Even before the Supreme Court reversed Roe v. Wade last month, doctors in Texas were already seeing the effects of abortion restrictions.
Last September, a state law began using the threat of civil lawsuits to effectively ban the procedure after six weeks of pregnancy.
Dr. Kimberly Pilkinton, an OB/GYN with the Texas Association of Obstetricians and Gynecologists, said some providers were being forced to send patients out of state to receive care for complications that would have been handled locally before, including labor that begins before a fetus can survive outside the womb.
“Sometimes there are unintended consequences [to policies],” she said.
Texas is at the leading edge of what doctors fear will be a wave of more complicated pregnancies and sicker patients in the wake of the high court’s decision.
“It’s going to have catastrophic consequences for maternal health, fetal health,” said Dr. Katherine Pocius, medical director of family planning at Massachusetts General Hospital.
Years of research have shown that unintended pregnancies are more likely to result in babies born prematurely or with low birth weight. These tiny, fragile infants may require intensive care and sometimes suffer life-long disabilities.
Women whose health problems — such as diabetes or hypertension — are triggered or worsened by pregnancy will not have the option to terminate in some states, and will need medical attention. Women with complications from pregnancy may also see delayed care, ultimately making them sicker, as physicians struggle to define exactly when a mother’s life is threatened or to care for pregnancies that are not even viable.
“There absolutely will be more complicated pregnancies across the United States,” said Dr. Erika Werner, chief of obstetrics and gynecology at Tufts Medical Center and Tufts Medical School.
In Massachusetts, expectant parents will receive the care they need. But doctors are preparing for an influx of cases from other states.
Dr. Emily Herzberg, pediatrician with the Division of Neonatology and Newborn Medicine at Mass General for Children, said people with medically complex pregnancies may come to Massachusetts to receive care in a place where abortion is one of the options discussed.
“We get referrals from outside communities and outside states already,” she said. “I do anticipate we may have an increased number.”
In the next year, at least 75,000 people will have a birth that they did not plan for and did not want, according to conservative estimates, said Dr. Katharine White, a family planning specialist at Boston Medical Center and obstetrics and gynecology professor at the Boston University School of Medicine.
Women whose pregnancies aren’t planned often discover them later and start prenatal care later, increasing the chances of problems, White said.
Scientists from the University of California San Francisco found that women who were denied an abortion and gave birth reported more life-threatening complications, such as eclampsia and postpartum hemorrhage, compared to those who received wanted abortions. Additionally, women who were denied an abortion and gave birth reported more chronic headaches or migraines, joint pain, and gestational hypertension compared to those who had an abortion.
States with abortion restrictions may also see an increase in the number of children born with severe health issues. If physicians live in a state that won’t allow them to intervene earlier, hospitals may end up devoting resources caring for babies who cannot survive.
Although most states with abortion restrictions have language to allow pregnancy terminations if the mother’s life is at risk, the language is sometimes ambiguous.
“How sick is too sick? How life-threatening is too life-threatening?” said Dr. Chloe A. Zera, maternal-fetal medicine expert at Beth Israel Deaconess Medical Center and vice president of health policy advocacy at the Society for Maternal Fetal Medicine.
In a famous incident in Ireland, a pregnant woman died of sepsis in 2012 after her doctors refused to perform an abortion. The resulting outrage led Ireland to legalize abortion.
“Providers will be put in horrible situations of making decisions that are medically appropriate versus being scared by legal implications,” said Pocius, the Mass. General doctor. “It’s a scary place.”
“Doctors, our first thing is to take care of people,” said Pilkinton, a practicing physician in Texas. “It’s hard not to just do what our training and medical knowledge tells us to do. Now more than before we have to consider legal aspects.”
Physicians in Texas are even concerned about discussing the risks of miscarriage with pregnant patients, Pilkinton said, out of fear that it could violate some of the language in new state laws that prohibits counseling women on abortion.
Conversations between providers and hospitals are ongoing to prepare for the myriad circumstances that might arise in how to protect patients. More than before, physicians are having to advocate for their patients to receive necessary medical care that has now become controversial, such as for failed pregnancies, medical complications at pre-viable stages, and ectopic pregnancies.
“We’re going to need to document even more than in the past, and really be an advocate for our patients in those situations,” Pilkinton said.
Pilkinton feared there may be further consequences downstream as well, if abortion laws dissuade medical students from training in states with restrictive laws. Data show that doctors are more likely to practice medicine within a 200-mile radius of where they undertake residency training, Pilkinton said.
Dr. Kellie Lease Stecher, cofounder of Patient Care Heroes, which helps health care workers with mental health needs, and a practicing OB/GYN in Minnesota, said restrictions on how to practice may also force doctors to leave the field or move to other states, further exacerbating access issues that could lead to poorer health outcomes for women.
“We’re just going to see a mass exodus of physicians who are amazing and qualified, leaving states where they cannot practice evidence-based medicine,” Stecher said. “We will have a vacuum of care in those areas.”
Hospitals are already full, due to a behavioral health crisis, sicker patients who have deferred care during the pandemic, and lingering COVID-19 complications. If restrictions in other states draw more patients with pregnancy complications to Massachusetts, hospitals may struggle to accommodate them.
“We’re trying to figure out how to do that,” Pocius said
An earlier version of this story misspelled the name of one of the physicians quoted. The correct spelling is Dr. Erika Werner, who is chief of obstetrics and gynecology at Tufts Medical Center and Tufts Medical School.