As physicians continue to navigate care for patients with complex pregnancies in states with abortion bans, a group of maternal-fetal medicine specialists has developed new guidelines to help providers in those states navigate legal risks for themselves and medical challenges for their high-risk patients. 

Maternal-fetal medicine specialists handle some of the most high-risk pregnancies, including patients with high blood pressure, diabetes, cancer, fetal anomalies or other complications. In states with abortion bans, those conditions can become even more dangerous for a patient if a doctor is unsure when they can terminate a pregnancy without potentially jeopardizing their medical license or facing criminal penalties that can include jail time.

“Individuals at high risk for pregnancy-associated morbidity and mortality have unique needs for reproductive health services, including abortion care,” the Society for Maternal-Fetal Medicine wrote in a special statement published this month. 

Ten states plus the District of Columbia allow abortion access without gestational restrictions, while 13 states ban abortion at all stages. Following the implementation of those bans since 2022, many hospital systems and clinics have offered different interpretations of how to avoid legal jeopardy under the bans and what qualifies under exceptions, leading to confusion and delays in care that have been documented in many states nationwide. 

To mitigate those problems, the guidelines encourage providers and administrators to set up referral networks across state lines, work to find agreement on what is permissible under state law and counsel patients on their options even in states with restrictions to deliver the highest-quality care. 

“We are uniquely positioned as high-risk pregnancy experts to make that case to our leaders,” said Dr. Justin Lappen, a maternal-fetal medicine specialist in Ohio who chaired the committee that developed the statement. “And a statement like this would give providers and our colleagues some confidence to be leaders in this space.”

The Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists agree that access to abortion and counseling about options is the standard of care for obstetric patients, but there are conscientious exceptions for doctors who do not want to provide abortion care. 

Some doctors choose to affiliate with the American Association of Pro-Life Obstetricians and Gynecologists, and offer their own guidance about approaching complications, which still includes termination in some situations. The group is officially a partner of the Alliance Defending Freedom and several anti-abortion groups, as well as the Alliance for Hippocratic Medicine, which is the group that sued to revoke federal approval of one of two drugs used to terminate a pregnancy or treat miscarriages.

A representative from the American Association of Pro-Life Obstetricians and Gynecologists could not be reached for comment before publication.

Worse outcomes for high-risk patients

Nationwide, women in states with bans have reported difficulties receiving care when experiencing pregnancy complications. 

One of the most common emergencies occurs when a patient’s amniotic sac breaks before a fetus is viable. If left untreated, it can quickly turn into a deadly infection. The statement noted that after Texas passed Senate Bill 8 in 2021 banning abortion at an early gestation, waiting to treat patients in those medical situations dramatically increased negative health outcomes. According to research cited in the statement, complications such as blood transfusion, intensive care admission and serious infection resulted in 57% of cases, versus comparable research in states without restrictions that showed a complication rate of 33%. In all of the cases, the fetus did not survive.

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The guidance states hospitals and clinics should expand their abortion care to the extent allowed by law, and recognize maternal-fetal medicine specialists as sources of best care practices. It also instructs providers to work with legal teams in their networks to understand the federal Emergency Medical Treatment and Labor Act and when it may require abortion care, as well as encouraging training for basic termination procedures. 

Dr. David Hackney, a maternal-fetal medicine specialist in Ohio who published a book in August about navigating high-risk pregnancy care under Dobbs, said the statement will be useful for many providers nationwide.

“We don’t always focus enough on hospital administration, care and systems, but there’s always so much that can be done in those regions that is almost — if not more — important,” Hackney said.

After the Dobbs decision in June 2022, Hackney said, many individual healthcare systems didn’t know what to do when faced with certain situations where termination might be needed, and set a patchwork of policies that increased confusion for providers. But in the years since, providers and administrators in some healthcare systems have come together to reach informal agreements about what they are comfortable doing within the confines of an abortion ban.

“You have some defense if everyone has agreed to do the same thing,” he said.

When laws are unclear, he said, people will most often lean toward over-complying, which can create worse outcomes for the patient. 

“Even outside of abortion, medical care tends to work better when you have consensus and you have common best practices, even if it’s on a regional level,” he said. 

‘When they need me, they call me’

Many specialists’ cases aren’t emergencies, but rather pregnancies that put a patient at risk because of underlying health conditions, whether they existed before a pregnancy or developed during pregnancy, or late-term diagnoses of fetal anomalies that upend a wanted pregnancy. 

In those cases, the maternal-fetal organization says, patients should be told that their options include termination, even if that can’t happen in their home state.

Dr. Leilah Zahedi-Spung, a maternal-fetal medicine specialist who co-authored the special statement, moved to Colorado from Tennessee in 2023 after that state enacted a near-total abortion ban.

She said she saw firsthand how difficult it was in Tennessee to try to take care of patients without clarity around the law and without leadership that was willing or able to try to provide support. One goal of the statement is to help provide that kind of support to physicians, she said.

“We know you’re in a tough situation, we’re not blind to that. No one is blaming you for what you can and cannot do,” Zahedi-Spung said.

The society’s statement suggests that providers establish relationships with leaders within their clinical settings as well as in the community, region and state to agree on legal interpretations of abortion restrictions, particularly those who might hold leadership positions themselves. It also encourages doctors to establish referral networks locally and between states to ensure patient access.

“I have lots of people from Texas who have my phone number, and when they need me, they call me,” Zahedi-Spung said. “That is a system that works. And then those patients go back to safe providers who can take care of them.”  

Stateline reporter Kelcie Moseley-Morris can be reached at kmoseley@stateline.org.

More than half of women of reproductive age have seen or heard the false claim that hormones in contraceptives are harmful, and about 4 in 10 have been exposed to the false idea that hormones in contraceptives limit your ability to get pregnant in the future, according to a new survey.

The survey by KFF, a nonprofit health research organization, also found that about a third of women between the ages of 18 and 49 have seen or heard the inaccurate assertion that natural family planning methods are just as effective as hormonal birth control, and a similar percentage have been exposed to the erroneous idea that emergency contraceptive pills cause abortions.

According to the American College of Obstetricians & Gynecologists, long-acting reversible contraception and hormonal birth control are much more effective at preventing pregnancy than fertility awareness-based methods such as menstrual cycle tracking.

A large majority of reproductive age women said health care providers are their most trusted source for reliable health care information, with 85% saying they trust them a great deal or a fair amount. In contrast, only 26% said they trust U.S. Department of Health and Human Services Secretary Robert F. Kennedy Jr. for reliable health information, and 48% said they trust federal health agencies. About 25% said they trust AI tools and chatbots, and 14% said they trust  social media and social media influencers.

Kennedy has made several statements related to reproductive and sexual health that contradict the medical consensus, including that prenatal exposure to Tylenol and COVID vaccines may be linked to autism. Under Kennedy, HHS has shifted the focus of federal family planning and pregnancy prevention grants away from expanding contraceptive services and toward promoting childbearing or what’s known as restorative reproductive medicine.

The KFF survey found that among 3,538 women of reproductive age, about 35% said they saw or heard something about contraception on social media in the past 12 months.

Of those who saw social media posts about contraception, 78% said they had used contraception in the past 12 months, with 62% using hormonal methods. Of those, 8% stopped and 9% started a new method because of something they saw or heard on social media.

But for a larger share of this group, contraception-related posts led to further consultation, either with a doctor (19%) or online or from AI (36%). Women ages 18 to 25 were more likely to consult AI or the internet (46%) compared with women ages 36 to 49 (29%).

Stateline reporter Sofia Resnick can be reached at sresnick@stateline.org.

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A federal court ruling out of Idaho has potential implications for exceptions in abortion bans nationwide and could eventually end up before the U.S. Supreme Court to decide.

U.S. District Judge B. Lynn Winmill ruled earlier this month that the 14th Amendment of the U.S. Constitution provides a narrow right for a pregnant patient to obtain an abortion if the pregnancy could be a risk to their health, including their mental health. It’s the first ruling since the U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health in 2022 to find that the U.S. Constitution includes a right to abortion access in certain situations.  

Mary Ziegler, a legal historian and law professor at the University of California, Davis School of Law, said Winmill’s ruling could be the beginning of a “slow erosion” of the Dobbs decision, similar to the way that anti-abortion advocates used lawsuits and legislation to chip away at the law established by Roe v. Wade after it was decided in 1973.

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“They kind of worked over the course of decades to do a death by a thousand cuts, chipping away at its breadth,” Ziegler said. “This may be kind of a funhouse mirror version of that.”

For years, anti-abortion state officials and advocacy groups used various legal tactics to diminish access to abortion nationwide after Roe v. Wade determined that the procedure was a constitutional right. Over time, state legislatures passed procedural laws that made it more difficult for providers to offer abortion services, as well as so-called “fetal pain” laws, and worked up to passing the six-week and 15-week abortion bans that eventually led to Dobbs. 

Two years ago, U.S. Supreme Court justices were asked to consider whether Idaho could set aside federal law mandating stabilizing care in an emergency if that stabilizing care, in a doctor’s opinion, was to terminate a pregnancy. Now the question could be whether any pregnancy scenario where a patient’s physical or mental health is threatened is something that all states can regulate under Dobbs.

Health exceptions

Out of the 13 states that have near-total abortion bans, five have no exception for preserving a pregnant patient’s health, including Idaho, Arkansas, Mississippi, Oklahoma and South Dakota. 

All 13 have an exception to save a pregnant woman’s life, but doctors say there most often is no clear moment when they can easily say a person will die without an immediate abortion. Instead, doctors are left to guess whether terminating a pregnancy to save a patient would cost them their license to practice or land them in prison.

Even in states with health exceptions, some doctors hesitate to act because of the ban,  opting for delays that can cause medical complications such as organ damage or fertility loss. An Arkansas woman said she was denied an abortion during a miscarriage in 2024, resulting in a days-long ordeal that eventually led to her being transferred out of state to Kansas, where abortion is legal.

Winmill’s legal decision blocks enforcement of Idaho’s near-total abortion ban when a pregnancy is terminated under those circumstances. Idaho Attorney General Raúl Labrador, a Republican, appealed the decision to the 9th U.S. Circuit Court of Appeals on Wednesday, and also asked Winmill to pause that injunction while the decision is appealed.

“The state’s interest in protecting unborn children from unjustified abortion is irreparably harmed by the order, and public interest and equity support a stay for that same reason,” Idaho Assistant Solicitor General Aaron Green wrote in the request for a stay.

The attorney general and leadership at the Idaho Family Policy Center, a religious organization that helped craft the legislation that established the state’s ban, have expressed confidence that Winmill’s decision will be reversed quickly.

“The Fourteenth Amendment protects the basic rights that are part of the historical fabric of our nation, not a right to take the life of an innocent child in the womb, an act that was a crime at the time that the Fourteenth Amendment was ratified,” said Caleb Pirc, general counsel for the Idaho Family Policy Center, in a statement. “We fully expect Judge Winmill’s attempt to shoehorn a right to abortion into the Constitution to be swiftly rejected on appeal.” 

Supreme Court watch

Dr. Stacy Seyb, a maternal-fetal medicine specialist  for Idaho’s largest health system, St. Luke’s, sued state officials and the Idaho Board of Medicine in 2024, arguing that the state’s near-total ban prevented him from providing appropriate care to all of his patients. Maternal-fetal medicine specialists handle the most high-risk pregnancies, including patients carrying multiples and those with conditions such as high blood pressure and gestational diabetes.  

In his ruling, Winmill wrote that although Dobbs allowed states to regulate abortion access, that case was about elective abortions, and that his ruling was about a pregnant woman’s ability to seek care under “the most difficult and tragic circumstances,” almost always when the woman wanted the pregnancy.

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“By banning health-preserving abortion, Idaho attempts to deny this fundamental right on the basis that the threat of harm comes from a fetus, which depends on the woman for survival,” Winmill wrote. “But a pregnant woman’s health is not a state resource to be allocated at the legislature’s whim. The Fourteenth Amendment exists precisely to prevent subjugation like this.”

Winmill discussed the history of abortion bans in his opinion, writing that when the 14th Amendment was ratified in 1868, the states and territories that restricted abortion also included exceptions for therapeutic purposes when a doctor was acting in good faith.

But Winmill went further than many judges have gone by including a pregnancy’s threats to mental health, something that only Alabama has recognized as an explicit healthcare exception for abortions among states with bans, according to KFF. There, a psychiatrist is required to diagnose a pregnant patient with a serious mental illness that could result in their death or the death of the fetus in order to qualify for that exception.

“The brain is an organ of the body, and healthcare providers use empirical tools to reliably assess the risk of suicidality and the most effective treatments,” Winmill wrote. “It is an affront to human dignity to bar pregnant women from receiving life-saving care on the basis that the threat comes from a mental health condition rather than a physical health condition.”

Idaho’s role

Idaho has been at the center of the national debate about when health conditions take priority over an abortion ban since the first year after the Dobbs decision. 

The U.S. Department of Justice under former President Joe Biden sued Idaho to require that it acknowledge a federal law known as the Emergency Medical Treatment and Active Labor Act — better known as EMTALA — in the context of patients who come to the emergency room with pregnancies that may need to be terminated to prevent infection or other adverse health outcomes.

The U.S. Supreme Court heard that case in late April 2024, but sent it back to the lower appellate court in June, saying it was too early in the process for justices to have considered ruling on it. The case was later dropped by the DOJ under President Donald Trump, but St. Luke’s filed its own lawsuit against the state that is still ongoing. That case is also before Winmill in federal court.

At the time of the EMTALA arguments, Idaho officials had argued that if it allowed women to get a legal abortion in an emergency room, anyone could come to a hospital’s emergency department  and threaten to harm themselves.  

Tanya Pellegrini, co-director of litigation at The Lawyering Project and one of the attorneys who represented Seyb in this month’s case, said that wasn’t true under EMTALA, and it won’t be true following Winmill’s ruling. 

“I think the order really speaks for itself in terms of why mental health should not be treated differently from physical health,” Pellegrini said.

Ziegler said she won’t be surprised if Seyb’s case ends up before the Supreme Court in the near future, because it strikes at the heart of questions about the Dobbs decision that have yet to be fully resolved.

“It’s a really important question that they’ll have to address sooner or later,” Ziegler said. 

Stateline reporter Kelcie Moseley-Morris can be reached at kmoseley@stateline.org.

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