A recently published report by Physicians for Human Rights (PHR) analyzes the “cascading harms” resulting from abortion bans. The report is based on 33 semi-structured interviews with physicians from reproductive and non-reproductive health specialties across 20 states with three different legal frameworks for abortion: states with abortion bans before 12 weeks, states with abortion bans after 12 weeks, and states with abortion protections. The report finds that abortion bans and restrictions create cascading effects that extend far beyond reproductive health care, compromising the quality and effectiveness of medical care across reproductive and non-reproductive specialties.
Dr. Michele Heisler, medical director at PHR and professor of internal medicine and public health at the University of Michigan, described how abortion bans are impacting the medical field across the country. “Doctors waiting for ‘irreversible damage’ before offering care,” she said in a news release. “Patients given less effective medicines instead of the best available treatments. Health systems offering substandard and discriminatory care to pregnant patients. The consequences of state abortion bans are not only manifesting in harms to reproductive health care, but across many other medical specialties. From cancer care to pulmonology and beyond, the harms of abortion bans are cascading across the health system.”
The report sought to analyze the impact of abortions on multiple disciplines in part due to the prevalence of chronic and complex medical conditions among women in the United States. According to the report, as of 2019, approximately one in three women of reproductive age had at least one chronic condition that could compromise their health or lead to adverse outcomes during pregnancy. One of the participants, who were all quoted anonymously in the report, detailed the difficulties abortion restrictions cause to patients with coexisting conditions.
“I had a patient the other day who came to me at 15 weeks and had chronic kidney disease,” said Participant 3. “And at the start of her pregnancy her creatinine was 4 [normal range is generally up to about 1.1 mg/dL for women depending on lab and muscle mass], which is not a good predictor of a healthy and uneventful pregnancy. And by the time she had gotten to us at 15 weeks, her creatinine was [at a dangerously high level] …. But if you just were to look at her and talk to her, you would say, ‘Oh, you’re stable, you look healthy.’ The problem here is that many people are construing threat to maternal life as actually seeing a sick person in front of them, a physically ill-appearing sick person, and kind of just disregarding all of our training and evidence-based education to know that a rising creatinine, although someone might not physically look ill, is an extremely concerning sign in early pregnancy. And one that without a doubt will become worse as the pregnancy progresses .… And what we are doing is sitting and waiting almost for irreversible damage to occur before we do something and offer them [abortion care].”
Many providers in states with abortion restrictions are forced to delay care for conditions such as ectopic pregnancy. “The majority of people we see are not dying, but when somebody is coming in front of us and they are dying, we have to be able to think on our toes and make split second decisions,” said Participant 31. “And the last thing that we need is to have to stop and consider a law …. For instance, one patient, her beta HCG [a hormone produced by the placenta during pregnancy] was like 8,000, which would indicate that this is probably an ectopic pregnancy. But instead [of receiving treatment], the patient was sent home because they couldn’t see anything and so was told to come back in a couple days to get repeat blood work. Well, 12 hours later, the patient ended up having a ton of bleeding and pain at home and came in and she had a ruptured ectopic and was completely unstable.”
The patchwork landscape of abortion laws can make finding care difficult for patients. “I know of a patient who was on the border [between states with early gestational age limits], who went to the other state to get IVF [in vitro fertilization], came back home to have a baby, and had a medical complication,” said Participant 6. “That hospital administrator told her we couldn’t take care of you in [her state with a six-week ban]. She went back to where she got IVF, which was also a state with a [later gestational-age abortion] restriction and she was too far along, so then she had to go to a third state. And then by the time she got there she was septic. So, this is very unfortunate care all around and completely could have been avoided if she had [received the needed abortion care] in her own state.”
Participants also raised concerns about restrictions to medication abortion, which has come under scrutiny following legal challenges from conservative Christian activist group Alliance Defending Freedom. The drugs used in medication abortions, mifepristone and misoprostol, are also the best treatments for miscarriage management, and the drug methotrexate is the standard treatment for ectopic pregnancies. While mifepristone is the primary drug targeted by anti-abortion activists, physicians raised concerns about other medications being targeted.
“We use methotrexate usually in combination with some of our biologic medications [for]… patients who have pretty severe inflammatory bowel disease, said Participant 12, a gastroenterologist. It’s also used for patients that have comorbid inflammatory arthritis or other skin conditions, which is also quality of life and can lead to further joint damage, erosive joint disease, leading to significant debility and disability.”
The gastroenterologist also raised concerns about the impact that anti-abortion tactics — like use of the Comstock act to ban mailing medication abortion pills — could have on other patients. “If it becomes challenging to mail medications to our patients, whether from a specialty pharmacy or even just like good old CVS mailing service, it could become potentially dangerous to their health,” explained Participant 12. “If you don’t use methotrexate and you only use these medications by themselves, there is risk of failure of the medications and you can’t just restart them.”
Another participant detailed how delaying or denying access to medication abortion can further harm patients with pre-existing conditions. “I had a patient who [unintentionally] got pregnant even though she was supposed to be on contraception … and was still taking teratogenic medications [substances that interferes with normal fetal development and causes congenital disabilities] during pregnancy,” said Participant 17. “She made a decision to medically terminate and she was no longer in a window where she could have a medication abortion. And so she had to do procedural termination. And it was a huge stress for her. In a lot of our neurological diseases, stress actually triggers attacks. So stress is a big trigger in migraines, a big trigger in MS, a big trigger in seizures, et cetera. And [she now faced] the stress of having to go and do a termination procedure … the patient was suffering quite directly in that respect. And that of course puts her disease management at risk.”
Report authors emphasize the challenges of capturing data. “It’s really, really, really hard to document all of the ways that these laws are harming and frankly killing women,” said Participant 25. “And so when we get the report that these are the number of women who died because of restricted access to [abortion] care, that number is 100 percent going to be an underestimate. We are not going to include in that number the women who had pulmonary hypertension and their doctor didn’t talk to them about abortion as an option. We’re not even going to know about the women who wanted abortion but couldn’t put together the resources to get out of state to get that abortion.”
While Colorado has widespread protections for abortion patients, federal efforts to deny funding to Planned Parenthood impacted patients who relied on Medicaid. “We had a patient who was referred to us by the local emergency department,” explained Jack Teter, Planned Parenthood of the Rocky Mountains’ (PPRM) vice president of government affairs, during a meeting with Rep. Jason Crow (D-CO) last month. “She was having a missed abortion [a miscarriage in which the fetus didn’t form or is no longer developing, but the placenta and embryonic tissues are still in the uterus]. The emergency room said that she would best receive care at Planned Parenthood, so they sent her to us, and then we had to turn her away bleeding back to the hospital, even though the hospital had sent her to us.”
In response, Colorado legislators passed a bill to restore access to Medicaid services for Planned Parenthood patients during last month’s special session. “Despite Coloradans’ overwhelming support of reproductive freedom, Congressional Republicans continue to attack access to life-saving health care,” said Rep. Jenny Willford (D-Northglenn) in an Aug. 26 news release. “When Trump’s budget was signed into law, it forced Planned Parenthood to immediately cancel every appointment for Medicaid recipients. While corporations enjoy their new tax breaks, Coloradans on Medicaid risk losing access to STI testing, cancer screenings and abortion care. I’m proud to stand up for Coloradans with this new law that will restore access to life-saving care.”
