Navigating Loss of Abortion Services: A large Academic Medical Center Prepares for the Overturn of Row v. Wade : Obstetric Anesthesia Digest

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Navigating Loss of Abortion Services: A large Academic Medical Center Prepares for the Overturn of Row v. Wade

Harris, L.

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Obstetric Anesthesia Digest 42(4):p 160-162, December 2022. | DOI: 10.1097/01.aoa.0000891536.22708.f3
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Abstract

Because of its highly politicized nature, the authors fear medical centers will not be prepared to face the health care challenges put in place by the sudden illegalization of abortion across many states, especially Michigan. A 1931 Michigan law criminalizing abortion except to save the life of a pregnant person is forcing health care workers to begin understanding the consequences of this law. However, only some patients at the University of Michigan seeking abortion definitively require a life-saving abortion. This article discusses marginalized individuals, health care legal proceedings, and that health care workers themselves that will be affected by this change.

The increased distance of 20 to 260 miles between available abortion clinics now available to Michigan residents will prevent many from getting the care they desire, and this, unfortunately, impacts marginalized groups of people particularly. According to Guttmacher Institute, half of those previously receiving abortions are under the federal poverty level. Many cannot leave for abortions because of employment, monetary strain, and children. Black individuals are targeted as they are especially affected by systemic discrimination inside the legal and health care system. Black women are both more likely to die during childbirth and to be reported for a suspicious termination of a pregnancy, regardless of the underlying reason. Patients are deeply affected by this, which will impact health care.

Emergency department and primary care facilities will need to become acquainted with self-managed abortion complications and medications. This could include everything from sepsis, hemorrhage, pelvic-organ injury, and toxic exposures to mifepristone and misoprostol. While mifepristone and misoprostol are effective, those without the access or knowledge about these resources may attempt ineffective or dangerous abortion services including insertion into the cervix or vagina, ingestion of poison, or trauma. Hospitals now have to determine how and where to transport those requiring abortion services across state lines in a manner that does not negatively impact their neighboring states. Many health care representatives are willing and able to provide patients with the prerequisites to perform an efficient and relatively inexpensive abortion outside of their state, but some may not be able to.

Depending on future laws and enforcements, healthcare workers may not be able to provide many of the range of services they used to. Pharmacies, hospitals, IVF practitioners, etc., will have to determine whether they can safely offer abortion services and medications, if they can safely offer services to some at all. Those training to become medical professionals may have to travel outside of their state in order to receive the necessary abortion training required to receive their certification or their degree. Some fear abortion training will be halted altogether. In addition, a large percentage of healthcare workers are female. It is likely that a large percentage of health care workers experience many of these issues themselves. Many may have to travel for abortion care, work while pregnant, or take parental leave. Especially as maternal and child mortality will rise as women are coerced into childbirth, the healthcare strain on labor and delivery facilities and infant NICUs will likely rise while many will not be able to work as much. This article concludes with the notion that, although change is uncomfortable and sometimes frustrating, in this case it is inevitable, and acting quickly will support more people.

COMMENT

In this “Perspective” published in the New England Journal of Medicine in early June 2022, shortly before the Supreme Court of the United States repealed Roe v. Wade and Planned Parenthood v. Casey, a framework for preparation in states where abortion might become illegal is proposed.

The author, Lisa Harris, MD, PhD, Professor of Obstetrics and Gynecology at the University of Michigan, who’s research examines issues at the intersection of clinical obstetrics and gynecology and reproductive justice (law, policy, politics, ethics, history, sociology, and disparities in access to reproductive health resources), reports on the fears that medical centers across many states will not be prepared to face the many new challenges and threats resulting from the sudden illegalization of abortion.

In 1931, a Michigan law, one of the strictest to ever be passed in the country, criminalized abortion except to “preserve the life” of a pregnant person. Health care workers are forced to rethink the consequences of this law if Roe v. Wade was repealed, since much ambiguity surrounding what the risk of death must be and how imminently, for an abortion to be considered “lifesaving.” As an example, might abortion be allowed in a pregnant patient with severe pulmonary hypertension, for whom the mortality risk during pregnancy is 30% to 50% (or must her risk of dying be 100%)? Under this law, most pregnant patients will not “qualify” for abortion care in Michigan and will be left with 3 options: seek care in another state, self-manage an abortion, or give birth. The author helps us better understand what this might mean for pregnant patients, physicians and health care providers, and the US health care system at large.

Seeking care in another state will mean that Michigan residents may need to travel more than 260 miles away to find an available abortion clinic, which is expected to prevent many patients and particularly vulnerable and marginalized ones (teens and low-income patients) from getting the care they desire. According to the Guttmacher Institute, up to 50% of pregnant patients previously receiving abortions are under the federal poverty level and are now at risk of not being able to afford to travel, to take time away from work and leave children to seek abortion care remote from home. Clinicians in states with abortion bans may consider (although this may also be criminalized) to offer “fast-track” preparation to patients seeking out-of-state abortion care (with ultrasound, blood work, and subspecialist consultation) to ensure that patients with underlying illnesses can safely receive care on arrival. Strategies for transferring already hospitalized patients across state lines may also be considered.

Increases in self-managed abortions are expected and require from emergency department and primary care facilities to become acquainted with self-managed medication-induced abortions, as well as complications of unsafe methods (insertion of implements, objects, or caustic substances into the cervix or vagina; ingestion of poisons; or intentional trauma), which may require lifesaving critical care for sepsis, hemorrhage, pelvic-organ injury, or toxic exposures.

Increased births are also expected because people who cannot travel or manage their own abortion will give birth, with an increase of 5% to 17% in births in Michigan, which already has maternity care deserts. Maternity and neonatal intensive care units might be working over capacity, and an increase in complex medical needs for families and children is expected. Maternal mortality will increase (by an estimated 21%) because abortion is safer than childbirth, and the increase will disproportionately affect Black birthing people (33% vs. 13% among White birthing people), exaggerating the already existing ethnic/racial disparities in maternal health outcomes.

Additional dimensions of reproductive health care are expected to be affected: (1) the impact on of management of complex obstetric conditions (ectopic pregnancies, inevitable miscarriages, previable rupture of membranes with fetal cardiac activity, selective reductions for multifetal pregnancies), (2) the threat to medical education and family planning training (lack of training in miscarriage-management options), and (3) the impact on workforce participation since a large percentage of health care workers are female, and some might experience these issues themselves (having to travel for abortion care, work while pregnant, take parental leave and suffer the mental health consequences of continuing an undesired pregnancy). The author concludes that health systems that have viewed abortion as a political or partisan issue will soon have to recognize that lack of access to abortion care is a health care and equity issue, and thoughtful preparation is needed.

Comment by Ruth Landau, MD

Keywords:

Systems-based Practice; Ethics; Maternal Morbidity and Mortality

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