Last month, the U.S. Supreme Court reached a decision in Dobbs v. Jackson Women's Health Organization and overturned Roe v. Wade, the landmark 1973 ruling that guaranteed the right to abortion on a federal level. Now, abortion matters are being decided by individual states, some of which have already banned the medical procedure.
This has left many parents-to-be wondering how new reproductive health laws may impact their prenatal care. To help us answer some of the most common questions we’re hearing from the What to Expect Community, we reached out to three members of our Medical Review Board: Jennifer Yuk Ling Butt, M.D., an OB/GYN with New York-based Northwell Health; Lorene Temming, M.D., a maternal-fetal medicine physician; and James Greenberg, M.D., vice chairman of the Department of Obstetrics & Gynecology at Brigham and Women's Hospital in Boston.
"We're beginning to realize that this is not just about terminating pregnancies, but it can encompass a wide variety of diagnoses for women that are exceedingly common, like miscarriages," says Dr. Butt.
Likewise, Dr. Temming says that the Dobbs v. Jackson ruling "leaves women and health care workers across the country unsure of how to proceed as we await state-level decisions regarding bans and trigger laws. These laws impact not only abortion care but also miscarriage management, fertility treatment and management of high-risk pregnancies."
Women’s health experts say bans and restrictions on abortion will have devastating impacts on maternal health, and the Dobbs decision has been condemned by major physician organizations including the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, the American Academy of Pediatrics and the American Academy of Family Physicians.
Prior to the Dobbs decision, states that had the most restrictions on abortions were among the states with the highest maternal mortality rates. One study estimates that if a nationwide abortion ban were enacted, pregnancy-related deaths would increase by 21 percent.
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What does all of this mean for you and your reproductive health care? It’s important to note that a lot remains unknown and may vary from state to state. Still, experts have some idea of how care for miscarriages and ectopic pregnancies may change, as well how doctors will communicate with patients about certain types of prenatal testing.
How could an abortion ban impact the way an ectopic pregnancy is treated?
An ectopic pregnancy is a pregnancy that occurs when a fertilized egg grows outside of the uterus, typically in one of the fallopian tubes. As an ectopic pregnancy progresses, it can cause the fallopian tube to burst, which can lead to major, life-threatening internal bleeding. Ectopic pregnancies are not considered viable.
Treatment for an ectopic pregnancy if it’s caught early is typically a medication called methotrexate. But methotrexate has been targeted by some strict anti-abortion legislation and may be difficult or impossible to access for women with an ectopic pregnancy.
Ectopic pregnancies with detectable cardiac activity are particularly complicated, according to Dr. Greenberg. “It’s impossible to result in a viable pregnancy, but it has a heartbeat,” he says, noting that some states ban abortions after a heartbeat can be detected.
Laws restricting abortion in Alabama, Texas, Arkansas and Ohio include specific language allowing for abortions for ectopic pregnancies, but other abortion restrictions do not mention it explicitly. In those states, an abortion is still legal if the provider determines the procedure is necessary to save the life of the mother.
But there’s confusion about what constitutes a medical emergency, and many experts are concerned that this will lead to delays in care for ectopic pregnancies.
Dr. Greenberg says it’s hard to predict how more restrictive legislation around abortions will impact medical care in those situations. “I’m not sure that even the legislatures in more conservative states know,” he says.
In July 2022, the Department of Health and Human Services (HHS) updated guidance about the Emergency Medical Treatment and Active Labor Act (EMTALA). The HHS clarified that this federal law protects physicians who offer abortions in emergency or health-threatening situations (although it does not prevent a doctor from being sued). The hope is that this updated guidance will help eliminate confusion and empower providers to treat ectopic pregnancies.
What about a molar pregnancy or blighted ovum?
A molar pregnancy is a pregnancy that is not viable and did not form a fetus but, instead of ending in miscarriage, the pregnancy continues to develop and creates invasive tissue that can turn into cancer. The medical term for this is gestational trophoblastic disease (GTD), according to the National Cancer Institute (NCI) — defined as rare tumors that form from the tissues surrounding a fertilized egg.
A blighted ovum is what happens when an embryo never develops or stops developing and leaves an empty gestational sac.
A molar pregnancy may require your doctor to perform a dilation and curettage (D&C) to remove the abnormal tissue. A blighted ovum may call for either a D&C or medication to complete the miscarriage. Both medication and the D&C procedure may be affected by abortion bans.
Medication to complete the miscarriage, which may include misoprostol and mifepristone, is explicitly banned for use in inducing abortions by some legislation, Dr. Butt says. Some doctors may feel nervous about doing a D&C over fears it could be misconstrued as terminating a viable pregnancy, resulting in their prosecution.
Medication-induced abortions involve giving those two pills: mifepristone, which stops the pregnancy from growing and blocks the body’s use of progesterone, and misoprostol, which is taken right away or within 48 hours after and causes cramping and bleeding to empty the uterus.
Texas legislation known as S.B. No. 4 specifically calls out mifepristone, as well as misoprostol and methotrexate in trigger laws. In bans enacted in other states, the wording in the actual law is often vague and may just reference "drugs that can cause or induce abortion." So where do we draw the line?
"The laws can be confusing and, in some cases, it’s unclear what [they] should be,” Dr. Greenberg says.
What about missed or incomplete miscarriages?
There are different types of miscarriages, and those that aren't "complete miscarriages" — when all the pregnancy tissue has passed from the uterus out of the body — usually require medical treatment.
A missed miscarriage is a pregnancy where the fetus became non-viable or died in utero but there are no symptoms, so the mom may be unaware that she has miscarried until a routine prenatal appointment, when no signs of a fetal heartbeat are found.
An incomplete miscarriage is usually accompanied by vaginal bleeding and cervical dilation, but some tissue from the pregnancy remains in the uterus.
In both situations, "treatment [in the form of medication or a D&C] is necessary to help the body complete the miscarriage and prevent severe bleeding, infection and even death," Dr. Temming says.
But some reports suggest that providers in states with strict abortion laws may be reluctant to prescribe or dispense these medications, either because they're afraid of being seen as assisting in abortions or due to confusion over the law.
"Just being accused is a huge risk. Even if you're completely in the right and you're being very careful to follow laws,” Karen Meckstroth, an OB/GYN and professor at the University of California, San Francisco, told Roll Call.
Will parents-to-be still be able to get NIPT?
NIPT stands for non-invasive prenatal testing (also known as prenatal cell-free DNA screening). This is an optional blood test you can take any time after pregnancy week 10 that screens and looks for possible chromosomal abnormalities in your baby, like Down syndrome, trisomy 18 and trisomy 13.
Expectant parents typically get this test done to see if their baby is genetically healthy. Generally, if the test shows an increased risk of chromosomal anomalies, their practitioner would recommend a more conclusive, invasive test like amniocentesis or CVS to confirm the diagnosis. Sometimes, the decision may be made to terminate a pregnancy if the baby does in fact have certain chromosomal abnormalities.
Dr. Butt expects that parents in states with strict abortion laws will still be able to get NIPT, but what they can do about the results is another story.
"Screening for Down syndrome, trisomy 18 and trisomy 13 doesn’t equal termination if there is an abnormal result," she says. "But whether [expectant parents] would be able to act upon abnormal results is dependent on which state they’re in."
That means a woman may be forced to carry a baby with genetic abnormalities to term if she lives in a state with strict abortion laws and she's unable to travel to a state with fewer restrictions.
Dr. Greenberg agrees that NIPT will likely still be available for patients. "I have many patients already who don’t believe in abortion but they want the information to prepare themselves for their child having issues," he says.
What should you do if you want to get pregnant in a state where abortion is banned or restricted?
Think about what you’d want to do if you found yourself in a challenging, life-altering situation where abortion may previously have been an option. You may want to be prepared to travel to another state to receive appropriate medical care, says Dr. Temming.
Currently, there are no laws restricting travel across state lines for pregnancy termination, but there are still other financial and logistical hurdles you may need to clear before you can access this type of care.
Questions to ask yourself might include: What states are easiest for me to travel to? How will I pay for travel and lodging? Does my employer offer travel reimbursement to receive medical care in another state? Who will take care of my other children if I have them while I’m away?
It’s understandable if these hypotheticals are difficult for you to think about, or if the uncertainty of reproductive care in many parts of the country is leaving you feeling uneasy. If you’re wondering how abortion laws may affect you, talk to your doctor, who should be able to answer your questions or steer you toward someone who can.
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