Opinion: No, abortion restrictions will not outlaw medical care for miscarriage

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Title: Opinion: No, abortion restrictions will not outlaw medical care for miscarriage

Originally reported on coloradosun.com by Catherine J. Wheeler, M.D.,Thomas J. Perille, M.D.

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In overruling Roe and Casey, the U.S. Supreme Court challenged the people of the country and their elected state representatives to democratically address abortion jurisprudence. This is predicated on an honest discussion of abortion and the implications of abortion restrictions. 

Whether intentional or not, many stories in the media conflate miscarriages and induced abortions. Part of this reflects the use of the medical term “spontaneous abortion” to describe a miscarriage. Comparing induced abortions to miscarriages is like comparing killing someone with a gun to dying naturally from cancer. The former is an intentional act, and the latter is a tragic, but natural, part of the life cycle.  

States that propose or enact abortion restrictions are specifically targeting induced abortions. These involve the deliberate killing of the developing embryo or fetus in order to terminate the pregnancy. They don’t outlaw specific medical procedures (such as Dilation and curettage, dilation and evacuation, or dilation and extraction) unless the procedure is used during an induced abortion. D&C procedures are common and those that are used in the treatment of a miscarriage or for heavy menstrual bleeding are not impacted by abortion restrictions. Despite this fact, there have been ubiquitous articles claiming that abortion restrictions will adversely affect the health of women facing miscarriages and stillbirths.   

There has also been much confusion about the need for abortion in the rare circumstances that the women’s life is at risk by continuing a pregnancy. A careful review of laws in states which have enacted abortion restrictions documents that there is always an exception for premature delivery or abortion in the event the women’s life is in jeopardy.  

Obstetricians are trained to consider both their patients (except with induced abortion), and the mother’s life always takes precedence. Ectopic pregnancies are not viable and impose an immediate risk to the life of the mother. They are always treated either medically or surgically and are not impacted by abortion restrictions. There are several other pregnancy complications including premature rupture of the membranes with infection, severe hypertensive disorders, worsening heart disease, and cancer that pose a risk to the life of the woman. In consultation with their OB provider, women have made very difficult decisions weighing the risks of treatment vs. urgent premature delivery or abortion long before Roe and will continue to do so post-Roe. 

For the very rare medical conditions that arise later in pregnancy, but prior to viability which is now considered 22 weeks, the delivery of the fetus (either vaginally or by C-section) will result in the unintentional death of the fetus. However, after 22 weeks, the urgent delivery is quicker and safer than a multi-day induced abortion, does not require the intentional killing of the developing child, and will resolve the threat to the woman. 

Any competent physician recognizes that their first duty is to protect the life of the woman, since failing to do so would jeopardize the lives of both the woman and her developing embryo/fetus. Not only would it be professionally reprehensible to ignore the pregnant woman’s urgent needs, but it would be malpractice and grounds for revoking their license to practice medicine. While you can always find instances where physicians fail in their responsibilities, this is not an argument against abortion restrictions. Rather, it is an argument for vigorous peer review and professional accountability.  

Since Dobbs, there have been dire warnings that maternal mortality will increase. Maternal mortality is a complex issue for which there are many aggravating, and ameliorating, factors. Access to abortion has not been demonstrated to be a critical factor. Maternal mortality has been rapidly increasing in the US over the past two decades during a period of relatively free abortion access, unlike any other high-income country. The rates are highest among non-Hispanic Black women, who also have the highest rate of abortions.  

The worldwide experience further belies the notion that abortion access and maternal mortality are inextricably linked. Poland has one of the lowest maternal mortality rates in the world and one of the most restrictive abortion policies in the world. In Brazil, maternal mortality decreased more than 50% without legalizing abortion, but by improved medical care and access to care. There are many other examples demonstrating the disconnect between abortion access and maternal mortality.  

Finally, national and state pundits would have you believe the counter-intuitive notion that restricting abortion does not decrease abortion rates — or,conversely, that liberalizing abortion access does not increase abortion rates. The implication is that all the women with limited access to abortion or who are denied abortion simply travel to a state where it is legal or pursue self-induced abortions at home. This suggests that there is a fixed demand for abortion access. 

There is an abundance of evidence that abortion rates decrease with any number of restrictions. Even the methodologically flawed, but frequently cited, Turnaway study contains this finding:  within one week of being denied an abortion, 35% of women no longer wished they had obtained an abortion. By 5 years, only 2% of the women who were denied an abortion and gave birth still wished they had obtained one. This is a testament to the very real ambivalence many women have seeking an abortion and a window into why abortion restrictions/prohibitions reduce abortion rates. Furthermore, there is evidence that when abortion restrictions are in place, women and their partners choose more effective forms of birth control.

It is our hope that after the Dobbs decision, people will reexamine the arguments for and against abortion access in the light of facts, and not propaganda by either proponents or opponents of abortion access. And while anti-abortion and abortion rights advocates may never agree on the best legislative approach, our country and state will be better served, and laws better drafted, after informed dialogue and honest deliberation.  

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