OB/GYNs, emergency medicine specialists, family medicine practitioners, and others may routinely encounter patients presenting with symptoms of an ectopic pregnancy, miscarriage, or other obstetric complication—and they may be equipped to immediately and effectively respond, following well-established clinical standards. Yet in the wake of the Dobbs decision, which overturned Roe v. Wade, rapid changes in hospital protocols have at times amplified confusion over what is legally allowed. Clinicians in some states may feel pinned between their obligation to care for the patient and their obligation not to break the law.
As the spillover effects of states’ bans on abortion have begun to delay care in obstetric emergencies, The Doctors Company convened a discussion among three prominent OB/GYNs. These experts discussed how risks of delayed care have been increased—for patients and medical professionals—by some states’ responses to the Dobbs decision. “A lot of the stories stem from confusion about what can be done, and trying to react in the moment because there hadn't been much planning done,” says Daniel Grossman, MD, Professor at the University of California, San Francisco, and Director of Advancing New Standards in Reproductive Health (ANSIRH). The panelists’ discussion addressed what medical professionals and organizations should anticipate now.
Dobbs Creates Spillover Effects
Some interventions, medical and surgical, have multiple applications. Therefore, restrictions on care inevitably create domino effects. For instance, the medications commonly used for medication abortions, mifepristone and misoprostol, are also often the recommended intervention when a patient is experiencing a miscarriage. Likewise, certain procedures and medications used in abortion may also be appropriate to treat an ectopic pregnancy, which can cause massive internal bleeding and will never develop into a viable pregnancy—but can sometimes develop into a life-threatening emergency, if medical professionals cannot intervene in time.
The effects of bans on abortion can even spill over into non-OB/GYN care by restricting access to medications with applications for treating autoimmune diseases or certain forms of cancer. Since the Dobbs decision, patients with a variety of concerns find themselves facing unexpected, and in some cases alarming, delays in care.
Emergencies Amplify the Risks of Delayed Care
All healthcare providers know that, as Dr. Moayedi says, “Nobody’s body read the textbook.” There is no standard medical definition of “emergency.” Yet laws restricting abortion access are written with the expectation that patient’s bodies follow a simple course. For pregnant patients with complications, Dr. Moayedi says, very often, “They’re OK, OK, OK—and then they decompensate into the worst that you could possibly imagine. In what other area of healthcare would we wait in this way before offering lifesaving treatment?”
A recent JAMA article reinforces Dr. Moayedi’s point: “Many pregnant individuals are young and healthy; thus, they are able to compensate for severe physiologic derangements and might not appear ill until very late in their course of critical illness.” When interferences in care force medical professionals to wait to intervene, “withholding evidence-based care to have clear documentation of an unambiguous threat to life is dangerous.”
Moreover, as the JAMA authors emphasize, this situation exposes medical professionals to potential legal jeopardyvia the Emergency Medical Treatment and Labor Act (EMTALA). Thus, clinicians in family medicine, emergency departments, and OB/GYNs all face the potential to find themselves between risks of patient safety issues, with their attendant moral and legal consequences, on one hand, and new legal risks imposed by their state’s response to the Dobbs decision on the other.
Plan Ahead for High-Stakes Situations
Certain high-stakes, urgent situations are predictable—or at least, it is predictable that clinicians will encounter them. Therefore, medical professionals, practices, and institutions should reflect on and plan ahead for patient presentations such as ectopic pregnancies and preeclampsia, where delays in treatment could result in adverse outcomes for a pregnant patient, an infant, or both. “Everyone does their community a service by having these proactive conversations,” says Dr. Moayedi.
For instance, all presenters agreed that there should be no delay in lifesaving treatment when a patient presents with a tubal ectopic pregnancy—but delay is exactly what is happening at many institutions where the legal landscape is especially murky. In these situations, sometimes “multiple people need to weigh in to give an opinion before treatment could be provided, which is really just shocking,” Dr. Grossman says. He and colleagues at ANSIRH have already begun gathering narratives from emergency room clinicians “about these really tragic situations that they're seeing in emergency rooms,” highlighting the necessity for practices and institutions to have their difficult conversations—before another patient presents in an emergent situation.
“Many institutions waited and then the reaction is out of fear, out of urgency,” Dr. Moayedi says. “And those are the times when we most forget our mission and our values and our commitment to our communities, when we're acting out of fear and urgency.” She continues, “And so having those tough conversations is really crucial to start developing those partnerships and building out policies that really capture your organizational values.”
To prevent delays in care, practices and institutions, even those in “safe” states, should guard now, with as much active advanced planning as possible, against situations where weigh-in from multiple legal and administrative parties is required before clinical judgment can be acted upon. Such delays could be deadly.