Friday, September 29, 2023

What if a woman needs an abortion now for an ectopic pregnancy?

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Shreya Christina
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Even before the Supreme Court fell Roe v. Wade on June 24, stripping Americans of their abortion rights, the United States had a horribly high maternal mortality rate, ranking last in a survey of 10 equally wealthy countries. For doctors in states enacting restrictive abortion bans, the ruling is a healthcare crisis: In many cases, the only way to treat life-threatening conditions such as ectopic pregnancies is medical or surgical termination. The fear among many doctors is that the verdict in Dobbs v. Jackson Women’s Health Organization will drive death rates even higher.

States that introduce the strictest abortion bans, such as Missouri, where a “trigger law” went into effect on the day of the ruling — make exceptions for medical emergencies. But big questions remain: How can someone in a medical emergency get a life-saving abortion in a state with few or no providers? And who gets to decide what counts as a “life-saving” emergency?

Nobody seems to know for sure. But one thing is clear: the statement raises far more questions than it answers. And while the answers are debated, patients across the country suffer unnecessary, debilitating pain or death.

“We are entering uncharted territory,” said Lori Freedmana sociologist and associate professor of obstetrics and gynecology at the University of California at San Francisco.

There are a few broad categories of unknowns here: how doctors will act if they fear prosecution for providing care, how hospital attorneys will interpret state laws, and who will perform abortions in cases where it is legal to take the life of the patient. to save pregnant person .

Maternal health care in America is at a turning point. And with every unknown there is danger.

Fear of prosecution can change medical decision-making

Pregnancy can be dangerous even in the best of circumstances. “Being pregnant is more dangerous than not being pregnant. Birth is riskier than abortion,” said Jody Steinauer, physician and director of the Bixby Center for Global Reproductive Health at UC San Francisco. Pregnancy causes a range of physiological changes in a person’s body, and problems can arise in the process.

The American College of Obstetricians and Gynecologists recommends early abortions for patients with certain heart conditions, while patients with diabetes whose fetuses will develop serious abnormalities can spend time managing their diabetes before trying to conceive again. Obviously, some complications are long before they begin to affect a pregnant person’s vital signs, Steinauer said. For example, patients with poorly controlled diabetes are at greater risk for fetal abnormalities, and patients with mental health problems or heart disease may be at serious risk if they carry a pregnancy to term.

The dobbs pronunciation will make responding to those problems more difficult. A major source of uncertainty is how doctors will respond to the threat of prosecution for performing abortions, even in cases where their patient’s life is in danger. That fear of criminalization can lead to doctors delaying care longer than they would otherwise.

For doctors, a big part of that fear is that determining what is “life-saving” isn’t perfect.

“At what point do we say the danger has been activated?” early Carmel Shachar, executive director of the Petrie-Flom Center for Health Policy Law, Biotechnology and Bioethics at Harvard Law School. “That’s really unclear and it’s very difficult for health care providers because they want to provide timely medical care.”

What constitutes danger, and when, differs per patient. For example, if a patient has had a miscarriage in which the fetus has stopped developing, but the pregnant person has had no symptoms such as bleeding, she may develop sepsis, meaning their body will start to damage itself as a extreme reaction to an infection. The treatment for a missed miscarriage is removal of the fetal tissue — in other words, an abortion — and is best done as early as possible.

But without the protection of roe, doctors may be forced to wait to take action until their patient’s condition worsens. “Do you have to wait for the patient to become septic before acting?” asked Shachar.

As Anna North wrote for cafemadrid in 2019, some abortion opponents argue that complications such as missed miscarriages and ectopic pregnancies should be left to “solve on your own.” Physicians in abortion-banned states may feel they have no choice but to take a step back and wait.

“What’s really important and sad is that you really can’t keep the patient’s best interest in mind,” Freedman says. “Her suffering is not explained at all. Even if they can save her from long-term damage, she will still receive worse care. She will be held and scared even longer.”

Can doctors call or lawyers?

Even before the dobbs decision, deciding whether to have an abortion, especially in states with restrictive abortion laws, would often become a discussion that went beyond the doctor and patient to the legal team of a hospital and sometimes even a department chair or board of directors. But those discussions took place with the knowledge that, in essence, Roe v. Wade guaranteed that patients had the right to an abortion and that doctors had minimal risk of prosecution for performing it in response to a medical emergency. Now hospitals will be left to interpret their state’s laws, which could lead to even more confusion.

Physicians and hospital attorneys have a difficult task ahead of them in figuring out how to comply with the law, in part because the language used in the abortion debate and the laws that result from it have little foundation in medical science, Louise Perkins King said. a physician at Brigham and Women’s Hospital in Boston and director of reproductive bioethics at Harvard Medical School’s Center for Bioethics.

For example, when lawmakers talk about heart rate and fetal viability, they do it in a way that is completely different from how doctors use those words. Texas law, for example, calls the ‘dead, unborn child,’ but ‘that’s a word that means nothing to me as a midwife, because I’m dealing with the words ’embryo’, ‘fetus’ and maybe ‘neonate,’ said King.

That discrepancy between medical science and policy means that without clarification from prosecutors, hospital attorneys must decide on a case-by-case basis whether their doctors can perform abortions — and they’re likely to exercise extreme caution, delaying or denying patients the care they need. Many of these debates can simply come down to a matter of personality: If a hospital has a director who is strongly in favor of abortion rights, for example, he might be more lenient. This is, of course, ridiculous – a patient’s right to care should not depend on the whims of hospital management.

Even if there is legal clarity, there may not be ethical clarity. “It may be that in your state what is legal is in direct conflict with providing the best health outcomes for your patients,” Shachar said. “I think it’s going to be very complicated and very difficult for healthcare providers to process what happens if they know what the standard of care is, but they are legally unable to provide it.”

Where will abortions even take place?

for the dobbs Under the ruling, doctors in hospitals with restrictive abortion policies had the option to send their patients to other facilities, such as abortion clinics or different hospitals, that could instead perform emergency abortions. That’s what would happen in Catholic hospitals, said Freedman, who has studied abortion policies in Catholic hospital systems extensively. “But that was a very different context,” she said. Before June 24, those doctors were protected by: roe† even if they risked losing their job, they never ran the risk of criminal prosecution for doing their job.

That has changed.

Some doctors have already indicated they are willing to give their patients abortions, even if it means they are at risk of prosecution, King said. But that could pose even more problems: If a doctor is charged with a crime, their license will be revoked, meaning their patients — even those who may not need an abortion — aren’t getting the care they need.

Steinauer is also concerned about what will happen if and when freestanding abortion clinics are forced to close. “Many communities have these great independent abortion clinics that provide great care to our patients, and the local hospital doesn’t necessarily have to be involved, especially with prior abortion care,” Steinauer said.

In the past, those clinics often treated abortion care in the first trimester of pregnancy, including cases where patients had to have abortions for conditions such as heart disease, while hospitals and academic institutions would usually admit patients in their second or third trimester. Without those clinics to provide support, hospitals could become overloaded with patients they are not used to seeing. Care for those patients can then be postponed or even refused, based on the decisions made by a hospital’s legal team.

The Food and Drug Administration has approved drugs that can be used to induce abortion, and it may be possible to continue to receive them via telehealth across state lines, even as states pass sweeping bans on surgical abortions (an ongoing process). federal lawsuit may provide more clarity on this soon). U.S. Attorney General Merrick Garland has promised to protect Americans’ access to these drugs, which means it could remain a good option for many patients and help reduce the burden of closing those clinics, but it’s still not a perfect solution.

Abortion pills can cause complications in rare cases, and King is concerned that patients may choose to delay care or be afraid to tell their doctors what medications they have taken. That will disproportionately affect people of color, who are already dealing with medical prejudice. “My biggest fear is that someone will start taking medication at home because they have no other choice and then they will bleed and be too scared to get in,” King said.

It is likely that many of these questions will not be answered until they return to the Supreme Court, which Shachar says is inevitable. But that will take months, if not years.

It is difficult to predict what damage will be done in the meantime. “It’s hard to imagine Americans will tolerate women dying,” Freedman said. “I have a feeling doctors will get rowdy if it actually causes deaths. But there’s so much we don’t know. We never thought we’d see this day.”


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