After Dobbs’ decision, hospitals hesitated to discuss maternal care

TThe Supreme Court’s decision to overturn Roe v. Wade has transformed not only access to abortion but also maternal health care in the United States, forcing doctors in states with restrictive laws to avoid treating conditions such as ectopic pregnancies and miscarriages have started to shift. However, the full extent of the impact has been obscured in a polarized political climate in which doctors are often afraid to speak out or are blocked by their hospitals from talking about their experiences after Dobbs.

The extent to which the conversation has been silenced is reflected in a STAT survey of 100 hospitals—two from each state—that asked to speak to physicians about changes in maternal health care since the Dobbs ruling. Only six institutions made doctors available to speak about their work, and five of those were in states where abortion access remains protected.

Representatives from five additional hospitals said they would ask doctors if they were interested in speaking, but could not confirm a time; the rest either rejected the request without explanation or simply did not respond to STAT’s request.

Several reproductive health doctors said the lack of response reflects a climate in which fear of political scrutiny and financial repercussions has effectively suppressed transparency.

“There is so much uncertainty about what is permissible that the conservative, ‘safe’ approach is not to talk about it,” says Aileen Gariepy, director of complex family planning at Weill Cornell Medicine. “Even in an incredibly progressive state like New York, there has always been a lot of concern and stigma around abortion care among top executives, advertising and PR departments. That has been magnified.”

Hospitals employ PR and marketing teams that typically respond quickly to reporters’ requests for interviews on other topics, but in this case the response was very different. STAT contacted a variety of hospitals, including those from major for-profit chains such as HCA Healthcare’s Grand Strand Medical Center in South Carolina, teaching hospitals such as the University of Iowa Hospital and OSF Heart of Mary Medical Center, a Catholic hospital in Illinois . all of whom declined the interview request. Physicians were given a choice of three days for an interview and were given the opportunity to suggest other preferred times.

STAT asked to talk to doctors not specifically about abortion, but about changes in maternal health care more broadly after Dobbs, such as whether there were shifts in the number of appointments for pregnant patients in their first trimester, or in monitoring and treatment of conditions such as ectopic pregnancy and miscarriage.

Of the six hospitals that did agree to interviews, doctors at Weill Cornell, Women & Infants Hospital of Rhode Island, Stamford Hospital in Connecticut and Massachusetts General Hospital – all in states with permissive abortion laws – said they had not personally had to change care. in response to the fall of Roe.

“We are all aware that the situation in Massachusetts is not the case elsewhere,” said Jeff Ecker, chief of obstetrics and gynecology at Mass General. “When we listen to colleagues, we share their grief to some extent. It makes us feel happy.”

In many other states, Dobbs’ implications extend beyond abortion. Doctors in Louisiana have responded to premature premature rupture of membranes (PPROM), which makes a pregnancy unviable and leads to infection and sepsis in the mother if left untreated. performing Cesarean sections instead of providing medication, which is not standard care and carries risks including bleeding and fertility complications. Other patients have been refused care for miscarriage and standard prenatal appointments during the first trimester. And doctors sometimes have that too patients rejected Immediately Ectopic Pregnancy, in which the embryo implants outside the uterus. If ectopic pregnancies are left untreated, the fallopian tube can rupture, leading to serious health risks, including death.

Heather Spies, a gynecologist at Sanford Health in Sioux Falls, South Dakota, told STAT that the state’s ban on all abortions except to save the life of the mother has changed the treatment approach for PPROM and fatal fetal abnormalities. In the first case, she said, doctors are now taking additional steps to work with maternal fetal medicine specialists to confirm the diagnosis and risk to the mother’s life, and may also contact with legal support teams before moving forward.

For example, she said, there are cases where the membranes rupture long before a fetus can survive outside the uterus, the fetus is expelled halfway through, but there is still a fetal heartbeat. “That puts us in a difficult position. It can cause a conflict with the standard of care in some cases,” she said. Before Dobbs, doctors could provide medications to completely expel the fetus and thus reduce the risk of infection and bleeding. But if there is still a heartbeat now, Spies said, it could disrupt the speed at which doctors can intervene.

And if there are abnormalities that ensure that the fetus will not survive outside the womb, doctors can now no longer offer an abortion, even if the pregnancy carries serious health consequences, as long as it does not endanger the mother’s life is being brought. “It can cause damage to the uterus,” she said. “If there is heart disease or kidney disease in the mother, something that is likely to worsen, it is not covered by the law.”

Similarly, Abigail Cutler, a gynecologist at UW Health University Hospital in Wisconsin, told STAT that she experienced a shift in addressing early pregnancy issues immediately after Dobbs, before a Wisconsin judge last year invalidated a pre-Civil War law who had banned pregnancies. abortion. Treatment of patients with intrauterine nonviable pregnancies became more conservative, she said, because in the early days she said she knew some providers who were unsure if they could perform the standard of care, which was to provide medication or surgery to terminate the non-viable pregnancy for an ectopic pregnancy. pregnancy and PPROM.

She also felt pressure to wait for miscarriages to develop past the point of early bleeding and surges in hormone levels to be absolutely certain the fetus was not viable, while before Dobbs she presented patients with a range of treatment options, including medications to hasten the fetus. the miscarriage process.

“When we had the threat of a criminal abortion ban, there were moments of pause when we had to make sure we were obeying the law, which sometimes meant we couldn’t put patient preferences first,” Cutler said.

However, the doctors who spoke about their experiences were a strong minority, with many expressing frustration at the difficulties colleagues in other institutions face when talking about their work. “People want to say something, but a lot of people are afraid for their jobs,” said Melissa Russo, a maternal-fetal medicine specialist at Women & Infants Hospital of Rhode Island. “They can get into trouble just by talking to a reporter.”

Some are personally reluctant to speak publicly, doctors said, for fear of both personal attacks and legal repercussions. Even when doctors communicate with each other, Cutler says — for example, when people in states with abortion bans try to find care for patients elsewhere — they are often extremely conservative, choosing phone calls over writing. “Messages and requests for help can be quite cryptic. They will say, ‘This ectopic pregnancy is a threat to the mother’s health’ – which is clear to us,” she said. “There is a lot of uncertainty about what is and is not allowed. Doctors don’t want to go to prison, we want to take care of people.”

And when doctors feel comfortable talking, they are often discouraged from doing so, several doctors say. Hospitals also fear political and legal scrutiny, plus possible backlash from donors linked to abortion. “I know many physicians who provide abortion care in hospital systems that are silencing them because they don’t want to broadcast that they provide abortion care for fear of losing funding while local political figures retaliate,” said Chelsea Daniels, a hospital physician. Planned Parenthood clinic based in Miami, who said these doctors fear losing their jobs if they speak openly.

Similarly, Damla Karsan, a Houston-based gynecologist who last year sought and received legal permission to perform an abortion for her patient Kate Cox, because the pregnancy threatened her fertility and health, said she could only open up so much are about her abortion. her patient’s experience because she is employed by a clinic, Comprehensive Women’s Healthcare, rather than a hospital.

She also knew colleagues who were “muzzled” by the fear of losing their jobs, she said, and worried that the conversation about abortion and the way Dobbs had influenced health care had been muted. “That’s been one of my frustrations, that there hasn’t been more of a groundswell [of physicians speaking out].”

Ultimately, restrictions on talking about Dobbs’ impact have hurt patients, Gariepy says, especially marginalized populations like teenagers and those who don’t speak English as a first language, who already struggle to access accurate information about abortion-related health care.

Even in New York, she says, her work is not as publicized as the care of her colleagues in other disciplines. “You’ll see billboards about how we’re number one in orthopedic care. Here’s a heartwarming story of a baby who had a heart transplant and is now an Olympian,” she said. “There are no billboards about how we could provide abortion care for PPROM after 19 weeks and now the mother has healthy children.”

This story is part of the ongoing reproductive healthcare coverage supported by a grant from the Commonwealth Fund.