Doctors are dealing with 'moral distress' as they try to determine care for pregnant patients in states with abortion ban, particularly those facing medical emergencies, according to the Care Post Roe study led by Dr. Daniel Grossman at the University of California San Francisco. (Kieferpix/Getty Images)

In the two years since the U.S. Supreme Court started allowing states — what has become almost half of the country — to ban all or most abortions, doctors continue to report that these laws have detrimentally changed their jobs and the quality of care they can provide pregnant patients.

A research team led by Dr. Daniel Grossman at the University of California San Francisco has been studying the impacts on medical care of the Dobbs v. Jackson Women’s Health Organization decision that overturned the federal right to abortion under Roe v. Wade. On Monday they released their latest Care Post Roe findings. Having grown from 50 to 86 submissions since the preliminary findings were released in May 2023, the survey details medical situations gone wrong because of legal concerns over a state’s abortion ban.

When Grossman — a clinical and public health researcher who specializes in abortion and contraception — talked to States Newsroom last year about the early findings, he emphasized the patient fear palpable in the narratives of their doctors. They told stories about women traveling outside their ban states just to check if they could be pregnant, or during a medical emergency. But as more submissions continue to flow in, Grossman recently said he’s struck by the distress coming from the medical community.

“One thing that was notable in some of these more recent submissions,” Grossman told States Newsroom, “is how moral distress is being incorporated into medical education, like medical students and residents are essentially now learning about the moral distress as part of their medical education, as they’re learning about the care that they can’t provide.”

The Care Post Roe study details 86 submissions received between September 2022 and August 2024 from health professionals recounting cases involving patients from 19 states that, during the study’s time frame, fully or partly banned abortion. Participants described cases that “deviated from the usual standard” of care because of a state abortion ban, some that resulted in preventable complications like severe infections or the placenta growing too deep into the patient’s uterine wall. The participants were directed not to give details that could identify themselves or their patients.

Grossman said the study was designed this way to protect the identity of health providers and patients, many of whom currently fear prosecution for their medical decisions. Researchers also conducted optional in-depth interviews with more than 30 of the participants, but those findings were not included in Monday’s report.

The majority of submissions so far have come from Texas, Grossman said, the largest of the states and where abortion has been illegal the longest. According to the study, the narratives represent a range of different ages, income levels and racial and ethnic backgrounds, though a high proportion are Black and Latinx. Submissions were also reviewed by two physicians and were rejected if they did not contain information about a specific case or did not relate to a change in care since the Dobbs ruling.

Grossman said the study is limited in size and scope and doesn’t say how common these medical situations are or how they will trend over time. But he said the stories are consistent with ongoing news reports and lawsuits wherein doctors and patients describe denying and being denied care because of abortion bans. He said the study, which includes excerpts from health providers’ narratives, serves as a qualitative representation of the types of medical emergencies that doctors all over the country have been reporting.

The submissions were organized into several categories, including:

Second-trimester obstetric complications

The most common type of reported scenario involving second-trimester complications is the preterm prelabor rupture of membranes (PPROM). A doctor described treating a patient who had ruptured membranes at 16-18 weeks’ gestation but instead of being offered an abortion procedure or an induction termination, she had been sent home, where she had developed a severe infection.

“I meet her 2 days later in the ICU. She was admitted from the ER with severe sepsis…and bacteremia. Her fetus delivers; she is able to hold [the fetus]. We try every medical protocol we can find to help her placenta deliver; none are successful,” the physician writes. “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. I do a D&C.”

Ectopic pregnancies

Ectopic pregnancies occur when a fertilized egg implants outside the uterus. They are medical emergencies, but study participants reported cases of ectopic pregnancy requiring extra steps, such as consulting multiple physicians, as well as patients delaying care because they were too scared to be seen in their home states where abortion is banned.

“If [the patient] had seen [a] provider in [her home state] when bleeding started,” one doctor wrote, “she would have had the ectopic diagnosed about 6 weeks earlier, potentially eligible for [methotrexate] and therefore potentially avoided surgery, and even if [she] needed surgery [it] would have been at home with her family and support. Instead [she] had to… recover alone in a hotel room in a random state she had never been to before.”

Underlying medical conditions?

Some physicians described cases where patients had underlying medical conditions that complicated their pregnancies. In some cases, patients were delayed or denied treatment, worsening their conditions.

“She was mid-second trimester [16-18 weeks] when she presented. She has [more than 5] children at home and had severe postpartum cardiomyopathy when she gave birth a year ago, which has persisted,” a doctor wrote. “The risk of her dying from childbirth would have been extremely high — but she was unable to find anyone in her state willing to do the procedure.”

Miscarriage

Respondents also reported challenges with miscarriage management in states with abortion bans.

“The pharmacy refused to fill the medication until they had confirmation of its use but was unable to list what that confirmation needed to include,” one clinician wrote. “The back and forth delayed the care and ultimately the client could no longer face attempting to pick up the medication and decided to utilize expectant management [i.e. waiting for the tissue to pass naturally] due to the trauma of being refused her prescribed treatment.”

Fetal anomalies

Several submitted narratives involved patients whose pregnancies were complicated by fetal anomalies, many of which were described as being incompatible with neonatal life, though termination was not possible in their state.

“Due to the anencephaly, as soon as the umbilical cord was cut, the pink skin of the baby rapidly progressed to navy, only for the baby to be completely dark navy by the time they were wrapped in a blanket and handed to the mom,” a medical student physician wrote. “The patient was letting out a loud scream throughout the labor due to the sheer pain of giving birth, but the scream and wailing she let out once she saw the baby was soul-crushing.”

Denied other types of medical care?

One of the more shocking examples for Grossman involved a patient with a postpartum hemorrhage who needed a common procedure known as dilation and curettage, or D&C, which is used for abortions, miscarriages and sometimes to empty the uterus after the baby has been born. But according to the narrative submitted, a patient had been told by the labor and delivery staff that “D&Cs were now illegal for any reason.”

In another case, an abortion ban allegedly led to the cancellation of a patient’s liver transplant.

“Patient with… [an intrauterine device (IUD)] in place came in for liver transplant after there was a donor match found,” the physician wrote. “On routine pre-surgical testing she had a positive urine pregnancy test, and her bHCG quant was in the 1000s. Her transplant was cancelled because of her positive pregnancy test despite it being an undesired, very early pregnancy.”

Carceral system

Three submissions highlighted how patients in detention, awaiting trial, or on parole faced additional obstacles obtaining an abortion in states with bans.

“Asked for permission to leave her county (and state) to receive abortion care and was told NO,” a physician wrote. “Patient left the state for abortion care anyway. Given 24-hour waiting period in [state with legal abortion] and need for a 2-day procedure, was away for 3 days (2 separate trips). She also refused any sedation because she needed to be drug tested and couldn’t admit to leaving the state for a procedure.”

Researchers predict more poor-quality care if EMTALA ruled to exclude abortion care

“It is notable that the narratives reported here describing delayed and denied care have occurred with EMTALA still intact and hospitals required to provide emergency abortion care,” the study’s authors write, referring to the federal Emergency Medical Treatment and Labor Act, which the federal government has stipulated includes emergency abortion care, and which states with abortion bans have sued over. The U.S. Supreme Court this summer declined to rule on Idaho’s lawsuit challenging the federal requirements, allowing doctors to provide emergency abortions while litigation continues.

“Although it is difficult to assess from the narratives, some … may have been EMTALA violations since stabilizing care was not provided,” the researchers write. “Other cases, such as those where the patient was admitted to a hospital for observation or those involving a patient pregnant with a fetus with an anomaly incompatible with life, are likely not EMTALA violations. Regardless, we anticipate these cases of poor-quality care would become even more common if the Supreme Court were to rule that EMTALA does not apply to emergency abortion care.”

Overall, participants reported that their patients suffered emotionally and financially, sometimes even insured patients having to pay out of pocket for medical care because it was in another state. Grossman also noted that affected patients could face long-term physical and mental-health consequences because of the medical care they did or did not receive.

“When we came out with our first report, maybe I was a little bit more optimistic and thought that perhaps this information could be used to help streamline care, reduce these delays, and identify workarounds,” Grossman said. “And perhaps that has happened in some places, but I think it’s really clear now, more than two years out, that those kinds of fixes or Band-Aids on a bad policy just aren’t going to work, and that really it’s not possible to provide evidence-based care in these states. These bans need to be repealed.”