Abortion-law medical exceptions put pregnant people in danger, M.D.s say

Kaitlyn was near the beginning of her second trimester last October when she boarded a plane from Texas to Kansas. On her return home a few days later, she was no longer pregnant, and the 34-year-old wanted to do little more than cry in her own bed. Being in public was a struggle, let alone standing in line and going through airport security.

She had flown to Kansas for an abortion that was outlawed in her home state, though she and her doctor considered it medically appropriate. Scans had shown the fetus inside her had a lethal form of skeletal dysplasia. If it survived childbirth, which was extremely unlikely, doctors expected the newborn to soon suffocate from under-developed lungs. The baby’s bones would be so brittle, they would break just from being held.

Kaitlyn and her husband got the news shortly after Texas passed a highly restrictive abortion law, banning the procedure after six weeks of pregnancy except in medical emergencies. Her own doctor was so afraid of being sued, he didn’t bring up the possibility of ending the pregnancy. But if Kaitlyn didn’t have the ability to travel for an abortion, she doesn’t know if she would have survived.

advertisement

“The psychological burden would have been so high and I would have been so hormonal and emotional, I don’t know what could have happened,” she told STAT, which agreed to use only her first name because she fears repercussions for those who helped her if she’s identified. Kaitlyn had postpartum depression before, after she gave birth to her first son. The prospect of carrying a fetus that was destined for suffering and death was unfathomable. “I don’t know if I could have got up and gone to work with that baby inside of me for seven months,” she said. “I could see suicide being an option.”

Texas’s exception permitting abortion in medical emergencies likely wouldn’t apply to a circumstance like Katilyn’s, where death isn’t imminent. After the Supreme Court’s impending abortion ruling, whether it repeals Roe v. Wade outright or stops just short of that, several states are expected to pass laws that allow abortion only to save a pregnant person’s life. Some 22 states are certain to ban abortion following a repeal of Roe, according to the Guttmacher Institute, a reproductive health think tank, and a further four are highly likely to follow, with exemptions granted in limited medical emergencies.

advertisement

The wording varies slightly from state to state. Texas allows abortion for “a medical emergency”; Louisiana’s bill makes an exception to prevent “death or substantial risk of death,” or “permanent impairment of a life-sustaining organ”; and Idaho permits abortion “to prevent the death of the pregnant woman.” On Thursday, Oklahoma legislators approved a bill that would ban nearly all abortions starting from fertilization, with an exception to save the life of the mother “in a medical emergency.”

Those exceptions are so vaguely defined, and with such harsh penalties for providers deemed to have violated the terms, physicians say they will be effectively unable to provide proper medical care or even discuss abortion with patients.

“We take an oath to do no harm,” said Amanda Horton, a perinatologist in Texas who treats high-risk pregnancies. “I can’t do my job, I can’t provide ideal care if there are things I’m not allowed to talk about. That ultimately harms patients.”

The mental health consequences of being forced to carry an unviable pregnancy, for example, can be deadly. “Especially in the cases of psychotic illness, risk of suicide or infanticide is pretty high,” said Nichelle Haynes, a perinatal psychiatrist from the Reproductive Psychiatry Clinic of Austin. Studies show suicide is a leading cause of postpartum death. If someone previously had severe postpartum depression and was hospitalized after a suicide attempt, there’s a good chance of that happening again, especially if the pregnancy is unwanted, added Haynes.

From her perspective as a physician, that qualifies as a medical emergency: “The emergency is preventing that now.” But such a decision won’t be legally recognized in Texas, she said.

Even in more straightforward situations, where patients are in imminent physical danger, doctors are already struggling to provide care. Natalie Crawford, a fertility physician in Austin, said a pharmacy recently refused to fill a prescription for methotrexate, which treats an ectopic pregnancy by stopping the growth of the fertilized egg.

The pregnancy would never have resulted in the birth of a child, but was a serious risk to the mother. The embryo had attached in the patient’s fallopian tube which, if left untreated, would rupture and cause extensive internal bleeding. Emergency surgery could save the woman’s life if she were able to get to an emergency room fast enough but, if not, she would die from the blood loss.

“We told [the pharmacist] it’s a life-of-the-mother situation,” said Crawford. But they believed their employer wouldn’t permit the prescription. “They felt they would get in trouble.” And so Crawford’s team spent a day calling other pharmacies to find the medication for their patient. “It took extra manpower and time and it made me nervous about where we’re going to find this,” she said.

Doctors’ abilities to interpret medical exemptions, however they’re worded, are significantly limited when they face potential harsh punishment, said Florida State University law professor Mary Ziegler, who has written extensively on reproductive law.

“States are so determined to make it a serious crime, in some instances murder, the act of interpretation changes,” she said. “The more vague the language is, the more chilling effect that could have, because physicians don’t want to roll the dice.”

No body of law or precedents lay out what medical exemptions are permissible grounds for abortion. The procedure is considered life-saving treatment for several conditions, such as incomplete miscarriages, which can lead to sepsis and ultimately death if left untreated. But the political environment is so hostile, doctors say they will inevitably be afraid to respond in time.

“The more states are worried about exceptions slipping through the cracks, the more likely they are to put doctors in situations with people dying after incomplete miscarriages,” said Ziegler. “People will die.”

Potentially fatal pregnancies are relatively unusual, but still amount to thousands of patients a year in the U.S. Horton sees half a dozen high-risk cases a month, she said. Patients must be treated with an abortion if they develop profuse bleeding, caused by the placenta growing in the wrong location, or preeclampsia, a potentially fatal rise in blood pressure, that doesn’t respond to medication.

And non-pregnancy related health conditions can present serious risks to pregnant patients. Leukemia, for example, must be quickly treated with a form of chemotherapy that no fetus could survive. “It would be unwise and medically unsafe to allow a woman to experience chemotherapy, then have a pregnancy loss, then induce her,” said Horton. “It would seem cruel and unusual to receive chemotherapy and know that same medication is costing her unborn fetus its life.”

Physicians will inevitably be forced to wait for patients’ health to deteriorate to the point that their lives are clearly threatened, she said. “There are all kinds of situations where you’re in a gray zone by 1 p.m., and things will be worse by 5 p.m.,” said Wendy Parmet, director of the Center for Health Policy and Law at Northeastern University. “How much worse do you have to let it be? How much danger to the patient?”

Physicians are often wary of performing complex procedures during pregnancy, especially if they haven’t done so before. One of Horton’s patients a few years ago suffered heart failure when she was 17 weeks pregnant. “What was just terrible was no cardiac surgeon would offer her an operation to save her life, because she was pregnant,” she said. And so the patient needed an abortion before she could have her heart valve replaced.

“My concern is, in very restrictive states, that would not be enough to be considered maternal life at risk,” said Horton. “It would require continued escalation and deterioration of her own health before it’s deemed a medical emergency.”

These consequences will be worse for patients who are already marginalized, such as those who can’t afford to take time off work or travel to receive health care. Maternal mortality in the U.S. is significantly worse for Black women, and restrictions on abortion will only worsen that disparity, said Horton. Preeclampsia, one of the leading health risks in pregnancy, is more common in Black women, and symptoms are more likely to be dismissed in Black patients. One study estimates that if all abortions were banned in the U.S., there would be a 21% increase in pregnancy-related deaths overall, and a 33% increase among Black women.

Parmet noted that the political environment today is more hostile toward abortion than in earlier decades. Even pre-Roe, she said, law enforcement was unlikely to intervene if a hospital committee said an abortion was performed for a patient’s health.

“The pendulum has swung in such a striking direction. The needs of mothers and pregnant people have been placed on a backburner, with the intent that we’re a vessel to continue humanity,” said Horton. “The needs and wants of the mother are less important than the fetus.”