How The End Of Roe Will Affect Gynecological Care
“I was sitting in the hospital just this morning, and I was saying, ‘I don't know how I'm supposed to practice like this.’”
For years, state laws have challenged the legal right to abortion that was recognized by the U.S. Supreme Court in its 1973 decision in Roe v. Wade. Now, the end of a federal right to abortion is here. Today, the current Court overturned Roe, ruling six to three in Dobbs v. Jackson Women’s Health Organization that Roe was “egregiously wrong” and returning the abortion issue to the states. Thanks to so-called trigger laws and other measures that were already in place, abortion is now illegal in seven states, and will be in 10 more states in the next 30 to 90 days. Eleven more states will likely follow. Judges in Louisiana and Utah have blocked trigger laws temporarily. (Romper will update this story as state laws change.) In states that have outlawed abortion, residents who can get pregnant and do not have the means to travel to a state where the procedure is still legal have lost the right to control their reproductive futures. Hundreds of thousands of families will be affected; 60% of people who have abortions are already mothers.
But as many activists and physicians have noted since a draft of Justice Samuel Alito’s majority opinion in Dobbs leaked on May 2, the end of Roe has implications beyond abortion. What does it mean for embryos produced in IVF but not used? What will it mean for miscarriage and stillbirth care? Will these state laws, many of which impose severe penalties on OB-GYNs for providing abortions, lead to doctors making medical decisions that are in conflict with their training and not in the best interest of the patient? What aspect of basic gynecological and obstetrical care will new abortion restrictions disrupt that no one has realized yet?
The American College of Obstetricians and Gynecologists (ACOG) has been blunt about the way the ruling and trigger laws will impact both doctors and patients. “State legislators are taking it upon themselves to define complex medical concepts without reference to medical evidence,” the organization said in an explanation of its May update to its policy on abortion. “It is unacceptable for doctors and health care professionals to be punished, fined, or sued and face imprisonment for delivering evidence-based care.”
In early June, to explore how the end of Roe will affect reproductive care overall, Romper spoke to OB-GYNs in Hawaii and California, where abortion is still legal, and one in Alabama, where abortion access was already restricted under Roe and will shortly become illegal, except when physicians can prove an abortion is “necessary to prevent a serious health risk to the unborn child's mother.”
All three physicians, who provide abortions in the course of comprehensive reproductive care, stressed that while they are confident that the demise of Roe will mean sending or receiving patients from out of state to get abortion care, most of their predictions are speculative. “Many of these things, we're getting the hand that's dealt, and we don't know until it's happening,” says Dr. Yashica Robinson, M.D., an OB-GYN in Huntsville, Alabama, who until today was one of three remaining independent abortion providers based in the state. In early June, Robinson testified before a House Judiciary Committee Subcomittee about her experience as both a clinician and a former pregnant teenager without access to abortion.
“There's far reaching impact that we're going to see for years,” says Dr. Marit Pearlman Shapiro, M.D., a complex family planning fellow at the University of Hawaii. “We really sort of have no idea what's coming with all of this.”
More people will have complicated labors at full term.
This is partly just the result of more pregnancies going to term, since 147 in 10,000 U.S. deliveries already involve severe complications, a rate that increased by 45% between 2006 and 2015.
“We'll see an increase in complications of pregnancy and maternal mortality simply because more people — and more people with serious health conditions — will be forced to continue their pregnancies to term,” says Dr. Daniel Grossman, M.D., a clinician and director of the Advancing New Standards in Reproductive Health (ANSIRH) research program at the University of California San Francisco. Grossman cites 2021 modeling done by Amanda Stevenson, an assistant professor of sociology at the University of Colorado, which estimated that a complete abortion ban would result in a 21% increase in maternal mortality overall, and a 33% increase for Black Americans who are pregnant, a demographic that was already experiencing an “increasing maternal mortality crisis,” as Grossman puts it.
Care of ectopic pregnancies is unlikely to change.
There has been some speculation that doctors will be less aggressive in treating ectopic pregnancies, when a fertilized egg implants outside the uterus, because of fears over legal penalties on anyone who performs “unnecessary” abortions. However, there is no evidence of that happening in the U.S.
“An ectopic pregnancy is not a pregnancy that continues to a live birth,” Grossman says. “If it continues to grow, and most commonly it's growing in the fallopian tube, it can cause the fallopian tube to burst open. It can cause catastrophic internal bleeding.”
Grossman says he has heard of abortion restrictions in other countries leading to substandard care of an ectopic pregnancy. “In Latin America, for example, where abortion in many countries has been severely restricted or [is] even completely illegal, I've had stories where a patient had an ectopic pregnancy and had to be essentially just watched until there was evidence that the pregnancy had ruptured the fallopian tube and the pregnant person was in imminent danger of dying before they could intervene.”
“That’s the real nightmare situation,” Pearlman Shapiro says. “Any obstetrician, whether you're anti abortion or not, knows that an ectopic pregnancy is a life threatening emergency to any patient, and anyone who says otherwise has absolutely no idea what they are talking about.”
Both Grossman and Pearlman Shapiro were hopeful that even in post-Roe America, the existing standard of care for ectopic pregnancies will continue. In early June, Pearlman Shapiro said that even in Texas, which in September enacted a law banning abortion after a “fetal heartbeat” is observed, usually around six weeks, colleagues have reported no change in the treatment of ectopic pregnancies. “At least right now, it's still standard care, basic healthcare.”
Misoprostol and mifepristone may be harder to obtain.
Medication abortions involve two drugs: misoprostol, to soften and open the cervix, and mifepristone to prompt the uterus to contract and empty its contents. Now that the Court has overturned Roe, it is illegal to administer medication abortions in the same states that also ban surgical abortions. As with any controlled substance, many people will still find ways to access the drugs to self-manage abortions, especially since FDA data shows thes medications are safe to use, even when dispensed by mail.
However, it’s possible that restrictions on using them for abortion could impact patient access to these medications when OBGYNs prescribe them for many other, ACOG-approved non-abortion uses.
Misoprostol is often used to open the cervix to evacuate a first trimester miscarriage, insert an IUD, or perform a hysteroscopy, where a small camera is inserted into the uterus to look for malignancy or other abnormalities. Mifepristone may be used to speed up the delivery of a second trimester miscarriage or a stillbirth.
“I could imagine situations where if a clinician prescribed the medications for a patient, their pharmacy could be worried about filling the prescription because they might be participating in an abortion. The pharmacist could get involved or refuse to dispense in a way that is not consistent with the standard of care now,” Grossman says. “If states actually really try to restrict these medications, I think there will end up being scrutiny of the pharmacy.” In that case, a patient suffereing a miscarriage of a longed-for pregnancy or one terrified that they might have cancer could end up embroiled in a political fight to access a prescribed medication that they urgently need.
It could become harder to get an IUD.
If misoprostol remains accessible for non-abortion use, access to IUDs could be affected, Robinson says, because of a persistent myth that, in addition to their contraceptive function, IUDs are used to abort early pregnancies. The devices can be inserted within five days of unprotected intercourse as emergency contraception to prevent pregnancy, but even in that context, they do not end existing pregnancies. “Many people already consider intrauterine devices as abortifacients,” Robinson says, referencing a friend and fellow OBGYN who works at a hospital subject to religious doctrine. When she places an IUD, she has to provide a medical reason. “Within that [hospital] system, the administrators will not allow them to place intrauterine devices [exclusively] for contraception because it's considered as an abortifacient.”
Doctors may become less experienced with miscarriage management.
“The [dilation and curettage] procedure for having an abortion is the exact same procedure you would have to manage a miscarriage, and the medications to have an abortion are the same medications that you would have to manage a miscarriage,” Pearlman Shapiro notes. Physicians trained and practicing in states that ban abortion will have less experience performing these procedures when they are called upon to manage a miscarriage. “I think the biggest concern is that with fewer doctors and practitioners performing these procedures, the skill set is going to go down, absolutely.”
In many states, prenatal testing is now an FYI.
As part of standard prenatal care, patients in the late first trimester and early to mid second trimester of pregnancy can choose to undergo testing to determine if the fetus has significant genetic or anatomical abnormalities. When the tests detect an abnormality, the patient has the right to decide whether to keep or terminate the pregnancy. “The way that I was trained, best practice is that there is specific testing that we offer to every [pregnant] patient,” Robinson says. “Not that we push it on them, but we counsel them.” She will continue offering the testing, she said in early June, but when the results reveal a fetal abnormality, she can no longer offer them the option to terminate. “My hands will be tied … Post-Roe in Alabama, I won’t have the option to provide that care for them. I can let them know that it's there, but then some patients may be able to navigate to choose that option, and many of them won't.”
Second trimester miscarriages may become more traumatic — and more dangerous.
The ACOG standard of care for managing a second trimester miscarriage, where there is still a heartbeat but almost no chance of the fetus surviving, and no chance of surviving without significant disabilities, is to offer patients the option to terminate rather than risk the infection or bleeding that can occur if you wait for the body to evacuate the pregnancy itself.
“I had a patient come in a few weeks ago at 19 or 20 weeks, and her water was broken,” Robinson recalls. “It's highly likely [in that case] that you're not going to make it to viability, and you could risk getting sepsis, or the uterus getting infected, and then you're at risk for losing the womb altogether and not being able to try again for another pregnancy. It's reasonable to offer those patients [the option] to go ahead and expedite emptying the uterus so that they don't get sicker and sicker.”
Now that Roe has been overturned, doctors may be reluctant to provide that option in states that threaten serious penalties for physicians performing an abortion that isn’t absolutely medically necessary to save the pregnant person’s life.
“Depending on how laws are written in states that ban abortion or severely restrict it, it may be hard to intervene until there's really signs that the pregnancy is threatening the pregnant person's life,” Grossman says. “So it could really delay intervention and cause serious health risks to the pregnant person.” A recent New York Times story detailed three second trimester miscarriage cases in Poland, where the country’s near total abortion ban led doctors to delay termination even after the pregnant patients were gravely ill. Two of the women died, and the third nearly did.
Pearlman Shapiro worries that in that scenario, physicians will not only subject patients to unnecessary physical risks, but also add to the patient’s grief about losing the pregnancy. “We're prolonging that already really painful, emotionally challenging process for a patient and really just not really giving people standard healthcare.”
Abortion will be difficult to access even when you have a preexisting condition that makes pregnancy dangerous.
On the day we speak, Robinson is treating a pregnant patient who transferred from a large university hospital elsewhere in Alabama. Following her previous pregnancy, the patient, a mother of three, went into heart failure. She had developed peripartum cardiomyopathy, a potentially life-threatening heart condition caused by pregnancy. Once you have it, you are more likely to get it in subsequent pregnancies.
According to Robinson, the patient’s doctors at the university hospital recommended that she terminate the pregnancy for her safety, but her heart condition is not currently bad enough to meet their criteria for performing an abortion. They referred her to Robinson even though an outpatient clinic cannot provide the sophisticated cardiac monitoring during the procedure that her heart condition merits. “So now she's here in the outpatient clinic even though she knows that wasn't the first choice, that wasn't her main care team's first preference for her. This is all she has. I'm all she has. After June, I'm not even going to be a resource.”
Robinson predicts that even in a case like this, where the pregnant person’s condition is a threat to her health and life, Robinson will not be able to prove that to the state. “They're going to say, ‘Well this pregnancy doesn't immediately threaten the patient's life. Just like the patient who's sitting in my clinic today, her pregnancy is not threatening her life right now, while she's in the first trimester… Her plasma volume hasn't gone up yet, so her heart is not taking on that additional load the way it will as the pregnancy progresses,” at which point she is likely to be in grave danger. “When the heart has suffered an insult like that, sometimes it recovers and sometimes it does not.”
OB-GYNs face impossible choices.
“I was sitting in the hospital just this morning, and I was saying, ‘I don't know how I'm supposed to practice like this,’” Robinson says.
Before Roe was overturned, Alabama law required a physician providing an abortion past 19 weeks to find a second, concurring physician to sign off on the necessity of the procedure. Under the stayed 2019 law that the Alabama Attorney General’s office said Friday they will enforce “in short order,” the second signature is still required, but physicians who perform an abortion later found unnecessary to save the life of the mother will face a maximum sentence of 99 years in jail. “So for the patient that's 19 weeks and ruptured, how will I find another physician to sign their name to say, ‘Yes this patient should be able to terminate this pregnancy’?” Robinson asks. “With a patient that's ruptured, who could possibly deliver at any time, I can’t discharge them from the hospital and put them on a plane and fly them to California, either. That's bad medical practice.”
Would Robinson sign her own name approving an abortion in that case?
“Even though I care for my patients, I mean, I'm still human, and I have a family to take care of. I'm going to be thinking about, Can I afford a legal battle to say that what I was doing was right for this patient at the time? Because that's my personal legal battle to fight. I have to pay for those attorneys. So I'm going to be considering my own livelihood.
You ask me that, and I'm embarrassed to say that I hesitate.”