With the nation spinning from the leak of Supreme Court Justice Alito’s draft opinion suggesting that the Court will overturn the Roe v Wade abortion ruling, we spoke with 2 medical experts to better understand the potential effects of a federal ban on abortion on women’s health and what clinicians can do to help their patients. Erin Bradley, MD, MPH, is associate professor of Obstetrics, Gynecology, and Reproductive Biology at Massachusetts General Hospital and chair-elect of the American College of Obstetricians and Gynecologists (ACOG) District I. Alisa Goldberg, MD, MPH, is director of the Complex Family Planning Fellowship at Brigham and Women’s Hospital and associate professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School.
|• The United States has the highest maternal mortality rate of any developed country|
|• Rates of maternal mortality will increase and existing health disparities will increase if Roe v Wade is overturned|
|• Patients with ectopic pregnancy and premature rupture of membranes may experience significant delays in care because of the presence of a fetal heartbeat, putting the mother at risk for permanent infertility and loss of life|
|• Pregnant patients who develop cancer may not be able to abort their pregnancy to start chemotherapy|
|• Women who take medications with teratogenic and/or abortifacient properties for chronic conditions (eg, methotrexate for psoriasis) may not be able to fill prescriptions if they are of childbearing age|
|• Experts warn of a chilling effect on access to infertility treatments and contraception as well as threats to other privacy issues|
|• Access to learning uterine evacuation techniques in residency training will be difficult in states that ban abortion|
Q: What potential effects may the overturning of Roe v Wade have on women’s health in the US?
Dr Bradley: Besides the obvious clinical implications of the decision of whether or not to have a pregnancy, there are many medical issues where the health of the mother might be jeopardized by virtue of being pregnant or clinical guidelines recommend that patients do not become pregnant because the risk is so high, such as pulmonary hypertension.
We worry about nonviable pregnancies such as ectopic pregnancies, which need to be managed medically or surgically as they put the mother at increased risk for fallopian tube rupture and life-threatening bleeding. If the embryo in an ectopic pregnancy is recognized as a fetus, if the ban is established we would not be able to treat the mother. Women may also develop premature rupture of membranes and the baby has no chance of survival. Delaying treatment potentially puts the patient at grave risk of permanent infertility or loss of life.
We also worry about fetuses with anomalies that are not compatible with life such as anencephaly, where parts of the brain or skull are missing, or Potter syndrome, in which the kidneys fail to develop properly. We often don’t know that these anomalies are present until 20 weeks’ gestation. Women who do not have the option of early termination of a pregnancy in which the fetus is not going to survive are at risk for potential medical complications from delivering a larger size stillborn baby [see Maternal Mortality Facts], psychological ramifications from being forced to carry a baby they know is not going to survive, and losing a window of their fertility, particularly in older mothers.
Maternal Mortality Facts
|• The US has the highest maternal mortality rate of any developed country and the rate increased more than twofold between 1987 and 2017|
|• The maternal mortality rate was 23.8 deaths per 100,000 live births in 2020; this rate is nearly 3 times higher for Black individuals (55.3 deaths per 100,000 live births) than for White individuals|
|• Carrying a pregnancy to term is 33 times riskier than having an abortion, with 0.41 maternal deaths per 100,000 legal abortions between 2012 and 2018 compared with 23.8 deaths per 100,000 live births in 2020|
|• Approximately 18% of all pregnancies in the United States end in induced abortion|
Q: What are the potential effects of state legislation banning abortion if a fetal heartbeat is present?
Dr Goldberg: Many state laws are banning termination of pregnancy if there is a fetal heartbeat and some are proposing an all-out ban. If a patient ruptures their membranes and develops sepsis, the safest option is to empty the uterus and terminate the pregnancy. But many of these state bans have removed the health exception and only left in place life-threatening medical emergencies, which means that patients are going to be forced to get sicker before a clinician will be willing to terminate the pregnancy. We know that happened frequently before Roe v Wade.
Determining when patients meet the criteria for a life-threatening medical emergency is difficult. Before Roe v Wade, some clinicians made that mark and saved people and others missed the mark and women died. We are going to see this again in states that have removed the health exception. Ireland recently legalized abortion following a case in which Savita Halappanavar, a dentist, was hemorrhaging and developed an infection from what was determined to be a miscarriage at 17 weeks and requested termination of pregnancy to stop her bleeding but was denied because there was a heartbeat. [By the time the heartbeat was no longer detected, Dr Halappanavar developed sepsis and subsequently died.] Countries where abortion was illegal until the very recent past have seen many women die because of this chilling effect. Cases such as this also have led to legalization of abortion in Argentina and Columbia.
And we are going in the exact opposite direction and we are going to see the impact of that.
Dr Bradley: By the time patients with ectopic pregnancy are diagnosed, many have a fetal heartbeat. Having a heartbeat as an indicator for treatment decisions puts women in great jeopardy because once there is a heartbeat we can’t treat them medically in general and we have to use a surgical approach that is very proactive. I think clinicians will be afraid if they are in a setting where that surgical procedure might be investigated.
In terms of other potential chilling effects, we are concerned that infertility treatments such as in vitro fertilization may not be covered. My colleague in Texas said that her patient tried to pick up a prescription for methotrexate for psoriasis and was denied by a pharmacist. Even though the patient was in her mid-50s, the pharmacist knew that methotrexate could potentially interrupt a pregnancy.
Q: What are other chronic conditions in which pregnancy potentially puts mothers in danger?
Dr Goldberg: There will be patients diagnosed with cancer who will be forced to delay chemotherapy because they will not be able to terminate a pregnancy. Other patients may have a condition such as lupus that they thought was under control when they planned their pregnancy, but in the middle of their pregnancy their kidneys shut down, they start to go into renal failure, and they need to terminate the pregnancy so they can start taking pharmacotherapy or go on dialysis for their own survival. A number of medications are teratogenic, and women with chronic conditions may be taking medications that can cause major malformations in fetuses, such as valproate for epilepsy or tretinoin for dermatologic conditions, and accidentally become pregnant from contraception failure.
Other women have planned their pregnancy and then have an unforeseen circumstance such as a child who develops a life-threatening illness, or loss of their partner or their job and come in to terminate their pregnancy. I can’t begin to tell you how many times people say “I never, in a million years thought that this would happen to me.”
Dr Bradley: There are also women with complex cardiac histories in whom pregnancy could be very dangerous and potentially life-threatening. We also know that the severity of domestic violence and homicide rates increases in pregnant patients. Some pregnant persons may choose abortion for their safety and the safety of their families. These are agonizing decisions for patients and they need to be the ones making the decision.
Q: What about the potential effects of abortion bans on women’s mental health?
Dr Goldberg: Mental health will be affected and suicide rates in desperate pregnant persons unable to access abortion care are likely to increase as we saw pre-Roe v Wade.
Q: What other chilling effects might occur if Roe v Wade is overturned?
Dr Bradley: Contraception is very much in the crosshairs. We are very worried about the ramifications if the right to privacy is struck down. In Louisiana, a bill is moving forward that would classify having or performing an abortion as a homicide and may restrict intrauterine devices (IUDs) and Plan B as it defines personhood as beginning at the moment of fertilization. Mississippi Governor Tate Reeves was asked in an interview with CNN if the state’s legislation to ban abortions after 15 weeks of pregnancy [which is currently under review by the Supreme Court in Dobbs v Jackson Women’s Health Organization], would also ban IUDs and Plan B and his reply was this is “not what we are focused on at this time.”
[In a later interview, Reeves said he didn’t think future legislation in Mississippi would “apply to those that choose to use birth control.” The state is 1 of 13 states with trigger laws, which would ban abortion almost immediately if Roe v Wade is overturned. In Mississippi, the trigger law passed in 2007 is more extreme than the 15-week ban currently under review and would ban abortions except in the case of rape and life-threatening emergency; the trigger law would take effect within 10 days of the Supreme Court Roe v Wade decision.]
Dr Goldberg: Beyond health care, there are concerns that this type of legislation could ripple into other kinds of rights that are predicated on the right to privacy, such as issues around sexuality and gay marriage. In the leaked draft, the decision is predicated on what was written into the constitution in 1868, soon after the Civil War and long before women could vote.
The overturning of Roe v Wade may have a massively dangerous ripple effect.
Q: Can medical abortion be prescribed to a patient in another state via telehealth?
Dr Goldberg: A provider can only provide care to a patient located in the state where they have a license to practice medicine including care provided by telehealth. I practice in Massachusetts and if I wanted to provide care to a patient in Minnesota, I would have to have a Minnesota license and abide by Minnesota’s laws. Texas bans telemedicine medication abortion and considers it a felony.
Dr Bradley: I live in New England and some of my colleagues have licenses in Maine, New Hampshire, and Connecticut to be able to provide telehealth for our patients who commute. There was a period of forgiveness at the peak of the COVID-19 pandemic where insurers still paid for those out-of-state telehealth visits. Legislators are aware that telehealth rules were being relaxed and medical abortion is something they are going after. Some legislators are trying to enact laws that forbid patients from leaving state lines to get abortion services. Banning US citizens from traveling to another state to get any kind of care seems like we’ve entered a whole new realm of government overreach and intrusion.
Q: What do you envision women who seek abortion doing in states that enact bans?
Dr Goldberg: I think patients are going to try to get medical abortion pills off the internet. This may not include any provision of care from a licensed provider. There will be self-sourcing of medications from wherever women can get them.
Dr Bradley: The farther along a pregnancy is the less effective medical abortion is and the more dangerous it becomes. Every way you slice it, this is more dangerous for patients.
Q: How will the overturning of Roe v Wade affect medical education on abortion procedures?
Dr Bradley: As of now, our best estimate is that in the very near future, 26 states will probably lose access to abortion training. Texas has one of the biggest residency programs in the US with multiple subspecialties, including genetics and high-risk obstetrics, which are often involved in these difficult discussions with patients.
At the recent ACOG meeting, attendees were talking about training on avocados for surgical abortion techniques. The California Future of Abortion Council (CA FAB Council) released a report in December 2021 outlining a blueprint for the state to prepare the state if Roe v Wade is overturned.
[The council recommended improving the education pipeline by creating a California Reproductive Scholarship Corps, open to individuals training as physicians, nurse practitioners, certified nurse-midwives, physician assistants, and in other health care professions with diverse and/or rural backgrounds dedicated to providing abortion care in underserved areas in California. It also recommended requiring primary care and family medicine education programs to provide training in miscarriage management, medication abortion, and aspiration abortion, and creating a grant program for abortion training for those caring for underserved populations.]
Dr Goldberg: People will have access to webinars and slides online, but hands-on skills are going to suffer in states that ban abortion. A generation of OB/GYN physicians who complete their residency training in states where abortion is banned will get limited training in techniques to evacuate the uterus in the first and second trimester and, as a result, miscarriage and pregnancy loss care will also suffer. When there are no physicians comfortable performing a dilation and evacuation (D&E) in the setting of second-trimester septic abortion or hemorrhage, some women will wind up getting hysterotomies to remove nonviable pregnancies.
Q: How will the overturning of Roe v Wade affect research on abortion techniques?
Dr. Goldberg: Research that seeks to advance abortion care and improve the health of women of reproductive is going to most likely be heavily concentrated in states where abortion is legal, at least for the time being. In states where abortion is illegal, research is going to have to focus on documenting the harms of illegal abortion as researchers did in other countries like Ireland, Argentina, and Columbia.
Dr Bradley: It is important to document the harm because that is what resulted in Ireland getting rid of their abortion ban. Eventually, someone will care what is happening to women. With these ramifications right now, however, the focus seems to be solely on the fetus.
Q: What message do you have for clinicians in the United States?
Dr Goldberg: I would encourage clinicians who practice in women’s health and particularly those who see pregnant women and who practice in states where they can provide medication abortion to think about incorporating this service into their practices. This is a human rights issue.
Dr Bradley: My request is that clinicians vote and write to their legislators. We need a pledge for advocacy and we need it now before the midterms.