After Roe v Wade: US doctors are harassed, confused, and fearful, and maternal morbidity is increasingBMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o1920 (Published 01 August 2022) Cite this as: BMJ 2022;378:o1920
Early last month a pregnant 10 year old girl was brought from her home in Ohio to Indiana for an abortion after she had been raped. It was too late for her to be treated in Ohio, forcing her to travel 175 miles (280 km) across the state boundary.1
The story drew national and international attention and was denounced as fake. It turned out to be true. A 27 year old man was arrested and charged with rape.
Caitlin Bernard, an Indianapolis obstetrician and gynaecologist and assistant professor at Indiana University, treated the girl with a medication abortion. At the moment, abortion in Indiana is legal up to 20 weeks, but on 30 July the state senate approved a ban, with exceptions only for rape, incest, and to save the pregnant person’s life. The Indiana House of Representatives will now consider the bill. If approved, it will go into effect on 1 September.
Todd Rokita, Indiana’s attorney general, denounced Bernard as an “abortion activist acting as a doctor with a history of failing to report” and said that he would “be looking at her licensure.”
Bernard, a respected physician, had filed the required reports. A colleague published a supportive opinion piece in the New York Times and started a fund to help pay her legal expenses. Bernard is reported to be considering suing Rokita for defamation.2
Threats to doctor and her family
Bernard defended herself in the Washington Post, saying, “My mission has always been to provide the best care to each patient who comes to me. But for the past few weeks, life has been hard—for me and my family. I’ve been called a liar. I’ve had my medical and ethical integrity questioned on national television by people who have never met me. I’ve been threatened.”3
On 24 June the US Supreme Court overturned Roe v Wade, the 1973 decision that legalised abortion and left the regulation of abortion to the states.4 At present, about half of the 50 states ban or severely limit abortions, but the picture is changing daily as century old bans go into place in some states, bans are challenged in courts, and state legislatures debate changes to their laws.
The American College of Obstetricians and Gynecologists (ACOG) said, “Each piece of legislation is different, using different language and rationales. State legislators are taking it upon themselves to define complex medical concepts without reference to medical evidence. Some of the penalties for violating these vague, unscientific laws include criminal sentences.”
ACOG, the American Medical Association, the American College of Physicians, and more than 75 healthcare organisations have supported the right to abortion and opposed legislative interference. ACOG says, “Abortion is an essential component of comprehensive medical care, and people need unimpeded access to the full spectrum of reproductive health care options.”5
Confused and fearful
Doctors report being confused and fearful about how they can continue to practise in states where abortion laws are changing day by day and sometimes hour by hour.
Katie McHugh, an obstetrician and gynaecologist in Indianapolis, where abortion until 20 weeks is legal for the moment, told The BMJ about a patient who arrived from another state (around 200 miles away) with a miscarriage.
“A fetal heartbeat could still be detected. The local hospital sent her home and told her to come back if she became very sick.” Instead she travelled two and a half hours by car to McHugh.
“I don’t blame the physicians in [the other state]. I don’t know if abortion is legal now a trigger law is in effect. They could face lawsuits. As a physician, it’s unacceptable to have to watch the news to know what’s legal and how to practise,” said McHugh.
While McHugh spoke to The BMJ, a few miles away the Indiana state senate was discussing a bill to ban all abortions except for cases of rape, incest, or “permanent substantial impairment” to the health of the pregnant person. Doctors performing an illegal abortion would be committing a felony, with potential jail time, and could lose their licence. Since then the senate approved the bill and sent it to the house for consideration.
In such a fast moving situation, physicians worry about performing a legally justifiable abortion. “In an emergency, hospital care moves so quickly. There’s no lawyer on call at 4 in the morning,” Laura MacIsaac, a complex family planning specialist with the Mount Sinai Health System in New York, told a New York Times webcast. And Kimberly Mutcherson, a law professor at Rutgers University and expert in bioethics and reproductive justice, said, “You don’t want lawyers making these decisions.”6
Doctors often face problems in cases of premature rupture of membranes or ectopic pregnancies. The medications or treatments are the same as those used in abortions, and state laws do not recognise the difference.
Increase in maternal morbidity
The effect of abortion restrictions has already been seen in Texas. In a research letter published on 5 July in the American Journal of Obstetrics and Gynaecology, doctors at Clements University Hospital and Parkland Hospital, large safety net hospitals for Dallas County, looking at outcomes among pregnant women, reported that after the Texas ban maternal morbidity was almost double that among women in states without similar laws.7
Texas Senate Bill 4, passed in September 2021 (before Roe v Wade was overturned), says that a physician who performs an abortion, even in a maternal medical emergency, is committing a felony and faces jail time and a fine of $10 000 (£8200; €9800) unless there is an immediate threat to the pregnant person’s life. This study indicated that the law had increased maternal morbidity. The researchers at the two hospitals looked at 28 women who had an indication for abortion, such as preterm premature rupture of membranes, pre-eclampsia with severe features, or vaginal bleeding. The current national standard of care for patients in such cases allows for expectant management or immediate delivery after shared decision making. But after Senate Bill 4 was passed physicians were not intervening so quickly. Patients were managed expectantly for nine days before they developed a complication that qualified as an immediate threat to life.
Twenty six of the 28 patients in the study had premature preterm rupture of membranes, and the time from presentation to delivery was about nine days. The authors wrote, “Maternal morbidity—including conditions such as clinical chorioamnionitis and hemorrhage—occurred in 12 of the 28 patients (43%) and 9 of them (32%) required intensive care admissions, dilatation and curettage, or readmission. One patient required a hysterectomy after presenting at 20 weeks 6 days with hemoperitoneum from uterine rupture owing to a placenta accreta spectrum.
“Expectant management resulted in 57% of patients having a serious maternal morbidity compared with 33% who elected immediate pregnancy interruption under similar clinical circumstances reported in states without such legislation.”
Patient consent not needed (patient anonymised, dead, or hypothetical).