When South Carolina and North Carolina passed abortion bans in May 2023, they were among the last states in the Southeast to end standard pregnancy and abortion care.
Standard abortion care for women in most of the South and parts of the Midwest will now be denied to all but a small percentage of people. Those who want or need abortion care a couple of months into pregnancy will need to travel hundreds of miles to a state where abortion care is legal.
“As we saw when the Supreme Court decision came out, and we had already been seeing in Texas with Senate Bill 8, providers are hesitant to provide evidence-based care,” says Kari White, PhD, MPH, a lead investigator with the Texas Policy Evaluation Project and an associate professor at the University of Texas at Austin Steve Hicks School of Social Work.
White and colleagues asked healthcare providers to share anonymous and confidential narratives for a study about the way their pregnancy care had changed since the Supreme Court overturned Roe v. Wade in June 2022.1
“We saw in the media that clinicians were being told by their institutional leadership that they shouldn’t speak to the media about these kinds of things,” White says.
They received 50 submissions with detailed cases of care that deviated from the usual standard because of abortion restrictions. They continue to collect anonymous data and submissions.
“The most common types of submissions we received through the Care Post-Roe project were obstetric complications and, often, previable, ruptured membranes,” White explains. “Clinicians treating them know what is likely to happen if patients don’t have an abortion, but they [believe] — based on advice they received from their institution — that they cannot intervene until the patient’s condition deteriorates to where they’re experiencing hemorrhagic bleeding or sepsis.”
Only when the patient is critical can clinicians provide abortion care, which they would have provided before the patient’s condition deteriorated if these laws had not taken effect.
“There’s not [another] case in medicine where you would wait for someone to be sicker before you intervene to help them or save their life,” says Alice Abernathy, MD, MSHP, an assistant professor in the department of obstetrics and gynecology at the University of Pennsylvania Perelman School of Medicine. “If you have the option of performing a surgery on someone when they’re clinically stable, rather than hemorrhagic or septic, you’d perform the surgery. Why we would force someone to clinically deteriorate before performing the standard of care is beyond me.”
Abernathy and colleagues studied U.S. claims data from 2017 to 2020. They found that people with high-risk cardiovascular conditions were undergoing fewer abortions in states with restrictions.2
“Even prior to Dobbs, there were trends to restrict or regulate abortion access at the state level for many, many years,” Abernathy says. “In 2010, we saw an exponential rise in abortion challenges. What we aimed to do is look at the pre-Dobbs period, where we knew there was variation of abortion access at the national level, to see [differences in] receiving an abortion — even when it’s the standard of care for patients with high-risk cardiac conditions.”
High-risk cardiac patients face enormous risk when they enter pregnancy, Abernathy notes. Heart disease is the leading cause of maternal morbidity and mortality in the United States and the rate is rising.3
The increase in maternal mortality rates in the past two decades is partly related to an increase of about 24% in women with cardiac disease delivering babies.2
“This is where you enter into a case-by-case conversation with the pregnant person about what the risk of a cardiac event would look like, what care would look like, and discuss with them if that risk is something they would accept and continue a pregnancy,” Abernathy explains.
Since the Dobbs decision, there are reports that physicians in some abortion-ban states fear even engaging in these discussions with pregnant patients with high-risk cardiac and other conditions.1
“One of the basic principles in medical practice is to do no harm and to respect patient autonomy,” Abernathy says. “To do both of those things, you have to have a discussion with patients about what all their options are and what the risks and benefits are.”
It is hard to imagine patients continuing an extremely high-risk pregnancy because they are ignorant of their options or because their provider is hobbled in their practice by abortion restrictions and fear of litigation, Abernathy adds. “I have a forthcoming paper describing variation in rates of hypertensive disorders in pregnancy, which also contribute to maternal morbidity and mortality,” she says. “So many health indicators show that in states where abortion is restricted, the maternal health crisis is already worse.”
For those who desire an abortion and are early in their pregnancy, it may be possible to obtain a medication abortion through one of the remaining providers. Or they could access telemedicine appointments with providers in states where this is legal or by connecting with overseas medication abortion organizations, such as Aid Access.
Access to mifepristone remains under threat nationwide due to a federal lawsuit by an anti-abortion group. The Supreme Court blocked a Texas federal judge’s decision to take mifepristone off shelves, at least temporarily. As of early June, mifepristone remained available in states with laws ensuring abortion access.
But these options are of no help to women who are pregnant and experience a pregnancy crisis, such as a miscarriage, fatal fetal anomalies, maternal life-threatening illness, and others. Stories told in recent studies and news reports show that women are forced to wait until they are critically ill before they receive care that was routine pre-Dobbs.1,4 (For more information, see the related story in this issue.)
The results of one study showed that even a pre-Dobbs 22-week abortion ban created harm for marginalized patients.5 “The ban creates harm for folks in lower socioeconomic status, as well as communities of color,” says Sophie Hartwig, MPH, lead study author and co-administrative director and research project director at the Center for Reproductive Health Research in the Southeast (RISE) at Emory University.
A federal investigation into hospitals that deny women miscarriage treatment show the worst-case scenario already is happening. Hospitals and providers are forcing women to risk their lives to continue pregnancies that will not end with bringing their baby home.6,7 For example, one Missouri woman who experienced a miscarriage medical crisis was turned away from two hospitals and refused standard miscarriage care at two others. Finally, she had to travel to Illinois to end her pregnancy and preserve her health and life.7,8
In November 2022, the National Women’s Law Center (NWLC) filed a complaint with the Centers for Medicare & Medicaid Services (CMS) on behalf of Mylissa Farmer, pursuant to EMTALA, says Alison Tanner, litigation senior counsel, reproductive rights and health at NWLC in Washington, DC. EMTALA ensures patients receive emergency medical care. (For mor information, see the related story in this issue.)
On May 1, CMS said it issued notices of deficiency under EMTALA against Freeman Hospital West in Joplin, MO, and the University of Kansas Health System for failing to provide emergency abortion care to Farmer after she experienced preterm premature rupture of membranes at nearly 18 weeks of pregnancy in August 2022. CMS said the hospitals overrode their physicians’ medical judgment and denied the necessary emergency abortion care. The agency also noted that two other hospitals discouraged Farmer from seeking emergency care at their facilities.7,8
“These were the first federal enforcement actions against hospitals for denying emergency abortion care following the U.S. Supreme Court’s decision taking away the federal constitutional right to abortion in Dobbs,” Tanner says.
“Alongside these actions by CMS, Secretary [Xavier] Becerra issued a letter putting hospitals nationwide on notice that there would be consequences under federal law for refusing to provide emergency abortion care to pregnant patients, regardless of state abortion laws,” Tanner explains.9
Becerra’s letter stated that while many state laws have recently changed, the federal EMTALA requirements have not.7 “We hope these enforcement decisions will lead hospitals throughout the country to change their policies and practices, which will ultimately save countless lives,” Tanner says.
The NWLC complaint stated that Farmer continues to suffer harm physically and mentally from her mistreatment at the two hospitals. It also noted that she made an emotionally difficult decision to obtain tubal ligation because “she believes if she were to become pregnant again in Missouri, she would likely die.”7,8
NWLC also filed a complaint with the Kansas Human Rights Commission and the Department of Health and Human Services Office for Civil Rights, alleging the four hospitals discriminated against Farmer based on sex and were in violation of Section 1557 of the Affordable Care Act.7,10-11 The complaint with the Kansas Human Rights Commission argued that Farmer was denied emergency care because of her sex and pregnancy in violation of the Kansas Act Against Discrimination’s prohibition on sex discrimination in public accommodations.11
In July 2022, the Biden administration released updated guidance noting physicians are protected by federal law if they terminate a patient’s pregnancy as part of treatment in an emergency circumstance. Healthcare organizations that deny patients that care are under threat of losing their Medicare status.12
REFERENCES
- Grossman D, Joffe C, Kaller S, et al. Care Post-Roe: Documenting cases of poor-quality care since the Dobbs decision. Advancing New Standards in Reproductive Health/Texas Policy Evaluation Project. May 2023. https://www.ansirh.org/sites/d...
- Abernathy A, Schreiber CA, Srinivas SK. State restrictions on abortion are associated with fewer abortions in patients with high risk cardiovascular conditions. Contraception 2023 May 3;110057. doi: 10.1016/j.contraception.2023.110057. [Online ahead of print].
- Bright RA, Lima FV, Avila C, et al. Maternal heart failure. J Am Heart Assoc 2021;10:e021019.
- Goldberg M. You cannot hear these 13 women’s stories and believe the anti-abortion narrative. The New York Times. May 22, 2023. https://www.nytimes.com/2023/0...
- Hartwig SA, Youm A, Contreras A, et al. “The right thing to do would be to provide care… and we can’t:” Provider experiences with Georgia’s 22-week abortion ban. Contraception 2023 May 7;110059. doi: 10.1016/j.contraception.2023.110059. [Online ahead of print].
- Surana K. Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law. ProPublica. May 19, 2023. https://www.propublica.org/art...
- National Women’s Law Center. NWLC files EMTALA and sex discrimination complaints on behalf of Mylissa Farmer. Nov. 8, 2022. https://nwlc.org/resource/nwlc...
- Centers for Medicare & Medicaid Service. Administrative complaint. Nov. 8, 2022. https://nwlc.org/wp-content/up...
- The Secretary of Health and Human Services. Xavier Becerra letter to hospital and provider associations. May 1, 2023. https://nwlc.org/wp-content/up...
- Office for Civil Rights. Administrative complaint. Jan. 29, 2023. https://nwlc.org/wp-content/up...
- Kansas Human Rights Commission. Complaint. Jan. 31, 2023. https://nwlc.org/wp-content/up...
- Ollstein AM. Biden admin looks to protect doctors providing emergency abortions and warn those that don’t. Politico. July 11, 2022. https://www.politico.com/news/...
When South Carolina and North Carolina passed abortion bans in May 2023, they were among the last states in the Southeast to end standard pregnancy and abortion care. Standard abortion care for women in most of the South and parts of the Midwest will now be denied to all but a small percentage of people. Those who want or need abortion care a couple of months into pregnancy will need to travel hundreds of miles to a state where abortion care is legal.
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