On Friday, the Supreme Court overruled Roe v. Wade in a decision by Justice Samuel Alito. Last month, when a draft of that decision had leaked, Leah Torres wrote about the future of medical care for women.
If you want to understand the future of medical care for pregnant women in a post-Roe world, look no further than what is happening in Alabama. As others have pointed out for Slate, the leaked draft majority opinion in Dobbs v. Jackson Women’s Health Organization paves the way for criminalizing many aspects of pregnancy. While Texas’ abortion ban, S.B. 8, has essentially halted all abortions in the state, Alabama offers a glimpse of a troubling future in which the provision of medical care for pregnant people is deeply intertwined with the cultural attitudes that seek to criminalize “undesirable” pregnancy outcomes.
In the summer of 2020, I got a firsthand experience of these attitudes in action. Three weeks after starting to practice at West Alabama Women’s Center, my application for a medical license was denied and my temporary medical license revoked for what we can’t help but question may have been political reasons. Although I had been hired to offer general gynecological care, the Women’s Center has historically been known as an abortion clinic, and I am open on social media about my views that abortion should be on demand. Because of the eight-month-long process to reverse and reinstate my license, I did not begin to understand how dire health care access was in Alabama until I was able to practice medicine in March 2021.
I was astounded by how often patients were turned away from emergency rooms and their doctor’s offices in the middle of their miscarriages. No wonder Alabama has the third-highest maternal mortality rate in the nation, I initially thought. People are denied urgent medical attention outright, which left me wondering at first if health care providers were simply negligent and not keeping up with their medical education. Or was this lack of care a reflection of discrimination? Eventually, I landed on discrimination as the cause.
But I was wrong. The reality is much worse. Instead, these medical professionals seem to know what they are supposed to do, but choose not to.
I came to this realization when I saw a patient in active miscarriage (bleeding, passing clots, cramping) who had just had an office visit with her primary physician. She was forced to wait more than 48 hours in order to get the results of her bloodwork. Doctors will sometimes check a patient’s levels of HCG, or human chorionic gonadotropin, to help distinguish miscarriages from ongoing pregnancies or ectopic pregnancies. I could not understand why someone with all of the clinical signs of a miscarriage in progress was required to wait for much-needed intervention, all the while bleeding and cramping and suffering.
I was angry that the patient’s doctor did not just provide the standard medical treatment for a miscarriage: surgically removing the contents of her uterus, which would stop her pain and bleeding. Then I saw a different patient who was actively miscarrying, and a lightbulb clicked on: The doctors were afraid of being attacked by the state of Alabama.
Medical providers who treat pregnancy-related issues in red states exist in a constant state of fear of performing any procedure that can be classified as an abortion—even while the procedures remain legal. We know that we face the risk of being prosecuted, having our licenses revoked, or even being thrown in jail if we fail to precisely follow every regulation, no matter how arcane or medically unnecessary it is. (We can be cited if the clinic’s janitor’s closet isn’t the size deemed appropriate by the state, for example.)
Part of the problem is a culture that has decided abortion is akin to killing a child. Morality aside, health care providers have also been conditioned by the state to fear providing not only abortion care, but management of adverse pregnancy outcomes more generally. Abortion is outlawed in the state constitution, and state lawmakers made their moral position and hostility toward abortion clear in 2019 when Gov. Kay Ivey signed the Alabama Human Life Protection Act into law. The law banned abortions at every stage of pregnancy and criminalized doctors, charging them up to 99 years in prison for performing the procedure. Ultimately, a federal court overturned the law, but the state is poised to ban abortion outright through a “trigger law” that goes into effect as soon as Roe falls.
Ivey celebrated the law at the time, lauding it as a restoration of the state’s position on abortion prior to Roe. “In all meaningful respects, this bill closely resembles an abortion ban that has been a part of Alabama law for well over 100 years,” Ivey said during the bill’s signing, before noting the law itself was “unenforceable as a result of the U.S. Supreme Court decision in Roe v. Wade.” Enforceable or not, laws like this send a powerful message to doctors.
As an OB-GYN, I work in active fear of being arrested for providing evidence-based health care in this state. I am certain that I am not alone. Intervening in an ongoing pregnancy would be examined as an “abortion” by the medical board and subject to the same scrutiny as any procedure I perform in my clinic. Doctors know that if you perform anything that could even be suspected of an abortion, you had better have all of your regulations followed to the letter. No wonder, even though we are directed under federal law to provide appropriate medical care to any pregnant person who shows up in the ER with a medical emergency, few in Alabama are willing to risk their careers and liberty to provide that care.
Too often, I see and hear about examples of this stigma and fear at work when women come to me after being refused treatment in the local ER. For example, one patient started bleeding heavily at home. When she got out of bed in the morning, she said blood and clots ran down her legs and onto the floor. She rushed to the ER, where she told the nurse practitioner that she had taken mifepristone and misoprostol for a medication abortion 10 days earlier. The nurse practitioner knew the patient was experiencing an incomplete abortion, which happens when the body is not able to completely pass the pregnancy on its own. (Miscarriage and abortion are often indistinguishable clinically, and that’s a huge problem because people miscarrying will be denied care because of abortion suspicion.)
As is protocol, the nurse practitioner called the OB-GYN on call. He said he would not see the patient. No further explanation was given. The nurse practitioner then tried involving the ER physician; however, he was “in a meeting” and unavailable. Ultimately, she was told by hospital administrators to send the patient more than 2.5 hours away for care, back to the clinic that gave her the medication to end her pregnancy.
Desperate for help, the nurse practitioner called me. I, of course, said that if the patient was safe to drive (ride with a friend) all that way, I would certainly provide the needed care. Sarah had an aspiration procedure with me that took less than seven minutes from start to finish. It was uncomplicated and safe. She later told me that she slept in the car during the 2.5-hour ride back home. Seven minutes could not be spared by the doctors at her local emergency room where she was bleeding on their floor. Instead, she was told to go away.
Another patient went to the doctor’s office because she knew something was wrong following a medication abortion. Her primary physician was a family medicine doctor trained in performing dilation and curettage procedures. The patient was having an incomplete abortion, and the remnants of the pregnancy needed to be evacuated from inside her uterus to stop her from bleeding and avoid infection and sepsis. Her doctor scheduled the D&C in the operating room for the next day, and the patient showed up on time for her procedure. However, the hospital told him he could not perform the D&C because “it was not an emergency.”
The patient had to go back home, still bleeding. She called my clinic to see if we could help. I spoke with her doctor, who was denied the ability to perform the D&C. The hospital never gave him any more information, leaving him confused about why he could not care for his patient. Fortunately, she was able to make the two-hour trip to our clinic and I performed an uncomplicated and necessary aspiration procedure.
These are just two examples from a wide spectrum of how even just the threat of criminalizing abortion results in discrimination against pregnant people, mutating reproductive health care into something it never should be: inaccessible and dangerous. Many of the medical professionals in Alabama who refuse to treat women who are miscarrying are not incompetent or hateful—they are scared.
In no uncertain terms, these incidents will only get more frequent and more dangerous as more people—especially women of color—will be affected when the Supreme Court finalizes Justice Samuel Alito’s decision in Dobbs.
As we wait for the final ruling, which is expected in June, it is worth considering the reality already happening on the ground in states where stigma and laws against abortion have cowed providers into eschewing their responsibilities. It is truly unethical to turn away an actively bleeding patient in retaliation for them having chosen the still legal option to their own bodily autonomy, or to deny emergency medical care out of fear of financial, professional, and legal consequences from the state. I took an oath to provide care to those who need it, regardless of my personal views. I only wish the doctors and lawmakers of Alabama had done the same.