ST. LOUIS — ²Ñ¾±²õ²õ´Ç³Ü°ù¾±â€™s abortion ban appears to have had a chilling effect on the number of abortions provided in hospitals when there are health complications with a pregnant patient or her fetus, state health department data shows.
For nearly a decade, the number of hospital abortions in the state — abortions typically performed when a mother’s life is at risk or in cases of severe fetal anomalies — exceeded 80 a year and appeared to be steadily rising.
That trend quickly reversed halfway through 2022 when the U.S. Supreme Court struck down Roe v. Wade, triggering ²Ñ¾±²õ²õ´Ç³Ü°ù¾±â€™s strict abortion ban.
The following year, the number of hospital abortions dropped to 29, a nearly 72% decrease from 2021, when 102 took place.
Though ²Ñ¾±²õ²õ´Ç³Ü°ù¾±â€™s ban makes exceptions for medical emergencies, some providers say the state’s data suggests pregnant women may not be receiving adequate care when dealing with life-threatening medical conditions.
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“Hospital-based abortions occur when patients are faced with their worst fears about their own health or the health of their babies,†said Dr. Jennifer Smith, a . “The fact that there is such a significant decrease in hospital-based abortion is because doctors and hospitals cannot care for these patients in the way in which we were trained and the way in which patients deserve.â€
Number of hospital abortions in Missouri
Year | Hospital abortions |
---|---|
2013 | 81 |
2014 | 91 |
2015 | 88 |
2016 | 110 |
2017 | 90 |
2018 | 83 |
2019 | 103 |
2020 | 121 |
2021 | 102 |
2022 | 80 |
2023 | 29 |
Every week across the state, Smith said, women experiencing miscarriages are being denied treatment in emergency rooms, and doctors are required to delay abortions until their patients’ conditions significantly deteriorate.
Smith said one of her patients with heavy bleeding during her second trimester drove to Illinois for treatment for fear that she would not receive an abortion in Missouri if she needed one to save her life.
“Our patients are left to find care in other states and by other avenues, and this is clearly a risk to the health of Missourians and families,†Smith said.
²Ñ¾±²õ²õ´Ç³Ü°ù¾±â€™s defines a medical emergency as a situation that “so complicates the condition of a pregnant woman as to necessitate the immediate abortion of her pregnancy to avert the death of the pregnant woman or for which a delay will create a serious risk of substantial and irreversible physical impairment of a major bodily function of the pregnant woman.â€
If a prosecutor charges a provider with violating the law, the provider must prove in court the abortion was necessary. Violating this law constitutes a Class B felony, which is punishable by five to 15 years in prison, and may result in the loss of the provider’s medical license.
Smith has been an outspoken supporter of a statewide ballot measure Missourians are expected to vote on in November that would overturn ²Ñ¾±²õ²õ´Ç³Ü°ù¾±â€™s abortion law. If approved, the proposed “Right to Reproductive Freedom†constitutional amendment will establish a right in Missouri to abortion until fetal viability — when a fetus can survive outside the womb. That is around 24 weeks.
Dave Dillon, spokesman for the Missouri Hospital Association, did not go so far as to blame ²Ñ¾±²õ²õ´Ç³Ü°ù¾±â€™s abortion ban on the big drop in hospital-based procedures.
“While these data indicate fewer abortions for medical necessity are occurring in Missouri, they don’t explain why,†Dillon said. “The state’s abortion restrictions could result in individuals traveling out of state for this care. It’s simply not clear.â€
‘Nebulous’ laws
The abortion data, provided by the Missouri Department of Health and Senior Services at the request of the Post-Dispatch, shows the number of abortions performed each year in ²Ñ¾±²õ²õ´Ç³Ü°ù¾±â€™s hospitals, but does not name the hospitals.
Officials representing major hospital systems like BJC HealthCare across the state either refused to or did not respond to questions about reasons behind the drop in hospital-based abortions. Spokespeople for Mercy, a Catholic health system, and the publicly funded University of Missouri, said the abortion ban had little impact on their approach and policies.
BJC’s Barnes-Jewish Hospital in ºüÀêÊÓƵ — as a non-Catholic, private and institution for Washington University physicians — receives referrals from across the state and performs most of the hospital-based abortions in Missouri, said , who provided abortions for years at Barnes before becoming chief medical officer for what is now .
McNicholas pointed to two groups of patients who received hospital-based abortions before ²Ñ¾±²õ²õ´Ç³Ü°ù¾±â€™s ban and now no longer can.
The first is those who chose to terminate their pregnancies after discovering severe fetal abnormalities that are always or often fatal, such as , or .
The other is patients with pregnancy complications that may not be severe enough to meet the “medical emergency†exception.
Examples McNicholas has seen include a woman who discovered she had brain cancer and was pregnant, who faced either getting an abortion or delaying her cancer treatment, and a patient with severe heart disease requiring medication and a pacemaker who could die as the pregnancy progresses.
“These are folks for whom pregnancy does pose a risk to their life, maybe not today in this moment, but the combination of pregnancy and their medical condition make it such that continuing the pregnancy isn’t safe,†she said.
McNicholas said she sees patients like these now traveling to either abortion clinics in Illinois or hospitals in Chicago if they have more complex conditions — adding to the cost, stress and risks they are already facing with their health.
, director of the Complex Family Planning Division at Rush University Medical Center in Chicago, said, “We do see cases like that frequently, where a patient was denied care in their home state because the doctor wasn’t sure, does this really qualify in our state under the law, because the laws are all so nebulous.â€
Patients having to travel face delays in care and worsening complications, Laursen said. She often has to coordinate speaking with doctors and getting patient records from other states.
“There is also a lot of psychological damage because the patient just feels so much stigma,†she said. “And they have had to take time off work and there’s more cost. By the time these patients come to me, they’re just completely exhausted by everything they’ve gone through to get to this point.â€
Smith said she’s thankful her patients are a short drive across the Mississippi River into Illinois, where clinics, including one operated by Planned Parenthood Great Rivers, can perform abortions up to 26 and 28 weeks. She worries how rural patients far from the border are navigating their complicated pregnancies.
Still, Smith said, even her patients are fearful.
“I get more patients asking me to promise them that I will save them, especially if they have another child at home,†she said. “They want to make sure I understand that they need to be there for their children. … I’ve just never had to have this conversation with people.â€
“They are afraid to be pregnant in Missouri,†Smith said.
Chaos and lawsuits
With a “trigger†law enacted by a Republican-led Missouri Legislature in 2019, Missouri was the first state to ban abortion after Roe was overturned. More than a dozen states followed suit.
Doctors described what followed as “chaos,†saying they were unsure how to care for pregnant patients when their health is threatened.
Missouri Republican legislators insisted the state’s law was clear and accused “the Left†of dangerous rhetoric and misinformation.
A few weeks after ²Ñ¾±²õ²õ´Ç³Ü°ù¾±â€™s ban, the Missouri Department of Health and Senior Services issued a listing answers to four “frequently asked questions†about the regulations.
The document reiterated the state law that states that whether a patient’s condition fits the medical emergency definition is based on “reasonable medical judgment.â€
Providers and their legal advisers, however, said the document did little to ease concerns, considering the complexity of medical complications and their treatments. They worry that their decisions might be second-guessed by an overzealous prosecutor, potentially resulting in imprisonment.
A showed 61% of physicians practicing in states with abortion bans reported they are concerned about their legal risk when making decisions about the necessity of abortion care for their patients.
The survey also showed that 40% said they had been constrained in providing care for miscarriages, and 37% constrained in providing care for pregnancy-related emergencies.
have been filed across the country over the narrow scope of exceptions in state abortion bans.
In May, the the first challenge to a state’s abortion ban, filed on behalf of two doctors and 20 women who argued the state’s law prevented them from getting medical care for their complicated pregnancies.
One plaintiff was 18 weeks pregnant when the amniotic sac surrounding and protecting the baby ruptured, which is fatal to the fetus and puts the pregnant patient risk. Doctors refused to terminate the pregnancy because there was still cardiac fetal activity.
The woman went into sepsis, spent three days in intensive care and faces challenges in conceiving again.
The Texas judges ruled that the state’s law — similar to ²Ñ¾±²õ²õ´Ç³Ü°ù¾±â€™s in that it allows abortions in emergencies based on a doctor’s “reasonable medical judgment†— was clear enough for physicians to provide abortions in life-threatening scenarios “confident that the law permits it.â€
A hospital in Missouri — Freeman Health System in Joplin — along with the Kansas Health System in Kansas were the first to be investigated by the federal government n August 2022 refused to provide an abortion to a Missouri woman whose amniotic sac ruptured at 17 weeks of pregnancy because fetal cardiac activity was still detectable. She ultimately traveled to an abortion clinic in Illinois.
The EMTALA law requires hospitals to provide an exam and stabilizing care to whoever comes through their doors, regardless of their ability to pay.
The two hospitals have since submitted correction plans and are back in compliance with the law, according to a spokesperson with the Centers for Medicare and Medicaid Services, which is in charge of investigating alleged violations.
President Joe Biden’s administration also filed a lawsuit against Idaho, arguing Idaho’s strict abortion ban violates EMTALA by preventing emergency physicians from providing abortions to stabilize a patient.
The , which allowed hospitals in Idaho to perform an emergency abortion to protect a pregnant patient’s health, saying the Supreme Court got involved in the case too quickly.
The decision, however, left the question of whether EMTALA preempts Idaho’s ban, as well as other states’ bans, unresolved.
McNicholas said she believes Missourians are now receiving abortions if needed in emergencies.
In Missouri, it’s the gray areas that are leading sick, pregnant patients to go out-of-state to terminate their pregnancies, she and Smith say.
“I don’t take care of a patient in a vacuum,†Smith said. “This requires a hospital, and it requires a nursing staff and an anesthesia staff and all of that, and everybody has to feel comfortable that this is within the law, and because the law is so unclear as to where that line is, that in part is what the problem is.â€
McNicholas said many doctors feel like the law conflicts with informed consent — the process of educating a patient about the risk, benefits and alternatives of an intervention — which is an ethical obligation for medical providers. Especially for patients facing serious outcomes.
“We don’t have crystal balls to say it will happen in one week or five weeks or at the end of pregnancy, or maybe you are the 10% of people who will get through pregnancy with this condition and nothing will happen,†she said. “What we can do is counsel patients, tell them that our experience says that these are the things that we think are most likely; and, if you want to terminate your pregnancy to prevent those things, we can help you do that.â€
The doctors suspect that many Missourians are not able to access an abortion out-of-state because they can’t travel or are confused about their options.
“There are probably a lot of people that we don’t know about, that never make to somebody, and they either continue to their pregnancy and sustain complications or injuries,†McNicholas said, “or they don’t.â€