EXECUTIVE SUMMARY
The abortion crisis that a family planning physician warned about several years ago is here as state legislatures have passed many laws that would stop abortions and place women at risk of injury or death during pregnancy.
- These efforts are not following evidence and they are not what is best for their constituents, the physician notes.
- Health system mergers and changing administrative rules also affect how OB/GYNs work.
- The new state laws are similar to religious medical institutions’ policies prohibiting virtually all abortions, even in cases of miscarriage when there was a fetal heartbeat.
When a family planning physician co-authored an urgent paper on threats to reproductive health five years ago, he called for clinicians to get involved, urging them not to wait until a crisis arose.1 Now, he says, that crisis is here.
“It was important in the article we published in 2017 to point out all of these [problems] so we would not end up where we are in 2022,” says David L. Eisenberg, MD, MPH, FACOG, associate professor and associate director of OB/GYN at the Washington University in St. Louis (WUSTL) School of Medicine. “This is a call to arms for clinicians to get involved. We could tell there was this continued, calculated, strategic effort by folks who are not following evidence-based healthcare or public health practice.”
State Laws Are Detrimental
State legislatures are making decisions about policy and clinical care that are not best for the population they are targeting. “Some states, like Illinois, where I work, are better off because they have followed the evidence and best practices of how to improve the health and well-being of people,” Eisenberg explains. “Other states, like Missouri, where I also work, are worse off because they continue to promote the wrong values.” Many Southern and Midwestern states have passed laws that severely restrict or ban abortion care, putting their own political values ahead of patients and their families, he adds.
Since Eisenberg published his paper on threats to reproductive care, he has heard from physicians who have awakened to the legislative interference in their practice of medicine.
Health system mergers and changing administrative rules also affect the ability of OB/GYNs to work in ways that best serve patients.
“There are all kinds of examples of how these regressive approaches to sexual reproductive healthcare negatively affect the individual and folks who are subject to these,” Eisenberg says.
For instance, in 2019, Missouri enacted a law that defines an induced abortion by removing the words “or dying,” he says. Before the change, the law defined induced abortion as the intentional ending of a pregnancy to remove a dead or dying fetus.
“We know as healthcare providers when someone presents with a spontaneous abortion — the medical term for miscarriage — the cervix is open and they are bleeding, and there is little anyone can do to stop the embryo from passing from the uterus,” Eisenberg explains. “According to the state of Missouri, if you are doing what anyone in any healthcare capacity would consider miscarriage management, you cannot offer that miscarriage management when fetal cardiac activity is still present.”
It used to be that only Catholic hospitals would prohibit healthcare providers from evacuating a patient’s uterus before the patient becomes septic or needs blood transfusions and make patients wait until there was no cardiac activity, Eisenberg notes. Now, that same dangerous policy is enshrined in state law.
“In the past, institutions governed by religious directives would transfer the patient to another hospital,” Eisenberg says. “Now, every healthcare provider has to decide if this is an abortion or removal of a dead fetus, and what does that mean?”
Laws Put Doctors in a Quandary
This same level of misunderstanding is what prompts doctors in states with similar health policies to turn women away from life-saving treatment in the event of ectopic pregnancies or miscarriages.
“This is how we end up at a time when patients don’t get the life-saving care they need because of legislative, institutional, and insurance-based policies,” Eisenberg says. “The fact there are civil and criminal penalties is a significant problem, and it has a huge chilling effect on healthcare providers’ willingness to do what’s right for patients.”
Reproductive health providers already know how to manage patients experiencing pregnancy-related complications. What is more challenging to manage is the legislative interference in that doctor-patient relationship.
“In my own conversations with legislators who are creating these laws, the consequences of the law — the negative health consequences — are not their primary concern,” Eisenberg says. “They’re trying to pass laws that prove their faithfulness to some party platform or some political point so people who vote in the primary will come out and vote for them.”
Recently, some states, like California and Vermont, have expanded reproductive healthcare and abortion care. But many more have banned abortion and added more restrictions. If the U.S. Supreme Court rules in favor of allowing the Mississippi 15-week abortion ban to stand, ending its 1973 Roe v. Wade decision, then most women of reproductive age will lose abortion care — and, often, the best miscarriage management in their own states.
Affluent women and women who can scrape together enough time and money will be able to travel to states where safe and legal abortions will continue. “The people who can’t are those who are poor or people of color, and they’ll suffer the consequences of this practice,” he says.
Over the last six months, Eisenberg already has seen this shift to abortion travel. In his own abortion care practice at two outpatient facilities in Illinois, he has provided abortions to at least one woman from Texas every day.
“There is a larger and larger percentage of people from the states of Kentucky, Indiana, Louisiana, Mississippi, Oklahoma, Iowa, and Missouri coming to our clinics,” Eisenberg adds. “My team at WUSTL [performed] an analysis where we looked at the association between state-level restrictions on abortion and maternal mortality rates. States that restrict abortions have higher maternal mortality rates than those that protect abortion access or that are neutral.”2
While the analysis does not prove causation, Eisenberg and colleagues accounted for every meaningful variable, and the finding still was true.
“If you look at California, which is the most populous state in the country and has a demographic makeup that includes Native American women and African American women, they’ve seen reductions in maternal mortality in the last couple of decades because they follow the scientific evidence,” Eisenberg says.
In addition to maternal mortality, the consequences of forcing women to complete unintended pregnancies can lead to maternal health problems and other types of suffering.
“The patient, for example, who has known renal dysfunction in the setting of longstanding hypertension, and who gets pregnant and doesn’t want to continue that pregnancy, is taking her future renal function into account when choosing whether or not to end the pregnancy,” Eisenberg says. “Some may say they understand the risk and want the child, but many patients may not understand that risk and would be forced to have that pregnancy, which would make them much more likely to have permanent loss of renal function, ending with their being on dialysis.”
Eisenberg recalls a pregnant patient with renal failure who was admitted to a small, religiously affiliated hospital in Illinois. She could not obtain the first trimester abortion necessary to get discharged from the hospital, which had a strict anti-abortion policy.
“She was given dialysis and discharged from the hospital, driven hours to a clinic to get her first trimester abortion,” he notes. “Then, she was readmitted to the hospital to get inpatient dialysis and ongoing care.”
If Roe v. Wade is overturned, there will be a huge swath of the country where hospitals will be unable to provide life-saving abortion care.
A proposed federal law that could help protect that right, called the Women’s Health Protection Act, passed in the U.S. House of Representatives in September 2021. Physicians can do their part to encourage their legislators to vote for that bill in the Senate.
“I published that initial article as a wake-up call, so let’s not be the last person standing,” Eisenberg says.
REFERENCES
- Eisenberg DL, Leslie VC. Threats to reproductive health care: Time for obstetrician-gynecologists to get involved. Am J Obstet Gynecol 2017;216:256.e1-256.e4
- Addante AA, Eisenberg DL, Valentine MC, et al. The association between state-level abortion restrictions and maternal mortality in the United States, 1995-2017. Contraception 2021;104:496-501.
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