Post-Roe Emergency Medicine: Policy, clinical, training, and individual implications for emergency clinicians

Abstract

In June 2022, the United States Supreme Court decision Dobbs v. Jackson Women’s Health Organization overturned Roe v. Wade, removing almost 50 years of precedent, and enabling the imposition of a wide range of state-level restrictions on abortion access. Historical data from the United States and internationally demonstrate that the removal of safe abortion options will increase complications and the health risks to pregnant patients. Because the emergency department is a critical access point for reproductive healthcare, emergency clinicians must be prepared for the policy, clinical, educational, and legal implications of this change. The goal of this paper, therefore, is to describe the impact of the reversal of Roe v. Wade on health equity and reproductive justice, the provision of emergency care education and training, and the specific legal and reproductive consequences for emergency clinicians. Finally, we conclude with specific recommended policy and advocacy responses for emergency medicine clinicians.

Introduction

On June 24, 2022, the United States Supreme Court ruled on Dobbs v. Jackson Women’s Health Organization and overturned Roe v. Wade, removing almost 50 years of precedent and allowed individual states to determine restrictions on abortion. While the state-level policy landscape remains fluid, the Guttmacher Institute reports that 26 states (half of the United States) are likely to ban access to abortion, if their trigger laws have not already done so,¹ with critical implications for pregnant patients, those with reproductive potential, and the clinicians who care for them.

The Emergency Department (ED) is an important access point for reproductive healthcare. More than 900,000 ED visits each year are for early pregnancy loss, which does not include those presenting for ectopic pregnancy or other pregnancy complications.² Additionally, patients may present to the ED following a medication or procedural abortion. In data from the California Medicaid program following a cohort of patients undergoing abortion; 6.4% had an ED visit within 6 weeks after the procedure, and 0.87% had a visit for an abortion related complication. ³ Because of the important role of the ED in early pregnancy care and abortion access, the Dobbs decision has significant implications for emergency medicine. This paper aims to describe the impact of the reversal of Roe v. Wade on health equity and reproductive justice, the provision of emergency care; emergency medicine education and training; and the specific legal and reproductive consequences for emergency clinicians. It concludes with policy and advocacy recommendations for emergency medicine clinicians to advocate for safe, timely, and unrestricted access to comprehensive health care, which includes abortion.

Implications for health equity and reproductive justice

Reproductive autonomy is defined as “individuals’ ability to be fully empowered agents in their reproductive needs and decisions and to access reproductive health services without interference or coercion.”⁴ Reproductive justice addresses the intersectional nature of race, ethnicity, gender identity, sexual orientation and the unequal access to reproductive health care mediated by socioeconomic status, politics, geography, and culture.⁵ The Reproductive Justice framework is beyond the full scope of this paper, but in brief, it expands beyond reproductive choice to include: “the right for bodily autonomy, the right to sexual pleasure outside of reproduction, the right to have children, not have children, and parent children in safe and sustainable communities.”⁶ The reversal of Roe v. Wade directly limits reproductive autonomy and will exacerbate preexisting racial inequities in maternal and neonatal outcomes.

Racism is a driver of reproductive injustice⁷ and, as a result, Black, Hispanic, Indigenous people–in particular those of lower socioeconomic status and living in rural areas—continue to experience disproportionate barriers to accessing reproductive health care.⁸ Black women are more likely to experience barriers to accessing contraception and have the highest rate of unintended pregnancy of any racial group, while Hispanic women report the highest rate of unintended birth.^9,10 As a result, women from historically minoritized racial groups are more likely to require abortion care: Black women are four times more likely to have abortions as compared to non-Hispanic white women, and about twice as likely as compared to Hispanic women.¹¹ Challenges to accessing reproductive healthcare are further exacerbated by the synergistic impact of states that both did not expand Medicaid under the 2014 Affordable Care Act, making contraception more difficulty to access, and enacted trigger banned abortion laws, such as in Alabama and Missouri.^1,8

Internationally, in countries without access to safe abortion, unsafe abortion is a significant contributor to maternal mortality.^12–14 And, prior to 1973, pregnant people in the United States were often forced to resort to unsafe abortions resulting in complications such as hemorrhage, sepsis, pelvic injury, and death.¹⁵ Pregnancy carries a far higher risk of morbidity and mortality than an abortion, and forced pregnancy will therefore put pregnant people at higher risk of maternal morbidity and mortality.^16,17 Countries that have restricted abortion access over the past 30 years have higher rates of abortion and unintended pregnancies as compared to countries where abortion is legal and accessible.¹⁸

Maternal morbidity and mortality in the US is already highest in women of color and impacts people of lower SES.¹⁹ One study estimated that pregnancy-related mortality will increase by 21% overall under an abortion ban but, because of racial disparities, it will increase by 13% among those who are White and 33% among those who are Non-Hispanic Black.²⁰ Restrictive access to abortion is also linked to increased exposure to intimate partner violence during pregnancy. ²¹ Violence during pregnancy in turn results in negative birth outcomes. ²²

These racial disparities are further compounded by the socioeconomic implications of reproductive justice. There are significant socioeconomic barriers to abortion access that are exacerbated by the new restrictions. The rate of unintended pregnancy is five times higher among women who experience poverty as a result of inequitable access to reproductive health care.^11,23 Further restrictions on abortion access will force pregnant people in states with more restrictive abortion laws to travel to other states for an abortion. During a vulnerable and emotional time, these individuals are likely to incur even greater financial costs which some may not be able to afford. A study in Texas found that restrictive abortion laws were associated with a disproportionate reduction in the abortion rate among Hispanic women, particularly among those living in a county with a closed clinic and those who had to travel over 100 miles for abortion care.²⁴ Black women are also more likely to experience adverse birth outcomes associated with abortion restrictions.¹⁰

Additionally, the socioeconomic impact of giving birth is significant and forced pregnancy and birth will magnify preexisting disparities. Not only are low-income women more likely to have difficulty accessing abortion care, those who do not terminate undesired pregnancies are more likely to experience adverse economic consequences. In a 2018 study, women who were not able to get abortions had higher odds of poverty, were less likely to have full-time work, and more likely to require some form of public assistance.²⁵ Another study found that abortion denial was associated with increased debt and negative credit reports.²⁶

Finally, restrictive abortion laws have the potential to exacerbate additional disparities in reproductive health– for example, among transgender, nonbinary, and gender-expansive persons, ²⁷ as well as those with disabilities who already experience barriers to accessing timely reproductive health care.^28,29

Anticipated impact of the reversal of Roe v. Wade on the provision of emergency care

In 1973, the United States Supreme Court passed Roe v. Wade, which stated that unduly restrictive state regulation of abortion was unconstitutional, allowing pregnant people the freedom to make decisions about their own bodies. Since then, repeated challenges narrowed the scope of Roe v. Wade but did not overturn it, and that fundamental right had been preserved. While Roe v. Wade legalized abortion, many have continued to face barriers to obtaining safe medication or procedural abortions due to factors such as geography, racism, and poverty. ^11,30 Equitable access to the full spectrum of reproductive healthcare never truly existed, as each state created different restrictions on patients’ healthcare decision-making and access. Between 1973 and 2021, more than 1,300 abortion restrictions were enacted, with over 108 in 2021 alone. ³¹ 40 million women aged 13–44 (58% of the country) currently live in states that have demonstrated opposition to abortion rights. ³¹ After recent legislative bans on abortion in Texas, reports demonstrate significant maternal morbidity following state-mandated expectant management of obstetrical complications. ³²

Early detection and treatment of pregnancy complications are critical for preventing morbidity and mortality. ³³ ED diagnoses of ectopic pregnancies have been increasing, rising from 7.0 to 8.3 per 10,000 pregnancies between 2006 and 2010.³⁴ Treatment with methotrexate or procedural treatment with salpingostomy or salpingectomy to remove the ectopic pregnancy is often required as part of life-saving treatment for ectopic pregnancies and other pregnancy complications.³³ State laws criminalizing abortion after 6 weeks and only for lifesaving or medical emergencies has created ambiguity in how these laws will be adjudicated resulting in clinician fear of legal ramifications when managing ectopic pregnancies ^35,36

As safe and legal abortions are becoming increasingly more elusive, the frequency with which pregnant patients will pursue abortions without clinical supervision is likely to rise. The resultant complications will also become more common among pregnant patients. Emergency clinicians need to understand their role in the provision of comprehensive reproductive healthcare and the consequences of abortion restrictions on both emergency care and emergency clinicians. Restrictive laws on abortion, which is a part of comprehensive reproductive care, prevent clinicians from providing unbiased and safe care, and can result in a damaging effect on the clinician-patient relationship.

Patients may avoid seeking timely emergency care for critical health issues and/or may withhold key health information due to fear of legal repercussions. Multiple cases have been documented of patients being criminally investigated or arrested for self-management of abortion,³⁷ with a recent high-profile case involving a patient presenting to an ED. ³⁸ Evidence demonstrates that the involvement of law enforcement in emergency care is associated with “interruptions in treatment, breaches in health privacy, and potentially diminished patient trust.”³⁹ Despite the rapid changes in restrictive abortion laws, determining if a pregnant person who reports use of abortion medication has violated the law is not the job of an ED clinician. While, at the time of this manuscript preparation, no state currently mandates reporting of patients who may have had an illegal abortion; these laws would create a significant challenge for emergency clinicians. We concur with Watson et al’ that ED clinicians should be guided by the American College of Emergency Physicians’ code of ethics: “Personal information may only be disclosed when such disclosure is necessary to carry out a stronger conflicting duty, such as a duty to protect an identifiable third party from serious harm or to comply with a just law.” ³⁸ Emergency clinicians should consider care of these patients similar to those who are undocumented or use illicit drugs,³⁸ with verbal description of how the medical system is separated from the legal system, introduction to the patient about what limited set of information is required for their care, and careful attention to what is truly required for documentation in the chart for ongoing medical care. For example, the Society of Family Planning suggests: “patient believes she was pregnant and is now bleeding, without specifying additional details.” ⁴⁰

Anticipated impact on emergency medicine education and training

As a specialty, emergency medicine must continue to provide patient-centered, evidence-based, trauma-informed care for patients who present with complications of pregnancy or attempted terminations. The core obstetric emergency medicine content for both practicing emergency clinicians and trainees will need to expand to include patients presenting with complications of self-managed or unsafe abortions, as well as high risk conditions that would normally have been managed with access to abortion. Further, as the legal ramifications of this Supreme Court decision unfold, diverse interpretations of the law across states and definitions of “pregnancy” may change the way some emergency physicians are told to care for patients with complications of pregnancy with well-established best practices, such as ectopic pregnancies and retained products of conception. In order to meet this moment, we must define the new medical knowledge, procedural expertise, and communication skills that we will need to care for this population.

The Accreditation Council for Graduate Medical Education (ACGME) milestones provide a framework through which we can begin to forecast and organize future core competencies related to the care of obstetric emergencies for practicing emergency clinicians in a post-Roe world.⁴¹ Restrictions on reproductive health will have an impact on each of the domains of physician competency (Table 1). In addition to the examples listed in Table 1, it is uncertain how procedural competencies may need to expand, especially in states to which patients travel to seek care either for abortion procedures or following complications of self-managed abortion. ⁴²This could include skills such as control of uterine hemorrhage which are well within the competencies of EM physicians. Training EM physicians in procedures such as IUD insertion for emergency contraception, manual uterine aspiration (MUA), ⁴³medication abortion and medication for management of miscarriage may be considered depending on the practice setting, geographic location, and local needs of the patient population. ⁴²

Table 1:

ACGME core competencies impacted by the overturning of Roe v. Wade

ACGME Core Competency	Example of an impact on EM clinicians
Patient care	Obtaining essential components of a history for patients with vaginal bleeding may be difficult if clinicians are hesitant (due to legal implications or restrictions) to ask about instrumentation or access to medication assisted abortion. Clinicians may desire additional training in medication abortion*
Medical knowledge	Understanding the indications and contraindications to mifepristone/misoprostol regimens; increasing familiarity with managing uterine hemorrhage and infection.
Interpersonal communication	Establishing therapeutic relationships with patients who are pregnant and present with bleeding or pain will require a trauma-informed approach that balances patient care needs with right to privacy.
Professionalism	Clinicians may face ethical dilemmas requiring comfort with reaching out to hospital-level, local, or national resources to help with patient care.
Practice-based learning and improvement	Integrating evidence-based best practices with patient preference may be disrupted by state or local restrictions on abortion, including management of ectopic pregnancy and hemorrhage.
Systems-based practice	Clinicians will need to understand local protocols for coordinating care and transferring patients to other hospitals when patients present with complications of pregnancy (e.g., ectopic pregnancy). Increased formal and collaborative relationships with colleagues from obstetrics and gynecology services to ensure safe and appropriate referrals and follow up care.

^*E.g. https://abortionpillcme.teachtraining.org

Finally, The Model of Clinical Practice of Emergency Medicine (EM Model), which serves as the basis for content for the American Board of Emergency Medicine (ABEM) examinations, is reviewed and updated by an ABEM Task Force every three years. Under the list of the fundamental conditions for which patients present to the ED, topics under the subheading of “Complications of Pregnancy” include abortion, ectopic pregnancy, and first trimester bleeding, among others. As we learn more about the implications of this decision on our specialty, we should use a data driven approach to update the content of the EM model and thus inform the practice of EM physicians.

Legal Implications for emergency physicians

Legal jeopardy

The extent to which future laws will render standard of care practices illegal is unknown and of utmost concern. States enforcing restrictive abortion bans, such as Texas, are already imposing on physician autonomy and limiting the ability to practice evidence based medicine in caring for pregnant people.³⁵ Clinicians who violate state laws may be subjected to criminal penalties as severe as life imprisonment which undermines the ability to provide safe and essential evidence-based care. ⁴⁴ There are few existing protections in place as EM clinicians have historically not been targets of restrictive abortion laws and policies. As more patients visit the ED for pregnancy related care, this will need to be reassessed.

Many scenarios could result in legal risk for clinicians such as the prescription of emergency contraception (commonly provided to survivors of sexual assault), care for ectopic pregnancies, and emergency stabilization of hemorrhage during a miscarriage. For example, consider a patient presenting to the emergency department with an ectopic pregnancy, a non-viable pregnancy that, if unaddressed, will risk the life of the pregnant individual. Several states have attempted to pass legislation that would ban treatment for an ectopic pregnancy (Missouri, Texas). ^45,46 One unsuccessful bill went so far as to require reimplantation of an ectopic pregnancy (Ohio). ⁴⁷ These changes place EM clinicians in a difficult position of facing criminal charges for providing lifesaving care. While the Centers for Medicare and Medicaid Services (CMS) released a memorandum reinforcing Emergency Medical Treatment and Labor Act (EMTALA) obligations for pregnancy and pregnancy loss, ⁴⁸ legal scrutiny and challenges to this memorandum as well as state specific variations have already arisen. As a result, how these different scenarios will be interpreted under EMTALA and/or lead to malpractice cases is still unknown and a great source of concern for clinicians and the emergency medicine community at large. State-specific laws will create challenges for EM clinicians practicing in multiple states and for those who practice in states that routinely transfer and/or accept transfers from out of state hospitals.

Reproductive implications for emergency physicians

Changes in reproductive health care rights will also drastically impact the emergency medicine (EM) workforce, as 28.3% of EM physicians are women and woman account for 40% of resident physicians. ^49,50 Clinicians may miss important educational and career opportunities due to inability to travel for conferences or for meetings that are held in states with restrictive access to reproductive care while pregnant or attempting to become pregnant.

All clinicians who can become pregnant access reproductive healthcare for personal care and family planning, and many clinicians utilize assisted reproductive technology (ART) to build their families for a wide variety of reasons (e.g. infertility, lesbians or gay men). ⁵¹ These reproductive technology resources may be threatened by legislative changes with the overturning of Roe v Wade. ⁵²

Physicians who can become pregnant have higher rates of pregnancy-related complications than non-physicians. ⁵³ Childbearing delays, sometimes up to 7.4 years longer than the general population ⁵³ and infertility complications place pregnant clinicians into varying categories of advanced maternal age and subject them to accumulating pregnancy-associated health risks, including increased risks of ectopic pregnancies, fetal genetic abnormalities, early pregnancy loss, molar pregnancy, and intrauterine fetal demise. ⁵⁴ The higher burden of potential pregnancy-related complications among our colleagues further necessitates strong action to maintain access to the total breadth of reproductive resources such as emergency contraception, medication, and surgical abortion.

Additionally, the unknown impact of legislative changes on ART and in-vitro fertilization (IVF) threatens the diversity of families in EM who have used or who may seek to use reproductive technology. Previous data notes that 21% of female physicians tried to conceive for 1+ years, and 24% report being diagnosed with infertility. ⁵³ Legislative changes threaten both future embryos and existing embryos, including limitations on the number of eggs that may be fertilized in one IVF cycle, pre-implantation genetic testing, embryo freezing, and discarding of embryos with genetic abnormalities.⁵² Trigger laws could require mandatory transfer of multiple embryos at once, increasing the risk of a multi-fetal pregnancy, and significantly increasing the health risks of the pregnant individual.⁵²

The extent to which EM clinicians will be personally affected by the overturning of Roe v Wade generates more questions than answers, but several ethical and legal implications must be considered as we anticipate just how expansive restrictions may be. The biggest threat associated with the proposed changes undoubtedly targets and harms our patients. However, we would be remiss not to consider how these changes impact clinicians personally. It is critical that our specialty societies engage in advocacy efforts to ensure protections exist for EM clinicians and the future of our practice.

Conclusion

The nullification of Roe v. Wade, the 1973 Supreme Court decision that once affirmed the constitutional right to abortion, has already had a substantial impact on the reproductive rights of millions of Americans. Individuals who should be afforded autonomy over their medical decisions now face a future where those rights have been severely restricted or removed and personal, and often difficult choices, may no longer be theirs to make. Additionally, this judicial change will exacerbate preexisting racial, ethnic, and socioeconomic inequities in maternal and neonatal outcomes and damage the clinician-patient relationship, founded on the principle of honesty and shared decision making.

As emergency clinicians, we are trained to care for any individual that walks through the doors of our hospitals for any reason, without judgement, and with their personal interests and values in mind. In order to provide the best care, we as clinicians, and our patients as autonomous beings, must be fully empowered to make the best medical decisions for each individual circumstance. The reversal of Roe v. Wade ties our hands and interferes with our ability to treat each patient with the respect and dignity that they deserve. Instead, we will be faced with managing complications of late presentations of ectopic pregnancies, missed abortions or retained products, self-managed or unsafe abortions as pregnant people turn away from professional medical care for fear of reprisal. EM clinicians will also now manage increased complications of forced pregnancy in high-risk individuals. Clinicians will now be subject to increased scrutiny and state specific legal jeopardy for medical decisions that we have been trained to make and are evidence based standard of care. ⁵⁵

In response, EM clinicians should consider the following advocacy actions. On a policy level, we must advocate for legal protections for EM clinicians providing reproductive care as well as the expansion of telehealth and remote prescribing. Reassuringly, CMS has recently clarified that abortion required for stabilization of emergency conditions is protected under EMTALA, and preempts state law prohibiting abortion. Ongoing legal action and advocacy is needed to ensure this applies without exception in all states. ⁴⁸ Currently, no state mandates reporting of patients who may have had an abortion when restricted by state law. Emergency physicians must remain advocates for patient care, and strict protectors of patient confidentiality and privacy ³⁸. Institutionally, EM employers should consider financial support to enable pregnant clinicians to travel to receive necessary healthcare for pregnancy complications or termination. EM employers should also work with institutional/organizational legal counsel to determine state specific legal protections and implications for EM clinicians and provide this information to clinicians routinely. Recognizing that it may be financially difficult for many organizations to change venues of conferences that have been contracted years in advance, national EM associations should improve the accessibility of conferences for individual clinicians in early pregnancy who may be unable and/or hesitant to travel to states that limit access to early pregnancy care. Conference organizers should consider adding a clause in contracts moving forward that allow for cancellation/alterations based on discriminatory state practices. From an educational perspective, clinicians require additional training in options counseling, abortion provision, and the management of complications from unsafe abortions, as well as better access to information about specific state rules and resources. Individually, EM clinicians should have access to detailed information and understanding of the legal environment within their own state and hospital system to protect themselves professionally and personally. In particular EM clinicians will require knowledge of the implications of federal and state-specific laws on their own health and reproductive rights. This includes but is not limited to transparent information and flexible options for investing and pursuing ART for family planning and accessing care for pregnancy related complications (Table 2).

Table 2:

Recommended policy and advocacy actions and goals for EM clinicians

Domain	Policy or advocacy action
Policy	• Advocate for legal protections for emergency clinicians providing evidence based reproductive care • Champion the expansion of telehealth and remote prescribing to increase access to comprehensive reproductive care • Support the use of EMTALA to preempt state restrictions on abortion • Improve access to equitable reproductive care, including birth control and prenatal care
Institutional and organizational	• Employer support for pregnant clinicians to travel for necessary medical care • Employer provided information about state-specific regulations and protections for emergency physicians • EM national associations’ attention to location of conferences and meetings, with accessibility strategies for those unable to travel to states restricting reproductive care
Educational	• Additional training in options counseling, abortion provision, and management of unsafe abortion complications • Improved access to specific state rules, local and national resources
Individual	• Access to detailed information about state and hospital legal environment and legal protections • Information and options for pursing ART and pregnancy care

The ripple effects and implications of this major ruling stripping away reproductive rights will continue to be felt for years to come. In this paper, we describe the potential impacts on health equity and reproductive justice, the provision of emergency care, emergency medicine education and training, and legal and reproductive consequences for EM clinicians. However, there are likely additional and ever evolving consequences that we cannot even anticipate at this time. Unfortunately, the complexities of the new medical-legal landscape will play out in healthcare settings and will place an added responsibility on EM clinicians to understand our dynamic role in the provision of comprehensive reproductive healthcare and the many nuanced changes that will continue to arise. Most importantly, it is paramount that we advocate for both abortion access and reproductive justice in order to minimize harm to our patients and reduce unnecessary barriers to accessing safe and evidence-based care.