'I’m terrified': Louisiana doctors fear for patients — and themselves — under abortion ban
Pregnancy can be treacherous, especially for people with a variety of health conditions, from heart failure or a history of dangerously high blood pressure to a cancer diagnosis.
Doctors in Louisiana say these are the kinds of cases where someone might benefit from an abortion — but may no longer get one when Louisiana’s near total-abortion ban takes effect.
They describe fear, confusion and anxiety in hospitals over how to provide health care and stay within the law’s narrow exceptions for abortions that are still allowed. The overarching question, one doctor said, was this: “How close to dead do you have to be before a physician can act?”
🚨 We have an announcement 🚨— New Orleans Public Radio (@WWNO) July 11, 2022
There was so much to cover and talk about after SCOTUS overturned Roe v. Wade that we turned it into a new, surprise episode of Banned, a WWNO + WRKF podcast.
🎧 Listen here: https://t.co/PEjxXpAymu pic.twitter.com/DGXuQ9yxwU
New Orleans Public Radio interviewed five physicians: two OB/GYNs, a maternal-fetal medicine specialist, an emergency department physician and an oncologist who treats cancers in women’s reproductive organs, and they all said Louisiana’s abortion law, as written, puts women’s health and physician’s careers at risk.
“And I do believe there will be women who ultimately have very severe health outcomes, including death,” said Dr. Will Williams, a maternal-fetal medicine specialist in New Orleans.
Their comments echo the statements of 12 doctors and one midwife who submitted affidavits in a lawsuit over Lousiana’s ban criminalizing nearly all abortions. The only legal abortions under the law are in cases where the fetus is deemed “medically futile,” meaning it would not survive birth, or to save a patient’s life.
The exception for a patient’s life has two definitions. In one, abortions are allowed in the case of a “medical emergency” that requires an “immediate abortion” to save the “pregnant woman.” In the other, abortions are allowed when “necessary in good faith medical judgment or reasonable medical judgment” to prevent the death or “substantial risk of death” to the pregnant woman.
But the law’s simple language belies the complexities of actually providing health care, doctors said.
“I’m terrified for myself as a woman of reproductive age, and I’m terrified for my patients,” said Dr. Nina Breakstone, an emergency medicine physician in New Orleans.
The physicians interviewed each stressed that they’re not speaking on behalf of their institutions, given the fraught political and legal status of abortion care. One OB/GYN asked to speak anonymously for fear that even talking to a reporter about the need for abortion access would put her on the radar of law enforcement who might intimidate or try to prosecute her.
“Basically to try to shut you up,” she said.
Health risks associated with pregnancy
Pregnancy in and of itself carries risks, even for those otherwise healthy. The risk of death from pregnancy is 14 times greater than the risk of death from an abortion, according to the American College of Obstetricians and Gynecologists.
“I think that most people do not understand that pregnancy is a disaster,” Breakstone said. “Many things could go wrong at any time. And when those things go wrong, we need to be able to act quickly.”
And the problem now for physicians is: At what point in pregnancy is a health risk high enough to warrant an abortion?
If you’re carrying a wanted pregnancy, Williams is not the doctor you want to see. It’s his job to shepherd people with fetal or maternal complications through the fraught and unpredictable nine months of pregnancy.
It’s not uncommon for Williams to tell a patient that their pregnancy — because of their specific medical conditions — carries a 20 or 30 fold death risk. Each case is unique, he said, and each patient should be able to decide what’s best for them, including getting an abortion. But under the state’s new law, he fears that won’t always be the case.
Take for instance, he said, heart failure. As a pregnancy progresses, it puts strain on the patient’s heart. They face a risk of arrhythmias, an irregular heartbeat, which could “very easily lead to death.”
Or take high blood pressure.
“People who are totally healthy prior to pregnancy, develop disorders like preeclampsia” — dangerously high blood pressure — “that can lead to eclampsia. They can develop strokes, they can have blood clots that form in their legs, or in their lungs,” Williams said.
Based on state data, hundreds of abortions take place every year in the state for health reasons.
Louisiana law requires abortion providers to report the reasons a patient is seeking an abortion, and that data is compiled by the Louisiana Department of Health. But the data only tracks general reasons given by patients. Health department data show patients listed physical health or fetal anomaly for 163 of 7,444 abortions performed in 2021. In 2020, that number was 449 of 7,473 abortions.
Under Louisiana’s abortion ban, Williams said hospital leadership at Ochsner Health, where he works, has said abortions will be allowed for the sake of a severe maternal medical disorder, and he intends to keep providing those abortions.
But other doctors aren’t convinced. Preeclampsia is one of the most common complications in pregnancy, said the OB/GYN who fears being targeted for speaking to the media and who asked to remain anonymous. She’s worried that precisely because preeclampsia is so common, it won’t be deemed an exception under the law. Preeclampsia is also a contributor to maternal mortality.
The OB/GYN recalled a patient with a history of preeclampsia in a previous pregnancy. The patient’s blood pressure was normal at one visit, but just a few days later, a spike in blood pressure caused a placental abruption — when the placenta separates from the uterine wall — and the patient “almost bled to death.” The OB/GYN recommended the patient not get pregnant again.
She posed another scenario: What about a pregnant patient who has had a kidney transplant? The process of giving birth can impact kidney function, and could risk the patient’s life — but it also may not, the OB/GYN said.
“And is that going to be an exception for the life of the mother? I don’t think it’s going to be,” she said.
Doctors say there’s also uncertainty over whether people who need an abortion to get cancer treatment will be allowed one under the law, because the law’s generalized language doesn’t specifically carve out exceptions for cancer patients.
A few days before the U.S. Supreme Court overturned Roe v. Wade, a physician at one of Louisiana’s last abortion clinics was providing procedures. One of her patients that day had breast cancer, and was seeking an abortion so she could start chemotherapy.
The doctor also works at a Louisiana hospital, and she asked New Orleans Public Radio not to use her name for fear she’d lose her job if her abortion clinic work became publicized. The way that she interprets the law, abortions needed in order to start cancer treatment will also be banned.
Abortions can be a part of cancer treatment, said Dr. Tara Castellano, a New Orleans gynecologic oncologist who specializes in reproductive cancers, including ovarian, uterine and cervical cancer. She said abortions can be recommended when the standard of care — a hysterectomy, pelvic radiation and chemotherapies — are not compatible with pregnancy.
She believes some abortions will be allowed for cancer patients if there’s an immediate threat to the patient’s life. But as the law is written, Castellano said it’s not obvious whether a patient who has cancer, but who’s life isn’t in immediate danger, will still be allowed an abortion in order to access to cancer treatment.
That ambiguity could cause delays in care and risk a patient’s health.
“And in the setting of pregnancy and cancer, timing is everything,” Castellano said. “Nine months with untreated cancer is a long time, and can certainly compromise maternal outcomes.”
Delay in care, fear of prosecution
Those delays aren’t restricted to cancer patients. Other doctors fear a “cooling effect” on patients getting the health care they need because patients could be afraid to access abortions — knowing most are criminalized.
“Those patients certainly will show up to the doors later. They almost always show up sicker,” Williams added. “Had they sought that care earlier in their pregnancy, they could have avoided major complications.”
Doctors might avoid even offering abortions as an option, even when they might be allowed under the law, Castellano said.
“If people are skittish, and if you're risk averse as a physician, you might just not want to even go down that road as an option,” Castellano said.
Doctors are going to be hesitant to act, agreed the OB/GYN who asked to remain anonymous, either because doctors don’t know what the law requires or they’re afraid the law “is going to be used in a corrupt way to take away their freedom,” she said.
“Medicine is not black and white,” the OB/GYN added. “You can find two people that might disagree on a diagnosis. If one person decides that they disagree with you, or one prosecutor decides that they don't agree with you, they can bring charges against you.”
Breakstone fears it’s inevitable, in the current legal landscape, that doctors will be arrested and prosecuted in post-Roe Louisiana.
“It’s crazy. We’re in this legal limbo,” she said — a limbo not just over whether she could be arrested, but whether her hospital would defend her.
“If I do the right thing medically, and I get arrested for it, is my hospital going to bail me out? I have no idea,” Breakstone said.
The law could also reduce training for abortion procedures, resulting in fewer physicians able to confidently perform them, Williams said.
Before the new abortion ban, the vast majority of abortions — especially those that are deemed elective — were taking place at Louisiana abortion clinics, not hospitals. Even patients with medical reasons for abortions that would qualify as exceptions under the law had been told to go to abortion clinics.
Fewer doctors providing abortions “means more patients are going to end up getting transported, (and) there's going to be delays in care. And we know that delays and care when a patient is infected or a patient is bleeding are part of what leads to these terrible maternal outcomes that we see,” Williams said.
In the coming months, state officials are expected to provide some added clarity around what diagnoses will qualify as exceptions to the abortion ban.
Louisiana’s law requires the Department of Health to compile a list of “anomalies, diseases, disorders and other conditions” that will qualify as medically-futile pregnancies and allow for abortions under the law. The department said the list will be completed by Aug. 1.
Attorney General Jeff Landry said he’s working with the Louisiana State Medical Society and the Louisiana State Medical Board of Examiners “to work through particular issues that doctors have to try to clarify the concerns that they have.”
But physicians say no list can encompass every scenario they might face.
“I think a lot of us are scared. I don't want to go to jail for 10 years for doing the right thing by my patients,” Breakstone said. “And I don't want to be sued for malpractice and be an awful person for following the letter of whatever this ridiculous imprecise law is.”
Despite these risks, the doctors told New Orleans Public Radio they are committed to staying in Louisiana and caring for the people of this state.
“I have friends who say, ‘Why don't you just move back to Vermont where you don't have to deal with these legal stressors?’ But my heart's in Louisiana, my patients are in Louisiana. Whether I leave or not, they still need the care that I provide,” Williams said. “So here I will stay.”