Who are the real experts? Reproductive Healthcare in the Dobbs vs. Jackson Era
Written by: Sarah Weatherspoon, MD
There is a new before and after demarcation in our timeline: the post-Roe era. Many of my generation have grown up in an epoch defined by numerous attempts to reverse the landmark Roe vs. Wade ruling in 1973. For those who recall the time before Roe vs. Wade, there may be memories of themselves or friends who needed an abortion but could not get one or had a procedure done secretly or in an unsafe environment. Now we are again forming similar and dreadful memories since the Dobbs vs. Jackson ruling on June 4, 2022, which effectively ended the right to a safe abortion.
Being a part of the healthcare profession has taught me that everyone has a story affected by intrinsic and extrinsic factors, many of which are outside of a person’s control. As a physician, it is not my role to extrapolate my own problem-solving skills and life goals onto someone else coming from a rubric that will always be unique by the very fact we are individuals made up of a distinct genetic and environmental tapestry. Therefore, what I might decide for myself in terms of education, residence, or health is not what others may choose for themselves.
As a neurologist, I frequently discuss contraception with my patients. That may sound a bit odd, as it may seem to be the purview of a gynecologist or family practitioner. However, reproductive healthcare affects all aspects of medicine and every specialty. Many layers in healthcare make reproductive decisions extraordinarily personal and complicated. In neurology alone there are many factors to consider such as interactions between some forms of contraception and seizure medications, one making the other potentially less effective; there is a risk for fetal defects that are irreversible and potentially deadly secondary to some seizure medications; and there is the risk of harm and death secondary to seizures, particularly for women affected by hormonal changes during their menstrual cycle and pregnancy. In addition, some of the most vulnerable in our community - those with physical and intellectual disabilities – are at increased risk of unwanted pregnancy second to rape and incest as well as increased morbidity and mortality during pregnancy¹ ². If the niche area of epilepsy care has this many caveats related to reproductive health, you can know that hardly any medical specialty is exempt. For healthcare professionals, the onus is on us to speak up for our patients.
Racial and ethnic minority groups have long faced unjust legislation around reproductive rights. Already, People of Color (POC) are at higher risk of pregnancy-related deaths³. In addition, racial and ethnic minority groups are disproportionately affected by this most recent ruling as they are more likely to be insured through Medicaid and therefore have no access to abortion services which are excluded from federal funding⁴. POC are also twice as likely to face criminal charges in the setting of a self-managed abortion as compared to non-Hispanic Whites⁵. All people deserve access to the spectrum of reproductive healthcare options for healthy pregnancies and safe abortions without increased risk of penalization.
Following the Dobbs vs. Jackson ruling, the Tennessee trigger law (The Human Life Protection Act) went into effect, banning abortion. The single exception made to this otherwise total ban was for termination if the mother’s life is at risk – a determination that lacks any clear framework other than specifically excluding maternal mental health as a risk. This decision places an untenable burden on physicians to decide where the line in the sand is for ‘maternal risk.’ Texas leads the way on this Draconian approach with its own Senate House Bills 8 (the so-called Heartbeat Bill) and 4, which makes it a felony for a physician to terminate a pregnancy even in the setting of a maternal medical emergency. In 2022, two large, urban Texas hospitals published the results of the effect of this ruling. Compared to the time before these two House Bills, there was a significant increase in serious maternal morbidity using this model of ‘expectant management’ over offering the option of termination⁶. Fetal outcomes were also very poor. If we look to Texas as a model, then we can expect more pregnant persons to suffer unnecessarily with minimal fetal survival post-delivery, begging the question about how exactly human life is being protected as the law boldly claims.
It would be the other side of the paternalism coin to think that every person who can potentially become pregnant use contraception or that everyone with a fetal abnormality have an abortion. The complexities of maternal and fetal care extend beyond the provider-consumer relationship or even the patient-doctor relationship. As one medical ethicist proposed, we must engage in an ‘expert-expert’ relationship where the patient and the healthcare provider proceed forward in information-sharing and decision-making based on “mutual respect and trust that recognizes the unique expertise brought to the collaboration by both sides⁷.” In other words, these conversations and decisions are in the realm of medical professionals and the people who are pregnant. Together, they should be trusted to navigate these sometimes-murky waters themselves without the interference of legislators who have not sat knee to knee with a person confronted with the deeply personal decision of whether to continue or terminate a pregnancy.
It is our unceasing calling to engage our community and our legislators in understanding how nuanced and complicated this issue is for each person so that we move away from top-down medical and legislative paternalism to true partnership where the patient and their provider are the experts.