28 Nov, 13 | by BMJ
The US Supreme Court recently ruled in a 5:4 decision against an emergency application to stop a Texas law that requires doctors who perform abortions to have admitting privileges at a hospital within 30 miles. The basis for the Supreme Court ruling is that this restriction doesn’t place an “undue burden” on a woman seeking an abortion.
A first trimester abortion performed by a competent provider in a clean setting has a major complication rate of 0.05%. Mortality at or below 8 weeks is 0.1 per 100 000 legal induced abortions and rises slightly to 0.4 per 100 000 by 12 weeks. While major complications and mortality rates are still very low in the second trimester they do rise by gestational age. For example, at 13-15 weeks, mortality is 1.7/100 000 procedures and 8.9 per 100 000 procedures at and above 21 weeks.
Restrictive abortion laws, ironically touted as safety measures, result in delays getting care and increase the rate of second trimester procedures and therefore the risk. If all women choosing elective abortion accessed services before eight weeks’ gestation, more than 80% of abortion-related deaths could be prevented.
First trimester abortion in an outpatient setting is on par safety wise with colonoscopy, which has a serious complication rate of 0.8 per 1000 procedures (0.08%), however there is no law requiring gastroenterologists in Texas to have admitting privileges within 30 miles from their outpatient setting. Singling out abortion can therefore not be about patient safety.
Admitting privileges within 30 miles of an outpatient setting does nothing for patient safety. Dealing with a serious complication requires a stocked crash cart, oxygen, the expertise to administer emergent medical care, a telephone to call 911, and paramedics to take the patient to the closest hospital. Furthermore when an emergency room doctor or Ob/Gyn on call receives a patient in distress they don’t wait for the transferring physician.
The physician or healthcare provider performing a procedure may not be the best person to manage a surgical complication. Colonoscopy provides another good analogy as in the unlikely event of a perforation the required surgical care, if needed, would be performed by a surgeon. If Texas politicians are concerned about maintaining continuity of care for patients why allow gastroenterologists to perform colonoscopies at all?
The Supreme Court’s decision has a chilling ramification beyond the obvious immediate concern of reduced access to safe, legal abortion, which may lead to procedures at a later gestational age or even cause some women to attempt risky, unsupervised medical abortions with medications purchased across the Mexican border or online.
By allowing such a law to stand, five justices of the Supreme Court are saying that it is constitutional for the government to enact laws that flout science and interfere with the delivery of medical care for women based on political, personal, or religious agenda.
To place a woman at higher risk for a medical or surgical complication because of a law that ignores science and the standard of care is the very definition of an “undue burden.”
Jen Gunter is an obstetrician/gynaecologist in San Francisco. She blogs on her personal site at drjengunter.com.