As abortion bans loom, doctors worry over complications, second-guessing in emergency care

On any given day, dozens of protestors converge outside the Knoxville Center for Reproductive Health, this East Tennessee city’s only abortion provider after an arsonist torched a nearby Planned Parenthood clinic on New Year’s Eve.

The group has grown considerably in recent months, clinic staff say. As has the vehemence of their taunts and their pleas to patients to reconsider their choices.

The clinic, which also provides breast cancer screenings, contraceptives and general gynecological care faced a bomb scare last month when a suspicious box (ultimately containing only an air conditioning unit) was left outside. So, on one recent morning, even a cryptic warning from one of the protestors to a staffer to stay out of the building, especially today, was treated as a normal work day occurrence.

No one is staying home. The clock is ticking.

The expected end to legal abortion in Tennessee, as well as in most neighboring states, has led to an increase in patients seeking abortions, according to clinic staff. The waiting list here now is roughly two weeks long, they say. And that’s better than most clinics like this one throughout Tennessee and in other southern states.

"I think people are nervous, or they're getting scared," said Dr. Aaron Campbell, medical director of the 47-year-old Knoxville clinic, which is likely to close down if abortion in most cases becomes illegal, as expected. "I think people are cognizant of what's happening. They're trying to get in here just in case something does happen legally and they can't have that option in Tennessee anymore."

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But the implications don’t stop with abortion care, which is considered by the American College of Obstetricians and Gynecologists “to be an essential component of comprehensive, evidence-based healthcare.” 

According to more than a dozen health care professionals the USA TODAY Network interviewed in multiple southern states, the expected decision by the Supreme Court to overturn its landmark 1973 Roe v. Wade decision legalizing abortion could have a myriad of unanticipated consequences for women’s health care.

Legally confusing state abortion bans could lead to criminal investigations of some miscarriages, they say.  Some also worry that the bans might force doctors to delay treatment for certain types of failed pregnancies until women are near death from infections or bleeding.

Others wonder if hospital emergency rooms will soon be forced to treat complications from botched abortions not seen in 50 years. 

Health experts also predict that such laws will have a chilling effect on medical students wanting to specialize in obstetrics. Abortion care is a recommended component of this type of medical training and would be mostly inaccessible in states that have banned it. 

Strict abortion laws are also likely to drive many medical specialists -- such as fetal medicine experts, fertility experts, and obstetricians/ gynecologists -- to practice in other states rather than facing potential legal jeopardy.  

"I'm very concerned about the intended consequences (of overturning Roe), but also the unintended consequences that even those of us who are experts in the field can't anticipate," said Dr. Nikki Zite, a Knoxville-based OB/GYN and an officer with the Tennessee chapter of The American College of Obstetricians and Gynecologists. "I think people are very afraid. It's a very confusing time to be practicing medicine related to pregnancy, whether that's an emergency room physician, a family practice physician or an OB/GYN."

The end of Roe v. Wade

If Roe is overturned as many anticipate, individual state laws will govern abortion access. According to the reproductive rights research organization The Guttmacher Institute, 26 states would severely restrict access to abortion or ban it outright.

Tennessee’s 2019 post-Roe “trigger law” calls for banning abortion in most cases and would make it a felony for a doctor to perform one. Women seeking to terminate their pregnancies would be exempt from criminal prosecution.

Once the Supreme Court overturns Roe, the state Attorney General would notify the Tennessee Code Commission – setting off a 30-day countdown for the ban to take effect. For now, the Tennessee Attorney General’s Office won’t say how it’s planning for this expected outcome. 

“I know there are a lot of questions about this but it would not be prudent for the office to comment before the ruling comes out,” said spokeswoman Samantha Fisher.

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With the exception of North Carolina, Florida, and Georgia, most of the southern states have some form of ban on abortion on the books that could be enforced if federal abortion protections are taken away. Georgia has a six-week ban that has never taken effect but could be implemented pending the ruling.

North Carolina would be one of the few states in the southeast where abortion care is expected to remain legal.

North Carolina would likely be the nearest abortion provider for over 11 million women ages 15 to 49 in much of the southeast if Roe is overturned and states move to ban abortion. That’s up from 230,000 women currently, according to the Guttmacher Institute.

Unforeseen Consequences 

Many of the state abortion bans that could take effect, including Tennessee’s trigger ban, have exemptions that allow for abortions that are “necessary to prevent the death of the pregnant woman or to prevent serious risk of substantial and irreversible impairment of a major bodily function of the pregnant woman.”

But doctors interviewed for this story worry that this language is too vague and may make doctors, who could be subject to prison for breaking the law, hesitate in the case of medical emergencies.

Consider a woman coming into the ER with severe pain because she is in the process of miscarrying but whose fetus still has a heartbeat. At what point do doctors intervene to extract the fetus, even if they know the pregnancy will eventually fail?

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Even life-threatening ectopic pregnancies, in which a fertilized egg develops outside the uterus, may be subject to medical second-guessing, said Dr. Jessica Rosen, an emergency room physician in Nashville.

“I think, unfortunately, there’s so much uncertainty about how exactly it will be interpreted. I think there will be a lot of gray-area cases we’ll see in the ER,” Rosen said. “I have a lot of sympathy for my OB-GYN colleagues because I think that they're going to be put in some very difficult positions.”

Nashville’s primary birthing provider, Vanderbilt University Medical Center, declined to comment on the state’s trigger law and what guidance it’s providing its own doctors.

Dr. Beverly Gray, a general OB-GYN and residency director at Duke Obstetrics and Gynecology in Durham, uses the example of a woman who has an unplanned pregnancy while also getting treatment for cancer or heart disease. Without access to abortion they will require a higher level of care than might be available at their local health center, she said.

“Those patients are more likely to need critical care services around the time of their birth and hospitals will need providers that can practice more acute higher-level care,” Gray said.

It’s a situation that could worsen chronic healthcare provider shortages in maternity care.

An estimated 2.2 million women in the U.S. live in counties defined as maternity care deserts, with no birth centers, obstetricians, or hospitals with obstetric units, according to the March of Dimes. There is also an estimated shortage of about 8,000 obstetricians in the U.S. as of 2020, according to ACOG.

“Now you’re going to have a larger number of women carrying fetuses to term and less access to care," said Dr. Richard Shannon, the Chief Quality Officer for Duke Health in Durham. "I think you’re also going to see medical students wonder whether they should enter obstetrics given that an abortion or decision that a medically necessary abortion should be undertaken may cause a physician to think, “Do I want to risk being arrested, tormented or ostracized?”

The impact across state borders

Even in states like New York, which has protections in place for abortion, providers are anxiously awaiting a decision. 

Tenesia Richards, a clinical nurse manager and community outreach coordinator at a women’s health clinic in Manhattan, worries about what this will mean for a healthcare workforce that has been depleted after the COVID-19 pandemic and will have to respond to the needs of patients traveling in from out of state. The clinic’s goal is to be able to increase access and not turn away anyone, she said.

But this will mean making decisions that could impact the quality of care.

“When you have people coming in to get an abortion, they need to be scheduled more urgently than a pregnant person with no complications that needs an appointment. They end up getting pushed back,” she said. “This is a Pandora’s Box we are opening.”

Louisiana is among the states where lawmakers have passed some of the most abortion restrictions in the past four decades. When Frances Gill was in medical school at Tulane University, she felt the taboo against discussing abortion while teaching sex ed at local high schools. 

Gill was a volunteer with New Orleans Adolescent Reproductive Health Project and said that volunteers were trained not to mention abortion lest parents complain and attempt to oust the program. 

“If a student had a question, we could direct them to some resources, but we could never say, ‘This is where the abortion clinic is in town,’ or ‘This is how you get an appointment,’” Gill said. “It was safer for the existence of our program to never broach the topic.”

Gill is now a psychiatric resident at the Los Angeles County USC Medical Center. And while she may no longer teach sex ed, Gill said a nationwide abortion ban could impact psychiatrists. Psychiatrists already work to treat psychiatric illnesses that come with pregnancy. The peripartum period — the time directly before, during and after birth — is a “really high-risk time” for psychiatric illnesses, Gill said. 

“Having to deal with the stress of an unplanned or unwanted pregnancy and being forced by the state to carry that pregnancy to term and deliver in a situation where someone might be psychiatrically vulnerable, that definitely puts the patient at a higher level of risk,” Gill said. 

“If Roe v. Wade is overturned, I think every medical specialty will be affected by that.”

Note: This story was updated to expand on/clarify the nature of the bomb scare the Knoxville clinic faced in May 2022.

Frank Gluck is the health care reporter for The Tennessean. He can be reached at fgluck@tennessean.com. Follow him on Twitter at @FrankGluck.

Maria Clark is a general assignment reporter with The American South. Story ideas, tips, questions? Email her at mclark@gannett.com or follow her on Twitter @MariaPClark1.