Health

When to have an abortion? It’s not always obvious


OOne of the first patients the emergency physician, Dr. Taylor Nichols ever treated, was a woman with ectopic pregnancy—A dangerous condition in which a fertilized egg grows outside of the uterus, potentially causing life-threatening bleeding if it ruptures the organ in which the egg is developing. She has been admitted to the hospital stable. By the time Nichols examined her, she was already bleeding.

Nichols put her into an emergency surgery where an ob-gyn operated to save the patient’s life. By that point, it was clear that there was no other option. But did he practice in a state where the pregnancy was only allowed to be terminated when the patient’s life was at risk – and he had met her just hours before, when she was stable – “Wasn’t he?” do i have to call a lawyer instead of ob-gyn? ‘ Nichols wondered.

That question is hypothetical for Nichols, who works in California, where abortion is accessible. But for suppliers in some US states, it’s already a reality. In the aftermath of Supreme Court overturned Roe v. Wade, about a dozen states — including Arkansas, Missouri, and South Dakota — have banned or will soon ban nearly all abortions (although some state policies have been binding in court). Usually, these laws allow only limited exceptions, such as when pregnant woman’s life is at risk. But deciding when an abortion is a lifesaver isn’t always clear-cut.

Consider a patient with a complication such as preeclampsia (high blood pressure after 20 weeks of pregnancy), which can progress to death in rare cases. Can doctors intervene as soon as they fear it could become life-threatening, or will they have to wait until the condition becomes critical? Are ectopic pregnancies subject to abortion laws, as they never lead to the possibility of childbirth? Who has the final say on whether abortion is medically necessary: ​​the patient, the doctor, the hospital attorney or the state legislator? Currently, there are no clear answers to many of these questions, and providers can face hefty legal penalties or fines if their decisions are contrary to their state’s.

Read more: Study says women denied abortion could face long-term health problems

The confusion has affected patient care, according to anecdotal reports. Tammi Kromenaker, director of North Dakota’s only abortion clinic (which she plan to relocate soon to Minnesota), said she has received inquiries from doctors in North Dakota who are concerned about treating patients with ectopic pregnancies or incomplete miscarriages, in which the body does not eliminate all tissues related to pregnancy. As of July 28, providers in North Dakota can be sentenced to five years in prison for abortion, except in cases of rape or incest or when a pregnant woman’s life is at risk.

“Doctors should use their training and medical judgment to care for their patients. They don’t have to make laws to see what they can and can’t do,” said Kromenaker. “That delays patient care. That puts the patient’s health at risk.”

David Turok, associate professor in the Department of Obstetrics and Gynecology at the University of Utah and head of the family planning division, said: speaking on his own behalf, and not on behalf of the university). Turok indicates hypertension — occurs in There is one pregnancy in every dozen cases—And gestational diabetes (occurs in about 6-9% of pregnancies), both of which, in certain cases, can cause complications that threaten both mother and fetus.

It is difficult to understand how Utah’s law – which, if implemented, would allow abortion in cases where there is a “significant” risk to the mother – would apply to people with these conditions and another situation, he said. “We’re at a place now where we’re trying to navigate what legislators and lawyers have come up with, to language that’s really unrelated to medical practice,” Turok said. “How bad is the health condition that requires intervention?” The way the law is written “could mean different things to different people,” he said. “Who decides? It is not the patient? I think so.”

Elizabeth Nash, a principal policy associate at the Guttmacher Institute, argues that this confusion is by design. “The bottom line is that no exceptions are designed to be used,” Nash said. “Abortion opponents see any exceptions as loopholes, so they make these exceptions as narrow as possible.”

Read more: How a digital abortion footprint can lead to criminal charges — and what Congress can do about it

If the state disagrees with the clinician’s choice, the deposit can be high. In Alabama, abortion can land the provider in jail for life, unless there is a serious health risk to the pregnant woman. In Arkansas, it can lead to a 10-year sentence and/or a $100,000 fine, unless the abortion is deemed salvageable. In Texas, the 2021 law makes it easier sue anyone who helps someone get an abortion after about six weeks of pregnancy.

“Abortion and pregnancy outcomes under the microscope… in a way we haven’t seen in years,” said Heather Shumaker, director of abortion rights at the National Women’s Law Center. Shumaker says she would be surprised if the doctors’ decisions weren’t questioned at some point, especially in states hostile to abortion.

It takes personal risk to save a patient in an obvious life-or-death situation — like with an ectopic pregnancy that bleeds, Nichols says. Harder when there is a gray area. “You could be charged with a felony. Your license may be revoked. It’s your whole livelihood, something we’ve spent our lives training for,” he said.

Maria Rodriguez, professor of obstetrics and gynecology at the University of Oregon Health and Science School of Medicine, adds that it’s not always just one provider who has to decide if they’re willing to take the risk. A life-saving procedure can require multiple nurses, an anesthesiologist, and others—all of whom are subject to potential liability, depending on how their state’s laws are written. and explain. Rodriguez practices in Oregon, a state where access to abortion is protected. But during her training, she worked in a Catholic hospital restricts abortion servicesand she remembers trying to convince her colleagues to help her save a woman who was bleeding from a miscarriage.

“No one wants their doctor to be on the phone with a hospital attorney when they are bleeding,” says Rodriguez. In those situations, a delay of even a few minutes can mean the difference between life and death.

Louise Perkins King, a physician and director of the division of reproductive ethics at Harvard Medical School’s Center for Bioethics. Some conditions require quick decisions to prevent serious complications. Law enforcement agencies do not always have the time to run medical decisions. “The problem with these laws is that they don’t allow us to act,” King said, “to prevent us from getting to the point where it becomes clear that someone’s life is at stake.”

Dangerous complications can happen suddenly. “In a really unpleasant experience that I had while in the country, we had a woman with sepsis [after delivery], she ended up with gangrene in her extremities. King said. “The moment we can step in and have a roadmap to help someone, we should do that as quickly as possible, so that we don’t get caught up in these seconds-counting situations.”

Read more: The state of abortion rights around the world

Laws allowing abortions in cases of severe genetic defects would also be difficult to regulate, King said. For example, if a fetus develops hydrocephalus – in which the fluid puts pressure on the brain – expectant mothers who are unable to terminate their pregnancy early may require a cesarean section, as giving birth with a low head. Vaginal enlargement is not possible.

“You have to figure out how to keep the head of the baby unnaturally large and enlarged, which can be a very risky operation compared to a normal cesarean section,” King said. “This makes no sense to me from a medical point of view, because the fetus will not survive. And then you’ve seriously injured the pregnant woman. “

Rodriguez adds, mental health also needs to be considered. Suicide is the leading cause of maternal and neonatal mortality, she says, so performing an abortion to relieve severe psychological distress can ultimately be a lifesaver. Whether the states will agree, however, is another question.

“Every rule is very different,” says Shumaker. “Most of them are pretty vague about when abortion is allowed and how it is determined.”

Given all the regulatory uncertainty, Rodriguez says hospitals cannot let clinicians make these decisions alone. “We need the hospital’s attorneys, administrators and leadership to get through these issues now and clearly communicate what their team can and cannot do,” she said. That way, providers aren’t forced to make tough decisions with a potentially dying patient in front of them.

Shumaker added that clinicians should take detailed notes as to why any abortions they perform are medically necessary, in case those decisions are later challenged on medical grounds. legal side.

King said that legislators and attorneys general have a responsibility to clarify the law and make it clear to health care providers what will and will not be prosecuted. “These laws were written by legislators who didn’t take the time to understand what they were writing about,” King said. “They have a moral obligation to step in and fix that and change these laws so they’re clear, if they don’t want people to die for them.”

Other must-read stories from TIME


Write letter for Jamie Ducharme at jamie.ducharme@time.com.



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