Obstetrics

Medical management of early pregnancy loss costs less and offers similar quality of life to uterine aspiration, based on data from an analytical model.

Early pregnancy loss (EPL) occurs in more than 1 million women in the United States each year, and many patients are diagnosed before they show symptoms, wrote Divyah Nagendra, MD, of Cambridge Health Alliance, Mass., and colleagues.

A 2018 study showed that medical management of EPL with mifepristone added to misoprostol increased effectiveness and reduced the need for additional medication or subsequent uterine procedures, but the cost of mifepristone is perceived as a barrier, and the cost-effectiveness of its use, compared with surgical or expectant management, has not been well studied, the researchers noted.

“We already know that adding mifepristone to the medical management of early pregnancy loss increases the effectiveness of the regimen,” coauthor Courtney A. Schreiber, MD, of the University of Pennsylvania, Philadelphia, said in an interview. “Procedural uterine aspiration is highly effective as well, so patients and providers may consider the cost when deciding on a treatment strategy,” she added.

“If medication management is preferred by many patients, decreases the need to access in-person clinical care during a pandemic, and is found to be cost-effective, clinicians and policymakers should increase efforts to improve mifepristone availability and reduce access burdens,” the researchers wrote.

In a study published in the American Journal of Obstetrics & Gynecology, the researchers created a decision-analytic model using data from published literature and the Pregnancy Failure Regiments Trial (PreFaiR) to compare office-based uterine aspiration to medical management with mifepristone pretreatment followed by misoprostol for EPL.

The PrFaiR study randomized 300 women who experienced EPL before 12 weeks’ gestation to medication management with 800 mcg misoprostol vaginally, with or without pretreatment of 200 mg mifeprestone orally. The average age of the participants was 30.7 years, and demographics were similar between the groups.

The researchers used the PrFaiR data for medical management and patient-level data from published literature for uterine aspiration.

The primary outcome was the cost per quality-adjusted life year (QALY) gained. QALY was based on a modified utility score from the published literature. Effectiveness was based on QALY gained and the rate of complete expulsion of the gestational sac without additional intervention.

Overall, the mean costs per person were significantly higher for uterine aspiration, compared with medical management ($828 vs. $661, P = .004). Uterine aspiration was significantly more effective for complete gestational sac expulsion (97.3% vs. 83.8%, P = .0001). However, the QALYs were significantly higher for medical management, compared with uterine aspiration (0.082 vs. 0.079, P < .0001).

Cost-effectiveness was greater for medical management from a health care sector perspective, with lower costs and higher QALYs than uterine aspiration, the researchers noted.

They also evaluated the effect of mifepristone pretreatment on cost-effectiveness and found that medical management would remain cost effective, compared with uterine aspiration even if uterine aspiration procedures decreased in cost and mifepristone increased in cost, and even if medication management had a decreased completion rate and utility score, compared with uterine aspiration.

“Our analysis demonstrates that the incremental cost-effectiveness ratio (ICER) for medical management is well below the maximum willingness-to-pay threshold of approximately $100,000 per QALY gained,” the researchers wrote in their discussion of the findings.
 

Potential savings, uncertain access

Despite the potential savings and patient benefits, access to mifepristone remains a barrier, the researchers said.

Although the FDA lifted some restrictions on mifepristone in 2021 in the wake of the ongoing COVID-19 pandemic, the effect of new abortion-related restrictions remains to be seen.

The study findings were limited by several factors, including the use of 2018 National Medicare reimbursement rates to calculate costs, though actual costs vary by region and payer, the researchers noted. Other limitations include variations in cost of mifepristone by region and time and the differences in data sources between the uterine aspiration and medical management groups. More research is needed to assess QALYs for early pregnancy loss to establish standard measures and to assess the societal perspective of ESL as well as the health care perspective, they added.

However, the current results support medical management of EPL with mifepristone pretreatment followed by misoprostol as a “high-value care alternative” to office-based uterine aspiration, they said. “Increasing access to mifepristone and eliminating unnecessary restrictions will improve early pregnancy care,” they concluded.

“Given how effective procedural management is, we were slightly surprised that medical management remains cost effective,” Dr. Schreiber said in an interview.

Looking ahead in the wake of new restrictions on use for abortion, “patients may have difficulty accessing either medical or procedural management for early pregnancy loss,” Dr. Schreiber noted. “We support the accessibility of all evidence-based care and hope that our data will help overcome perceived financial barriers,” she said. Additional research needs include improved implementation and access to evidence-based early pregnancy loss care, she added.
 

Reasons to lift regulations

“Given the recent overturning of Roe v. Wade, any medications that are associated with abortion have increased scrutiny, especially mifepristone and misoprostol, even though these medications are also used for managing early pregnancy loss,” Sarah W. Prager, MD, of the University of Washington, Seattle, said in an interview. “Demonstrating that medication management of EPL with mifepristone/misoprostol is less expensive and has increased QALYs associated with it is yet another reason to deregulate mifepristone so it can also be more accessible for management of EPL,” said Dr. Prager, who was not involved in the study.

Dr. Prager said she was not surprised by the findings, as effective medication should be less expensive than a procedure. “I would caution that the increased QALYs found in this study should not be interpreted as a reason to restrict surgical management of EPL but to increase access also to medication management, even though medication has a slightly lower rate of complete gestational sac expulsion,” she noted. “Mode of management should be up to the patient, unless there is a clear medical reason for one or the other.”

Going forward, “the FDA has it in its power to remove the REMS, which would immediately make mifepristone a medication that can be prescribed through a pharmacy and therefore much more available,” said Dr. Prager. “Restrictions for both medication and surgical management of EPL will likely increase in states where abortion is illegal, and it could possibly lead to patients having less choice as to mode of management,” she explained.

“There are many studies showing that all modes of EPL management are safe and effective and should be supported with respect to patient choice,” Dr. Prager noted. “There are also substantial data supporting the overall safety of mifepristone, and there are no scientific or medical data suggesting the REMS increases safety in any way. Frankly, there are no good, evidence-based reasons to continue to keep the REMS in place,” she said.

The study was supported by the National Institute of Child Health and Human Development of the National Institutes of Health and a Society of Family Planning Research Fund Midcareer Mentor Award. The researchers had no financial conflicts to disclose. Dr. Prager had no financial conflicts to disclose and serves on the Editorial Advisory Board of Ob.Gyn. News.

[email protected]

Medical management of early pregnancy loss costs less and offers similar quality of life to uterine aspiration, based on data from an analytical model.

Early pregnancy loss (EPL) occurs in more than 1 million women in the United States each year, and many patients are diagnosed before they show symptoms, wrote Divyah Nagendra, MD, of Cambridge Health Alliance, Mass., and colleagues.

A 2018 study showed that medical management of EPL with mifepristone added to misoprostol increased effectiveness and reduced the need for additional medication or subsequent uterine procedures, but the cost of mifepristone is perceived as a barrier, and the cost-effectiveness of its use, compared with surgical or expectant management, has not been well studied, the researchers noted.

“We already know that adding mifepristone to the medical management of early pregnancy loss increases the effectiveness of the regimen,” coauthor Courtney A. Schreiber, MD, of the University of Pennsylvania, Philadelphia, said in an interview. “Procedural uterine aspiration is highly effective as well, so patients and providers may consider the cost when deciding on a treatment strategy,” she added.

“If medication management is preferred by many patients, decreases the need to access in-person clinical care during a pandemic, and is found to be cost-effective, clinicians and policymakers should increase efforts to improve mifepristone availability and reduce access burdens,” the researchers wrote.

In a study published in the American Journal of Obstetrics & Gynecology, the researchers created a decision-analytic model using data from published literature and the Pregnancy Failure Regiments Trial (PreFaiR) to compare office-based uterine aspiration to medical management with mifepristone pretreatment followed by misoprostol for EPL.

The PrFaiR study randomized 300 women who experienced EPL before 12 weeks’ gestation to medication management with 800 mcg misoprostol vaginally, with or without pretreatment of 200 mg mifeprestone orally. The average age of the participants was 30.7 years, and demographics were similar between the groups.

The researchers used the PrFaiR data for medical management and patient-level data from published literature for uterine aspiration.

The primary outcome was the cost per quality-adjusted life year (QALY) gained. QALY was based on a modified utility score from the published literature. Effectiveness was based on QALY gained and the rate of complete expulsion of the gestational sac without additional intervention.

Overall, the mean costs per person were significantly higher for uterine aspiration, compared with medical management ($828 vs. $661, P = .004). Uterine aspiration was significantly more effective for complete gestational sac expulsion (97.3% vs. 83.8%, P = .0001). However, the QALYs were significantly higher for medical management, compared with uterine aspiration (0.082 vs. 0.079, P < .0001).

Cost-effectiveness was greater for medical management from a health care sector perspective, with lower costs and higher QALYs than uterine aspiration, the researchers noted.

They also evaluated the effect of mifepristone pretreatment on cost-effectiveness and found that medical management would remain cost effective, compared with uterine aspiration even if uterine aspiration procedures decreased in cost and mifepristone increased in cost, and even if medication management had a decreased completion rate and utility score, compared with uterine aspiration.

“Our analysis demonstrates that the incremental cost-effectiveness ratio (ICER) for medical management is well below the maximum willingness-to-pay threshold of approximately $100,000 per QALY gained,” the researchers wrote in their discussion of the findings.
 

Potential savings, uncertain access

Despite the potential savings and patient benefits, access to mifepristone remains a barrier, the researchers said.

Although the FDA lifted some restrictions on mifepristone in 2021 in the wake of the ongoing COVID-19 pandemic, the effect of new abortion-related restrictions remains to be seen.

The study findings were limited by several factors, including the use of 2018 National Medicare reimbursement rates to calculate costs, though actual costs vary by region and payer, the researchers noted. Other limitations include variations in cost of mifepristone by region and time and the differences in data sources between the uterine aspiration and medical management groups. More research is needed to assess QALYs for early pregnancy loss to establish standard measures and to assess the societal perspective of ESL as well as the health care perspective, they added.

However, the current results support medical management of EPL with mifepristone pretreatment followed by misoprostol as a “high-value care alternative” to office-based uterine aspiration, they said. “Increasing access to mifepristone and eliminating unnecessary restrictions will improve early pregnancy care,” they concluded.

“Given how effective procedural management is, we were slightly surprised that medical management remains cost effective,” Dr. Schreiber said in an interview.

Looking ahead in the wake of new restrictions on use for abortion, “patients may have difficulty accessing either medical or procedural management for early pregnancy loss,” Dr. Schreiber noted. “We support the accessibility of all evidence-based care and hope that our data will help overcome perceived financial barriers,” she said. Additional research needs include improved implementation and access to evidence-based early pregnancy loss care, she added.
 

Reasons to lift regulations

“Given the recent overturning of Roe v. Wade, any medications that are associated with abortion have increased scrutiny, especially mifepristone and misoprostol, even though these medications are also used for managing early pregnancy loss,” Sarah W. Prager, MD, of the University of Washington, Seattle, said in an interview. “Demonstrating that medication management of EPL with mifepristone/misoprostol is less expensive and has increased QALYs associated with it is yet another reason to deregulate mifepristone so it can also be more accessible for management of EPL,” said Dr. Prager, who was not involved in the study.

Dr. Prager said she was not surprised by the findings, as effective medication should be less expensive than a procedure. “I would caution that the increased QALYs found in this study should not be interpreted as a reason to restrict surgical management of EPL but to increase access also to medication management, even though medication has a slightly lower rate of complete gestational sac expulsion,” she noted. “Mode of management should be up to the patient, unless there is a clear medical reason for one or the other.”

Going forward, “the FDA has it in its power to remove the REMS, which would immediately make mifepristone a medication that can be prescribed through a pharmacy and therefore much more available,” said Dr. Prager. “Restrictions for both medication and surgical management of EPL will likely increase in states where abortion is illegal, and it could possibly lead to patients having less choice as to mode of management,” she explained.

“There are many studies showing that all modes of EPL management are safe and effective and should be supported with respect to patient choice,” Dr. Prager noted. “There are also substantial data supporting the overall safety of mifepristone, and there are no scientific or medical data suggesting the REMS increases safety in any way. Frankly, there are no good, evidence-based reasons to continue to keep the REMS in place,” she said.

The study was supported by the National Institute of Child Health and Human Development of the National Institutes of Health and a Society of Family Planning Research Fund Midcareer Mentor Award. The researchers had no financial conflicts to disclose. Dr. Prager had no financial conflicts to disclose and serves on the Editorial Advisory Board of Ob.Gyn. News.

[email protected]

Medical management of early pregnancy loss costs less and offers similar quality of life to uterine aspiration, based on data from an analytical model.

Early pregnancy loss (EPL) occurs in more than 1 million women in the United States each year, and many patients are diagnosed before they show symptoms, wrote Divyah Nagendra, MD, of Cambridge Health Alliance, Mass., and colleagues.

A 2018 study showed that medical management of EPL with mifepristone added to misoprostol increased effectiveness and reduced the need for additional medication or subsequent uterine procedures, but the cost of mifepristone is perceived as a barrier, and the cost-effectiveness of its use, compared with surgical or expectant management, has not been well studied, the researchers noted.

“We already know that adding mifepristone to the medical management of early pregnancy loss increases the effectiveness of the regimen,” coauthor Courtney A. Schreiber, MD, of the University of Pennsylvania, Philadelphia, said in an interview. “Procedural uterine aspiration is highly effective as well, so patients and providers may consider the cost when deciding on a treatment strategy,” she added.

“If medication management is preferred by many patients, decreases the need to access in-person clinical care during a pandemic, and is found to be cost-effective, clinicians and policymakers should increase efforts to improve mifepristone availability and reduce access burdens,” the researchers wrote.

In a study published in the American Journal of Obstetrics & Gynecology, the researchers created a decision-analytic model using data from published literature and the Pregnancy Failure Regiments Trial (PreFaiR) to compare office-based uterine aspiration to medical management with mifepristone pretreatment followed by misoprostol for EPL.

The PrFaiR study randomized 300 women who experienced EPL before 12 weeks’ gestation to medication management with 800 mcg misoprostol vaginally, with or without pretreatment of 200 mg mifeprestone orally. The average age of the participants was 30.7 years, and demographics were similar between the groups.

The researchers used the PrFaiR data for medical management and patient-level data from published literature for uterine aspiration.

The primary outcome was the cost per quality-adjusted life year (QALY) gained. QALY was based on a modified utility score from the published literature. Effectiveness was based on QALY gained and the rate of complete expulsion of the gestational sac without additional intervention.

Overall, the mean costs per person were significantly higher for uterine aspiration, compared with medical management ($828 vs. $661, P = .004). Uterine aspiration was significantly more effective for complete gestational sac expulsion (97.3% vs. 83.8%, P = .0001). However, the QALYs were significantly higher for medical management, compared with uterine aspiration (0.082 vs. 0.079, P < .0001).

Cost-effectiveness was greater for medical management from a health care sector perspective, with lower costs and higher QALYs than uterine aspiration, the researchers noted.

They also evaluated the effect of mifepristone pretreatment on cost-effectiveness and found that medical management would remain cost effective, compared with uterine aspiration even if uterine aspiration procedures decreased in cost and mifepristone increased in cost, and even if medication management had a decreased completion rate and utility score, compared with uterine aspiration.

“Our analysis demonstrates that the incremental cost-effectiveness ratio (ICER) for medical management is well below the maximum willingness-to-pay threshold of approximately $100,000 per QALY gained,” the researchers wrote in their discussion of the findings.
 

Potential savings, uncertain access

Despite the potential savings and patient benefits, access to mifepristone remains a barrier, the researchers said.

Although the FDA lifted some restrictions on mifepristone in 2021 in the wake of the ongoing COVID-19 pandemic, the effect of new abortion-related restrictions remains to be seen.

The study findings were limited by several factors, including the use of 2018 National Medicare reimbursement rates to calculate costs, though actual costs vary by region and payer, the researchers noted. Other limitations include variations in cost of mifepristone by region and time and the differences in data sources between the uterine aspiration and medical management groups. More research is needed to assess QALYs for early pregnancy loss to establish standard measures and to assess the societal perspective of ESL as well as the health care perspective, they added.

However, the current results support medical management of EPL with mifepristone pretreatment followed by misoprostol as a “high-value care alternative” to office-based uterine aspiration, they said. “Increasing access to mifepristone and eliminating unnecessary restrictions will improve early pregnancy care,” they concluded.

“Given how effective procedural management is, we were slightly surprised that medical management remains cost effective,” Dr. Schreiber said in an interview.

Looking ahead in the wake of new restrictions on use for abortion, “patients may have difficulty accessing either medical or procedural management for early pregnancy loss,” Dr. Schreiber noted. “We support the accessibility of all evidence-based care and hope that our data will help overcome perceived financial barriers,” she said. Additional research needs include improved implementation and access to evidence-based early pregnancy loss care, she added.
 

Reasons to lift regulations

“Given the recent overturning of Roe v. Wade, any medications that are associated with abortion have increased scrutiny, especially mifepristone and misoprostol, even though these medications are also used for managing early pregnancy loss,” Sarah W. Prager, MD, of the University of Washington, Seattle, said in an interview. “Demonstrating that medication management of EPL with mifepristone/misoprostol is less expensive and has increased QALYs associated with it is yet another reason to deregulate mifepristone so it can also be more accessible for management of EPL,” said Dr. Prager, who was not involved in the study.

Dr. Prager said she was not surprised by the findings, as effective medication should be less expensive than a procedure. “I would caution that the increased QALYs found in this study should not be interpreted as a reason to restrict surgical management of EPL but to increase access also to medication management, even though medication has a slightly lower rate of complete gestational sac expulsion,” she noted. “Mode of management should be up to the patient, unless there is a clear medical reason for one or the other.”

Going forward, “the FDA has it in its power to remove the REMS, which would immediately make mifepristone a medication that can be prescribed through a pharmacy and therefore much more available,” said Dr. Prager. “Restrictions for both medication and surgical management of EPL will likely increase in states where abortion is illegal, and it could possibly lead to patients having less choice as to mode of management,” she explained.

“There are many studies showing that all modes of EPL management are safe and effective and should be supported with respect to patient choice,” Dr. Prager noted. “There are also substantial data supporting the overall safety of mifepristone, and there are no scientific or medical data suggesting the REMS increases safety in any way. Frankly, there are no good, evidence-based reasons to continue to keep the REMS in place,” she said.

The study was supported by the National Institute of Child Health and Human Development of the National Institutes of Health and a Society of Family Planning Research Fund Midcareer Mentor Award. The researchers had no financial conflicts to disclose. Dr. Prager had no financial conflicts to disclose and serves on the Editorial Advisory Board of Ob.Gyn. News.

[email protected]

My first thought when I heard the Supreme Court’s ruling on Roe v. Wade was of a patient of mine who I had been privileged to meet earlier in my residency. She was a child when she became pregnant after a nonconsensual encounter with a much older man.

I remember how small and shy she looked, curled into herself in her too-large hospital gown. I remember thinking that it was autumn, and she should have been at her first homecoming dance, not sitting in the ER staring mutely at the hospital-issued safety socks on her feet. Her mother, puffy-eyed from crying, was sitting on the bed beside her, stroking her hair.

Together, my patients and I talked about the pregnancy. She told me how scared she was, how she didn’t want to “kill her baby”, but that she also wasn’t sure she could take care of a child. She told me that she was terrified of childbirth, that she didn’t want her friends at school to know and to judge her. We talked about how she was a victim; how she was an innocent child, too. I reassured her, and her mom emphatically agreed – her body was still her own.

The man who hurt her did not take that from her. She could make any choice she wanted, and it would be the right choice.

Eventually, she was able to make a decision which was best for her. I don’t know what became of her, but I hope she is well now, and I hope she’s thriving and happy. I also hope that she doesn’t see the news about Roe v. Wade and feel stripped of her personhood, as many women did.

When I heard about the Supreme Court decision I thought of her, and how important our conversation was to the trajectory of her life. I wondered if across the country these conversations might be silenced, and patients might be left to navigate this important facet of their health alone.

Some version of the conversation I had with my young patient occurs in exam rooms across the country countless times a day. Sometimes these conversations are cut and dry. Other times, they are accompanied by heartbreak and tears.

These conversations are common – one in four women in the United States have had an abortion. I have had many friends who were faced with deciding what to do after an unexpectedly positive pregnancy test. The reasons were different for each person – one was raped at a party, another’s birth control failed, the boyfriend of a third friend wouldn’t wear a condom – but the underlying sentiments were the same for each woman. They thought: “This is a difficult choice, but it’s a choice I’m ready to make. I’m not ready to have a baby at this point in my life.”

My friends talked to their doctors, who assisted them in making an informed choice. Some of them chose abortion. Others chose to deliver their baby. All were helped along in their decision by a physician who was there to support them and assist them in making a well-considered choice for their individual circumstance.
 

Economic and health consequences of restricting access to abortion

The facts are clear: Nearly half of all pregnancies in American women in 2011 were unplanned, and about 4 in 10 of them ended in an elective abortion, according to the Guttmacher Institute.¹ Restricting access to abortions does not stop abortions from happening; it limits the opportunity for women to seek advice from trusted friends and professionals and it reduces access to safe abortions.

The people who will be most harmed by these restrictions are the most socially and economically vulnerable. Wealthy, mobile women with the ability to travel to other states or countries will always be able to access abortion care; low-income, work-tethered women and women with other children to care for at home will struggle to do so.

Denying women abortion services puts them at increased risk for lifelong, multigenerational economic hardship. Women who sought abortions but were unable to obtain them experienced an increase in household poverty which lasted years relative to women who were able to receive an abortion, according to the authors of The Turnaway Study.² They were less socially, geographically, and economically mobile, and were less likely to go on to receive a higher education.

In a country where citizens do not have paid maternity leave, affordable and accessible childcare services, or universal health care, raising a child is an enormous financial burden. Women who are denied abortions also are much more likely to end up as a single parent, shouldering that burden alone.

Additionally, low socioeconomic status is associated with increased all-cause mortality. People who live in poverty are disproportionately affected by diabetes and other chronic health conditions, and have lower life expectancies overall.

The reversal of Roe v. Wade is not only going to lead directly to patient death by decreasing access to safe abortion, causing women to pursue unsafe alternatives; it will also indirectly result in more women being driven into and remaining in poverty and suffering the health consequences.

In addition to risking a woman’s life medically, pregnancy also significantly increases that individual’s risk of being a victim of intimate partner violence. The number one cause of death in pregnant women is homicide, most often by their sexual partner, said an article published in Nature in 2021.³ Therefore, restricting a woman’s ability to control if and when she has children could put her at risk for death from serious pregnancy-related complications and unsafe abortion consequences and increase her likelihood of dying by domestic violence.
 

Patient-physicians interactions are changed

As a physician I hope that I am able to convey my intense respect for and support of a woman’s autonomy into every family planning visit I conduct. Unfortunately, this ruling will not only have an immediate impact on the lives of women across the country – it will also alter the way many of us interact with our patients on a day-to-day basis. When patients can report doctors to authorities in some states for offering terminations, and doctors can report patients for seeking them, there will be absolutely no trust in the therapeutic relationship.

With this ruling, the content of private and protected conversations between patients and their physicians will be subject to censure and potentially criminal consequences.

Regardless of where I eventually practice medicine, I should not be in the position of talking to a patient and telling them that they do not have any agency over their body unless they have the money and resources to travel to a state where abortion is legal. I should not have to tell a child that she must carry and birth another child just to appease the often-fickle whims of lawmakers.

The conversation I had with my pediatric patient was important to her health and to her future, and she deserved to have the chance to discuss her feelings with a trusted physician. Every woman has the right to make her own decisions within the sanctity of the exam room, not from the distance of a courtroom.

Dr. Persampiere is a resident in the family medicine residency program at Abington (Pa.) Jefferson Health. You can contact her directly at [email protected] or via [email protected].

References

1. Unintended pregnancy in the United States. Guttmacher Institute. 2019 Jan 9. https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states

2. Foster D et al. The harms of denying a woman a wanted abortion - ANSIRH. https://www.ansirh.org/sites/default/files/publications/files/the_harms_of_denying_a_woman_a_wanted_abortion_4-16-2020.pdf

3. Subbaraman N. 2021 Nov 12. Homicide is a top cause of maternal death in the United States. Nature News. https://www.nature.com/articles/d41586-021-03392-8

My first thought when I heard the Supreme Court’s ruling on Roe v. Wade was of a patient of mine who I had been privileged to meet earlier in my residency. She was a child when she became pregnant after a nonconsensual encounter with a much older man.

I remember how small and shy she looked, curled into herself in her too-large hospital gown. I remember thinking that it was autumn, and she should have been at her first homecoming dance, not sitting in the ER staring mutely at the hospital-issued safety socks on her feet. Her mother, puffy-eyed from crying, was sitting on the bed beside her, stroking her hair.

Together, my patients and I talked about the pregnancy. She told me how scared she was, how she didn’t want to “kill her baby”, but that she also wasn’t sure she could take care of a child. She told me that she was terrified of childbirth, that she didn’t want her friends at school to know and to judge her. We talked about how she was a victim; how she was an innocent child, too. I reassured her, and her mom emphatically agreed – her body was still her own.

The man who hurt her did not take that from her. She could make any choice she wanted, and it would be the right choice.

Eventually, she was able to make a decision which was best for her. I don’t know what became of her, but I hope she is well now, and I hope she’s thriving and happy. I also hope that she doesn’t see the news about Roe v. Wade and feel stripped of her personhood, as many women did.

When I heard about the Supreme Court decision I thought of her, and how important our conversation was to the trajectory of her life. I wondered if across the country these conversations might be silenced, and patients might be left to navigate this important facet of their health alone.

Some version of the conversation I had with my young patient occurs in exam rooms across the country countless times a day. Sometimes these conversations are cut and dry. Other times, they are accompanied by heartbreak and tears.

These conversations are common – one in four women in the United States have had an abortion. I have had many friends who were faced with deciding what to do after an unexpectedly positive pregnancy test. The reasons were different for each person – one was raped at a party, another’s birth control failed, the boyfriend of a third friend wouldn’t wear a condom – but the underlying sentiments were the same for each woman. They thought: “This is a difficult choice, but it’s a choice I’m ready to make. I’m not ready to have a baby at this point in my life.”

My friends talked to their doctors, who assisted them in making an informed choice. Some of them chose abortion. Others chose to deliver their baby. All were helped along in their decision by a physician who was there to support them and assist them in making a well-considered choice for their individual circumstance.
 

Economic and health consequences of restricting access to abortion

The facts are clear: Nearly half of all pregnancies in American women in 2011 were unplanned, and about 4 in 10 of them ended in an elective abortion, according to the Guttmacher Institute.¹ Restricting access to abortions does not stop abortions from happening; it limits the opportunity for women to seek advice from trusted friends and professionals and it reduces access to safe abortions.

The people who will be most harmed by these restrictions are the most socially and economically vulnerable. Wealthy, mobile women with the ability to travel to other states or countries will always be able to access abortion care; low-income, work-tethered women and women with other children to care for at home will struggle to do so.

Denying women abortion services puts them at increased risk for lifelong, multigenerational economic hardship. Women who sought abortions but were unable to obtain them experienced an increase in household poverty which lasted years relative to women who were able to receive an abortion, according to the authors of The Turnaway Study.² They were less socially, geographically, and economically mobile, and were less likely to go on to receive a higher education.

In a country where citizens do not have paid maternity leave, affordable and accessible childcare services, or universal health care, raising a child is an enormous financial burden. Women who are denied abortions also are much more likely to end up as a single parent, shouldering that burden alone.

Additionally, low socioeconomic status is associated with increased all-cause mortality. People who live in poverty are disproportionately affected by diabetes and other chronic health conditions, and have lower life expectancies overall.

The reversal of Roe v. Wade is not only going to lead directly to patient death by decreasing access to safe abortion, causing women to pursue unsafe alternatives; it will also indirectly result in more women being driven into and remaining in poverty and suffering the health consequences.

In addition to risking a woman’s life medically, pregnancy also significantly increases that individual’s risk of being a victim of intimate partner violence. The number one cause of death in pregnant women is homicide, most often by their sexual partner, said an article published in Nature in 2021.³ Therefore, restricting a woman’s ability to control if and when she has children could put her at risk for death from serious pregnancy-related complications and unsafe abortion consequences and increase her likelihood of dying by domestic violence.
 

Patient-physicians interactions are changed

As a physician I hope that I am able to convey my intense respect for and support of a woman’s autonomy into every family planning visit I conduct. Unfortunately, this ruling will not only have an immediate impact on the lives of women across the country – it will also alter the way many of us interact with our patients on a day-to-day basis. When patients can report doctors to authorities in some states for offering terminations, and doctors can report patients for seeking them, there will be absolutely no trust in the therapeutic relationship.

With this ruling, the content of private and protected conversations between patients and their physicians will be subject to censure and potentially criminal consequences.

Regardless of where I eventually practice medicine, I should not be in the position of talking to a patient and telling them that they do not have any agency over their body unless they have the money and resources to travel to a state where abortion is legal. I should not have to tell a child that she must carry and birth another child just to appease the often-fickle whims of lawmakers.

The conversation I had with my pediatric patient was important to her health and to her future, and she deserved to have the chance to discuss her feelings with a trusted physician. Every woman has the right to make her own decisions within the sanctity of the exam room, not from the distance of a courtroom.

Dr. Persampiere is a resident in the family medicine residency program at Abington (Pa.) Jefferson Health. You can contact her directly at [email protected] or via [email protected].

References

1. Unintended pregnancy in the United States. Guttmacher Institute. 2019 Jan 9. https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states

2. Foster D et al. The harms of denying a woman a wanted abortion - ANSIRH. https://www.ansirh.org/sites/default/files/publications/files/the_harms_of_denying_a_woman_a_wanted_abortion_4-16-2020.pdf

3. Subbaraman N. 2021 Nov 12. Homicide is a top cause of maternal death in the United States. Nature News. https://www.nature.com/articles/d41586-021-03392-8

My first thought when I heard the Supreme Court’s ruling on Roe v. Wade was of a patient of mine who I had been privileged to meet earlier in my residency. She was a child when she became pregnant after a nonconsensual encounter with a much older man.

I remember how small and shy she looked, curled into herself in her too-large hospital gown. I remember thinking that it was autumn, and she should have been at her first homecoming dance, not sitting in the ER staring mutely at the hospital-issued safety socks on her feet. Her mother, puffy-eyed from crying, was sitting on the bed beside her, stroking her hair.

Together, my patients and I talked about the pregnancy. She told me how scared she was, how she didn’t want to “kill her baby”, but that she also wasn’t sure she could take care of a child. She told me that she was terrified of childbirth, that she didn’t want her friends at school to know and to judge her. We talked about how she was a victim; how she was an innocent child, too. I reassured her, and her mom emphatically agreed – her body was still her own.

The man who hurt her did not take that from her. She could make any choice she wanted, and it would be the right choice.

Eventually, she was able to make a decision which was best for her. I don’t know what became of her, but I hope she is well now, and I hope she’s thriving and happy. I also hope that she doesn’t see the news about Roe v. Wade and feel stripped of her personhood, as many women did.

When I heard about the Supreme Court decision I thought of her, and how important our conversation was to the trajectory of her life. I wondered if across the country these conversations might be silenced, and patients might be left to navigate this important facet of their health alone.

Some version of the conversation I had with my young patient occurs in exam rooms across the country countless times a day. Sometimes these conversations are cut and dry. Other times, they are accompanied by heartbreak and tears.

These conversations are common – one in four women in the United States have had an abortion. I have had many friends who were faced with deciding what to do after an unexpectedly positive pregnancy test. The reasons were different for each person – one was raped at a party, another’s birth control failed, the boyfriend of a third friend wouldn’t wear a condom – but the underlying sentiments were the same for each woman. They thought: “This is a difficult choice, but it’s a choice I’m ready to make. I’m not ready to have a baby at this point in my life.”

My friends talked to their doctors, who assisted them in making an informed choice. Some of them chose abortion. Others chose to deliver their baby. All were helped along in their decision by a physician who was there to support them and assist them in making a well-considered choice for their individual circumstance.
 

Economic and health consequences of restricting access to abortion

The facts are clear: Nearly half of all pregnancies in American women in 2011 were unplanned, and about 4 in 10 of them ended in an elective abortion, according to the Guttmacher Institute.¹ Restricting access to abortions does not stop abortions from happening; it limits the opportunity for women to seek advice from trusted friends and professionals and it reduces access to safe abortions.

The people who will be most harmed by these restrictions are the most socially and economically vulnerable. Wealthy, mobile women with the ability to travel to other states or countries will always be able to access abortion care; low-income, work-tethered women and women with other children to care for at home will struggle to do so.

Denying women abortion services puts them at increased risk for lifelong, multigenerational economic hardship. Women who sought abortions but were unable to obtain them experienced an increase in household poverty which lasted years relative to women who were able to receive an abortion, according to the authors of The Turnaway Study.² They were less socially, geographically, and economically mobile, and were less likely to go on to receive a higher education.

In a country where citizens do not have paid maternity leave, affordable and accessible childcare services, or universal health care, raising a child is an enormous financial burden. Women who are denied abortions also are much more likely to end up as a single parent, shouldering that burden alone.

Additionally, low socioeconomic status is associated with increased all-cause mortality. People who live in poverty are disproportionately affected by diabetes and other chronic health conditions, and have lower life expectancies overall.

The reversal of Roe v. Wade is not only going to lead directly to patient death by decreasing access to safe abortion, causing women to pursue unsafe alternatives; it will also indirectly result in more women being driven into and remaining in poverty and suffering the health consequences.

In addition to risking a woman’s life medically, pregnancy also significantly increases that individual’s risk of being a victim of intimate partner violence. The number one cause of death in pregnant women is homicide, most often by their sexual partner, said an article published in Nature in 2021.³ Therefore, restricting a woman’s ability to control if and when she has children could put her at risk for death from serious pregnancy-related complications and unsafe abortion consequences and increase her likelihood of dying by domestic violence.
 

Patient-physicians interactions are changed

As a physician I hope that I am able to convey my intense respect for and support of a woman’s autonomy into every family planning visit I conduct. Unfortunately, this ruling will not only have an immediate impact on the lives of women across the country – it will also alter the way many of us interact with our patients on a day-to-day basis. When patients can report doctors to authorities in some states for offering terminations, and doctors can report patients for seeking them, there will be absolutely no trust in the therapeutic relationship.

With this ruling, the content of private and protected conversations between patients and their physicians will be subject to censure and potentially criminal consequences.

Regardless of where I eventually practice medicine, I should not be in the position of talking to a patient and telling them that they do not have any agency over their body unless they have the money and resources to travel to a state where abortion is legal. I should not have to tell a child that she must carry and birth another child just to appease the often-fickle whims of lawmakers.

The conversation I had with my pediatric patient was important to her health and to her future, and she deserved to have the chance to discuss her feelings with a trusted physician. Every woman has the right to make her own decisions within the sanctity of the exam room, not from the distance of a courtroom.

Dr. Persampiere is a resident in the family medicine residency program at Abington (Pa.) Jefferson Health. You can contact her directly at [email protected] or via [email protected].

References

1. Unintended pregnancy in the United States. Guttmacher Institute. 2019 Jan 9. https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states

2. Foster D et al. The harms of denying a woman a wanted abortion - ANSIRH. https://www.ansirh.org/sites/default/files/publications/files/the_harms_of_denying_a_woman_a_wanted_abortion_4-16-2020.pdf

3. Subbaraman N. 2021 Nov 12. Homicide is a top cause of maternal death in the United States. Nature News. https://www.nature.com/articles/d41586-021-03392-8

Pregnant women with polycystic ovary syndrome (PCOS) appear to be at significantly increased risk of experiencing cardiac complications while hospitalized during and after delivery.

An estimated 5 million women of childbearing age in the United States have PCOS, a hormone disorder linked to infertility. PCOS is also known to contribute to the development of cardiometabolic abnormalities like high cholesterol and high blood pressure, which are associated with acute cardiovascular complications during delivery.

But a study, published online  in the Journal of the American Heart Association, found that even after accounting for pre-eclampsia, age, comorbidities, and race, PCOS was linked to a 76% increased risk for heart failure, a 79% higher risk of a weakened heart, and an 82% increased risk of having blood clots in the hours and days around giving birth in hospital settings, compared with women without PCOS.

“Perhaps women need a closer follow-up during their pregnancy,” said Erin Michos, MD, MHS, associate director of preventive cardiology at Johns Hopkins Medicine, Baltimore, and a co-author of the study. “They’re counseled about the difficulties of getting pregnant, but what about when they get pregnant?”

Hospitalizations of women with PCOS were also associated with longer stays (3 vs. 2 days) and higher costs ($4,901 vs. $3616; P < .01), compared with women without PCOS.

Over the 17-year analysis period, the number of women with PCOS rose from 569 per 100,000 deliveries to 15,349 per 100,000 deliveries. The researchers attributed the increase in part to greater awareness and diagnosis of the disorder. Dr. Michos and her colleagues used the National Inpatient Sample, managed by the Agency for Healthcare Research and Quality, to pull claims data for women who gave birth in hospitals between 2002 and 2019.
 

Solutions?

Dr. Michos said there may be more prevention work from og.gyns. to both educate patients about their heart risks during the delivery process and also to refer them to relevant cardiac specialists.

“These women may seek out a gynecologist because of the symptoms, perhaps irregular menses, but along with that should come counseling of the long-term cardiovascular complication,” Dr. Michos said. “And after a pregnancy there should be a good handoff to a primary care provider, so they get a cardiovascular assessment.”

Lifestyle management before, during, and after pregnancy can help prevent the onset of the long-term consequences of cardiac complications during delivery, according to Valerie Baker, MD, director of the division of reproductive endocrinology and infertility at Hopkins Medicine, and her colleagues in a viewpoint published in the journal Fertility and Sterility.

“Once women with PCOS are identified by screening to be at higher risk for [cardiovascular disease], the foundational approach should be lifestyle management followed by statin therapy,” Dr. Baker’s group wrote. “These interventions should include dietary management and physical activity, especially for those who are prediabetic.”

The current study came on the heels of a June 14 meta-analysis by Dr. Michos’ group that found that women with PCOS may be twice as likely as those without PCOS to have coronary artery calcification, a precursor to atherosclerosis and a sign of the early onset of cardiovascular disease.

“We shouldn’t assume that all women of reproductive age are low risk,” Dr. Michos said. “This is the window of time that we can reshape the trajectory early in life.”

The study was supported by the Amato Fund for Women’s Cardiovascular Health research at Johns Hopkins University and through grant support from the American Heart Association (940166). Dr. Michos reported advisory board participation for AstraZeneca, Amarin, Novartis, Novo Nordisk, Bayer, Boehringer Ingelheim, Esperion, and Pfizer. Study coauthor Michael Honigberg, MD, reported consulting fees from CRISPR Therapeutics, unrelated to the present work. The remaining authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Pregnant women with polycystic ovary syndrome (PCOS) appear to be at significantly increased risk of experiencing cardiac complications while hospitalized during and after delivery.

An estimated 5 million women of childbearing age in the United States have PCOS, a hormone disorder linked to infertility. PCOS is also known to contribute to the development of cardiometabolic abnormalities like high cholesterol and high blood pressure, which are associated with acute cardiovascular complications during delivery.

But a study, published online  in the Journal of the American Heart Association, found that even after accounting for pre-eclampsia, age, comorbidities, and race, PCOS was linked to a 76% increased risk for heart failure, a 79% higher risk of a weakened heart, and an 82% increased risk of having blood clots in the hours and days around giving birth in hospital settings, compared with women without PCOS.

“Perhaps women need a closer follow-up during their pregnancy,” said Erin Michos, MD, MHS, associate director of preventive cardiology at Johns Hopkins Medicine, Baltimore, and a co-author of the study. “They’re counseled about the difficulties of getting pregnant, but what about when they get pregnant?”

Hospitalizations of women with PCOS were also associated with longer stays (3 vs. 2 days) and higher costs ($4,901 vs. $3616; P < .01), compared with women without PCOS.

Over the 17-year analysis period, the number of women with PCOS rose from 569 per 100,000 deliveries to 15,349 per 100,000 deliveries. The researchers attributed the increase in part to greater awareness and diagnosis of the disorder. Dr. Michos and her colleagues used the National Inpatient Sample, managed by the Agency for Healthcare Research and Quality, to pull claims data for women who gave birth in hospitals between 2002 and 2019.
 

Solutions?

Dr. Michos said there may be more prevention work from og.gyns. to both educate patients about their heart risks during the delivery process and also to refer them to relevant cardiac specialists.

“These women may seek out a gynecologist because of the symptoms, perhaps irregular menses, but along with that should come counseling of the long-term cardiovascular complication,” Dr. Michos said. “And after a pregnancy there should be a good handoff to a primary care provider, so they get a cardiovascular assessment.”

Lifestyle management before, during, and after pregnancy can help prevent the onset of the long-term consequences of cardiac complications during delivery, according to Valerie Baker, MD, director of the division of reproductive endocrinology and infertility at Hopkins Medicine, and her colleagues in a viewpoint published in the journal Fertility and Sterility.

“Once women with PCOS are identified by screening to be at higher risk for [cardiovascular disease], the foundational approach should be lifestyle management followed by statin therapy,” Dr. Baker’s group wrote. “These interventions should include dietary management and physical activity, especially for those who are prediabetic.”

The current study came on the heels of a June 14 meta-analysis by Dr. Michos’ group that found that women with PCOS may be twice as likely as those without PCOS to have coronary artery calcification, a precursor to atherosclerosis and a sign of the early onset of cardiovascular disease.

“We shouldn’t assume that all women of reproductive age are low risk,” Dr. Michos said. “This is the window of time that we can reshape the trajectory early in life.”

The study was supported by the Amato Fund for Women’s Cardiovascular Health research at Johns Hopkins University and through grant support from the American Heart Association (940166). Dr. Michos reported advisory board participation for AstraZeneca, Amarin, Novartis, Novo Nordisk, Bayer, Boehringer Ingelheim, Esperion, and Pfizer. Study coauthor Michael Honigberg, MD, reported consulting fees from CRISPR Therapeutics, unrelated to the present work. The remaining authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Pregnant women with polycystic ovary syndrome (PCOS) appear to be at significantly increased risk of experiencing cardiac complications while hospitalized during and after delivery.

An estimated 5 million women of childbearing age in the United States have PCOS, a hormone disorder linked to infertility. PCOS is also known to contribute to the development of cardiometabolic abnormalities like high cholesterol and high blood pressure, which are associated with acute cardiovascular complications during delivery.

But a study, published online  in the Journal of the American Heart Association, found that even after accounting for pre-eclampsia, age, comorbidities, and race, PCOS was linked to a 76% increased risk for heart failure, a 79% higher risk of a weakened heart, and an 82% increased risk of having blood clots in the hours and days around giving birth in hospital settings, compared with women without PCOS.

“Perhaps women need a closer follow-up during their pregnancy,” said Erin Michos, MD, MHS, associate director of preventive cardiology at Johns Hopkins Medicine, Baltimore, and a co-author of the study. “They’re counseled about the difficulties of getting pregnant, but what about when they get pregnant?”

Hospitalizations of women with PCOS were also associated with longer stays (3 vs. 2 days) and higher costs ($4,901 vs. $3616; P < .01), compared with women without PCOS.

Over the 17-year analysis period, the number of women with PCOS rose from 569 per 100,000 deliveries to 15,349 per 100,000 deliveries. The researchers attributed the increase in part to greater awareness and diagnosis of the disorder. Dr. Michos and her colleagues used the National Inpatient Sample, managed by the Agency for Healthcare Research and Quality, to pull claims data for women who gave birth in hospitals between 2002 and 2019.
 

Solutions?

Dr. Michos said there may be more prevention work from og.gyns. to both educate patients about their heart risks during the delivery process and also to refer them to relevant cardiac specialists.

“These women may seek out a gynecologist because of the symptoms, perhaps irregular menses, but along with that should come counseling of the long-term cardiovascular complication,” Dr. Michos said. “And after a pregnancy there should be a good handoff to a primary care provider, so they get a cardiovascular assessment.”

Lifestyle management before, during, and after pregnancy can help prevent the onset of the long-term consequences of cardiac complications during delivery, according to Valerie Baker, MD, director of the division of reproductive endocrinology and infertility at Hopkins Medicine, and her colleagues in a viewpoint published in the journal Fertility and Sterility.

“Once women with PCOS are identified by screening to be at higher risk for [cardiovascular disease], the foundational approach should be lifestyle management followed by statin therapy,” Dr. Baker’s group wrote. “These interventions should include dietary management and physical activity, especially for those who are prediabetic.”

The current study came on the heels of a June 14 meta-analysis by Dr. Michos’ group that found that women with PCOS may be twice as likely as those without PCOS to have coronary artery calcification, a precursor to atherosclerosis and a sign of the early onset of cardiovascular disease.

“We shouldn’t assume that all women of reproductive age are low risk,” Dr. Michos said. “This is the window of time that we can reshape the trajectory early in life.”

The study was supported by the Amato Fund for Women’s Cardiovascular Health research at Johns Hopkins University and through grant support from the American Heart Association (940166). Dr. Michos reported advisory board participation for AstraZeneca, Amarin, Novartis, Novo Nordisk, Bayer, Boehringer Ingelheim, Esperion, and Pfizer. Study coauthor Michael Honigberg, MD, reported consulting fees from CRISPR Therapeutics, unrelated to the present work. The remaining authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Water immersion during labor and birth significantly reduced use of medications, maternal pain, and postpartum hemorrhage, compared with standard care with no water immersion, based on data from 36 studies including more than 150,000 women.

“Resting and laboring in water can reduce fear, anxiety, and pain perception; it helps optimize the physiology of childbirth through the release of endogenous endorphins and oxytocin,” and data from randomized, controlled trials have shown a reduced need for epidural analgesia with water immersion, Ethel Burns, PhD, of Oxford (England) Brookes University Faculty of Health and Life Sciences, and colleagues wrote.

Although previous studies have not shown an increased risk for adverse events for newborns following water birth, “There is a need to understand which clinical practices, when performed as part of water immersion care, result in the optimum outcomes for mother and newborn,” the researchers said.

In a systematic review and meta-analysis published in BMJ Open, the researchers identified studies published since 2000 that examined maternal or neonatal interventions and/or outcomes when birthing pools were used for labor and/or birth.

The primary objective was to compare intrapartum interventions and outcomes for water immersion during labor with standard care with no water immersion.

Water immersion generally involves the use of a birth pool for relaxation and pain relief in early labor, and some women proceed with immersion through the second stage of labor and delivery. Of the 36 included studies, 31 took place in a hospital setting, 4 in a midwife-led setting, and 1 in a mixed setting. Most of the studies (25) involved women who planned to have/had a water birth, and these studies included 151,742 women. Another seven studies including 1,901 women involved in water immersion for labor only, three studies including 3,688 women involved in water immersion during labor and water birth; the timing of water immersion was unclear in the remaining study of 215 women.

Overall, water immersion significantly reduced the use of epidurals (odds ratio, 0.17), injected opioids (OR, 0.22), and episiotomy (OR, 0.16). Maternal pain and postpartum hemorrhage also were significantly reduced with water immersion (OR, 0.24 and OR, 0.69, respectively).

Maternal satisfaction was significantly increased with water immersion, and the odds of an intact perineum increased as well (OR, 1.95 and OR, 1.48).

The overall odds of cord avulsion increased with water immersion (OR, 1.94), but the absolute risk was low, compared with births without water immersion (4.3 vs. 1.3 per 1,000). No significant differences in other identified neonatal outcomes were observed across the studies.

The study findings were limited by several factors including the inconsistency of reporting on birth setting, care practices, interventions, and outcomes, and the inclusion of only three outcomes for meta-regression analysis, the researchers noted. In addition, only four studies were conducted in midwifery-led settings.

“This is important because birth pool use is most prevalent in midwifery-led settings,” the researchers wrote.” Evidence-based practice of water immersion requires research that reflects the context of care provision.

“We suggest that studies incorporate the following fundamentals to advance the evidence: birth pool description, clearly described maternal and obstetric characteristics, the birth setting, the care model and use of standardized definitions.”

Despite the limitations and need for additional research, the data overall support the potential benefits from water immersion births for healthy women and newborns, the researchers concluded.

A Clinical Report issued by the American Academy of Pediatrics in January 2022 advised against water immersion during the second stage of labor and delivery. According to the report, the potential for neonatal infections from organisms such as Legionella and Pseudomonas species, is low, but does exist, and could result in serious complications.
 

Education is essential

Increasing numbers of women are seeking home births and water births, Marissa Platner, MD, a maternal-fetal medicine specialist at Emory University, Atlanta, said in an interview.

“Given the conflicting data and lack of data, it is important to be able to educate birthing mothers based on best available evidence,” said Dr. Platner, who was not involved in the study.

“I was not surprised by the findings, because the adverse outcomes that are of concern, such as neonatal sepsis, were not clearly addressed,” Dr. Platner said. Given that sepsis “is a rare outcome in the population of low-risk individuals, the study may not have been powered to assess for this. The findings of maternal pain and satisfaction being improved with water immersion are well known. ACOG [American College of Obstetricians and Gynecologists] has also stated that water immersion during the first stage of labor is safe and can help with pain control.” 

On a practical level, “I think clinicians can use this guidance to discuss the potential benefits of water immersion in the first stages of labor, but would caution women regarding the unknown but possible risks of the water birth, given these findings are less clear,” Dr. Platner said.

“I think the findings regarding maternal outcomes are valid and consistent with the AAP/ACOG recommendations in terms of improving maternal pain control; however, more research is needed to determine the safety of the second stage of labor occurring in the water, given the potential for neonatal infection and respiratory distress, which could not be adequately addressed in this study,” Dr. Platner emphasized.

The study was supported by Oxford Brookes University. The researchers had no financial conflicts to disclose. Dr. Platner had no financial conflicts to disclose.

Water immersion during labor and birth significantly reduced use of medications, maternal pain, and postpartum hemorrhage, compared with standard care with no water immersion, based on data from 36 studies including more than 150,000 women.

“Resting and laboring in water can reduce fear, anxiety, and pain perception; it helps optimize the physiology of childbirth through the release of endogenous endorphins and oxytocin,” and data from randomized, controlled trials have shown a reduced need for epidural analgesia with water immersion, Ethel Burns, PhD, of Oxford (England) Brookes University Faculty of Health and Life Sciences, and colleagues wrote.

Although previous studies have not shown an increased risk for adverse events for newborns following water birth, “There is a need to understand which clinical practices, when performed as part of water immersion care, result in the optimum outcomes for mother and newborn,” the researchers said.

In a systematic review and meta-analysis published in BMJ Open, the researchers identified studies published since 2000 that examined maternal or neonatal interventions and/or outcomes when birthing pools were used for labor and/or birth.

The primary objective was to compare intrapartum interventions and outcomes for water immersion during labor with standard care with no water immersion.

Water immersion generally involves the use of a birth pool for relaxation and pain relief in early labor, and some women proceed with immersion through the second stage of labor and delivery. Of the 36 included studies, 31 took place in a hospital setting, 4 in a midwife-led setting, and 1 in a mixed setting. Most of the studies (25) involved women who planned to have/had a water birth, and these studies included 151,742 women. Another seven studies including 1,901 women involved in water immersion for labor only, three studies including 3,688 women involved in water immersion during labor and water birth; the timing of water immersion was unclear in the remaining study of 215 women.

Overall, water immersion significantly reduced the use of epidurals (odds ratio, 0.17), injected opioids (OR, 0.22), and episiotomy (OR, 0.16). Maternal pain and postpartum hemorrhage also were significantly reduced with water immersion (OR, 0.24 and OR, 0.69, respectively).

Maternal satisfaction was significantly increased with water immersion, and the odds of an intact perineum increased as well (OR, 1.95 and OR, 1.48).

The overall odds of cord avulsion increased with water immersion (OR, 1.94), but the absolute risk was low, compared with births without water immersion (4.3 vs. 1.3 per 1,000). No significant differences in other identified neonatal outcomes were observed across the studies.

The study findings were limited by several factors including the inconsistency of reporting on birth setting, care practices, interventions, and outcomes, and the inclusion of only three outcomes for meta-regression analysis, the researchers noted. In addition, only four studies were conducted in midwifery-led settings.

“This is important because birth pool use is most prevalent in midwifery-led settings,” the researchers wrote.” Evidence-based practice of water immersion requires research that reflects the context of care provision.

“We suggest that studies incorporate the following fundamentals to advance the evidence: birth pool description, clearly described maternal and obstetric characteristics, the birth setting, the care model and use of standardized definitions.”

Despite the limitations and need for additional research, the data overall support the potential benefits from water immersion births for healthy women and newborns, the researchers concluded.

A Clinical Report issued by the American Academy of Pediatrics in January 2022 advised against water immersion during the second stage of labor and delivery. According to the report, the potential for neonatal infections from organisms such as Legionella and Pseudomonas species, is low, but does exist, and could result in serious complications.
 

Education is essential

Increasing numbers of women are seeking home births and water births, Marissa Platner, MD, a maternal-fetal medicine specialist at Emory University, Atlanta, said in an interview.

“Given the conflicting data and lack of data, it is important to be able to educate birthing mothers based on best available evidence,” said Dr. Platner, who was not involved in the study.

“I was not surprised by the findings, because the adverse outcomes that are of concern, such as neonatal sepsis, were not clearly addressed,” Dr. Platner said. Given that sepsis “is a rare outcome in the population of low-risk individuals, the study may not have been powered to assess for this. The findings of maternal pain and satisfaction being improved with water immersion are well known. ACOG [American College of Obstetricians and Gynecologists] has also stated that water immersion during the first stage of labor is safe and can help with pain control.” 

On a practical level, “I think clinicians can use this guidance to discuss the potential benefits of water immersion in the first stages of labor, but would caution women regarding the unknown but possible risks of the water birth, given these findings are less clear,” Dr. Platner said.

“I think the findings regarding maternal outcomes are valid and consistent with the AAP/ACOG recommendations in terms of improving maternal pain control; however, more research is needed to determine the safety of the second stage of labor occurring in the water, given the potential for neonatal infection and respiratory distress, which could not be adequately addressed in this study,” Dr. Platner emphasized.

The study was supported by Oxford Brookes University. The researchers had no financial conflicts to disclose. Dr. Platner had no financial conflicts to disclose.

Water immersion during labor and birth significantly reduced use of medications, maternal pain, and postpartum hemorrhage, compared with standard care with no water immersion, based on data from 36 studies including more than 150,000 women.

“Resting and laboring in water can reduce fear, anxiety, and pain perception; it helps optimize the physiology of childbirth through the release of endogenous endorphins and oxytocin,” and data from randomized, controlled trials have shown a reduced need for epidural analgesia with water immersion, Ethel Burns, PhD, of Oxford (England) Brookes University Faculty of Health and Life Sciences, and colleagues wrote.

Although previous studies have not shown an increased risk for adverse events for newborns following water birth, “There is a need to understand which clinical practices, when performed as part of water immersion care, result in the optimum outcomes for mother and newborn,” the researchers said.

In a systematic review and meta-analysis published in BMJ Open, the researchers identified studies published since 2000 that examined maternal or neonatal interventions and/or outcomes when birthing pools were used for labor and/or birth.

The primary objective was to compare intrapartum interventions and outcomes for water immersion during labor with standard care with no water immersion.

Water immersion generally involves the use of a birth pool for relaxation and pain relief in early labor, and some women proceed with immersion through the second stage of labor and delivery. Of the 36 included studies, 31 took place in a hospital setting, 4 in a midwife-led setting, and 1 in a mixed setting. Most of the studies (25) involved women who planned to have/had a water birth, and these studies included 151,742 women. Another seven studies including 1,901 women involved in water immersion for labor only, three studies including 3,688 women involved in water immersion during labor and water birth; the timing of water immersion was unclear in the remaining study of 215 women.

Overall, water immersion significantly reduced the use of epidurals (odds ratio, 0.17), injected opioids (OR, 0.22), and episiotomy (OR, 0.16). Maternal pain and postpartum hemorrhage also were significantly reduced with water immersion (OR, 0.24 and OR, 0.69, respectively).

Maternal satisfaction was significantly increased with water immersion, and the odds of an intact perineum increased as well (OR, 1.95 and OR, 1.48).

The overall odds of cord avulsion increased with water immersion (OR, 1.94), but the absolute risk was low, compared with births without water immersion (4.3 vs. 1.3 per 1,000). No significant differences in other identified neonatal outcomes were observed across the studies.

The study findings were limited by several factors including the inconsistency of reporting on birth setting, care practices, interventions, and outcomes, and the inclusion of only three outcomes for meta-regression analysis, the researchers noted. In addition, only four studies were conducted in midwifery-led settings.

“This is important because birth pool use is most prevalent in midwifery-led settings,” the researchers wrote.” Evidence-based practice of water immersion requires research that reflects the context of care provision.

“We suggest that studies incorporate the following fundamentals to advance the evidence: birth pool description, clearly described maternal and obstetric characteristics, the birth setting, the care model and use of standardized definitions.”

Despite the limitations and need for additional research, the data overall support the potential benefits from water immersion births for healthy women and newborns, the researchers concluded.

A Clinical Report issued by the American Academy of Pediatrics in January 2022 advised against water immersion during the second stage of labor and delivery. According to the report, the potential for neonatal infections from organisms such as Legionella and Pseudomonas species, is low, but does exist, and could result in serious complications.
 

Education is essential

Increasing numbers of women are seeking home births and water births, Marissa Platner, MD, a maternal-fetal medicine specialist at Emory University, Atlanta, said in an interview.

“Given the conflicting data and lack of data, it is important to be able to educate birthing mothers based on best available evidence,” said Dr. Platner, who was not involved in the study.

“I was not surprised by the findings, because the adverse outcomes that are of concern, such as neonatal sepsis, were not clearly addressed,” Dr. Platner said. Given that sepsis “is a rare outcome in the population of low-risk individuals, the study may not have been powered to assess for this. The findings of maternal pain and satisfaction being improved with water immersion are well known. ACOG [American College of Obstetricians and Gynecologists] has also stated that water immersion during the first stage of labor is safe and can help with pain control.” 

On a practical level, “I think clinicians can use this guidance to discuss the potential benefits of water immersion in the first stages of labor, but would caution women regarding the unknown but possible risks of the water birth, given these findings are less clear,” Dr. Platner said.

“I think the findings regarding maternal outcomes are valid and consistent with the AAP/ACOG recommendations in terms of improving maternal pain control; however, more research is needed to determine the safety of the second stage of labor occurring in the water, given the potential for neonatal infection and respiratory distress, which could not be adequately addressed in this study,” Dr. Platner emphasized.

The study was supported by Oxford Brookes University. The researchers had no financial conflicts to disclose. Dr. Platner had no financial conflicts to disclose.

Nevada is already seeing more out-of-state patients seeking an abortion, which state officials expected after the Supreme Court overturned Roe v. Wade.

Las Vegas has seen a 200% increase in patients traveling from Texas, compared with the same time last year, according to the Las Vegas Review-Journal.

Patients are also expected from Arizona, Idaho, Oklahoma, and Utah after the ruling. Abortion providers are preparing for a ripple effect as abortion bans begin across the country.

“We haven’t seen the peak yet,” Kristina Tocce, MD, medical director for Planned Parenthood of the Rocky Mountains and an obstetrician-gynecologist in Colorado, told the newspaper.

“I don’t think we’re going to see any decrease anytime in the near future,” she said.

Nevada made the right to abortion part of state law more than 3 decades ago, in 1990, which protects abortions up to 24 weeks. Colorado passed a similar law this year.

In June, before Roe was overturned, Dr. Tocce said the organization expected abortions to rise by 80% – or about 10,000 patients – in the Rocky Mountain region, which includes southern Nevada, Colorado, and New Mexico.

Even before the ruling took place, Planned Parenthood saw higher numbers of patients as abortion bans took effect in Texas and Oklahoma, she said. After the 6-week ban took place in Texas, about 45% of traveling patients went to Oklahoma. Now that a ban is in place in Oklahoma, patients are going elsewhere.

Las Vegas providers have asked patients why they decided to travel to southern Nevada for services rather than Colorado or New Mexico, which are closer to Texas, Dr. Tocce said. Patients cited several reasons, including direct flight paths, cheaper plane tickets, and the presence of family or friends who could support them.

“We’re going to see such a demand on abortion in any state that has secure access,” Dr. Tocce said. “Patients may be forced to travel further away.”

After Roe was overturned, Nevada Gov. Steve Sisolak held an emergency news conference to reaffirm the state’s commitment to protecting abortion rights. He also said he wasn’t sure about Nevada’s capacity to support out-of-state patients but providers were researching and preparing.

Two Planned Parenthood centers in southern Nevada are adding staff and increasing their hours, Dr. Tocce told the newspaper last month, though there weren’t immediate plans to increase the number of locations or add centers near state borders.

Last week, Governor Sisolak signed an executive order that stops Nevada agencies from helping other states investigate patients seeking an abortion in Nevada. The order also protects patients from extradition and health care providers from losing their license for providing abortion services.

As abortion bans continue to roll out across the U.S., patients will likely consider traveling to states that have certain protections and accessible appointments, Dr. Tocce said.

“We’re in such an ambiguous time right now, we just don’t know what each state is going to attempt to enact,” she said. “My head just swims with all of the possibilities. If that’s challenging for me, I can’t even imagine what it’s going to be like for a patient to navigate.”

A version of this article first appeared on WebMD.com.

Nevada is already seeing more out-of-state patients seeking an abortion, which state officials expected after the Supreme Court overturned Roe v. Wade.

Las Vegas has seen a 200% increase in patients traveling from Texas, compared with the same time last year, according to the Las Vegas Review-Journal.

Patients are also expected from Arizona, Idaho, Oklahoma, and Utah after the ruling. Abortion providers are preparing for a ripple effect as abortion bans begin across the country.

“We haven’t seen the peak yet,” Kristina Tocce, MD, medical director for Planned Parenthood of the Rocky Mountains and an obstetrician-gynecologist in Colorado, told the newspaper.

“I don’t think we’re going to see any decrease anytime in the near future,” she said.

Nevada made the right to abortion part of state law more than 3 decades ago, in 1990, which protects abortions up to 24 weeks. Colorado passed a similar law this year.

In June, before Roe was overturned, Dr. Tocce said the organization expected abortions to rise by 80% – or about 10,000 patients – in the Rocky Mountain region, which includes southern Nevada, Colorado, and New Mexico.

Even before the ruling took place, Planned Parenthood saw higher numbers of patients as abortion bans took effect in Texas and Oklahoma, she said. After the 6-week ban took place in Texas, about 45% of traveling patients went to Oklahoma. Now that a ban is in place in Oklahoma, patients are going elsewhere.

Las Vegas providers have asked patients why they decided to travel to southern Nevada for services rather than Colorado or New Mexico, which are closer to Texas, Dr. Tocce said. Patients cited several reasons, including direct flight paths, cheaper plane tickets, and the presence of family or friends who could support them.

“We’re going to see such a demand on abortion in any state that has secure access,” Dr. Tocce said. “Patients may be forced to travel further away.”

After Roe was overturned, Nevada Gov. Steve Sisolak held an emergency news conference to reaffirm the state’s commitment to protecting abortion rights. He also said he wasn’t sure about Nevada’s capacity to support out-of-state patients but providers were researching and preparing.

Two Planned Parenthood centers in southern Nevada are adding staff and increasing their hours, Dr. Tocce told the newspaper last month, though there weren’t immediate plans to increase the number of locations or add centers near state borders.

Last week, Governor Sisolak signed an executive order that stops Nevada agencies from helping other states investigate patients seeking an abortion in Nevada. The order also protects patients from extradition and health care providers from losing their license for providing abortion services.

As abortion bans continue to roll out across the U.S., patients will likely consider traveling to states that have certain protections and accessible appointments, Dr. Tocce said.

“We’re in such an ambiguous time right now, we just don’t know what each state is going to attempt to enact,” she said. “My head just swims with all of the possibilities. If that’s challenging for me, I can’t even imagine what it’s going to be like for a patient to navigate.”

A version of this article first appeared on WebMD.com.

Nevada is already seeing more out-of-state patients seeking an abortion, which state officials expected after the Supreme Court overturned Roe v. Wade.

Las Vegas has seen a 200% increase in patients traveling from Texas, compared with the same time last year, according to the Las Vegas Review-Journal.

Patients are also expected from Arizona, Idaho, Oklahoma, and Utah after the ruling. Abortion providers are preparing for a ripple effect as abortion bans begin across the country.

“We haven’t seen the peak yet,” Kristina Tocce, MD, medical director for Planned Parenthood of the Rocky Mountains and an obstetrician-gynecologist in Colorado, told the newspaper.

“I don’t think we’re going to see any decrease anytime in the near future,” she said.

Nevada made the right to abortion part of state law more than 3 decades ago, in 1990, which protects abortions up to 24 weeks. Colorado passed a similar law this year.

In June, before Roe was overturned, Dr. Tocce said the organization expected abortions to rise by 80% – or about 10,000 patients – in the Rocky Mountain region, which includes southern Nevada, Colorado, and New Mexico.

Even before the ruling took place, Planned Parenthood saw higher numbers of patients as abortion bans took effect in Texas and Oklahoma, she said. After the 6-week ban took place in Texas, about 45% of traveling patients went to Oklahoma. Now that a ban is in place in Oklahoma, patients are going elsewhere.

Las Vegas providers have asked patients why they decided to travel to southern Nevada for services rather than Colorado or New Mexico, which are closer to Texas, Dr. Tocce said. Patients cited several reasons, including direct flight paths, cheaper plane tickets, and the presence of family or friends who could support them.

“We’re going to see such a demand on abortion in any state that has secure access,” Dr. Tocce said. “Patients may be forced to travel further away.”

After Roe was overturned, Nevada Gov. Steve Sisolak held an emergency news conference to reaffirm the state’s commitment to protecting abortion rights. He also said he wasn’t sure about Nevada’s capacity to support out-of-state patients but providers were researching and preparing.

Two Planned Parenthood centers in southern Nevada are adding staff and increasing their hours, Dr. Tocce told the newspaper last month, though there weren’t immediate plans to increase the number of locations or add centers near state borders.

Last week, Governor Sisolak signed an executive order that stops Nevada agencies from helping other states investigate patients seeking an abortion in Nevada. The order also protects patients from extradition and health care providers from losing their license for providing abortion services.

As abortion bans continue to roll out across the U.S., patients will likely consider traveling to states that have certain protections and accessible appointments, Dr. Tocce said.

“We’re in such an ambiguous time right now, we just don’t know what each state is going to attempt to enact,” she said. “My head just swims with all of the possibilities. If that’s challenging for me, I can’t even imagine what it’s going to be like for a patient to navigate.”

A version of this article first appeared on WebMD.com.

In the wake of the Supreme Court’s June decision to repeal a federal right to abortion, many women will now be faced with the prospect of carrying an unwanted pregnancy to term.

One group of researchers has studied the fate of these women and their families for the last decade. Their findings show that women who were denied an abortion are worse off physically, mentally, and economically than those who underwent the procedure.

“There has been much hypothesizing about harms from abortion without considering what the consequences are when someone wants an abortion and can’t get one,” said Diana Greene Foster, PhD, professor of obstetrics and gynecology at University of California, San Francisco.

Dr. Foster leads the Turnaway Study, one of the first efforts to examine the physical and mental health effects of receiving or being denied abortions. The ongoing research also charts the economic and social outcomes of women and their families in either circumstance.

Dr. Foster and her colleagues have followed women through childbirth, examining their well-being through phone interviews months to years after the initial interviews.

The economic consequences of carrying an unwanted pregnancy are clear. Women who did not receive a wanted abortion were more likely to live under the poverty line and struggle to cover basic living expenses like food, housing, and transportation.

The physical toll is also significant.

A 2019 analysis from the Turnaway Study found that eight out of 1,132 participants died, two after delivery, during the five-year follow up period – a far greater proportion than what would be expected among women of reproductive age. The researchers also found that women who carry unwanted pregnancies have more comorbid conditions before and after delivery than other women.

Lauren J. Ralph, PhD, MPH, an epidemiologist and member of the Turnaway Study team, examined the physical well-being of women after delivering their unwanted pregnancies.

“They reported more chronic pain, more gestational hypertension, and were more likely to rate their health as fair or poor,” Dr. Ralph said. “Somewhat to our surprise, we also found that two women denied abortions died due to pregnancy-related causes. This is my biggest concern with the loss of abortion access, as all scientific evidence indicates we will see a rise in maternal deaths as a result.”

At least one preliminary study, released as a preprint and not yet peer reviewed, estimates that the number of women who will die each year from pregnancy complications will rise by 24%. For Black women, mortality could jump from 18% to 39% in every state, according to the researchers from the University of Colorado, Boulder.
 

State of denial

Regulations set in place at abortion clinics in each state individually determine who is able to obtain an abortion, dictated by a “gestational age limit” – how far along a woman is in her pregnancy from the end of her menstrual cycle. Some of the women from the Turnaway Study were unable to receive an abortion because of how far along they were. Others were granted the abortion because they were just under their state’s limit.

Before the latest Supreme Court ruling, this limit was 20 weeks in most states. Now, the cutoff can be as little as 6 weeks – before many women know they are pregnant – or zero weeks, under the most restrictive laws. 

Over 70% of women who are denied an abortion carry the pregnancy to term, according to Dr. Foster’s analysis. 

Interviews with nearly 1,000 women – in both the first and second trimester of pregnancy – in the Turnaway Study who sought abortions at 30 abortion clinics around the country revealed the main reasons for seeking the procedure were (a) not being able to afford a child; (b) the pregnancy coming at the wrong time in life; or (c) the partner involved not being suitable.

According to the U.S. Centers for Disease Control and Prevention, 59.7% of women seeking an abortion in the United States are already mothers. Having an unplanned child results in dramatically worse economic circumstances for their other children, who become nearly four times more likely to live below the poverty line than their peers. They also experience slower physical and mental development as a result of the arrival of the new sibling.

The latest efforts by states to ban abortion could make the situation much worse, said Liza Fuentes, DrPh, senior research scientist at the Guttmacher Institute. “We will need further research on what it means for women to be denied care in the context of the new restrictions,” Dr. Fuentes told this news organization. 

Researchers cannot yet predict how many women will be unable to obtain an abortion in the coming months. But John Donahue, PhD, JD, an economist and professor of law at Stanford (Calif.) University, estimated that state laws would prevent roughly one-third of the 1 million abortions per year based on 2021 figures.

Dr. Ralph and her colleagues with the Turnaway Study know that restricting access to abortions will not make the need for abortions disappear. Rather, women will be forced to travel, potentially long distances at significant cost, for the procedure or will seek medication abortion by mail through virtual clinics.

But Dr. Ralph said she’s concerned about women who live in areas where telehealth abortions are banned, or who discover their pregnancies late, as medical abortions are only recommended for women who are 10 weeks pregnant or less.

“They may look to self-source the medications online or elsewhere, potentially putting themself at legal risk,” she said. “And, as my research has shown, others may turn to self-managing an abortion with herbs, other drugs or medications, or physical methods like hitting themselves in the abdomen; with this they put themselves at both legal and potentially medical risk.”

Constance Bohon, MD, an ob.gyn. in Washington, D.C., said further research should track what happens to women if they’re forced to leave a job to care for another child.

“Many of these women live paycheck to paycheck and cannot afford the cost of an additional child,” Dr. Bohon said. “They may also need to rely on social service agencies to help them find food and housing.”

Dr. Fuentes said she hopes the Turnaway Study will inspire other researchers to examine laws that outlaw abortion and the corresponding long-term effects on women.

“From a medical and a public health standpoint, these laws are unjust,” Dr. Fuentes said in an interview. “They’re not grounded in evidence, and they incur great costs not just to pregnant people but their families and their communities as well.”

A version of this article first appeared on Medscape.com.

In the wake of the Supreme Court’s June decision to repeal a federal right to abortion, many women will now be faced with the prospect of carrying an unwanted pregnancy to term.

One group of researchers has studied the fate of these women and their families for the last decade. Their findings show that women who were denied an abortion are worse off physically, mentally, and economically than those who underwent the procedure.

“There has been much hypothesizing about harms from abortion without considering what the consequences are when someone wants an abortion and can’t get one,” said Diana Greene Foster, PhD, professor of obstetrics and gynecology at University of California, San Francisco.

Dr. Foster leads the Turnaway Study, one of the first efforts to examine the physical and mental health effects of receiving or being denied abortions. The ongoing research also charts the economic and social outcomes of women and their families in either circumstance.

Dr. Foster and her colleagues have followed women through childbirth, examining their well-being through phone interviews months to years after the initial interviews.

The economic consequences of carrying an unwanted pregnancy are clear. Women who did not receive a wanted abortion were more likely to live under the poverty line and struggle to cover basic living expenses like food, housing, and transportation.

The physical toll is also significant.

A 2019 analysis from the Turnaway Study found that eight out of 1,132 participants died, two after delivery, during the five-year follow up period – a far greater proportion than what would be expected among women of reproductive age. The researchers also found that women who carry unwanted pregnancies have more comorbid conditions before and after delivery than other women.

Lauren J. Ralph, PhD, MPH, an epidemiologist and member of the Turnaway Study team, examined the physical well-being of women after delivering their unwanted pregnancies.

“They reported more chronic pain, more gestational hypertension, and were more likely to rate their health as fair or poor,” Dr. Ralph said. “Somewhat to our surprise, we also found that two women denied abortions died due to pregnancy-related causes. This is my biggest concern with the loss of abortion access, as all scientific evidence indicates we will see a rise in maternal deaths as a result.”

At least one preliminary study, released as a preprint and not yet peer reviewed, estimates that the number of women who will die each year from pregnancy complications will rise by 24%. For Black women, mortality could jump from 18% to 39% in every state, according to the researchers from the University of Colorado, Boulder.
 

State of denial

Regulations set in place at abortion clinics in each state individually determine who is able to obtain an abortion, dictated by a “gestational age limit” – how far along a woman is in her pregnancy from the end of her menstrual cycle. Some of the women from the Turnaway Study were unable to receive an abortion because of how far along they were. Others were granted the abortion because they were just under their state’s limit.

Before the latest Supreme Court ruling, this limit was 20 weeks in most states. Now, the cutoff can be as little as 6 weeks – before many women know they are pregnant – or zero weeks, under the most restrictive laws. 

Over 70% of women who are denied an abortion carry the pregnancy to term, according to Dr. Foster’s analysis. 

Interviews with nearly 1,000 women – in both the first and second trimester of pregnancy – in the Turnaway Study who sought abortions at 30 abortion clinics around the country revealed the main reasons for seeking the procedure were (a) not being able to afford a child; (b) the pregnancy coming at the wrong time in life; or (c) the partner involved not being suitable.

According to the U.S. Centers for Disease Control and Prevention, 59.7% of women seeking an abortion in the United States are already mothers. Having an unplanned child results in dramatically worse economic circumstances for their other children, who become nearly four times more likely to live below the poverty line than their peers. They also experience slower physical and mental development as a result of the arrival of the new sibling.

The latest efforts by states to ban abortion could make the situation much worse, said Liza Fuentes, DrPh, senior research scientist at the Guttmacher Institute. “We will need further research on what it means for women to be denied care in the context of the new restrictions,” Dr. Fuentes told this news organization. 

Researchers cannot yet predict how many women will be unable to obtain an abortion in the coming months. But John Donahue, PhD, JD, an economist and professor of law at Stanford (Calif.) University, estimated that state laws would prevent roughly one-third of the 1 million abortions per year based on 2021 figures.

Dr. Ralph and her colleagues with the Turnaway Study know that restricting access to abortions will not make the need for abortions disappear. Rather, women will be forced to travel, potentially long distances at significant cost, for the procedure or will seek medication abortion by mail through virtual clinics.

But Dr. Ralph said she’s concerned about women who live in areas where telehealth abortions are banned, or who discover their pregnancies late, as medical abortions are only recommended for women who are 10 weeks pregnant or less.

“They may look to self-source the medications online or elsewhere, potentially putting themself at legal risk,” she said. “And, as my research has shown, others may turn to self-managing an abortion with herbs, other drugs or medications, or physical methods like hitting themselves in the abdomen; with this they put themselves at both legal and potentially medical risk.”

Constance Bohon, MD, an ob.gyn. in Washington, D.C., said further research should track what happens to women if they’re forced to leave a job to care for another child.

“Many of these women live paycheck to paycheck and cannot afford the cost of an additional child,” Dr. Bohon said. “They may also need to rely on social service agencies to help them find food and housing.”

Dr. Fuentes said she hopes the Turnaway Study will inspire other researchers to examine laws that outlaw abortion and the corresponding long-term effects on women.

“From a medical and a public health standpoint, these laws are unjust,” Dr. Fuentes said in an interview. “They’re not grounded in evidence, and they incur great costs not just to pregnant people but their families and their communities as well.”

A version of this article first appeared on Medscape.com.

In the wake of the Supreme Court’s June decision to repeal a federal right to abortion, many women will now be faced with the prospect of carrying an unwanted pregnancy to term.

One group of researchers has studied the fate of these women and their families for the last decade. Their findings show that women who were denied an abortion are worse off physically, mentally, and economically than those who underwent the procedure.

“There has been much hypothesizing about harms from abortion without considering what the consequences are when someone wants an abortion and can’t get one,” said Diana Greene Foster, PhD, professor of obstetrics and gynecology at University of California, San Francisco.

Dr. Foster leads the Turnaway Study, one of the first efforts to examine the physical and mental health effects of receiving or being denied abortions. The ongoing research also charts the economic and social outcomes of women and their families in either circumstance.

Dr. Foster and her colleagues have followed women through childbirth, examining their well-being through phone interviews months to years after the initial interviews.

The economic consequences of carrying an unwanted pregnancy are clear. Women who did not receive a wanted abortion were more likely to live under the poverty line and struggle to cover basic living expenses like food, housing, and transportation.

The physical toll is also significant.

A 2019 analysis from the Turnaway Study found that eight out of 1,132 participants died, two after delivery, during the five-year follow up period – a far greater proportion than what would be expected among women of reproductive age. The researchers also found that women who carry unwanted pregnancies have more comorbid conditions before and after delivery than other women.

Lauren J. Ralph, PhD, MPH, an epidemiologist and member of the Turnaway Study team, examined the physical well-being of women after delivering their unwanted pregnancies.

“They reported more chronic pain, more gestational hypertension, and were more likely to rate their health as fair or poor,” Dr. Ralph said. “Somewhat to our surprise, we also found that two women denied abortions died due to pregnancy-related causes. This is my biggest concern with the loss of abortion access, as all scientific evidence indicates we will see a rise in maternal deaths as a result.”

At least one preliminary study, released as a preprint and not yet peer reviewed, estimates that the number of women who will die each year from pregnancy complications will rise by 24%. For Black women, mortality could jump from 18% to 39% in every state, according to the researchers from the University of Colorado, Boulder.
 

State of denial

Regulations set in place at abortion clinics in each state individually determine who is able to obtain an abortion, dictated by a “gestational age limit” – how far along a woman is in her pregnancy from the end of her menstrual cycle. Some of the women from the Turnaway Study were unable to receive an abortion because of how far along they were. Others were granted the abortion because they were just under their state’s limit.

Before the latest Supreme Court ruling, this limit was 20 weeks in most states. Now, the cutoff can be as little as 6 weeks – before many women know they are pregnant – or zero weeks, under the most restrictive laws. 

Over 70% of women who are denied an abortion carry the pregnancy to term, according to Dr. Foster’s analysis. 

Interviews with nearly 1,000 women – in both the first and second trimester of pregnancy – in the Turnaway Study who sought abortions at 30 abortion clinics around the country revealed the main reasons for seeking the procedure were (a) not being able to afford a child; (b) the pregnancy coming at the wrong time in life; or (c) the partner involved not being suitable.

According to the U.S. Centers for Disease Control and Prevention, 59.7% of women seeking an abortion in the United States are already mothers. Having an unplanned child results in dramatically worse economic circumstances for their other children, who become nearly four times more likely to live below the poverty line than their peers. They also experience slower physical and mental development as a result of the arrival of the new sibling.

The latest efforts by states to ban abortion could make the situation much worse, said Liza Fuentes, DrPh, senior research scientist at the Guttmacher Institute. “We will need further research on what it means for women to be denied care in the context of the new restrictions,” Dr. Fuentes told this news organization. 

Researchers cannot yet predict how many women will be unable to obtain an abortion in the coming months. But John Donahue, PhD, JD, an economist and professor of law at Stanford (Calif.) University, estimated that state laws would prevent roughly one-third of the 1 million abortions per year based on 2021 figures.

Dr. Ralph and her colleagues with the Turnaway Study know that restricting access to abortions will not make the need for abortions disappear. Rather, women will be forced to travel, potentially long distances at significant cost, for the procedure or will seek medication abortion by mail through virtual clinics.

But Dr. Ralph said she’s concerned about women who live in areas where telehealth abortions are banned, or who discover their pregnancies late, as medical abortions are only recommended for women who are 10 weeks pregnant or less.

“They may look to self-source the medications online or elsewhere, potentially putting themself at legal risk,” she said. “And, as my research has shown, others may turn to self-managing an abortion with herbs, other drugs or medications, or physical methods like hitting themselves in the abdomen; with this they put themselves at both legal and potentially medical risk.”

Constance Bohon, MD, an ob.gyn. in Washington, D.C., said further research should track what happens to women if they’re forced to leave a job to care for another child.

“Many of these women live paycheck to paycheck and cannot afford the cost of an additional child,” Dr. Bohon said. “They may also need to rely on social service agencies to help them find food and housing.”

Dr. Fuentes said she hopes the Turnaway Study will inspire other researchers to examine laws that outlaw abortion and the corresponding long-term effects on women.

“From a medical and a public health standpoint, these laws are unjust,” Dr. Fuentes said in an interview. “They’re not grounded in evidence, and they incur great costs not just to pregnant people but their families and their communities as well.”

A version of this article first appeared on Medscape.com.

A new study ties the odds of conception to the advantages of the neighborhood a woman lives in.

In a cohort of more than 6,000 women who were trying to get pregnant without fertility treatments, the probability of conception was reduced 21%-23% per menstrual cycle when comparing the most disadvantaged neighborhoods with the least disadvantaged.

“When disadvantaged neighborhood status was categorized within each state (as opposed to nationally), the results were slightly larger in magnitude,” wrote authors of the study published online in JAMA Network Open.

Among 6,356 participants, 3,725 pregnancies were observed for 27,427 menstrual cycles of follow-up. Average age was 30, and most participants were non-Hispanic White (5,297 [83.3%]) and had not previously given birth (4,179 [65.7%]).

When the researchers compared the top and bottom deciles of disadvantaged neighborhood status, adjusted fecundability ratios (the per-cycle probability of conception) were 0.79 (95% confidence interval [CI], 0.66-0.96) for national-level area deprivation index (ADI) rankings and 0.77 (95% CI, 0.65-0.92) for within-state ADI rankings. ADI score includes population indicators related to educational attainment, housing, employment, and poverty.

“These findings suggest that investments in disadvantaged neighborhoods may yield positive cobenefits for fertility,” the authors wrote.

The researchers used the Pregnancy Study Online, for which baseline data were collected from women in the United States from June 19, 2013, through April 12, 2019.

In the United States, 10%-15% of reproductive-aged couples experience infertility, defined as the inability to conceive after a year of unprotected intercourse.
 

Reason behind the numbers unclear

Mark Hornstein, MD, director in the reproductive endocrinology division of Brigham and Women’s Hospital and professor at Harvard Medical School, both in Boston, said in an interview that this study gives the “what” but the “why” is harder to pinpoint.

What is not known, he said, is what kind of access the women had to fertility counseling or treatment.

The association between fertility and neighborhood advantage status is very plausible given the well-established links between disadvantaged regions and poorer health outcomes, he said, adding that the authors make a good case for their conclusions in the paper.

The authors ruled out many potential confounders, such as age of the women, reproductive history, multivitamin use, education level, household income, and frequency of intercourse, and still there was a difference between disadvantaged and advantaged neighborhoods, he noted.

Dr. Hornstein said his own research team has found that lack of knowledge about insurance coverage regarding infertility services may keep women from seeking the services.

“One of the things I worry about it access,” he said. “[The study authors] didn’t really look at that. They just looked at what the chances were that they got pregnant. But they didn’t say how many of those women had a workup, an evaluation, for why they were having difficulty, if they were, or had treatment. So I don’t know if some or all or none of that difference that they saw from the highest neighborhood health score to the most disadvantaged – if that was from inherent problems in the area, access to the best health care, or some combination.”
 

Discussions have focused on changing personal behaviors

Discussions on improving fertility often center on changing personal behaviors, the authors noted. “However, structural, political, and environmental factors may also play a substantial role,” they wrote.

The findings are in line with previous research on the effect of stress on in vitro outcomes, they pointed out. “Perceived stress has been associated with poorer in vitro fertilization outcomes and reduced fecundability among couples attempting spontaneous conception,” the authors noted.

Studies also have shown that living in a disadvantaged neighborhood is linked with comorbidities during pregnancy, such as increased risks of gestational hypertension (risk ratio for lowest vs. highest quartile: 1.24 [95% CI, 1.14-1.35]) and poor gestational weight gain (relative risk for lowest vs. highest quartile: 1.1 [95% CI, 1.1-1.2]).

In addition, policies such as those that support civil rights, protect the environment, and invest in underresourced communities have been shown to improve health markers such as life expectancy.

Policy decisions can also perpetuate a cycle of stress, they wrote. Disadvantaged communities may have more air pollution, which has been shown to have negative effects on fertility. Unemployment has been linked with decreased population-level fertility rates. Lack of green space may result in fewer areas to reduce stress.

A study coauthor reported grants from the National Institutes of Health during the conduct of the study; nonfinancial support from Swiss Precision Diagnostics GmbH, Labcorp, Kindara.com, and FertilityFriend.com; and consulting for AbbVie outside the submitted work. No other author disclosures were reported. Dr. Hornstein reported no relevant financial relationships.

A new study ties the odds of conception to the advantages of the neighborhood a woman lives in.

In a cohort of more than 6,000 women who were trying to get pregnant without fertility treatments, the probability of conception was reduced 21%-23% per menstrual cycle when comparing the most disadvantaged neighborhoods with the least disadvantaged.

“When disadvantaged neighborhood status was categorized within each state (as opposed to nationally), the results were slightly larger in magnitude,” wrote authors of the study published online in JAMA Network Open.

Among 6,356 participants, 3,725 pregnancies were observed for 27,427 menstrual cycles of follow-up. Average age was 30, and most participants were non-Hispanic White (5,297 [83.3%]) and had not previously given birth (4,179 [65.7%]).

When the researchers compared the top and bottom deciles of disadvantaged neighborhood status, adjusted fecundability ratios (the per-cycle probability of conception) were 0.79 (95% confidence interval [CI], 0.66-0.96) for national-level area deprivation index (ADI) rankings and 0.77 (95% CI, 0.65-0.92) for within-state ADI rankings. ADI score includes population indicators related to educational attainment, housing, employment, and poverty.

“These findings suggest that investments in disadvantaged neighborhoods may yield positive cobenefits for fertility,” the authors wrote.

The researchers used the Pregnancy Study Online, for which baseline data were collected from women in the United States from June 19, 2013, through April 12, 2019.

In the United States, 10%-15% of reproductive-aged couples experience infertility, defined as the inability to conceive after a year of unprotected intercourse.
 

Reason behind the numbers unclear

Mark Hornstein, MD, director in the reproductive endocrinology division of Brigham and Women’s Hospital and professor at Harvard Medical School, both in Boston, said in an interview that this study gives the “what” but the “why” is harder to pinpoint.

What is not known, he said, is what kind of access the women had to fertility counseling or treatment.

The association between fertility and neighborhood advantage status is very plausible given the well-established links between disadvantaged regions and poorer health outcomes, he said, adding that the authors make a good case for their conclusions in the paper.

The authors ruled out many potential confounders, such as age of the women, reproductive history, multivitamin use, education level, household income, and frequency of intercourse, and still there was a difference between disadvantaged and advantaged neighborhoods, he noted.

Dr. Hornstein said his own research team has found that lack of knowledge about insurance coverage regarding infertility services may keep women from seeking the services.

“One of the things I worry about it access,” he said. “[The study authors] didn’t really look at that. They just looked at what the chances were that they got pregnant. But they didn’t say how many of those women had a workup, an evaluation, for why they were having difficulty, if they were, or had treatment. So I don’t know if some or all or none of that difference that they saw from the highest neighborhood health score to the most disadvantaged – if that was from inherent problems in the area, access to the best health care, or some combination.”
 

Discussions have focused on changing personal behaviors

Discussions on improving fertility often center on changing personal behaviors, the authors noted. “However, structural, political, and environmental factors may also play a substantial role,” they wrote.

The findings are in line with previous research on the effect of stress on in vitro outcomes, they pointed out. “Perceived stress has been associated with poorer in vitro fertilization outcomes and reduced fecundability among couples attempting spontaneous conception,” the authors noted.

Studies also have shown that living in a disadvantaged neighborhood is linked with comorbidities during pregnancy, such as increased risks of gestational hypertension (risk ratio for lowest vs. highest quartile: 1.24 [95% CI, 1.14-1.35]) and poor gestational weight gain (relative risk for lowest vs. highest quartile: 1.1 [95% CI, 1.1-1.2]).

In addition, policies such as those that support civil rights, protect the environment, and invest in underresourced communities have been shown to improve health markers such as life expectancy.

Policy decisions can also perpetuate a cycle of stress, they wrote. Disadvantaged communities may have more air pollution, which has been shown to have negative effects on fertility. Unemployment has been linked with decreased population-level fertility rates. Lack of green space may result in fewer areas to reduce stress.

A study coauthor reported grants from the National Institutes of Health during the conduct of the study; nonfinancial support from Swiss Precision Diagnostics GmbH, Labcorp, Kindara.com, and FertilityFriend.com; and consulting for AbbVie outside the submitted work. No other author disclosures were reported. Dr. Hornstein reported no relevant financial relationships.

A new study ties the odds of conception to the advantages of the neighborhood a woman lives in.

In a cohort of more than 6,000 women who were trying to get pregnant without fertility treatments, the probability of conception was reduced 21%-23% per menstrual cycle when comparing the most disadvantaged neighborhoods with the least disadvantaged.

“When disadvantaged neighborhood status was categorized within each state (as opposed to nationally), the results were slightly larger in magnitude,” wrote authors of the study published online in JAMA Network Open.

Among 6,356 participants, 3,725 pregnancies were observed for 27,427 menstrual cycles of follow-up. Average age was 30, and most participants were non-Hispanic White (5,297 [83.3%]) and had not previously given birth (4,179 [65.7%]).

When the researchers compared the top and bottom deciles of disadvantaged neighborhood status, adjusted fecundability ratios (the per-cycle probability of conception) were 0.79 (95% confidence interval [CI], 0.66-0.96) for national-level area deprivation index (ADI) rankings and 0.77 (95% CI, 0.65-0.92) for within-state ADI rankings. ADI score includes population indicators related to educational attainment, housing, employment, and poverty.

“These findings suggest that investments in disadvantaged neighborhoods may yield positive cobenefits for fertility,” the authors wrote.

The researchers used the Pregnancy Study Online, for which baseline data were collected from women in the United States from June 19, 2013, through April 12, 2019.

In the United States, 10%-15% of reproductive-aged couples experience infertility, defined as the inability to conceive after a year of unprotected intercourse.
 

Reason behind the numbers unclear

Mark Hornstein, MD, director in the reproductive endocrinology division of Brigham and Women’s Hospital and professor at Harvard Medical School, both in Boston, said in an interview that this study gives the “what” but the “why” is harder to pinpoint.

What is not known, he said, is what kind of access the women had to fertility counseling or treatment.

The association between fertility and neighborhood advantage status is very plausible given the well-established links between disadvantaged regions and poorer health outcomes, he said, adding that the authors make a good case for their conclusions in the paper.

The authors ruled out many potential confounders, such as age of the women, reproductive history, multivitamin use, education level, household income, and frequency of intercourse, and still there was a difference between disadvantaged and advantaged neighborhoods, he noted.

Dr. Hornstein said his own research team has found that lack of knowledge about insurance coverage regarding infertility services may keep women from seeking the services.

“One of the things I worry about it access,” he said. “[The study authors] didn’t really look at that. They just looked at what the chances were that they got pregnant. But they didn’t say how many of those women had a workup, an evaluation, for why they were having difficulty, if they were, or had treatment. So I don’t know if some or all or none of that difference that they saw from the highest neighborhood health score to the most disadvantaged – if that was from inherent problems in the area, access to the best health care, or some combination.”
 

Discussions have focused on changing personal behaviors

Discussions on improving fertility often center on changing personal behaviors, the authors noted. “However, structural, political, and environmental factors may also play a substantial role,” they wrote.

The findings are in line with previous research on the effect of stress on in vitro outcomes, they pointed out. “Perceived stress has been associated with poorer in vitro fertilization outcomes and reduced fecundability among couples attempting spontaneous conception,” the authors noted.

Studies also have shown that living in a disadvantaged neighborhood is linked with comorbidities during pregnancy, such as increased risks of gestational hypertension (risk ratio for lowest vs. highest quartile: 1.24 [95% CI, 1.14-1.35]) and poor gestational weight gain (relative risk for lowest vs. highest quartile: 1.1 [95% CI, 1.1-1.2]).

In addition, policies such as those that support civil rights, protect the environment, and invest in underresourced communities have been shown to improve health markers such as life expectancy.

Policy decisions can also perpetuate a cycle of stress, they wrote. Disadvantaged communities may have more air pollution, which has been shown to have negative effects on fertility. Unemployment has been linked with decreased population-level fertility rates. Lack of green space may result in fewer areas to reduce stress.

A study coauthor reported grants from the National Institutes of Health during the conduct of the study; nonfinancial support from Swiss Precision Diagnostics GmbH, Labcorp, Kindara.com, and FertilityFriend.com; and consulting for AbbVie outside the submitted work. No other author disclosures were reported. Dr. Hornstein reported no relevant financial relationships.

As states ban or limit abortion in the wake of the demise of Roe v. Wade, physicians are turning their attention to widely-used drugs that can cause birth defects. At issue: Should these drugs still be prescribed to women of childbearing age if they don’t have the option of terminating their pregnancies?

javi_indy/ Thinkstock

“Doctors are going to understandably be terrified that a patient may become pregnant using a teratogen that they have prescribed,” said University of Pittsburgh rheumatologist Mehret Birru Talabi, MD, PhD, who works in a state where the future of abortion rights is uncertain. “While this was a feared outcome before Roe v. Wade was overturned, abortion provided an escape hatch by which women could avoid having to continue a pregnancy and potentially raise a child with congenital anomalies. I believe that prescribing is going to become much more defensive and conservative. Some clinicians may choose not to prescribe these medications to patients who have childbearing potential, even if they don’t have much risk for pregnancy.”

Other physicians expressed similar concerns in interviews. Duke University, Durham, N.C., rheumatologist Megan E. B. Clowse, MD, MPH, fears that physicians will be wary of prescribing a variety of medications – including new ones for which there are few pregnancy data – if abortion is unavailable. “Women who receive these new or teratogenic medications will likely lose their reproductive autonomy and be forced to choose between having sexual relationships with men, obtaining procedures that make them permanently sterile, or using contraception that may cause intolerable side effects,” she said. “I am very concerned that young women with rheumatic disease will now be left with active disease resulting in joint damage and renal failure.”

Abortion is now banned in at least six states, according to The New York Times. That number may rise to 16 as more restrictions become law. Another five states aren’t expected to ban abortion soon but have implemented gestational age limits on abortion or are expected to adopt them. In another nine states, courts or lawmakers will decide whether abortion remains legal.

Only 20 states and the District of Columbia have firm abortion protections in place.

Numerous drugs are considered teratogens, which means they may cause birth defects. Thalidomide is the most infamous, but there are many more, including several used in rheumatology, dermatology, and gastroenterology. Among the most widely used teratogenic medications are the acne drugs isotretinoin and methotrexate, which are used to treat a variety of conditions, such as cancer, rheumatoid arthritis, and psoriasis.

Dr. Clowse, who helps manage an industry-supported website devoted to reproductive care for women with lupus (www.LupusPregnancy.org), noted that several drugs linked to birth defects and pregnancy loss are commonly prescribed in rheumatology.

“Methotrexate is the most common medication and has been the cornerstone of rheumatoid arthritis [treatment] for at least two decades,” she said. “Mycophenolate is our best medication to treat lupus nephritis, which is inflammation in the kidneys caused by lupus. This is a common complication for young women with lupus, and all of our guideline-recommended treatment regimens include a medication that causes pregnancy loss and birth defects, either mycophenolate or cyclophosphamide.”

Rheumatologists also prescribe a large number of new drugs for which there are few data about pregnancy risks. “It typically takes about two decades to have sufficient data about the safety of our medications,” she said.

Reflecting the sensitivity of the topic, Dr. Clowse made clear that her opinions don’t represent the views of her institution. She works in North Carolina, where the fate of abortion rights is uncertain, according to The New York Times.

What about alternatives? “The short answer is that some of these medications work really well and sometimes much better than the nonteratogenic alternatives,” said Dr. Birru Talabi. “I’m worried about methotrexate. It has been used to induce abortions but is primarily used in the United States as a highly effective treatment for cancer as well as a myriad of rheumatic diseases. If legislators try to restrict access to methotrexate, we may see increasing disability and even death among people who need this medication but cannot access it.”

Rheumatologists aren’t the only physicians who are worrying about the fates of their patients in a new era of abortion restrictions. Gastroenterologist Sunanda Kane, MD, MSPH, of the Mayo Clinic, Rochester, Minn., said several teratogenic medications are used in her field to treat constipation, viral hepatitis, and inflammatory bowel disease.

“When treating women of childbearing age, there are usually alternatives. If we do prescribe a medication with a high teratogenic potential, we counsel and document that we have discussed two forms of birth control to avoid pregnancy. We usually do not prescribe a drug with teratogenic potential with the ‘out’ being an abortion if a pregnancy does occur,” she said. However, “if abortion is not even on the table as an option, we may be much less likely to prescribe these medications. This will be particularly true in patients who clearly do not have the means to travel to have an abortion in any situation.”

Abortion is expected to remain legal in Minnesota, where Dr. Kane practices, but it may be restricted or banned in nearby Wisconsin, depending on the state legislature. None of her patients have had abortions after becoming pregnant while taking the medications, she said, although she “did have a patient who because of her religious faith did not have an abortion after exposure and ended up with a stillbirth.”

The crackdown on abortion won’t just pose risks to patients who take potentially dangerous medications, physicians said. Dr. Kane said pregnancy itself is a significant risk for patients with “very active, uncontrolled gastrointestinal conditions where a pregnancy could be harmful to the mother’s health or result in offspring that are very unhealthy.” These include decompensated cirrhosis, uncontrolled Crohn’s disease or ulcerative colitis, refractory gastroparesis, uncontrolled celiac sprue, and chronic pancreatitis, she said.

“There have been times when after shared decisionmaking, a patient with very active inflammatory bowel disease has decided to terminate the pregnancy because of her own ongoing health issues,” she said. “Not having this option will potentially lead to disastrous results.”

Dr. Clowse, the Duke University rheumatologist, echoed Dr. Kane’s concerns about women who are too sick to bear children. “The removal of abortion rights puts the lives and quality of life for women with rheumatic disease at risk. For patients with lupus and other systemic rheumatic disease, pregnancy can be medically catastrophic, leading to permanent harm and even death to the woman and her offspring. I am worried that women in these conditions will die without lifesaving pregnancy terminations, due to worries about the legal consequences for their physicians.”

The U.S. Supreme Court’s ruling that overturned Roe v. Wade has also raised the prospect that the court could ultimately allow birth control to be restricted or outlawed.

While the ruling states that “nothing in this opinion should be understood to cast doubt on precedents that do not concern abortion,” Justice Clarence Thomas wrote a concurrence in which he said that the court should reconsider a 1960s ruling that forbids the banning of contraceptives. Republicans have dismissed concerns about bans being allowed, although Democrats, including the president and vice president, starkly warn that they could happen.

“If we as providers have to be concerned that there will be an unplanned pregnancy because of the lack of access to contraception,” Dr. Kane said, “this will have significant downstream consequences to the kind of care we can provide and might just drive some providers to not give care to female patients at all given this concern.”

The physicians quoted in this article report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

As states ban or limit abortion in the wake of the demise of Roe v. Wade, physicians are turning their attention to widely-used drugs that can cause birth defects. At issue: Should these drugs still be prescribed to women of childbearing age if they don’t have the option of terminating their pregnancies?

javi_indy/ Thinkstock

“Doctors are going to understandably be terrified that a patient may become pregnant using a teratogen that they have prescribed,” said University of Pittsburgh rheumatologist Mehret Birru Talabi, MD, PhD, who works in a state where the future of abortion rights is uncertain. “While this was a feared outcome before Roe v. Wade was overturned, abortion provided an escape hatch by which women could avoid having to continue a pregnancy and potentially raise a child with congenital anomalies. I believe that prescribing is going to become much more defensive and conservative. Some clinicians may choose not to prescribe these medications to patients who have childbearing potential, even if they don’t have much risk for pregnancy.”

Other physicians expressed similar concerns in interviews. Duke University, Durham, N.C., rheumatologist Megan E. B. Clowse, MD, MPH, fears that physicians will be wary of prescribing a variety of medications – including new ones for which there are few pregnancy data – if abortion is unavailable. “Women who receive these new or teratogenic medications will likely lose their reproductive autonomy and be forced to choose between having sexual relationships with men, obtaining procedures that make them permanently sterile, or using contraception that may cause intolerable side effects,” she said. “I am very concerned that young women with rheumatic disease will now be left with active disease resulting in joint damage and renal failure.”

Abortion is now banned in at least six states, according to The New York Times. That number may rise to 16 as more restrictions become law. Another five states aren’t expected to ban abortion soon but have implemented gestational age limits on abortion or are expected to adopt them. In another nine states, courts or lawmakers will decide whether abortion remains legal.

Only 20 states and the District of Columbia have firm abortion protections in place.

Numerous drugs are considered teratogens, which means they may cause birth defects. Thalidomide is the most infamous, but there are many more, including several used in rheumatology, dermatology, and gastroenterology. Among the most widely used teratogenic medications are the acne drugs isotretinoin and methotrexate, which are used to treat a variety of conditions, such as cancer, rheumatoid arthritis, and psoriasis.

Dr. Clowse, who helps manage an industry-supported website devoted to reproductive care for women with lupus (www.LupusPregnancy.org), noted that several drugs linked to birth defects and pregnancy loss are commonly prescribed in rheumatology.

“Methotrexate is the most common medication and has been the cornerstone of rheumatoid arthritis [treatment] for at least two decades,” she said. “Mycophenolate is our best medication to treat lupus nephritis, which is inflammation in the kidneys caused by lupus. This is a common complication for young women with lupus, and all of our guideline-recommended treatment regimens include a medication that causes pregnancy loss and birth defects, either mycophenolate or cyclophosphamide.”

Rheumatologists also prescribe a large number of new drugs for which there are few data about pregnancy risks. “It typically takes about two decades to have sufficient data about the safety of our medications,” she said.

Reflecting the sensitivity of the topic, Dr. Clowse made clear that her opinions don’t represent the views of her institution. She works in North Carolina, where the fate of abortion rights is uncertain, according to The New York Times.

What about alternatives? “The short answer is that some of these medications work really well and sometimes much better than the nonteratogenic alternatives,” said Dr. Birru Talabi. “I’m worried about methotrexate. It has been used to induce abortions but is primarily used in the United States as a highly effective treatment for cancer as well as a myriad of rheumatic diseases. If legislators try to restrict access to methotrexate, we may see increasing disability and even death among people who need this medication but cannot access it.”

Rheumatologists aren’t the only physicians who are worrying about the fates of their patients in a new era of abortion restrictions. Gastroenterologist Sunanda Kane, MD, MSPH, of the Mayo Clinic, Rochester, Minn., said several teratogenic medications are used in her field to treat constipation, viral hepatitis, and inflammatory bowel disease.

“When treating women of childbearing age, there are usually alternatives. If we do prescribe a medication with a high teratogenic potential, we counsel and document that we have discussed two forms of birth control to avoid pregnancy. We usually do not prescribe a drug with teratogenic potential with the ‘out’ being an abortion if a pregnancy does occur,” she said. However, “if abortion is not even on the table as an option, we may be much less likely to prescribe these medications. This will be particularly true in patients who clearly do not have the means to travel to have an abortion in any situation.”

Abortion is expected to remain legal in Minnesota, where Dr. Kane practices, but it may be restricted or banned in nearby Wisconsin, depending on the state legislature. None of her patients have had abortions after becoming pregnant while taking the medications, she said, although she “did have a patient who because of her religious faith did not have an abortion after exposure and ended up with a stillbirth.”

The crackdown on abortion won’t just pose risks to patients who take potentially dangerous medications, physicians said. Dr. Kane said pregnancy itself is a significant risk for patients with “very active, uncontrolled gastrointestinal conditions where a pregnancy could be harmful to the mother’s health or result in offspring that are very unhealthy.” These include decompensated cirrhosis, uncontrolled Crohn’s disease or ulcerative colitis, refractory gastroparesis, uncontrolled celiac sprue, and chronic pancreatitis, she said.

“There have been times when after shared decisionmaking, a patient with very active inflammatory bowel disease has decided to terminate the pregnancy because of her own ongoing health issues,” she said. “Not having this option will potentially lead to disastrous results.”

Dr. Clowse, the Duke University rheumatologist, echoed Dr. Kane’s concerns about women who are too sick to bear children. “The removal of abortion rights puts the lives and quality of life for women with rheumatic disease at risk. For patients with lupus and other systemic rheumatic disease, pregnancy can be medically catastrophic, leading to permanent harm and even death to the woman and her offspring. I am worried that women in these conditions will die without lifesaving pregnancy terminations, due to worries about the legal consequences for their physicians.”

The U.S. Supreme Court’s ruling that overturned Roe v. Wade has also raised the prospect that the court could ultimately allow birth control to be restricted or outlawed.

While the ruling states that “nothing in this opinion should be understood to cast doubt on precedents that do not concern abortion,” Justice Clarence Thomas wrote a concurrence in which he said that the court should reconsider a 1960s ruling that forbids the banning of contraceptives. Republicans have dismissed concerns about bans being allowed, although Democrats, including the president and vice president, starkly warn that they could happen.

“If we as providers have to be concerned that there will be an unplanned pregnancy because of the lack of access to contraception,” Dr. Kane said, “this will have significant downstream consequences to the kind of care we can provide and might just drive some providers to not give care to female patients at all given this concern.”

The physicians quoted in this article report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

As states ban or limit abortion in the wake of the demise of Roe v. Wade, physicians are turning their attention to widely-used drugs that can cause birth defects. At issue: Should these drugs still be prescribed to women of childbearing age if they don’t have the option of terminating their pregnancies?

javi_indy/ Thinkstock

“Doctors are going to understandably be terrified that a patient may become pregnant using a teratogen that they have prescribed,” said University of Pittsburgh rheumatologist Mehret Birru Talabi, MD, PhD, who works in a state where the future of abortion rights is uncertain. “While this was a feared outcome before Roe v. Wade was overturned, abortion provided an escape hatch by which women could avoid having to continue a pregnancy and potentially raise a child with congenital anomalies. I believe that prescribing is going to become much more defensive and conservative. Some clinicians may choose not to prescribe these medications to patients who have childbearing potential, even if they don’t have much risk for pregnancy.”

Other physicians expressed similar concerns in interviews. Duke University, Durham, N.C., rheumatologist Megan E. B. Clowse, MD, MPH, fears that physicians will be wary of prescribing a variety of medications – including new ones for which there are few pregnancy data – if abortion is unavailable. “Women who receive these new or teratogenic medications will likely lose their reproductive autonomy and be forced to choose between having sexual relationships with men, obtaining procedures that make them permanently sterile, or using contraception that may cause intolerable side effects,” she said. “I am very concerned that young women with rheumatic disease will now be left with active disease resulting in joint damage and renal failure.”

Abortion is now banned in at least six states, according to The New York Times. That number may rise to 16 as more restrictions become law. Another five states aren’t expected to ban abortion soon but have implemented gestational age limits on abortion or are expected to adopt them. In another nine states, courts or lawmakers will decide whether abortion remains legal.

Only 20 states and the District of Columbia have firm abortion protections in place.

Numerous drugs are considered teratogens, which means they may cause birth defects. Thalidomide is the most infamous, but there are many more, including several used in rheumatology, dermatology, and gastroenterology. Among the most widely used teratogenic medications are the acne drugs isotretinoin and methotrexate, which are used to treat a variety of conditions, such as cancer, rheumatoid arthritis, and psoriasis.

Dr. Clowse, who helps manage an industry-supported website devoted to reproductive care for women with lupus (www.LupusPregnancy.org), noted that several drugs linked to birth defects and pregnancy loss are commonly prescribed in rheumatology.

“Methotrexate is the most common medication and has been the cornerstone of rheumatoid arthritis [treatment] for at least two decades,” she said. “Mycophenolate is our best medication to treat lupus nephritis, which is inflammation in the kidneys caused by lupus. This is a common complication for young women with lupus, and all of our guideline-recommended treatment regimens include a medication that causes pregnancy loss and birth defects, either mycophenolate or cyclophosphamide.”

Rheumatologists also prescribe a large number of new drugs for which there are few data about pregnancy risks. “It typically takes about two decades to have sufficient data about the safety of our medications,” she said.

Reflecting the sensitivity of the topic, Dr. Clowse made clear that her opinions don’t represent the views of her institution. She works in North Carolina, where the fate of abortion rights is uncertain, according to The New York Times.

What about alternatives? “The short answer is that some of these medications work really well and sometimes much better than the nonteratogenic alternatives,” said Dr. Birru Talabi. “I’m worried about methotrexate. It has been used to induce abortions but is primarily used in the United States as a highly effective treatment for cancer as well as a myriad of rheumatic diseases. If legislators try to restrict access to methotrexate, we may see increasing disability and even death among people who need this medication but cannot access it.”

Rheumatologists aren’t the only physicians who are worrying about the fates of their patients in a new era of abortion restrictions. Gastroenterologist Sunanda Kane, MD, MSPH, of the Mayo Clinic, Rochester, Minn., said several teratogenic medications are used in her field to treat constipation, viral hepatitis, and inflammatory bowel disease.

“When treating women of childbearing age, there are usually alternatives. If we do prescribe a medication with a high teratogenic potential, we counsel and document that we have discussed two forms of birth control to avoid pregnancy. We usually do not prescribe a drug with teratogenic potential with the ‘out’ being an abortion if a pregnancy does occur,” she said. However, “if abortion is not even on the table as an option, we may be much less likely to prescribe these medications. This will be particularly true in patients who clearly do not have the means to travel to have an abortion in any situation.”

Abortion is expected to remain legal in Minnesota, where Dr. Kane practices, but it may be restricted or banned in nearby Wisconsin, depending on the state legislature. None of her patients have had abortions after becoming pregnant while taking the medications, she said, although she “did have a patient who because of her religious faith did not have an abortion after exposure and ended up with a stillbirth.”

The crackdown on abortion won’t just pose risks to patients who take potentially dangerous medications, physicians said. Dr. Kane said pregnancy itself is a significant risk for patients with “very active, uncontrolled gastrointestinal conditions where a pregnancy could be harmful to the mother’s health or result in offspring that are very unhealthy.” These include decompensated cirrhosis, uncontrolled Crohn’s disease or ulcerative colitis, refractory gastroparesis, uncontrolled celiac sprue, and chronic pancreatitis, she said.

“There have been times when after shared decisionmaking, a patient with very active inflammatory bowel disease has decided to terminate the pregnancy because of her own ongoing health issues,” she said. “Not having this option will potentially lead to disastrous results.”

Dr. Clowse, the Duke University rheumatologist, echoed Dr. Kane’s concerns about women who are too sick to bear children. “The removal of abortion rights puts the lives and quality of life for women with rheumatic disease at risk. For patients with lupus and other systemic rheumatic disease, pregnancy can be medically catastrophic, leading to permanent harm and even death to the woman and her offspring. I am worried that women in these conditions will die without lifesaving pregnancy terminations, due to worries about the legal consequences for their physicians.”

The U.S. Supreme Court’s ruling that overturned Roe v. Wade has also raised the prospect that the court could ultimately allow birth control to be restricted or outlawed.

While the ruling states that “nothing in this opinion should be understood to cast doubt on precedents that do not concern abortion,” Justice Clarence Thomas wrote a concurrence in which he said that the court should reconsider a 1960s ruling that forbids the banning of contraceptives. Republicans have dismissed concerns about bans being allowed, although Democrats, including the president and vice president, starkly warn that they could happen.

“If we as providers have to be concerned that there will be an unplanned pregnancy because of the lack of access to contraception,” Dr. Kane said, “this will have significant downstream consequences to the kind of care we can provide and might just drive some providers to not give care to female patients at all given this concern.”

The physicians quoted in this article report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Facebook and Instagram have begun removing posts and temporarily banning users that offer abortion pills to women who may not be able to access them after the Supreme Court overruled Roe v. Wade.

After the decision was overturned on June 24, social media posts exploded across platforms during the weekend, explaining how women could legally obtain abortion pills in the mail. Some offered to mail the prescriptions to women in states that now ban the procedure.

General posts about abortion pills, as well as ones that mentioned specific versions such as mifepristone and misoprostol, spiked on Friday morning across Facebook, Instagram, Reddit, and Twitter. By Sunday, more than 250,000 mentions had been posted, the media intelligence firm Zignal Labs told The Associated Press.

But Meta, the parent company of Facebook and Instagram, began removing some of these posts almost right away, the AP reported. Journalists at news outlets saved screenshots of posts that offered pills and were removed minutes later. Users were notified that they were banned, according to Vice.

On June 24, a Vice reporter posted the phrase “abortion pills can be mailed” on Facebook, which was flagged within seconds for violating the platform’s community rules against buying, selling, or trading medical or nonmedical drugs. The reporter was given the option to “agree” or “disagree” with the decision, and after they chose to “disagree,” the post was removed.

On June 27, the post that Vice “disagreed” had violated the standards was reinstated, the news outlet reported. The reporter wrote a new post with the phrase “abortion pills can be mailed,” which was flagged instantly for removal. After the reporter “agreed” with the decision, the account was suspended for 24 hours.

Similarly on June 27, a reporter for the AP wrote a post on Facebook that said, “If you send me your address, I will mail you abortion pills.” The post was removed within 1 minute, and the account was put on a “warning” status for the post. Other posts that offered “a gun” or “weed” were not flagged or removed, the AP reported.

Marijuana is illegal under federal law and can’t be sent through the mail, the AP reported. But abortion pills can be obtained through the mail legally.

Meta won’t allow people to gift or sell pharmaceuticals on its platform but will allow posts that share information about accessing pills, Andy Stone, a Meta spokesperson, wrote in a Twitter comment in response to the Vice article on June 27.

“Content that attempts to buy, sell, trade, gift, request, or donate pharmaceuticals is not allowed,” he wrote. “Content that discusses the affordability and accessibility of prescription medication is allowed. We’ve discovered some instances of incorrect enforcement and are correcting these.”

U.S. Attorney General Merrick Garland said on June 24 that the Food and Drug Administration has approved the use of mifepristone for medication abortion up to 10 weeks. In 2021, the FDA also made it possible and legal to send abortion pills via mail.

“States may not ban mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy,” he said in a statement.

At the same time, some Republican lawmakers have tried to stop residents from getting abortion pills through the mail, the AP reported. States such as Tennessee and West Virginia have prohibited providers from prescribing the medication through telemedicine consultations, and Texas has made it illegal to send abortion pills through the mail.

A version of this article first appeared on WebMD.com.

Facebook and Instagram have begun removing posts and temporarily banning users that offer abortion pills to women who may not be able to access them after the Supreme Court overruled Roe v. Wade.

After the decision was overturned on June 24, social media posts exploded across platforms during the weekend, explaining how women could legally obtain abortion pills in the mail. Some offered to mail the prescriptions to women in states that now ban the procedure.

General posts about abortion pills, as well as ones that mentioned specific versions such as mifepristone and misoprostol, spiked on Friday morning across Facebook, Instagram, Reddit, and Twitter. By Sunday, more than 250,000 mentions had been posted, the media intelligence firm Zignal Labs told The Associated Press.

But Meta, the parent company of Facebook and Instagram, began removing some of these posts almost right away, the AP reported. Journalists at news outlets saved screenshots of posts that offered pills and were removed minutes later. Users were notified that they were banned, according to Vice.

On June 24, a Vice reporter posted the phrase “abortion pills can be mailed” on Facebook, which was flagged within seconds for violating the platform’s community rules against buying, selling, or trading medical or nonmedical drugs. The reporter was given the option to “agree” or “disagree” with the decision, and after they chose to “disagree,” the post was removed.

On June 27, the post that Vice “disagreed” had violated the standards was reinstated, the news outlet reported. The reporter wrote a new post with the phrase “abortion pills can be mailed,” which was flagged instantly for removal. After the reporter “agreed” with the decision, the account was suspended for 24 hours.

Similarly on June 27, a reporter for the AP wrote a post on Facebook that said, “If you send me your address, I will mail you abortion pills.” The post was removed within 1 minute, and the account was put on a “warning” status for the post. Other posts that offered “a gun” or “weed” were not flagged or removed, the AP reported.

Marijuana is illegal under federal law and can’t be sent through the mail, the AP reported. But abortion pills can be obtained through the mail legally.

Meta won’t allow people to gift or sell pharmaceuticals on its platform but will allow posts that share information about accessing pills, Andy Stone, a Meta spokesperson, wrote in a Twitter comment in response to the Vice article on June 27.

“Content that attempts to buy, sell, trade, gift, request, or donate pharmaceuticals is not allowed,” he wrote. “Content that discusses the affordability and accessibility of prescription medication is allowed. We’ve discovered some instances of incorrect enforcement and are correcting these.”

U.S. Attorney General Merrick Garland said on June 24 that the Food and Drug Administration has approved the use of mifepristone for medication abortion up to 10 weeks. In 2021, the FDA also made it possible and legal to send abortion pills via mail.

“States may not ban mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy,” he said in a statement.

At the same time, some Republican lawmakers have tried to stop residents from getting abortion pills through the mail, the AP reported. States such as Tennessee and West Virginia have prohibited providers from prescribing the medication through telemedicine consultations, and Texas has made it illegal to send abortion pills through the mail.

A version of this article first appeared on WebMD.com.

Facebook and Instagram have begun removing posts and temporarily banning users that offer abortion pills to women who may not be able to access them after the Supreme Court overruled Roe v. Wade.

After the decision was overturned on June 24, social media posts exploded across platforms during the weekend, explaining how women could legally obtain abortion pills in the mail. Some offered to mail the prescriptions to women in states that now ban the procedure.

General posts about abortion pills, as well as ones that mentioned specific versions such as mifepristone and misoprostol, spiked on Friday morning across Facebook, Instagram, Reddit, and Twitter. By Sunday, more than 250,000 mentions had been posted, the media intelligence firm Zignal Labs told The Associated Press.

But Meta, the parent company of Facebook and Instagram, began removing some of these posts almost right away, the AP reported. Journalists at news outlets saved screenshots of posts that offered pills and were removed minutes later. Users were notified that they were banned, according to Vice.

On June 24, a Vice reporter posted the phrase “abortion pills can be mailed” on Facebook, which was flagged within seconds for violating the platform’s community rules against buying, selling, or trading medical or nonmedical drugs. The reporter was given the option to “agree” or “disagree” with the decision, and after they chose to “disagree,” the post was removed.

On June 27, the post that Vice “disagreed” had violated the standards was reinstated, the news outlet reported. The reporter wrote a new post with the phrase “abortion pills can be mailed,” which was flagged instantly for removal. After the reporter “agreed” with the decision, the account was suspended for 24 hours.

Similarly on June 27, a reporter for the AP wrote a post on Facebook that said, “If you send me your address, I will mail you abortion pills.” The post was removed within 1 minute, and the account was put on a “warning” status for the post. Other posts that offered “a gun” or “weed” were not flagged or removed, the AP reported.

Marijuana is illegal under federal law and can’t be sent through the mail, the AP reported. But abortion pills can be obtained through the mail legally.

Meta won’t allow people to gift or sell pharmaceuticals on its platform but will allow posts that share information about accessing pills, Andy Stone, a Meta spokesperson, wrote in a Twitter comment in response to the Vice article on June 27.

“Content that attempts to buy, sell, trade, gift, request, or donate pharmaceuticals is not allowed,” he wrote. “Content that discusses the affordability and accessibility of prescription medication is allowed. We’ve discovered some instances of incorrect enforcement and are correcting these.”

U.S. Attorney General Merrick Garland said on June 24 that the Food and Drug Administration has approved the use of mifepristone for medication abortion up to 10 weeks. In 2021, the FDA also made it possible and legal to send abortion pills via mail.

“States may not ban mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy,” he said in a statement.

At the same time, some Republican lawmakers have tried to stop residents from getting abortion pills through the mail, the AP reported. States such as Tennessee and West Virginia have prohibited providers from prescribing the medication through telemedicine consultations, and Texas has made it illegal to send abortion pills through the mail.

A version of this article first appeared on WebMD.com.

The U.S. Supreme Court’s decision to overturn Roe v. Wade, the landmark ruling in 1973 establishing a constitutional right to abortion, has spurred abortion rights supporters and opponents into action, speeding up their efforts to protect or remove access to abortion.

For now, the fight moves to the states, where so-called trigger laws have already banned nearly all abortions in a handful of states. More will likely take effect soon.

“Half of [the states] are going to have quite restrictive abortion laws, and about half will pretty much maintain the status quo,” said Ron Allen, JD, a constitutional law expert and professor of law at Northwestern University, Chicago. “My guess is, the largest population will be in those states that maintain the status quo, [though] that’s not terribly consoling to somebody in Arkansas, [which has a trigger law.]”

Federal and state officials spoke out quickly about what protections are still in place for access to abortion, and some governors have taken new actions to expand that protection.

While abortion rights advocates called on Congress to pass legislation legalizing abortion access nationwide, others, including former Vice President Mike Pence, said a national ban on abortions should be the next step.
 

Federal, state protections

President Joe Biden quickly addressed the issue of women needing to travel out of state to access abortion. In his statement on June 24, he said: “So if a woman lives in a state that restricts abortion, the Supreme Court’s decision does not prevent her from traveling from her home state to the state that allows it. It does not prevent a doctor in that state from treating her.”

In a statement also issued June 24, Attorney General Merrick Garland expressed strong disagreement with the court’s decision and also pointed out it does not mean that states can’t keep abortion legal within their borders. Nor can states ban reproductive services provided to their residents outside their own borders.

Women living in states banning access to abortion, “must be free to seek care in states where it is legal.” Others are free to inform and counsel each other about reproductive care available in other states, he said, citing the First Amendment.

Doctors who provide abortion services in states where the services remain legal, as well as patients who receive the services, will be protected under the Freedom of Access to Clinic Entrances Act, Mr. Garland said in a statement from the Department of Justice.

States reiterated protection for health care providers. For instance, California Gov. Gavin Newsom signed a law June 24 protecting California abortion providers from civil liability when they provide care for women traveling from states where abortion is banned or access to it is narrowed.

Officials from other states with abortion access began publicizing their status as “safe havens.” New York Attorney General Letitia James tweeted: “While other states strip away the fundamental right to choose, New York will always be a safe haven for anyone seeking an abortion.”

Gov. Newsom, too, among other state officials, has promised his state would be a sanctuary for women in need.

After the ruling, New York Gov. Kathy Hochul and the New York State Department of Health launched a new website and campaign, Abortion Access Always, providing a single destination for information about rights, providers, support, and other details.
 

Abortion pill

Mr. Garland and President Biden strongly warned states not to try to interfere with access to the so-called abortion pill. Approved 20 years ago by the FDA to safely end early pregnancies, the medication, mifepristone (formerly called RU-486) is taken along with misoprostol, a drug also used to prevent stomach ulcers. Medication abortion now accounts for more than half of all abortions, according to the Guttmacher Institute.

In his statement, Mr. Garland noted that the “FDA has approved the use of the medication mifepristone. States may not ban mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy.”

Plan C, an information campaign for abortion services, has a state-by-state directory of ways to find the pills, even in states restricting access to abortion, said Elisa Wells, Plan C’s cofounder and codirector.
 

Calls for national access

On June 24, President Biden called on Congress to restore the protections of Roe v. Wade as federal law. “No executive action from the president can do that,” he said. If Congress lacks the vote to do that now, voters need to make their voices heard, he said.

“The Supreme Court is but one of many government bodies that can protect the right to abortion,” Nancy Northup, JD, president and CEO of the Center for Reproductive Rights, New York, said June 24. “We will be looking to the Congress to pass the Women’s Health Protection Act. Congress can solve this as a national problem. We’ll be looking to the Biden administration to use the extent of its powers.”

The Women’s Health Protection Act would prohibit government restrictions on access to abortion services.

Sen. Bernie Sanders (I-Vt.) tweeted: “Democrats must now end the filibuster in the Senate, codify Roe v. Wade, and once again make abortion legal and safe.”

“The federal government can do a lot of things,” said Mr. Allen. “It’s interesting that we focus on the administrative agencies. The fight over Roe is a fight in large measure over who should be deciding and whether these are issues that should be decided by agencies or a court or legislators.”

Anger, he said, “should be directed at legislators, and that’s who should be acting here, and that means people have to get out and vote.”
 

Calls for a national ban

Former Vice President Pence told far-right publication Breitbart News that the court’s decision should lead to a national ban on abortion.

He also took to Twitter. Among other posts, he said: “Having been given this second chance for Life, we must not rest and must not relent until the sanctity of life is restored to the center of American law in every state in the land!”
 

Organizations’ actions

Organizations on both sides of the issue have mobilization and expansion plans.

NRLC: The National Right to Life Committee will now focus on state legislatures, said Laura Echevarria, the group’s communications director.

“We will continue to work on these [antiabortion] laws in the states we can get these passed,” she said. There’s no one size fits all. “New York is not going to pass a law that Alabama is going to pass. Every state is going to be doing something different.”

“The next big thing is to build that safety net” for women who decide to avoid abortion, she said. More than 2,700 “pregnancy help” centers operate in the United States. “We don’t run them, they are independent.” But the NRLC supports them. The centers provide pregnancy support and financial help, “two big reasons why women get abortions.”

She added: “The prolife movement often gets a bad rap, like we don’t care about women, and we do.” In an open letter issued May 12 to state lawmakers, the NRLC said: “We state unequivocally that we do not support any measure seeking to criminalize or punish women and we stand firmly opposed to include such penalties in legislation.”

ACLU: Anthony D. Romero, JD, executive director of the American Civil Liberties Union, issued a statement on Jun 24 that read in part: “Second-class status for women has once again become the law because of today’s decisions.”

As the fight plays out in the court, the ACLU urges voters to head to the polls, noting that state constitutional amendments to preserve reproductive freedom are on the ballot in Kansas in August and in Vermont and Kentucky in November.
 

Planned Parenthood

“A majority of justices ruled to throw away nearly 50 years of precedent and take away the right to control our bodies and personal health care decisions,” the Planned Parenthood site posted.

On June 25, the Planned Parenthood Association of Utah filed suit in Utah state court, planning to request a temporary restraining order against the state’s ban on abortion at any point in pregnancy. The law took effect June 24.
 

Abortion rights offers of help

As legislators and public officials focused on what the next steps should be, social media lit up over the weekend with offers of help for women in states without access to abortion.

One meme posted on social media focused on “camping.” Reportedly created by a woman who needed abortions before the 1973 Roe v. Wade decision, it reads: “If you are a person who suddenly finds yourself with a need to go camping in another state friendly towards camping, just know that I will happily drive you, support you, and not talk about the camping trip to anyone ever.”

While the camping code word quickly picked up steam, one Twitter user who favored the court’s decision called the trend of using camping as a code word to help people access abortions “horrible.”

TikTok users also offered their homes and help to women from other states who might need either. And one Airbnb host posted this invitation on Facebook: “My Airbnb is free for any American woman coming to Los Angeles for an abortion. Hugs and cute kittens, too.”

A version of this article first appeared on Medscape.com.

The U.S. Supreme Court’s decision to overturn Roe v. Wade, the landmark ruling in 1973 establishing a constitutional right to abortion, has spurred abortion rights supporters and opponents into action, speeding up their efforts to protect or remove access to abortion.

For now, the fight moves to the states, where so-called trigger laws have already banned nearly all abortions in a handful of states. More will likely take effect soon.

“Half of [the states] are going to have quite restrictive abortion laws, and about half will pretty much maintain the status quo,” said Ron Allen, JD, a constitutional law expert and professor of law at Northwestern University, Chicago. “My guess is, the largest population will be in those states that maintain the status quo, [though] that’s not terribly consoling to somebody in Arkansas, [which has a trigger law.]”

Federal and state officials spoke out quickly about what protections are still in place for access to abortion, and some governors have taken new actions to expand that protection.

While abortion rights advocates called on Congress to pass legislation legalizing abortion access nationwide, others, including former Vice President Mike Pence, said a national ban on abortions should be the next step.
 

Federal, state protections

President Joe Biden quickly addressed the issue of women needing to travel out of state to access abortion. In his statement on June 24, he said: “So if a woman lives in a state that restricts abortion, the Supreme Court’s decision does not prevent her from traveling from her home state to the state that allows it. It does not prevent a doctor in that state from treating her.”

In a statement also issued June 24, Attorney General Merrick Garland expressed strong disagreement with the court’s decision and also pointed out it does not mean that states can’t keep abortion legal within their borders. Nor can states ban reproductive services provided to their residents outside their own borders.

Women living in states banning access to abortion, “must be free to seek care in states where it is legal.” Others are free to inform and counsel each other about reproductive care available in other states, he said, citing the First Amendment.

Doctors who provide abortion services in states where the services remain legal, as well as patients who receive the services, will be protected under the Freedom of Access to Clinic Entrances Act, Mr. Garland said in a statement from the Department of Justice.

States reiterated protection for health care providers. For instance, California Gov. Gavin Newsom signed a law June 24 protecting California abortion providers from civil liability when they provide care for women traveling from states where abortion is banned or access to it is narrowed.

Officials from other states with abortion access began publicizing their status as “safe havens.” New York Attorney General Letitia James tweeted: “While other states strip away the fundamental right to choose, New York will always be a safe haven for anyone seeking an abortion.”

Gov. Newsom, too, among other state officials, has promised his state would be a sanctuary for women in need.

After the ruling, New York Gov. Kathy Hochul and the New York State Department of Health launched a new website and campaign, Abortion Access Always, providing a single destination for information about rights, providers, support, and other details.
 

Abortion pill

Mr. Garland and President Biden strongly warned states not to try to interfere with access to the so-called abortion pill. Approved 20 years ago by the FDA to safely end early pregnancies, the medication, mifepristone (formerly called RU-486) is taken along with misoprostol, a drug also used to prevent stomach ulcers. Medication abortion now accounts for more than half of all abortions, according to the Guttmacher Institute.

In his statement, Mr. Garland noted that the “FDA has approved the use of the medication mifepristone. States may not ban mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy.”

Plan C, an information campaign for abortion services, has a state-by-state directory of ways to find the pills, even in states restricting access to abortion, said Elisa Wells, Plan C’s cofounder and codirector.
 

Calls for national access

On June 24, President Biden called on Congress to restore the protections of Roe v. Wade as federal law. “No executive action from the president can do that,” he said. If Congress lacks the vote to do that now, voters need to make their voices heard, he said.

“The Supreme Court is but one of many government bodies that can protect the right to abortion,” Nancy Northup, JD, president and CEO of the Center for Reproductive Rights, New York, said June 24. “We will be looking to the Congress to pass the Women’s Health Protection Act. Congress can solve this as a national problem. We’ll be looking to the Biden administration to use the extent of its powers.”

The Women’s Health Protection Act would prohibit government restrictions on access to abortion services.

Sen. Bernie Sanders (I-Vt.) tweeted: “Democrats must now end the filibuster in the Senate, codify Roe v. Wade, and once again make abortion legal and safe.”

“The federal government can do a lot of things,” said Mr. Allen. “It’s interesting that we focus on the administrative agencies. The fight over Roe is a fight in large measure over who should be deciding and whether these are issues that should be decided by agencies or a court or legislators.”

Anger, he said, “should be directed at legislators, and that’s who should be acting here, and that means people have to get out and vote.”
 

Calls for a national ban

Former Vice President Pence told far-right publication Breitbart News that the court’s decision should lead to a national ban on abortion.

He also took to Twitter. Among other posts, he said: “Having been given this second chance for Life, we must not rest and must not relent until the sanctity of life is restored to the center of American law in every state in the land!”
 

Organizations’ actions

Organizations on both sides of the issue have mobilization and expansion plans.

NRLC: The National Right to Life Committee will now focus on state legislatures, said Laura Echevarria, the group’s communications director.

“We will continue to work on these [antiabortion] laws in the states we can get these passed,” she said. There’s no one size fits all. “New York is not going to pass a law that Alabama is going to pass. Every state is going to be doing something different.”

“The next big thing is to build that safety net” for women who decide to avoid abortion, she said. More than 2,700 “pregnancy help” centers operate in the United States. “We don’t run them, they are independent.” But the NRLC supports them. The centers provide pregnancy support and financial help, “two big reasons why women get abortions.”

She added: “The prolife movement often gets a bad rap, like we don’t care about women, and we do.” In an open letter issued May 12 to state lawmakers, the NRLC said: “We state unequivocally that we do not support any measure seeking to criminalize or punish women and we stand firmly opposed to include such penalties in legislation.”

ACLU: Anthony D. Romero, JD, executive director of the American Civil Liberties Union, issued a statement on Jun 24 that read in part: “Second-class status for women has once again become the law because of today’s decisions.”

As the fight plays out in the court, the ACLU urges voters to head to the polls, noting that state constitutional amendments to preserve reproductive freedom are on the ballot in Kansas in August and in Vermont and Kentucky in November.
 

Planned Parenthood

“A majority of justices ruled to throw away nearly 50 years of precedent and take away the right to control our bodies and personal health care decisions,” the Planned Parenthood site posted.

On June 25, the Planned Parenthood Association of Utah filed suit in Utah state court, planning to request a temporary restraining order against the state’s ban on abortion at any point in pregnancy. The law took effect June 24.
 

Abortion rights offers of help

As legislators and public officials focused on what the next steps should be, social media lit up over the weekend with offers of help for women in states without access to abortion.

One meme posted on social media focused on “camping.” Reportedly created by a woman who needed abortions before the 1973 Roe v. Wade decision, it reads: “If you are a person who suddenly finds yourself with a need to go camping in another state friendly towards camping, just know that I will happily drive you, support you, and not talk about the camping trip to anyone ever.”

While the camping code word quickly picked up steam, one Twitter user who favored the court’s decision called the trend of using camping as a code word to help people access abortions “horrible.”

TikTok users also offered their homes and help to women from other states who might need either. And one Airbnb host posted this invitation on Facebook: “My Airbnb is free for any American woman coming to Los Angeles for an abortion. Hugs and cute kittens, too.”

A version of this article first appeared on Medscape.com.

The U.S. Supreme Court’s decision to overturn Roe v. Wade, the landmark ruling in 1973 establishing a constitutional right to abortion, has spurred abortion rights supporters and opponents into action, speeding up their efforts to protect or remove access to abortion.

For now, the fight moves to the states, where so-called trigger laws have already banned nearly all abortions in a handful of states. More will likely take effect soon.

“Half of [the states] are going to have quite restrictive abortion laws, and about half will pretty much maintain the status quo,” said Ron Allen, JD, a constitutional law expert and professor of law at Northwestern University, Chicago. “My guess is, the largest population will be in those states that maintain the status quo, [though] that’s not terribly consoling to somebody in Arkansas, [which has a trigger law.]”

Federal and state officials spoke out quickly about what protections are still in place for access to abortion, and some governors have taken new actions to expand that protection.

While abortion rights advocates called on Congress to pass legislation legalizing abortion access nationwide, others, including former Vice President Mike Pence, said a national ban on abortions should be the next step.
 

Federal, state protections

President Joe Biden quickly addressed the issue of women needing to travel out of state to access abortion. In his statement on June 24, he said: “So if a woman lives in a state that restricts abortion, the Supreme Court’s decision does not prevent her from traveling from her home state to the state that allows it. It does not prevent a doctor in that state from treating her.”

In a statement also issued June 24, Attorney General Merrick Garland expressed strong disagreement with the court’s decision and also pointed out it does not mean that states can’t keep abortion legal within their borders. Nor can states ban reproductive services provided to their residents outside their own borders.

Women living in states banning access to abortion, “must be free to seek care in states where it is legal.” Others are free to inform and counsel each other about reproductive care available in other states, he said, citing the First Amendment.

Doctors who provide abortion services in states where the services remain legal, as well as patients who receive the services, will be protected under the Freedom of Access to Clinic Entrances Act, Mr. Garland said in a statement from the Department of Justice.

States reiterated protection for health care providers. For instance, California Gov. Gavin Newsom signed a law June 24 protecting California abortion providers from civil liability when they provide care for women traveling from states where abortion is banned or access to it is narrowed.

Officials from other states with abortion access began publicizing their status as “safe havens.” New York Attorney General Letitia James tweeted: “While other states strip away the fundamental right to choose, New York will always be a safe haven for anyone seeking an abortion.”

Gov. Newsom, too, among other state officials, has promised his state would be a sanctuary for women in need.

After the ruling, New York Gov. Kathy Hochul and the New York State Department of Health launched a new website and campaign, Abortion Access Always, providing a single destination for information about rights, providers, support, and other details.
 

Abortion pill

Mr. Garland and President Biden strongly warned states not to try to interfere with access to the so-called abortion pill. Approved 20 years ago by the FDA to safely end early pregnancies, the medication, mifepristone (formerly called RU-486) is taken along with misoprostol, a drug also used to prevent stomach ulcers. Medication abortion now accounts for more than half of all abortions, according to the Guttmacher Institute.

In his statement, Mr. Garland noted that the “FDA has approved the use of the medication mifepristone. States may not ban mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy.”

Plan C, an information campaign for abortion services, has a state-by-state directory of ways to find the pills, even in states restricting access to abortion, said Elisa Wells, Plan C’s cofounder and codirector.
 

Calls for national access

On June 24, President Biden called on Congress to restore the protections of Roe v. Wade as federal law. “No executive action from the president can do that,” he said. If Congress lacks the vote to do that now, voters need to make their voices heard, he said.

“The Supreme Court is but one of many government bodies that can protect the right to abortion,” Nancy Northup, JD, president and CEO of the Center for Reproductive Rights, New York, said June 24. “We will be looking to the Congress to pass the Women’s Health Protection Act. Congress can solve this as a national problem. We’ll be looking to the Biden administration to use the extent of its powers.”

The Women’s Health Protection Act would prohibit government restrictions on access to abortion services.

Sen. Bernie Sanders (I-Vt.) tweeted: “Democrats must now end the filibuster in the Senate, codify Roe v. Wade, and once again make abortion legal and safe.”

“The federal government can do a lot of things,” said Mr. Allen. “It’s interesting that we focus on the administrative agencies. The fight over Roe is a fight in large measure over who should be deciding and whether these are issues that should be decided by agencies or a court or legislators.”

Anger, he said, “should be directed at legislators, and that’s who should be acting here, and that means people have to get out and vote.”
 

Calls for a national ban

Former Vice President Pence told far-right publication Breitbart News that the court’s decision should lead to a national ban on abortion.

He also took to Twitter. Among other posts, he said: “Having been given this second chance for Life, we must not rest and must not relent until the sanctity of life is restored to the center of American law in every state in the land!”
 

Organizations’ actions

Organizations on both sides of the issue have mobilization and expansion plans.

NRLC: The National Right to Life Committee will now focus on state legislatures, said Laura Echevarria, the group’s communications director.

“We will continue to work on these [antiabortion] laws in the states we can get these passed,” she said. There’s no one size fits all. “New York is not going to pass a law that Alabama is going to pass. Every state is going to be doing something different.”

“The next big thing is to build that safety net” for women who decide to avoid abortion, she said. More than 2,700 “pregnancy help” centers operate in the United States. “We don’t run them, they are independent.” But the NRLC supports them. The centers provide pregnancy support and financial help, “two big reasons why women get abortions.”

She added: “The prolife movement often gets a bad rap, like we don’t care about women, and we do.” In an open letter issued May 12 to state lawmakers, the NRLC said: “We state unequivocally that we do not support any measure seeking to criminalize or punish women and we stand firmly opposed to include such penalties in legislation.”

ACLU: Anthony D. Romero, JD, executive director of the American Civil Liberties Union, issued a statement on Jun 24 that read in part: “Second-class status for women has once again become the law because of today’s decisions.”

As the fight plays out in the court, the ACLU urges voters to head to the polls, noting that state constitutional amendments to preserve reproductive freedom are on the ballot in Kansas in August and in Vermont and Kentucky in November.
 

Planned Parenthood

“A majority of justices ruled to throw away nearly 50 years of precedent and take away the right to control our bodies and personal health care decisions,” the Planned Parenthood site posted.

On June 25, the Planned Parenthood Association of Utah filed suit in Utah state court, planning to request a temporary restraining order against the state’s ban on abortion at any point in pregnancy. The law took effect June 24.
 

Abortion rights offers of help

As legislators and public officials focused on what the next steps should be, social media lit up over the weekend with offers of help for women in states without access to abortion.

One meme posted on social media focused on “camping.” Reportedly created by a woman who needed abortions before the 1973 Roe v. Wade decision, it reads: “If you are a person who suddenly finds yourself with a need to go camping in another state friendly towards camping, just know that I will happily drive you, support you, and not talk about the camping trip to anyone ever.”

While the camping code word quickly picked up steam, one Twitter user who favored the court’s decision called the trend of using camping as a code word to help people access abortions “horrible.”

TikTok users also offered their homes and help to women from other states who might need either. And one Airbnb host posted this invitation on Facebook: “My Airbnb is free for any American woman coming to Los Angeles for an abortion. Hugs and cute kittens, too.”

A version of this article first appeared on Medscape.com.