By Stacey Kusterbeck
Staffing challenges and low birth volumes are leading health systems to close their obstetric services, particularly in rural areas.1 More than one-third of counties nationwide have become “maternity care deserts” with no birth centers or obstetric hospitals and no obstetric providers.2
People with complications during pregnancy go to the nearest ED, regardless of whether the hospital has obstetric care available. “There is a lot of unplanned obstetric care that is shifting to EDs,” reports Lisa A. Wolf, PhD, RN, CEN, FAEN, FAAN, director of emergency nursing research for the Emergency Nurses Association.
After the June 2022 Dobbs v. Jackson Women’s Health Organization Supreme Court decision, there was a flurry of reports and news stories on potential medicolegal challenges in the OB/GYN and ED settings. “People were talking to physicians in states with abortion bans, and especially to people working in labor and delivery, but no one was talking to ED nurses. And we are the people who see it, recognize it, and have to figure out what to do about it, along with our physician colleagues,” says Wolf.
Wolf and colleagues wanted to learn about the decision-making processes of ED nurses caring for patients with obstetrical emergencies in states with abortion bans. “Knowing there are a lot of pregnant and postpartum people who will show up in EDs, what does that look like for ED nurses who are now trying to manage the effect of abortion bans?” asks Wolf.
The researchers interviewed 13 ED nurses in Kentucky, Alabama, and Texas in 2023.3 Nurses reported seeing more OB patients in general, and in particular, more patients coming in with early miscarriages. One nurse typically saw about a dozen pregnant patients every week; another nurse sent 15 pregnant patients to OB on a single shift. “It’s not that people are going to show up in EDs seeking an elective abortion. That’s not what we’re talking about. What we’re talking about is that the Dobbs decision extends to the care of pregnant patients with pre-viable fetuses,” explains Wolf.
EDs may have limited obstetrical care available, or none at all. The ED nurses reported focusing on getting pregnant patients out of the ED and to the hospital’s obstetric unit or, in hospitals without obstetric units, nurses were focused on transferring the patient to the appropriate facility. In the experience of some nurses, tension arose in those cases. “Some of the OB providers were really resisting transfer, and I think it’s because they understood they couldn’t do anything. If it’s a patient with a premature rupture of membranes, they don’t want to be caught in a situation where they are going to lose their license because they did something to intervene,” says Wolf.
Emergency physicians (EPs) face similar challenges in caring for pregnant patients in terms of determining when it is legally permissible to intervene. “But the nurses are also struggling — and part of the reason is that no one is telling them anything,” says Wolf. Each of the ED nurses reported that they had no administrative guidance on how state abortion laws affected clinical practices for pregnant patients. “They had literally no policies, no meetings. There was nothing — no communication at all from the administration down to the ED,” says Wolf.
The ED nurses reported significant knowledge gaps on obstetric emergencies and lack of obstetrics training. This further complicated the management of OB cases. In a 2021 study with similar findings, Wolf and colleagues interviewed 39 ED nurses from five EDs on triage of obstetric emergencies. They also reviewed charts of 12,766 patients of childbearing age who presented with headache, abdominal pain, chest pain, or shortness of breath.4 “All of those presentations in a pregnant patient can be very high-risk,” says Wolf.
The researchers wanted to know if the ED nurses took the patient’s pregnancy into account when making triage decisions. “What we found is that basically, no, they didn’t. They made no connection between the pregnancy and these other complications, because they didn’t have any education around it,” says Wolf. Of patients with a systolic blood pressure higher than 140 mmHg, 94% were under-triaged. In 86.5% of cases, there was no pregnancy status documented in the ED chart. “The ED nurses were not even looking for the pregnancy, because it had no meaning to them in terms of risk,” says Wolf.
In addition to those previously established clinical knowledge gaps, the ED nurses in the 2023 study also reported legal knowledge gaps. Nurses generally were unaware of how their state’s abortion law affected their clinical practice. “There was really this very consistent universal ignorance of the impact of the restrictions. Nurses thought of this as avoiding the political nature of this type of care. But nurses do need to understand the implications,” says Wolf.
While all potential legal implications of the state abortion laws are not fully clear, lawsuits already are underway. A group of patients sued the state of Texas for denying them abortions despite serious pregnancy problems.5
Generally speaking, following hospital policies is legally protective for ED nurses. “But in this case, there is no hospital policy. There is an atmosphere of real concern around what is allowed and what is not,” says Wolf.
The ED nurses worried about the possibility of being accused of violating state law and felt unsupported. Some of the ED nurses acknowledged self-censoring what they told pregnant patients (such as information on the legality of abortion in surrounding states). Without clear guidance from hospital administration, says Wolf, “There is a lot of self-policing. It comes down to the reluctance to be a test case.”
REFERENCES
- Sonenberg A, Mason DJ. Maternity care deserts in the US. JAMA Health Forum 2023;4:e225541.
- Brigance C, Lucas R, Jones E, et al. Nowhere to go: Maternity care deserts across the U.S. (Report No. 3). March of Dimes. Published 2022. https://www.marchofdimes.org/sites/default/files/2022-10/2022_Maternity_Care_Report.pdf
- Wolf L, Noblewolf HS, Callihan M, Moon MD. What if it were me? A qualitative exploratory study of emergency nurses’ clinical decision making related to obstetrical emergencies in the context of a post-Roe environment. J Emerg Nurs 2023;49:714-723.
- Wolf LA, Delao AM, Evanovich Zavotsky K, Baker KM. Triage decisions involving pregnancy-capable patients: Educational deficits and emergency nurses’ perceptions of risk. J Contin Educ Nurs 2021;52:21-29.
- Tanne JH. Women’s lawsuit against Texas reveals nationwide problems over abortions. BMJ 2023;380:579.
Staffing challenges and low birth volumes are leading health systems to close their obstetric services, particularly in rural areas. More than one-third of counties nationwide have become “maternity care deserts” with no birth centers or obstetric hospitals and no obstetric providers.
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