Once, when I was the obstetrician-gynecologist assigned to cover Christmas at my hospital, I was called to the emergency department for a patient undergoing a first-trimester pregnancy loss. Early pregnancy losses are common and generally uncomplicated. But this patient showed signs of possible infection.
This can be life-threatening. Thankfully, the treatment is a simple one — a dilation and curettage procedure, or D and C, in which a doctor dilates the cervix and empties out the uterus. This basic procedure is a staple of OB-GYN care. It’s the first surgery most of us learn.
I remember my patient shook with discomfort when I pressed on her belly. I remember her eyelids were pale, a sign she had lost too much blood. I remember our team starting an IV, ordering a dose of medicine to help her uterus contract and readying an operating room.
But I don’t remember whether this patient came to us with a spontaneous miscarriage or whether she had undergone a pregnancy termination. It really doesn’t matter. The care needed is identical in both cases. And the medical systems I work in were designed to provide that care every day and every night, even on Christmas.
This seems simple to me. But around the country, it’s not that simple any longer. Patients presenting with complications related to pregnancy terminations are now being excluded from the care that the medical establishment is supposed to provide.
In Georgia, Amber Thurman died in a hospital after doctors waited more than 20 hours to perform a D and C. She had taken abortion pills, but her body failed to expel all of the tissue from the pregnancy. Candi Miller died at home days after taking abortion pills she obtained online and suffering similar complications; an investigating committee found that her death was in part attributable to the fear that prevented her from seeking care.
We don’t know all the details of these cases, but there are emerging patterns in multiple states of hospitals delaying or denying standard reproductive care, and of women unwilling to risk going to those hospitals, for fear of legal trouble, including possible criminal charges. The decision in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade, paved the way for anti-abortion laws in many states. This created an environment in which most abortion is now not just illegal in many instances, it’s also more dangerous than that. Reproductive health care in some states is no longer treated as fundamental medical care. And that makes even a safe treatment, such as a medication abortion — that is, an abortion induced by pills — into something lonelier and riskier than it should be.
This situation is upsettingly close to where we were more than half a century ago. Before Roe v. Wade was decided in 1973, pregnancy termination was illegal in many states. Women still ended pregnancies, but they did so outside the medical system in a variety of ways, some more dangerous than others. This was the era of coat-hanger abortions and women found bleeding to death in back alleys.
Roe v. Wade gave abortion patients the advantages of being part of a medical system — sterile equipment, trained personnel, pain management. Being within the medical system also meant that doctors could do research on these procedures, assess their safety and create better technologies. At this time, complications from abortion decreased markedly.
In the two years since Dobbs, we haven’t returned to the back-alley era, largely because of a major advance originating in the 1980s: the discovery of highly effective medication to induce abortion. The modern regimen of abortion pills has been well studied. When taken correctly, it causes a complete, uncomplicated pregnancy termination about 95 percent of the time, usually at home, and without any need for further medical intervention.
Medication abortion is significantly safer than staying pregnant in this country, especially for women of color. But even a treatment that is 95 percent safe will mean that one person out of every 20 will need some sort of follow-up care. The vast majority will just need a second dose of medication, or perhaps some antibiotics; some will need that very routine D and C. And that’s where things are going very wrong for many women in this country today.
Many state anti-abortion laws are vague, with severe but unclear punishments for anyone who helps a woman obtain an abortion, including the doctor who cares for her. Because hospitals and doctors may be reluctant to touch these patients, care will be delayed or patients will no longer trust that they can safely access that care. Women who need help are increasingly on their own.
This is going to get worse. As abortion has become more geographically restricted, more people are using medication abortion far from the supervision of qualified medical providers. Some of the medication comes from abortion aid organizations; others may be from black market sellers. They are offering these drugs to patients, many of whom are desperate and who plan to take them by themselves, without support — what’s known as a self-managed abortion. Sometimes people use these pills in ways that are different from the ways they were studied. Research on self-managed abortion and its impressive safety is growing, but those studies presume that someone who gets into real trouble can access basic medical care. That assumption no longer holds for large parts of our country, as Ms. Thurman and Ms. Miller discovered.
Given this new landscape, some people have questioned whether medication abortions really are safe. Perhaps, they say, abortion rights organizations should rethink the aid they are giving. That is the wrong solution to this problem. Yes, medication abortion is less safe when no follow-up care is available, as is pregnancy, and taking an over-the-counter painkiller, and scraping your knee, all of which have rare but real risks. No treatment is completely safe when given without support or access to emergency services.
What’s killing women isn’t the increasing use of medication abortion; it’s the laws and leaders who have created a situation in which those patients are denied basic care. What’s killing these women is not abortion; it’s the isolation, the absence of care, the ejection of reproductive health care from the systems that should provide it.
The post Abortion Pills Are Safe. Post-Roe America Isn’t. appeared first on New York Times.