Abortion Access and Pregnancy Dangers Continue

By Melinda Young

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The lesson of the first 2.5 years after the U.S. Supreme Court overturned Roe v. Wade, sending women’s reproductive rights back to the 1800s (literally — in the case of some states), is that this issue cannot be solved quickly. As Contraceptive Technology Update is being written, voting is underway for the 2024 election. The result is unknown at this time, but it is clear that whoever wins the presidency and whichever way voters in Florida and several other states vote on abortion access measures, women will continue to suffer harm from existing state abortion bans. This issue will look at some of the repercussions of the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization and hear from providers and researchers on what can be done to mitigate the damage to their patients’ health and lives.

Unless the U.S. Congress and the next president of the United States pass a bill that rescinds the 1873 Comstock Act, there is a possibility that the U.S. Supreme Court, with or without the help of the executive branch, will revive that zombie law, outlawing all mailing of abortion medication and possibly even prohibiting abortion clinics and providers from receiving any abortion tools and supplies anywhere in the United States. This would amount to a nationwide abortion ban without exceptions.

“In the case of a national ban, we can look to Texas for possible outcomes,” says Terri-Ann Thompson, PhD, senior research scientist at Ibis Reproductive Health in Cambridge, MA. Thompson is the senior author of a study about pharmacies and online medication abortion services before and after Dobbs. Although her study does not address what pharmacies would do if there were a national ban, she said other research offers a glimpse into this type of future. (See the story about pharmacies and online medication abortion in the upcoming January 2025 issue of Contraceptive Technology Update.)

“Following the ban on abortion provision in Texas, other studies showed a marked increase in requests for self-managed medication abortion from services like Aid Access,” Thompson says. “There was also a display of innovation and tremendous work on the part of abortion funds and providers to get people to the service they desired, and I imagine we will see similar outcomes if a national abortion ban is instituted in the United States.”

Some problems related to the Dobbs decision were anticipated, including the way that the most vulnerable patients are being affected by these bans. These include minors, people of color, and those with fewer economic resources. Some experts may have predicted we would see an increase in arrests of women because of their pregnancies, and a new study confirms that has happened.¹

Also, more women are dying from pregnancy causes. New research shows that has happened in Texas, where maternal mortality cases rose by 56% between 2019 and 2022, likely because of that state banning abortion earlier than Dobbs with its Senate Bill 8, passed in September 2021.²

Some of the repercussions that are more surprising are that women having miscarriages are being denied health- or life-saving care even when the embryo or fetus has died or when there is nothing remaining but fetal tissue. One such case, involving the tragic death of Amber Nicole Thurman, was highlighted by Vice President Kamala Harris in October 2024 during her talk with Oprah Winfrey.³

Another problem with the bans is how they affect women receiving fertility treatment and even treatment for chronic diseases and cancer. For instance, treatment of breast cancer, glioma, leiomyoma, endometriosis, and meningioma are among the conditions that have been treated with mifepristone — the abortion medication — as an adjuvant therapeutic agent. Use of mifepristone in cancer treatment and research started more than 25 years ago.^4,5

There are several ways that abortion bans can affect women with cancer and other chronic illnesses. One implication is for women who want to protect their fertility options because of their medical diagnosis, and they decide to harvest their eggs and preserve them for future use, says Georgia Robins Sadler, BSN, MBA, PhD, FAACE, a professor in the department of surgery at the University of California San Diego (UCSD) School of Medicine in La Jolla. Sadler is the senior author of a paper on how abortion bans affect cancer patients.⁶ (See the story on abortion bans’ effect on cancer treatment in this issue.)

As anti-abortion legislators increasingly embrace the idea of fetal personhood, fertility treatments such as in vitro fertilization are at risk. Fertilized ova may need to be maintained indefinitely — even when the people who preserved them die. This also affects the cost of fertility treatment, which is not affordable for many people, and it puts a larger financial and legal burden on fertility clinics that have to carry those costs and legal risks, especially when families that started the process walk away, leaving the zygotes with the clinic.

“The more layers of the onion we peeled off, the more our eyes started to cry,” Sadler says. “It got deeper and deeper — like a stone thrown into a pool of water that creates a big ripple.”

The more immediate concern is how cancer and other patients who are pregnant or even have the potential of becoming pregnant may be denied treatment.

“About 500 women a year are anticipated to be pregnant during cancer diagnosis,” says Emily Smith, an undergraduate and pre-med student in public health at the University of California San Diego in La Jolla. Smith also is a scholar of the National Cancer Institute Program at UCSD, and she is the first author on the paper about how abortion bans affect cancer patients.⁶

“There are articles about how women with chronic illnesses, including arthritis, are denied refills of their medications because pharmacies don’t know what to do with the Dobbs decision,” Smith says.^7-9 Reports show women with Crohn’s disease, arthritis, lupus, and other debilitating conditions being denied their treatment or forced to jump through more hoops to receive their treatment because of anti-abortion laws, even when they were not pregnant.^7-9 (See story on Dobbs and cancer treatment in this issue.)

Internists also need to know more about abortion bans and the impact on their patients, says Cynthia Chuang, MD, MSc, a professor of medicine and public health sciences and co-director of Penn State Center for Women’s Health Research at Penn State College of Medicine in Hershey, PA. “Probably with few exceptions, we all care for reproductive-age patients who have potential to get pregnant,” Chuang says. “One in four women have had an abortion by the time they’re 45 years, and one in five pregnancies in the U.S. end in abortion, so our patients are getting abortion care whether you realize or recognize it.”

Many internists take care of patients with complicated issues that make pregnancy high risk, and Chuang recently published a paper about abortion to inform this audience of a topic that affects some of their patients. Chuang and some other internists even perform abortion care.¹⁰ “I always wanted to be involved in abortion care,” she notes. “I went into medicine and decided I really liked internal medicine more than [OB/GYN], and I did not pursue doing abortion care at that time.”

She changed her mind after the Dobbs decision and began to work two days a month as an abortion provider at a new Planned Parenthood clinic. But her current mission is to simply help her internist colleagues understand how they need to be informed about abortion care because they will have some patients with dangerous pregnancies who need to be aware of all options.

“If you take care of a patient with complex cardiac or pulmonary issues, it’s important to inform people of what their risks are so they can make a decision of what they want to do,” Chuang explains. “It’s not that we’re encouraging people to have an abortion, but we want to give them all the information we can about the risks of their pregnancy.”

The chill factor from abortion bans has resulted in preventable deaths and injuries among pregnant women, as well as medical problems for women with cancer and other diseases.

Georgia’s six-week abortion ban led to two women dying after taking medication abortion pills without receiving standard medical care.^11,12 One of the two women, whose names came to national attention after articles published by ProPublica, was Candi Miller. Miller had two young children, and she had lupus, diabetes, and hypertension. When she unintentionally became pregnant in the fall of 2022, she ordered abortion pills online, but her body did not expel all of the fetal tissue. A dilation and curettage (D&C) procedure would clear her uterus and prevent sepsis. But she was afraid to go to a hospital because of Georgia’s abortion ban and well-publicized penalties. As a result, she self-medicated her pain with fentanyl and died after days of suffering in bed.¹²

Another woman who died in Georgia from the lack of adequate medical care was a single mother named Amber Nicole Thurman. Thurman had taken abortion pills she received out of state. She also died because her body did not expel all of the fetal tissue. But she had gone to a Georgia hospital for a D&C and was denied care for 20 hours. There was no fetus — only remnants of her pregnancy, and doctors still refused to provide the procedure that would have saved her life until her infection spread and her organs began to fail.¹¹

“Both cases are tragic, but the [Amber Thurman] case is especially heartbreaking because this is a patient who did everything a doctor would want them to do: She went to a clinic in North Carolina, came back to her home state, and was denied standard care,” says Angel M. Foster, DPhil, MD, AM, a professor in the faculty of health sciences at the University of Ottawa in Ottawa, Ontario, Canada. Foster also is the co-founder of The Massachusetts Medication Abortion Access Project (MAP).

“It is unconscionable that they wouldn’t provide care for 20 hours before providing uterine evacuation,” Foster says. “And the fact that doctors in the hospital were getting advice that they couldn’t intervene was because of the way these laws are written, where they feel threatening to clinicians and have them risk their livelihood and are a violation of their license if they do this.”

There are always cases where medication abortion or miscarriages will fail and require follow-up care, often with a routine D&C or aspiration procedure. Some bodies retain fetal products, and this can lead to sepsis.

“Why were they not treating her? It’s so baffling,” Foster says. “This case should not have come against the embryonic cardiac activity laws in Georgia; it was clearly a nonviable situation that led to this kind of infection.”

Another preventable pregnancy death was of 26-year-old Taysha Wilkinson-Sobieski, who was newly married and had a young son. The Indiana woman experienced cramping in her pregnancy and went to the nearest hospital, which had recently closed its maternity ward — a trend occurring in abortion-ban states because of OB/GYNs leaving the states. The hospital sent her to a different hospital, where she died from a ruptured fallopian tube caused by her ectopic pregnancy, according to a video that made the rounds on social media in October 2024.^13,14

One of the surprising consequences of the Dobbs decision is that accessing medication abortion has become easier since Roe was overturned as a result of the government making changes to allow tele-abortion services and also because of Aid Access and other organizations that will send mifepristone and misoprostol to women in abortion-ban states.

But the bans are causing much more suffering for pregnant women, even when they had no intention of ending their pregnancies. “The irony is that Dobbs has been horrible for obstetrics,” Foster says. “There are cases out of Texas, Florida, Idaho of people being medevacked to other states.” These are pregnant people who need abortion care to save their health, lives, and mental health because of problematic and doomed pregnancies.

“The degree to which Dobbs has wreaked havoc on obstetrics is predictable and visible, and it’s dystopian,” Foster says. “You can present for emergency care, and someone turns you away because you’re not quite at the brink of death yet. These are features — not bugs — of these laws.”

The abortion ban laws are written with confusing, nonmedical, and threatening language. They are written by people, such as legislators and lawyers, who do not know how pregnancies work and the dangers of high-risk pregnancies and pregnancy crises, she adds. “The penalties are so severe that clinicians who want to provide care are struggling with what they can do,” Foster says.

References

1. Tanne JH. More than 200 women faced pregnancy related criminal charges in the year after US abortion law was overturned. BMJ. 2024;386:q2136.
2. Edwards E, Essamuah Z, Kane J. A dramatic rise in pregnant women dying in Texas after abortion ban. NBC News. Sept. 20, 2024. https://www.nbcnews.com/news/rcna171631
3. Mizelle S, Navarro A. Harris speaks about abortion in Georgia, highlighting deaths of two Georgia women. CBS News. Sept. 20, 2024. https://www.cbsnews.com/news/harris-abortion-georgia-deaths-two-georgia-women/
4. Koide SS. Mifepristone. Auxiliary therapeutic use in cancer and related disorders. J Reprod Med. 1998;43(7):551-560.
5. Llaguna-Munive M, Vazquez-Lopez MI, Jurado R, Garcia-Lopez P. Mifepristone repurposing in treatment of high-grade gliomas. Front Oncol 2021; Feb. 18. doi: 10.3389/fonc.2021.606907.
6. Smith ER, Sadler GR. Cancer care in post-Roe America: How do we move forward? J Cancer Educ. 2024; Oct. 8. doi: 10.1007/s13187-024-02512-y. [Online ahead of print].
7. Castronuovo C. Many female arthritis drug users face restrictions after Dobbs. Bloomberg Law. Nov. 14, 2022. https://news.bloomberglaw.com/health-law-and-business/many-female-arthritis-drug-users-face-restrictions-after-dobbs
8. Christensen J. Women with chronic conditions struggle to find medications after abortion laws limit access. CNN Health. July 22, 2022. https://www.cnn.com/2022/07/22/health/abortion-law-medications-methotrexate/index.html
9. Upham B. Women with RA, other diseases, may have trouble accessing methotrexate because of abortion restrictions. Everyday Health. July 1, 2022. https://www.everydayhealth.com/rheumatoid-arthritis/women-with-ra-may-have-trouble-accessing-methotrexate-due-to-abortion-restrictions/
10. Chuang CH, Horvath S. Abortion. Ann Intern Med. 2024;177(10):ITC145-ITC160.
11. Surana K. Abortion bans have delayed emergency medical care. In Georgia, experts say this mother’s death was preventable. ProPublica. Sept. 16, 2024. https://www.propublica.org/article/georgia-abortion-ban-amber-thurman-death
12. Surana K. Afraid to seek care amid Georgia’s abortion ban, she stayed at home and died. ProPublica. Sept. 18, 2024. https://www.propublica.org/article/candi-miller-abortion-ban-death-georgia
13. Blando A. The life of the mother, the grief of her child: What abortion bans take from us. Ms. Oct. 1, 2024. https://msmagazine.com/2024/10/01/life-death-mother-children-no-parent-abortion-ban-miscarriage-ectopic/
14. Indiana mom Taysha Wilkinson-Sobieski killed by state’s abortion ban. NowThis. https://www.msn.com/en-xl/news/other/indiana-mom-taysha-wilkinson-sobieski-killed-by-state-s-abortion-ban/vi-AA1runZx

Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.