What Can OB/GYNs Do to Protect Patients — and Themselves?
Faced with new and unprecedented laws banning abortion, physicians need to learn all they can about their states’ laws.
“There’s a real concern that this will end up impacting people who have spontaneous loss, where it’s clear the pregnancy cannot continue, but there may still be embryonic or fetal cardiac activity,” says Daniel Grossman, MD, FACOG, professor in the department of obstetrics, gynecology, and reproductive sciences and the director of Advancing New Standards in Reproductive Health at the University of California, San Francisco. “Clinicians will be prevented from intervening, and patients will have serious risk of complications and dying.”
Abortion bans across half of the United States will lead to significant harm in other ways. In addition to health risks in pregnancy, patients with an unwanted pregnancy face worse outcomes related to poverty and intimate partner violence.
“People who are forced to continue a pregnancy are more likely to remain tethered to an abusive partner,” Grossman says. “Those who have an abortion are more likely to get out of the relationship and end the abuse.”
Reproductive health leaders suggest these ways to protect patient safety in the face of new abortion bans:
• Form professional groups to address standards and strategies. Health system and healthcare professional groups need to create standards for pregnancy care for patients with health- and life-threatening problems during pregnancy. When health systems and state medical boards meet to discuss new standards, a physician who can perform abortions should be included.
When is it necessary for an abortion to preserve the life of the woman?
“Doctors and other healthcare professionals need to define this,” says Lisa H. Harris, MD, PhD, professor and associate chair in the departments of obstetrics and gynecology at the University of Michigan.
States that allow abortions to save the life of the woman do not clarify allowable risk. “Does it mean there has to be a 100% chance of dying imminently, or whether there is a 50% chance of dying?” Harris asks. “It’s not explicit in the law that the [pregnant] woman has any role in interpreting that risk.”
For many women, even a 10% chance of dying if she continues a pregnancy that will never produce a living baby is too much risk. “I see women who are already mothers and have a pregnancy that is life-threatening in some way, and their priority is to be alive for the children they already have,” Harris explains. “They may not be willing to assume a 50% — or even a 10% — risk.”
The patient’s values should be part of the discussion when health professionals are writing standards. “As a doctor, my first priority is to know what matters most to the patient I’m caring for, and to help them make decisions that align with that,” Harris says.
• End ectopic pregnancies. Ectopic pregnancies are another safety issue. Although these pregnancies pose grave dangers to pregnant people, and there is no possibility of the pregnancy resulting in a living baby, some physicians and hospitals are reluctant to end them before they become a crisis. In Texas, there have been cases of women with ectopic pregnancies sent out of state for life-preserving medical care.1
The National Abortion Federation hotline fielded a call from a woman with an ectopic pregnancy. She was told by both her primary care provider and the local hospital that they could not end her pregnancy, and she had to travel out of state. She drove more than 12 hours to a hospital in New Mexico.1
“There are no circumstances under which an ectopic pregnancy could have a good outcome,” Harris says. “It’s a life-threatening condition.”
• Help women safely end miscarriages. “If someone is hemorrhaging in miscarriage or has an infection early in pregnancy, these are clear cases where there won’t be an outcome other than pregnancy loss,” Harris says. “We’re working with our legal counsel to define these situations where it would be allowable to end the pregnancy, under the law.” Medical societies and legal professionals need to create consensus guidelines to help providers feel safe and to establish a standard of care, she adds.
If medical professionals choose not to help a woman safely end a non-viable, potentially life-threatening pregnancy, then they are putting their own needs ahead of the patient’s needs. “The typical risk-benefit balance is you help the patient see the risks of a certain path and benefits of a certain path,” Harris explains. “Those are the risks and benefits to the patient, but here, the doctor is balancing the risk to the patient with their own risk. That’s a risk-benefit that has no ethical underpinning.”
• Respect HIPAA and do not report suspected abortions. “I think it’s going to be very important for clinicians to do everything we can to make sure patients are not criminalized if they seek healthcare,” Grossman says. “I do not have concerns about the medical risks of self-managing abortion — I do have a concern about the legal risks.”
Women in the United States have been arrested, jailed, and prosecuted for allegedly self-managing an abortion, or for miscarriages when they tested positive for substance use. It is up to healthcare providers to protect patients by not reporting them because of a miscarriage or self-managed abortion.
“There is no jurisdiction with mandatory reporting for self-managed abortion, and there’s no reason we should ever get police involved,” Grossman explains. “Those kinds of actions put patients at risk and make patients afraid to seek care.”
An American College of Obstetricians and Gynecologists policy opposes criminalizing pregnant patients for actions they may take during pregnancy.2
“We need to be careful about what we do, what we ask patients, and what we document in the medical record,” Grossman explains. “Management of patients who present with an incomplete abortion after using medication is exactly the same as management of patients who have a spontaneous pregnancy loss, and we don’t need to know that they took something.”
Hospitals should create a policy describing what providers should ask of patients and what needs to be documented.
“As far as sharing that information with police, HIPAA makes it clear health information should not be shared with anyone unless it’s related to getting payment or treatment or needed for healthcare system operations for auditing and monitoring circumstances,” Grossman says. “If a physician is bound by a law for mandatory reporting, that’s different, but it’s not the case with self-managed abortion.”’
• Be a resource to patients. Clinicians in abortion-ban states need to let patients know they can be a resource for them if patients ever have a question about an unplanned pregnancy.
“Patients can come to their clinician, who will continue to provide them unbiased information and help them get the care they need, even if it means getting care in another state,” Grossman says. “It’s up to clinicians to be aware of what resources are available in their state and to help people find the closest clinic that can see them and help them access this care.”
REFERENCES
- Kitchener C. The Texas abortion ban has a medical exception. But some doctors worry it’s too narrow to use. The Lily. Oct. 22, 2021.
- American College of Obstetricians and Gynecologists. Statement of policy: Opposition to criminalization of individuals during pregnancy and the postpartum period. December 2020.