Banning abortion prevents us from providing safe care to all pregnant women

On 24 June 2022, the Supreme Court of the United States overturned Roe v Wade and revoked the constitutional right to abortion. Following the Dobbs decision, control of abortion policies was returned to individual states. The election on 5 November further degrades hope for progress in women’s health. With Donald Trump now the president-elect, a federal abortion ban is likely, and even access to in vitro fertilisation and contraception may be at risk.1

Many political and moral problems exist with a male dominated court and political party deciding who can make decisions about women’s reproductive autonomy. But as a healthcare professional in obstetrics and gynaecology, what concerns me most is the court’s limited view of what is at stake here: the ability to keep pregnant women healthy. Abortion is completely banned in 13 states and heavily restricted in others. This removes far more than access to the narrow definition of abortion these lawmakers used: ending an unwanted pregnancy. Banning abortion takes away the ability of healthcare professionals in obstetrics and gynaecology to do their jobs.

I take care of patients whether they themselves are healthy or sick, whether their pregnancies are normal or complex, and whether they want to deliver a baby or have an abortion. Because I live in California, I can provide whatever care is the right care for my patient. But I have many colleagues throughout the country who are now legally prohibited from doing the same.

There are many complicated reasons for patients ending pregnancies, and decisions are often difficult and nuanced. Sometimes, patients are not even really making decisions, but instead they are succumbing to circumstances if they are unwell, their babies are sick, or there is a problem with the placenta. Pregnant women in the post Roe era face many complexities and dangers, in both the first and the second trimesters, whether they made a choice to terminate a pregnancy or not.

Two patients died recently in the first trimester because of barriers to care in their home states.2 In some states, a patient presenting with an impending miscarriage who is actively haemorrhaging cannot seek treatment until either the fetal heartbeat has stopped or a hospital committee has deemed that her life is at sufficient risk. In other states, if a physician performs an abortion judging a woman’s life to be endangered, but a court later disagrees, that physician could lose their licence and even end up in prison. A patient presenting with a non-viable ectopic pregnancy may wait so long for treatment that her haemorrhage ends up leading to hysterectomy, preventing her from ever having children. A patient who must arrange childcare before seeking treatment for her life threatening pregnancy complication may find that she has presented for care too late, past the gestational age at which abortion is allowed in her state and must therefore incur costs and risks to herself and her family by travelling long distances for care.

In the second trimester, pregnancy only becomes riskier. I have seen women presenting with pre-eclampsia so severe that their organs are starting to fail. In these circumstances, their babies are usually too underdeveloped and are not yet viable outside the uterus. In such cases, through a dilation and evacuation (D&E) I can save the mother’s life by safely ending the pregnancy that is killing her. This is the most common procedure for termination of pregnancy in the second trimester. At other times, severe infection that may have already killed the baby can also put the mother’s life at risk. When this happens, I can empty the uterus quickly and safely by way of D&E while never making an incision. Infections that are left untreated put women at risk of sepsis, surgical complications, and death. This can result in two deaths, both of mother and baby.

In states with abortion bans or heavy restrictions, some of these patients do not make it home to their families. Although medically speaking the appropriate treatment may be clear, the legal reality is more complicated. In 33 US states, D&E is heavily restricted, and possibly illegal if a court does not agree on the level of danger to a woman’s life.3 In addition, many providers trained to perform this procedure have left to find jobs in other states, and patients who live in these 33 states are increasingly unable to find care.4 There is no question: maternal and infant mortality increase in states where abortion is restricted. As women’s healthcare providers leave, access to all pregnancy care is at stake.5678

About 40% of residents in obstetrics and gynaecology are now training in states where abortion is either illegal or severely restricted, and they will be unlikely to graduate competent in safely evacuating a uterus in these circumstances.9 When patients present with severe pre-eclampsia or sepsis before viability in these states they will be denied a lifesaving procedure and may be hundreds of miles from someone who is trained to do it. Or in other states, even in the first trimester, doctors will be forced to wait for ethics boards or hospital attorneys to decide when a patient is “sick enough” for them to intervene. The US already has astounding rates of maternal mortality, higher than every other high income country.10 And it has, and will continue, to get worse.

I have been in practice for long enough to have met many patients whose pregnancies will not have happy endings. The oversimplification of how we view pregnancy, childbirth, and abortion has led to a disastrous patchwork of access to care in this country. In electing Donald Trump to the presidency, our job in obstetrics and gynaecology will get harder, and we will watch our patients suffer.