases, reproductive rights policies are decided not directly by voters, but by the lawmakers whom voters elect — to their state legislatures, governors’ offices, county and state judgeships, the House of Representatives, and the US Senate. A number of key federal and state-level races could have tremendous impact on the state of reproductive rights in the US.

Here’s a breakdown of what these electoral outcomes mean for abortion access and reproductive rights.

Alabama Amendment 2

Alabama voters voted to pass Amendment 2, a ballot measure that will recognize the personhood of unborn fetuses. Amendment 2 essentially acts as a “trigger ban,” or law that would immediately outlaw abortion if Roe is reversed. As Rewire reported last week, Amendment 2 does not specifically make abortion illegal. But it includes highly dangerous language that prioritizes personal and religious beliefs over full recognition of women’s bodily autonomy.

Measures like this have made it to the ballots in Colorado, Mississippi, and North Dakota in recent years, but all have previously failed. Alabama’s Amendment 2 will only impact abortion access if Roe is reversed, but it’s worth noting that Roe’s reversal is substantially more likely than it previously was in light of Brett Kavanaugh’s confirmation to the Supreme Court, which also could have helped turn out greater numbers of voters in favor of the measure.

In Alabama, 93 percent of counties lack an abortion provider, compared with 90 percent of counties across the country. The state also maintains some of the most restrictive and burdensome abortion laws in the country, including requirements that women seeking abortion care receive biased and inaccurate state-directed counseling, a 48-hour waiting period, an ultrasound, and parental consent for minors. Public funding for abortions is available only in cases of life endangerment, rape, and incest, and is otherwise banned for elective abortions.

Oregon Measure 106

In 2017, Oregon governor Kate Brown signed into law a bill that covered the costs of all abortion and reproductive health care for patients in the state. Oregon Measure 106, which Oregon voters rejected on Tuesday, would have reversed Brown’s Reproductive Health Equity Act.

Oregon has long been a blue-state with more liberalized laws around reproductive rights. However, this election cycle, Brown faced a competitive race against a Republican challenger who received millions from conservative PACs, and leading up to the election, almost half of all Oregon voters supported Measure 106.

Bans on public funding for abortion are widely criticized by pro-choice advocates as discriminatory for changing elective abortion from right to socioeconomic privilege.

West Virginia Amendment 1

In West Virginia, voters passed Amendment 1, or the “No Constitutional Right to an Abortion Amendment.” As its name would suggest, Amendment 1 proposes changing West Virginia’s constitution to state that nothing in it “secures or protects a right to abortion or requires the funding of abortion.” West Virginia already has anti-abortion trigger laws in its state constitution, which means Amendment 1 will simply impact Medicaid funding of abortion, which is currently available in some specific circumstances.

Similar to Alabama, West Virginia has some of the most restrictive abortion laws in the country. Ninety-eight percent of West Virginia counties, compared to 90 percent of all US counties, lack an abortion provider. Women seeking abortion care are required to receive biased, inaccurate state-directed counseling, and wait at least 24 hours before having the abortion.

Races That Could Substantially Impact Reproductive Rights

In the Senate, several pro-choice senators who could have acted as a buffer to reject anti-choice judicial nominees lost key races. Missouri Sen. Claire McCaskill, Florida Sen. Bill Nelson, Indiana Sen. Joe Donnelly, and North Dakota Sen. Heidi Heitkamp lost their races to anti-choice Republican challengers.

As of early Wednesday afternoon, a narrow victory has been called for pro-choice Montana Sen. Jon Tester over his anti-choice Republican challenger, Matt Rosendale; the race between Arizona Senate candidates Kyrsten Sinema, a Democrat who identifies as pro-choice, and Martha McSally, a Republican who identifies as anti-choice, remains too close to call.

In Texas, the notoriously anti-women, anti-choice incumbent Sen. Ted Cruz narrowly won reelection over Beto O’Rourke, who famously spoke out about how abortion restrictions disproportionately impact women of color.

While senators don’t always vote to confirm judicial nominees along party lines, electing senators with firm pro-choice records is key to protecting the Supreme Court and courts across the country, which comprise the most powerful arbiters of reproductive rights in this country.

Meanwhile, the House of Representatives elected historic numbers of women — and pro-choice, Democratic women, at that, which could substantially impact reproductive rights too. The House will now serve as a front to protect the Affordable Care Act, including its measures to make reproductive health care more affordable and accessible, and to protect funding for Planned Parenthood. The majority could also potentially be used to introduce legislation to protect abortion rights on the federal level.

And across the country, states like Iowa, whose Gov. Kim Reynolds signed into law a six-week abortion ban, replaced several anti-choice governors with pro-choice governors. Some states that flipped from red to blue governors’ offices include Kansas, Wisconsin, New Mexico, Maine, Michigan, Nevada, and Illinois, all of whom now have pro-choice governors. Democrats also flipped state legislative bodies in New Mexico, Minnesota, New Hampshire (both House and Senate), Colorado, Maine, and New York, and dismantled supermajorities in North Carolina’s anti-choice state legislature and Michigan’s state senate.

State governors and legislatures have tremendous impact on reproductive rights in their respective states, which explains the vast disparity in accessibility of abortion in Democratic and Republican-leaning states. With a conservative, anti-choice majority on the Supreme Court and the potential for abortion rights to either be reversed or dismantled piece-by-piece in the years to come, it’s crucial that we elect governors and state legislatures who will serve as a buffer to protect reproductive rights.

(Photos by Jack Taylor + Rich Fury/Getty Images)