CPQ Medicine (2022) 13:6
Mini-Review

The Effects of Abortion Bans on Women’s Healthcare

Anne Louise Phelan

Retired Physician, Blacksburg, Virginia, USA

*Correspondence to: Dr. Anne Louise Phelan, Retired Physician, Blacksburg, Virginia, USA.

Copyright © 2022 Dr. Anne Louise Phelan. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 25 October 2022
Published: 29 November 2022

Keywords: Abortion; Women; Healthcare

On June 23, 2022, Americans lived in a country where women had the right to reproductive autonomy and physicians had the right to care for pregnant women according to their best judgment and abilities. On June 24, 2022, that autonomy was gone. The Supreme Court of the United States [SCOTUS] issued an opinion in “Dobbs v. Jackson Women’s Health Center” that abortion was not a constitutionally-protected right and it returned the matter “to the people,” namely, individual state legislatures [1].

While right-to-life devotees were jubilant over a hard-won victory to save the lives of innocent unborn babies, many moderate members of the public were confused and upset. Adamantly pro-choice activists were shocked, dismayed, and acutely apprehensive about both the predictable and unforeseen consequences of this decision. Even in states where abortion was still legal, medical professionals were alarmed over the dangers that strict abortion bans would pose to women of reproductive age.

Abortion Rights in the United States
After three centuries of antiquated laws that banned and/or criminalized abortion, in 1973, in the landmark decision “Roe v Wade, SCOTUS established a woman’s constitutional right to abortion up to the point of fetal viability outside the womb [2]. The decision was based on the 14^th amendment’s guarantee of equal access to life and liberty and the presumption of a fundamental right to privacy between a woman and her physician. A woman’s right to terminate a pregnancy up to approximately 28 weeks’ gestation became the law of the land. That endpoint receded somewhat because of technologic advances in neonatal intensive care but reproductive autonomy was still considered settled law for nearly 50 years.

Immediately after the Roe v. Wade decision, conservative activists began pushing back. In 1976, Congress passed “The Hyde Amendment” which forbade the use of federal funds for abortion services unless the life of the mother was at stake. Since then, multiple state laws and regulations have chipped away at abortion services. These included mandatory waiting periods and fetal ultrasounds and earlier cut-off dates for legal abortions, as well as requirements that abortion providers have clinical privileges at nearby hospitals. But for the most part, the constitutional right to abortion services remained part of the fabric of American life.

However, in the last decade or so, multiple forces converged to put Roe in danger [3]. Many conservative state legislatures passed “trigger laws” that would automatically ban “medically unnecessary” abortions in the first and second trimesters if Roe were struck down. Early in 2022, Texas passed a bill that allowed ordinary citizens to sue anyone whom they believed aided and abetted an abortion after six weeks of pregnancy. The evangelical Christian right, a staunchly anti-abortion voting bloc, began amassing enough political power to directly influence elections.

During his four-year tenure, former president of the United States, Donald J. Trump, loaded federal courts with pro-life judges and named three explicitly antiabortion judges to the Supreme Court. Along with two other ultra-conservative justices, SCOTUS was primed to strike down Roe as soon as a relevant case came before the court. When the constitutionality of Mississippi’s Gestation Age Act 0f 2018, which outlawed abortion after 15 weeks, was challenged by Jackson Women’s Health Center, one of only two abortion clinics in the state, Roe fell, sending fear and confusion throughout the U.S. healthcare system.

Trigger laws went into effect immediately after Roe was overturned; legislatures in other states quickly started to pass restrictions and bans of their own. An archaic 1749 law in Wisconsin and a 1931 law in Michigan that banned abortion were set to be reinstated. In Texas, elective abortions after six weeks became criminal acts punishable by fines and prison sentences. In Mississippi, physicians could lose their medical licenses if they performed an illegal abortion.

The Immediate Aftermath
A basic tenet of acute care medicine is that physicians must do their best to prevent urgent medical conditions from becoming life-threatening. If a patient has chest pain from coronary artery disease, it would be antithetical to physicians’ training to wait until he has a heart attack to intervene. If a patient has appendicitis, surgeons won’t purposefully wait until the appendix ruptures to perform an appendectomy. But now, in states where preserving the life of the mother may be the only exception to abortion bans, early intervention of complications of pregnancy are fraught with danger [4].

Following the Dobb’s decision, the mere threat of criminal or civil liability for performing a now illegal abortion changed physicians’ approach to women with complicated pregnancies. For example, in Texas, a woman’s amniotic membranes ruptured at 20 weeks, draining amniotic fluid from her uterus. Amniotic fluid is vital for the development of the heart, lungs and urinary tract; membranes that rupture before 26 weeks almost always result in fetal demise or stillbirth.

However, the administration and ethics committee at the Texas hospital where she sought care refused to allow doctors to terminate the pregnancy because a heartbeat was still detectable. She was sent home. It wasn’t until she became dangerously septic - with a high fever and pus oozing from her vagina - that physicians got permission to induce labor. Predictably, the infant was stillborn [5].

Overall, about 25% of pregnancies result in natural miscarriage, also referred to as a “spontaneous abortion.” Sometimes a miscarriage occurs so early that it is mistaken for a heavy menstrual period. However, as the pregnancy progresses, complications can occur. The most common complication is incomplete expulsion of a dead or dying fetus and its associated tissues, a condition referred to as an “incomplete” or “missed” abortion. Prolonged heavy bleeding and infection often ensue.

Medication-induced abortions and surgical abortions are the only effective interventions to mitigate or prevent serious complications from an incomplete miscarriage. Since the procedures for performing an elective abortion and treating an incomplete miscarriage are essentially the same, the new restrictions and bans on abortion create substantial legal peril for the provider and dangerous delays in definitive treatment for the patient.

If a fetal heartbeat is detectable, physicians in states where abortions are banned or severely restricted must wait until the miscarriage puts a woman’s life in serious imminent danger before performing an abortion. Blood loss must be excessive; fever must be dangerously high; vital signs must be unstable; consciousness must fade; blood pressure must drop. Only when one or more of these conditions arise can physicians perform an abortion without automatically facing legal jeopardy. Even then, they must document their reasoning in great detail and, as in the Texas case, they may need permission from their hospital’s ethics committee and/or board of directors before proceeding.

A woman from Baton Rouge, Louisiana was pregnant with her fourth child when she found out the fetus had acrania, a condition in which the skull fails to form. Because the skull and brain develop in concert, the brain is usually malformed or absent as well. But the specific condition of “acrania” was not on Louisiana’s list of fatal disorders for which an abortion could lawfully proceed and the woman had to arrange for an abortion in another state. She suffered no lasting physical harm, but the delay in treatment caused her significant emotional distress [6].

Long-Term Consequences
The situations described above represent the most immediate and drastic dilemmas that practitioner and patient must face because of abortion bans. But non-urgent situations can be equally significant [7]. A 10-year-old rape victim in Ohio was denied an abortion in her home state because her pregnancy was more than six weeks along, the state’s new cut-off for a legal abortion.

Children’s immature bodies are more vulnerable to injury from pregnancy than those of physically mature females. They have a higher risk of preterm birth and cesarean sections, as well as injuries to their bladder, uterus and bowel that can lead to incontinence and impaired future fertility. Rectovaginal and cysto-vaginal fistulas (abnormal passages between organs) that can develop after injury, are common causes of a lifetime of misery for females in countries where child marriage and early child-bearing are common. They could become more common in the U.S. in states where abortions are tightly restricted or banned.

On the other end of the spectrum, women over age forty are much more vulnerable to pregnancy complications and exacerbation of pre-existing medical conditions than younger women. In states where abortion is legal only when the mother’s life is at stake, she can’t terminate her pregnancy pre-emptively even if she and her physician agree that continuing the pregnancy possesses unacceptable risks.

Abortion bans aren’t just leading to more unplanned pregnancies; they are also leading fewer planned pregnancies. Women and their male partners in states where abortion is banned are reconsidering having a child if abortion isn’t an option should the pregnancy develop a complication. Fearing that contraceptives may become difficult to procure in anti-abortion states, many women are seeking long-term contraceptives such as IUDs and stockpiling Plan B and abortion pills from the internet. The Washington Post reports that area urologists are scheduling two to three times as many vasectomies following the June 24 Supreme Court decision as they previously had, as men fear for the lives of the women they love [8].

Homicide is a leading cause of death in pregnant women [9]. Women forced to carry a fetus to term in an abusive relationship may experience an escalation of abuse during pregnancy. Women also have a harder time escaping an abusive partner if they have a child together.

Lack of abortion access could consign a victim of rape to months and years, even a lifetime, of social stigma and adverse health and economic outcomes, compounding manifold the injury from the original crime.

Women who unintentionally become pregnant as a result of consensual sex may also face serious social consequences when elective abortions are no longer available. They are less likely to complete their education and training and more likely to live in poverty than women who have full reproductive autonomy. The younger they are, the greater the socio-economic impact. Because of emotional bonding that occurs as pregnancy progresses, putting up a child for adoption can be more traumatic than having a first trimester abortion.

Pro-life advocates often cite complications from an abortion as a reason to ban it, but it’s much less dangerous than carrying a pregnancy to term. Gallbladder disease, urinary tract infections and Type II diabetes occur more frequently as the pregnancy progresses. Many pre-existing medical conditions, such as heart failure, osteoarthritis and diabetes, are aggravated by pregnancy. Others require medications that are contraindicated during pregnancy. Among them are the seizure medication valproic acid, the psychiatric medication lithium, and several cardiovascular medications.

Complications can occur during childbirth that require emergency caesarian section, a procedure that poses significantly more danger than an elective or therapeutic abortion. These include breech presentation, arrested or obstructed labor, fetal distress and cephalopelvic disproportion, a condition in which the baby’s head is too large to pass through the pelvic outlet.

If a woman is diagnosed with a serious medical condition during pregnancy, her treatment options may be limited in states that ban abortion [10]. Certain diagnostic measures such as x-rays and CT scans, as well as treatments such as cancer chemotherapy, can harm the fetus. If the life of the fetus trumps her own, the mother’s treatment will be delayed until childbirth which will reduce her chance of a cure.

As abortion bans take effect, more restrictions will emerge for medication-induced abortions. Almost half of all elective abortions and incomplete miscarriages in the first trimester of pregnancy in the U.S. currently are induced or completed using a combination of mifepristone-which arrests the development of the fetus-and misoprostol-which softens the cervix and expels the uterine contents.

While women in states with abortion bans can still get abortion pills through out-of-state or international websites, they must manage the process on their own. The complications of a medication-induced abortion are similar to those of a spontaneous miscarriage. The definitive treatment is surgical abortion. Women are likely to delay seeking treatment out of fear of legal retribution and, if they do seek treatment, they may be denied appropriate care.

Women who take methotrexate for rheumatoid arthritis might have difficulty precuring it since it can also induce an abortion [11]. In Canada, methotrexate is routinely used explicitly for that purpose. An American pharmacist, however, might be reluctant to fill the prescription out of fear of violating anti-abortion laws.

States that ban abortion from the moment of conception might also outlaw some contraceptive methods like the IUD and Plan B, wrongfully designating them as “abortifacients” (contraceptives that allow conception but prevent implantation in the uterus). In reality, the copper IUD prevents sperm from reaching an ovum by thickening the cervical mucus and progesterone-secreting IUDs also suppress ovulation. Plan B interrupts ovulation if taken within 24 to 72 hours of intercourse. Restrictions on contraception will inexorably increase unplanned and unwanted pregnancies, as well as pregnancy-related complications.

Some state legislators are contemplating endowing embryos with full “personhood rights” from the moment of conception [12]. Interfering with their development into fully formed infants could then be considered homicide. In vitro fertilization could be banned if unused embryos couldn’t be disposed of. If too many embryos successfully implant in the woman’s uterus but can’t be selectively aborted, the woman’s health is endangered from the burden of carrying multiple fetuses and the chance that any embryo will result in live birth is significantly reduced.

Because in vitro fertilization requires multiple visits to a specialist, it will become impracticable for most women if they have to travel to another state for fertility treatment. Pro-life advocates would advise adoption in cases like this, but many couples understandably yearn for a biological child.

Research involving human embryos could come to a standstill in states with strict abortion bans or “personhood” amendments. Genetic screening for serious mutations or inherited diseases will be pointless where disposing affected embryos is illegal.

In South Carolina, legislators contemplated, but ultimately rejected, a bill punishing healthcare professionals for informing patients about their options for terminating an unwanted pregnancy. However, based on the rapidity with which abortion bans have been enacted in other states, free speech about abortion care could be the next casualty.

Conclusion
History demonstrates that abortion bans do not eliminate elective abortions or obviate the need for abortion services. Women who can’t get safe and legal elective abortions may, in desperation, resort to dangerous means to terminate their pregnancy.

Those who need therapeutic abortions may experience undue delays and unnecessary physical and emotional trauma.

Governments should not interfere with the provision of professionally-accepted, science-based medical treatment under any circumstances. Reproductive care is no exception. Physicians should not have to risk their pregnant patients’ lives in order to stay in compliance with state law. It’s therefore imperative that all women of childbearing age have access to safe and legal abortion services.

Conflicts of Interest: No

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