January 31, 2023 – Acute care surgeons should prepare to treat complications of forced pregnancies and unsafe abortions following the Supreme Court’s decision to overturn Roe v Wade in the USA in 2022, argue experts in an opinion piece published in the journal Trauma Surgery & Acute Care Open.
The decision will disproportionately affect poor women and women of colour and will be harmful to patients, their families, and communities, and so “should be denounced by the profession,” they say.
Abortion is very common in the USA, and constitutes “essential healthcare”, say the authors. But the Supreme Court’s overturning of Roe v. Wade in June 2022 led to twelve states effectively banning abortion overnight, and many others planning strict legislation, including limiting abortions to 6 weeks after conception.
As nearly 60% of American women of childbearing age —around 40 million—now find themselves in states that are hostile to abortion, abortions outside of a formal medical setting, or self-managed abortions (SMAs), are likely to increase.
The authors stress that, when conducted under safe conditions, abortion is an extremely effective and safe procedure.
And they point out that one major difference from the pre-Roe era is that abortion medication is now widely available across state lines, via mail order.
Acute care services are unlikely to be needed for complications of mail-order medical abortions, as, when prescribed by a qualified provider, this type of abortion is “roughly 14 times safer than pregnancy itself”, however they acknowledge that patients may be seeking pain management.
In these cases, the experts argue that “it is imperative to protect the privacy of the patient and treat the medical issue at hand without allowing intrusive criminal legal systems to impose on patient care”.
But the authors say surgeons should prepare to treat complications, such as infection or haemorrhage, that may occur if pregnant people seek an unsafe SMA, either by ingesting a toxic substance or self-inflicted physical injury.
Such unsafe approaches to a self-managed abortion can also result in injury to the uterus, bowel, bladder, and circulatory system.
In such cases, the experts say there should be an “emphasis on non-judgemental treatment,” and that providers have the ethical duty to protect patient privacy, and “to not report these complications” to law enforcement in states where abortion is prohibited.
As pregnancy itself is riskier than legal abortion, and given the high maternal death rate in the USA, acute care surgeons will likely face patients with complications resulting from forced pregnancy, such as haemorrhage, eclampsia, obstructed labour, and sepsis.
The experts also argue that the increase in forced pregnancy following the Dobbs decision will further marginalise women of colour and poorer women, who are more likely to seek abortion services and trauma care, as those denied abortion are more likely to go on to live in poverty.
The authors go on to say that women with a history of intimate partner violence will also be disproportionately impacted, as these women experience higher rates of unintended pregnancy.
What’s more, previous studies have shown a “dramatic increase in maternal mortality in states where abortion is restricted” that has disproportionately affected black and Indigenous patients.
So the authors argue that prohibitive legislation “will lead to increased death of pregnant patients from external violence as well as from physical complications of forced violence”.
The authors also warn against a possible “brain drain” in obstetrics and gynaecology, as abortion bans impact technical training not only for abortion treatment, but also miscarriages and other aspects of pregnancy care, further worsening reproductive care for women.
They conclude: “All physicians, including trauma and acute care surgeons, play a role in the care of people who can become pregnant, and all physicians will be impacted by the consequences of this ruling.
“As medical providers and responsible citizens of a society that fails to equitably care for its most vulnerable, we must act to prevent harm both in our medical practice and with our voices.”
Trauma Surgery & Acute Care Open
Trauma of abortion restrictions and forced pregnancy: urgent implications for acute care surgeons
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