Care Post Roe: Documenting cases of poor quality care since the Dobbs decision
Executive Summary Since the US Supreme Court decision in Dobbs v. Jackson Women’s Health Organization in June 2022, total bans on abortion have gone into effect in 14 states, and severe restrictions have been enacted in others, including bans before many people know they are pregnant. In addition to restricting access to abortion care, these new laws have affected obstetric and gynecologic care and general medical care more broadly. The Care Post-Roe Study seeks to learn about how clinical care has changed by documenting cases of care that was different from the usual standard due to abortion laws that went into effect since the Dobbs ruling. This study allows health care providers to share these narratives anonymously and confidentially, at a time when they are being forbidden by their employers or hospital leadership from speaking with the press about these cases.
This report presents the preliminary findings of the Care Post-Roe Study. Between September 2022 and March 2023, we received 50 submissions from health care providers describing detailed cases of care that deviated from the usual standard due to new laws restricting abortion. The patients described in the narrative submissions lived in one of 14 states that banned or restricted abortion following Dobbs. Patients described in the narratives submitted by health care providers represent a range of different ages, income levels, and racial and ethnic backgrounds, with a notable proportion involving patients reported to be Black or Latinx.
Cases in the narratives fell into several categories:
Obstetric complications in the second trimester prior to fetal viability, including preterm prelabor rupture of membranes, hemorrhage, cervical dilation, and hypertension;
Ectopic pregnancy, including cesarean scar ectopic;
Underlying medical conditions that made continuing a pregnancy dangerous;
Severe fetal anomalies;
Extreme delays in obtaining abortion care; and
Delays obtaining medical care unrelated to abortion.
The post-Dobbs laws and their interpretations altered the standard of care across these scenarios in ways that contributed to delays, worsened health outcomes, and increased the cost and logistic complexity of care. In several cases, patients experienced preventable complications, such as severe infection or having the placenta grow deep into the uterine wall and surrounding structures, because clinicians reported their “hands were tied,” making it impossible for them to provide treatment sooner. One physician described a case of a patient who had ruptured membranes at 16- 18 weeks’ gestation but was denied an abortion because of a new state law. She was sent home and developed a severe infection requiring management in the intensive care unit. The patient subsequently delivered her fetus but required a procedure to remove her placenta. The physician wrote, “The anesthesiologist cries on the phone when discussing the case with me—if the patient needs to be intubated, no one thinks she will make it out of the OR.” Health care providers described feeling moral distress when they were unable to provide evidencebased care, and some reported considering moving their practices to a state where abortion remains legal.
These preliminary findings from the Care Post-Roe Study document a wide range of harm to people with the capacity for pregnancy in states with bans or severe restrictions on abortion care. Clinicians must be able to use their medical judgment to provide evidence-based care for their patients and prevent medical emergencies, without risk of criminal prosecution.
New research shows how abortion clinics are responding one year post-Roe
Data from ANSIRH’s Abortion Facility Database show that “abortion bans have created an untenable situation that health care providers are now left to manage”. The two major findings of the research are that:
1) abortion clinics across the country are offering care later in pregnancy to meet the needs of those delayed in accessing abortion care due to cost, travel and other logistical barriers, and
2) more and more clinics are offering telehealth for medical abortion in more states, which involves mailing medication to a patient’s home. This underscores just how devastating a negative decision in the legal battle on the availability of mifepristone would be to abortion care.
However, abortion clinics are continuing to meet the evolving needs of their patients despite the troubling landscape where 14 states have now banned abortion care altogether.
A year after fall of Roe v. Wade, 25 million women live in states with abortion bans or restrictions
One year ago, the U.S. Supreme Court rescinded a five-decade-old right to abortion, prompting a seismic shift in debates about politics, values, freedom and fairness. Twenty-five million women of childbearing age (about 40% of the total in the country) now live in states where the law makes abortions harder to get than they were before the ruling.
More than 5.5 million more live in states where restrictions have been adopted but are on hold pending court challenges. Bans on abortion no later than 12 weeks into pregnancy are on the books in nearly every state in the Southeast — though some are not in effect.
Many laws that make exceptions for medical emergencies do not clearly define those situations.
As some states restricted abortion, others locked in access. Clinics moved across state lines, added staff and lengthened hours to accommodate women leaving their home states to end their pregnancies.
In 25 states, abortion remains generally legal up to at least 24 weeks of pregnancy. In 20 of those states, protections have been solidified through constitutional amendments or laws. Officials in many of those states, including California, Colorado, Minnesota, New Mexico and New York, have explicitly invited women from places where the procedure is banned.
Women have flocked to states with legal access. Kansas is one of the closest places to obtain abortions for people in parts of Missouri, Arkansas, Oklahoma and Texas. A new clinic opened in Kansas City four days before Dobbs. Within weeks, the clinic was overwhelmed. Even after lengthening hours, hiring staff and flying in physicians, it’s been able to take only about 10% to 15% of people who have sought an abortion there.
In anticipation of out-of-state patients, states such as Hawaii have passed laws to allow more health care workers, such as nurse practitioners, to provide abortions. In New Jersey, officials late last year announced a grant to train more medical professionals to perform the procedures.
Violence against abortion providers continues to rise following Roe reversal
Since 1977, there have been 11 murders, 42 bombings, 200 arsons, 531 assaults, 492 clinic invasions, 375 burglaries, and thousands of other incidents of criminal activities directed at patients, providers, and volunteers.
The 2022 Violence & Disruption Statistics show increases in major incidents like arsons, burglaries, death threats, and invasions overall; a sharp increase in violence and disruption in states that are protective of abortion rights; and anti-abortion centers ramping up efforts to deceive and obstruct patients seeking abortion care. In a year marked by a devastating Supreme Court decision that overturned Roe v. Wade, and subsequent state abortion bans, anti-abortion extremists were emboldened and traveled to states where abortion remained legal to target clinics there.
The 2022 statistics show a decrease in some activities, including trespassing and assault and battery, which are likely attributed to clinic closures. In 2022, dozens of clinics across the country were forced to close as a result of state-level abortion bans and anti-abortion extremism. Some of the closed clinics were unable to report any data in 2022 and others only reported for part of the year. These closures account for some decreases in incidents, including reports of assault & battery as one of the clinics that closed had reported more than 100 incidents in 2021 and reported no data for 2022. We also suspect under-reporting in some categories due to provider fatigue, staff turnover, and some clinics not having the staff or capacity to monitor or report protesters or other anti-abortion activity, especially as they managed surges in patients. We have also seen anti-abortion individuals and groups begin to use encrypted communication tools and services like Signal, Telegram, Discord, and Session. These tools allow extremists to coordinate and share anti-abortion sentiment, actions and tactics more privately and anonymously. This shift likely contributed to a slight decrease in the incidents of hate email/internet harassment that we were able to document in 2022.
One year after Dobbs, getting an abortion is much more expensive
While the long-term consequences of the end of Roe v. Wade could take years to tally, one outcome is already clear: a year after the Supreme Court ended the constitutional right to abortion, the costs associated with ending a pregnancy have soared.
The Brigid Alliance, which provides logistical support to people seeking abortion care, estimates that the average cost of traveling for care has increased 41% since the first half of 2022, when it was just over $1,000. The average spend for patients that need to fly has jumped 17% to $994; while a hotel stay — usually three nights — is up 29% to $919, according to the group.
Though inflation accounts for some of the increase, state-by-state abortion bans mean people live an average of 275 miles further from a clinic than they did a year ago, according to Caitlin Myers, a researcher at Middlebury College. In Texas, the average drive to a clinic increased to 499 miles in March from 43 miles a year earlier, costing $131 extra in petrol for a round trip.
At another logistical abortion fund — the Midwest Access Coalition — the average cost per patient covered is now about $1,200, roughly double what it was before the ruling…
More than a third of patients in 2022 had to travel out of state due to restrictions where they live, up from 24% the year before, according to the Women’s Reproductive Rights Assistance Project…
From July 2022 to May 2023, the National Abortion Federation, which runs a hotline for patients seeking care, helped pay for 1,090 hotel rooms, a 195% increase from the same period a year ago. The group helped fund 982 trips by plane, train or bus, up from 293 the year before.
In addition to travel, mandatory wait times in restrictive states mean patients need to take more time away from work and child care than when Roe was the law of the land. In Utah and North Carolina, for example, someone seeking an abortion must wait 72 hours between an initial consultation and receiving care. Nearly 60% of those ending a pregnancy already have children, and about half live at or below the poverty line…
There’s so far been little new research on the exact economic impact of the Dobbs decision, though earlier studies showed that prior abortion restrictions depressed women’s wages and labor force participation. Before last June, the Institute for Women’s Policy Research estimated that state-level abortion restrictions cost state economies $105 billion per year….[continues]
Abortion pills by mail and possible financial assistance in five US states from Carafem
One in three women has lost access to abortion care in their home state since June 2022. Carafem, a national provider of abortion care and reproductive healthcare services in the US, part of DKT International, has been working hard to increase access to abortion pills both online and in-person, and is now serving individuals in 17 states. Carafem introduced Immediate Evaluation in January 2023 – a new service available 24/7 in five states — where people can visit their website to find out immediately if they are eligible for abortion pills by mail and screen for financial assistance.
This service costs US$199 and is available to anyone who is medically eligible in Illinois, Colorado, New Mexico, Maine or Maryland whose menstrual period started less than about 10 weeks ago. Carafem partners with abortion funds to offer financial assistance to people traveling from out of state who qualify.
SOURCE: News and Updates from DKT International , 24 June 2023
Rep. Ayanna Pressley seeks to decriminalise abortion through new legislation
US House of Representatives Rep. Ayanna Pressley (D-Mass.), chairwoman of the Pro-Choice Caucus’ Abortion Rights and Access Task Force, introduced a new federal abortion law bill on 22 June, called the Abortion Justice Act, to protect patients and providers from criminalisation by making care more readily accessible and removing systemic barriers, as well as calling for federal investments in abortion care, i.e. including coverage of travel and accrued costs, such as lost wages, and increased federal spending on abortion training, research, outreach and doula care.
SOURCE: The Hill, by Cheyanne M Daniels, 22 June 2023