In February 2023, Kyleigh Thurman was sent home from a Texas emergency department (ED) bleeding and in pain. Although she was experiencing an ectopic pregnancy, a potentially deadly condition, physicians refused to treat her because of the state’s abortion ban, her lawyers allege.
Mylissa Farmer, whose water broke prematurely, was told by emergency physicians in Missouri and Kansas that her fetus could not survive and she was at risk of bleeding and serious infection but that laws prohibited terminating her pregnancy, an amicus brief states. She wound up traveling four hours while in labor to receive necessary care.
In Florida, a 15-weeks-pregnant patient leaked amniotic fluid for an hour in an ED waiting room and then miscarried in a public restroom, according to the Associated Press (AP).
Dozens of other patients have also suffered similar experiences since the U.S. Supreme Court’s Dobbs decision overturned the constitutional right to an abortion in 2022, the AP reports.
In the 13 U.S. states that ban abortion and in the others that severely restrict it, such cases unfold amid physicians’ fear of punishment and confusion over exemptions like those to save a patient’s life. In Texas, for example, a doctor deemed to have performed an illegal abortion faces up to 99 years in prison.
“ED staff sometimes are afraid to perform any sort of procedure, such as those for miscarriage management, that could be interpreted as ending a pregnancy, even though these are not elective abortions,” says Atsuko Koyama, MD, an emergency medicine (EM) physician in Arizona.
Each year EDs across the United States tally some 3.8 million visits by pregnant patients. Some come with conditions, such as high blood pressure, that can quickly escalate from mild to life-threatening.
“It’s a different ball game now in terms of balancing the criminal consequences of state laws … against what are tenets of foundational care for us,” says Alison Haddock, MD, president of the American College of Emergency Physicians (ACEP).
Those tenets include adhering to the Emergency Medical Treatment & Labor Act (EMTALA), the federal law requiring EDs that receive Medicare funding — virtually all EDs — to provide care to stabilize patients in a medical emergency. In July, the U.S. Department of Health and Human Services issued a letter reminding providers and hospitals that EMTALA requires them to perform an abortion when the procedure is necessary to stabilize a patient’s emergency condition (or to safely transfer the patient). EMTALA overrides state restrictions, the agency went on to say. This guidance has faced legal challenges, but the Supreme Court has so far declined to weigh in, leaving the legal landscape murky.
“It’s a different ball game now in terms of balancing the criminal consequences of state laws … against what are tenets of foundational care for us.”
Alison Haddock, MD
President, American College of Emergency Physicians
Meanwhile, the fallout on emergency medicine continues. Some future ED physicians say they want to avoid training in restrictive states, and current providers grapple with varied challenges that may include treating patients who’ve had to continue risky pregnancies.
“I feel handicapped in helping patients, and I feel hopeless,” says Maya Barker, MD*, an emergency physician at a major academic hospital in Texas. “I never thought I would see this day. It’s been devastating.”
When pregnancy becomes an emergency
Four U.S. states allow abortions only when necessary to save the life of the pregnant patient. Nine other states with bans also allow exceptions for serious health risks, such as “serious permanent impairment of a life-sustaining organ.” But what qualifies for an exemption can seem hazy because state laws are not written in precise medical terms.
So EM physicians say that they at times must treat pregnancy-related conditions in a dramatically altered landscape.
Those conditions include premature rupture of the amniotic sac (PPROM), commonly called water breaking. “I had a terrifying case early on in which a patient’s water broke in the second trimester,” Barker recalls. “Those fetuses frequently do not survive, and the condition put the mother at risk of sepsis, which could have killed her. But the fetus still had a heartbeat,” so, Barker says, she couldn’t provide what she believed was appropriate treatment. “That’s the definition of moral injury,” she says, referring to the emotional harm physicians experience when they feel unable to provide quality care.
“Now, worried doctors sometimes say, ‘You’re not bleeding so much. You’re not dying. Go home and miscarry there.’”
Andreia Alexander, MD, PhD
Indiana University School of Medicine
Ectopic pregnancy, in which a fertilized egg implants outside the uterus, making viability impossible, is another pregnancy complication that often brings patients to the ED. In such cases, the fetus may still have a heartbeat, leaving some emergency physicians afraid to end the pregnancy, says Haddock. But continuation of an ectopic pregnancy can put the pregnant person’s health in serious jeopardy, because it can cause fallopian tube rupture, severe shock, and hemorrhage.
ED physicians also treat miscarriages, which affect 10% to 20% of pregnancies. “We see miscarriages daily,” says Andreia Alexander, MD, PhD, an assistant professor of emergency medicine at the Indiana University School of Medicine. “Ideally, we have a few approaches at our disposal, including providing medication to expedite the passing of tissue. Now, worried doctors sometimes say, ‘You’re not bleeding so much. You’re not dying. Go home and miscarry there.’”
Laws: Confusing or clear?
Not all emergency physicians in states with bans say they are confused by the abortion laws.
“Some physicians feel like these laws are not about the care we provide because they are intended for elective abortions,” says Haddock. “There is great diversity in opinions in emergency medicine.”
Some physicians argue that individuals who oppose abortion bans — and not legal restrictions — are creating the confusion, and that laws clearly allow treating dire emergencies such as ectopic pregnancies.
But others say that real-world pregnancy emergencies aren’t always so cut-and-dried, in part because it can be challenging to determine just how close to danger a pregnant patient truly is.
“I’ve seen a bleeding pregnant patient who otherwise looked great and who I believe got sent home because of lack of clarity around abortion laws,” says Alexander. “A few hours later she came back by ambulance in very bad shape.”
Given current conditions, some hospitals are working to help ED providers handle murky questions. “Our health care system did a really good job,” says Alexander. “They set up decision pathways so that our staff would know what to do. We also have an OB/GYN on call 24 hours to advise us, and if they think it’s necessary, they can bring in the hospital’s attorneys.” Unfortunately, says Haddock, the creation of such EM-specific resources is not common.
Without robust resources, understanding varied and evolving laws can be tough, physicians say. The Texas legislature eventually added a provision allowing a legal defense for physicians facing prosecution or civil liability for terminating ectopic pregnancies and PPROM, says Barker, “but some doctors still don’t know about that.”
Patients may be even less likely to understand legal complexities. “I had a bleeding patient who waited to be seen because she’d had an abortion in the past and worried that she would get in trouble because we’d assume she had one now,” says Alexander. “She wound up needing a blood transfusion.”
Further fallout for EM physicians
Some emergency physicians say abortion restrictions complicate their work in ways beyond the immediate provision of pregnancy-related emergency care.
In Texas, Barker feels rattled by required abortion-related documentation. “We need to report any complication related to abortion, even if the procedure was performed long ago or in another state, which seems Big Brotherish to me. Also, it’s stressful having to remember to do this after a busy shift, since there’s a 72-hour deadline.”
She also says abortion restrictions can hamstring sensitive conversations with pregnant patients. “We diagnose pregnancy all the time in EDs, and sometimes those are unwanted. But because of penalties for aiding and abetting abortions, I find myself treading cautiously. I’ve been advised to say only that a patient can seek a second opinion in a nonrestrictive state.”
In states where providers can counsel pregnant patients about abortion, they may feel pressure to do so quickly. “In some cases, the clock is ticking. Indiana allows abortions up to 10 weeks in instances of rape, so we need to connect patients to help quickly,” says Alexander.
Abortion laws can also complicate matters when a high-risk pregnancy needs to be terminated for medical reasons and doing so requires transferring the patient out of state, says Jessica Kroll, MD, president of Idaho’s ACEP chapter. “In a high-risk, complicated pregnancy, we’re on the phone with our maternal-fetal doctor, our risk management department, our lawyers, and out-of-state hospitals,” she says. We ask, ‘Can we treat the person here legally? How time-sensitive is their need? Is a bed available in another state? And is this patient stable enough for a three-hour helicopter ride?’”
Physicians point to another difficult shift in ED care: the potentially drastic actions taken by patients with unwanted pregnancies.
“If they don’t know they can go out of state, or if they can’t for some reason, patients may resort to self-harm,” says Alexander. “Between 2018, when I started working here, and 2023, when the law went into effect, I had never seen a pregnant patient who attempted suicide or tried to harm the fetus. I’ve now seen five.”
“One person I saw really sticks with me,” she adds. “She threw herself from a moving car.”
ED physicians also note the impact on their own mental health. “It’s been a roller coaster for almost two years, as abortion access has worked its way through the courts. We’re not talking about just a possible fine or malpractice suit, but a felony conviction,” says Kroll.
And as her ACEP chapter’s president, she has found the stress to be even higher. “We’ve had a lot of harassment of health care workers here, and I was getting a lot of media calls,” she says. “At times, I’ve been afraid for myself and my family.”
What about the next generation of emergency physicians?
Beyond impacting current providers, abortion laws are affecting where future emergency physicians want to train.
Consider some recent data: In the last Match® cycle (2023-2024), nearly 40% of medical school respondents said state reproductive health laws had moderately or strongly influenced their residency application decisions. What’s more, the number of U.S. MD students applying to EM residencies in states that have abortion bans dropped 7.1% in 2024 — and rose 2.4% in states that allow the procedure — according to an AAMC report.
“We saw a relatively sharp decline in states with bans,” says Atul Grover, MD, PhD, executive director of the AAMC Research and Action Institute and a coauthor of the report. “That’s concerning in part because underserved populations will be hardest hit. Many states with restrictions are those already facing physician shortages, and physicians often stay in states where they train. About half stay in the state where they complete residency, and the rate is even higher if they’ve gone through medical school there as well.”
Some trainees say they want to avoid restrictive states to safeguard their own reproductive care.
“I was a medical student in Georgia when Roe was overturned, and I was terrified,” says Trupti Patel, DO, now an EM resident at Mount Sinai in Manhattan. “Even on the 1% chance I would become pregnant, I was concerned about my options. I worried about the effect on my career, my limited finances, and my future.”
“We saw a relatively sharp decline [in EM residency applications] in states with bans. That’s concerning in part because underserved populations will be hardest hit.”
Atul Grover, MD, PhD
Executive director, AAMC Research and Action Institute
Students also say they hope to avoid educational and legal constraints. “I did apply to residencies in restrictive states because students can’t risk applying only where they most hope to train,” says Susan Jones,* a Boston University School of Medicine fourth-year student. “But it’s a priority for me to receive the full gamut of education. Plus, trying to interpret convoluted laws [as a resident] seemed mind-boggling.”
For her part, Patel is grateful to have landed a residency in a less-restrictive environment. “I did rotations in emergency medicine and OB-GYN in two Southern states during medical school,” which meant that until her New York residency, she hadn’t seen a dilation and evacuation, a procedure used for both abortions and miscarriage management that removes the contents of the uterus.
Meanwhile, some EM leaders are working to address education-related concerns. For example, a 2023 Journal of Graduate Medical Education article laid out recommendations for adapting EM residencies after Dobbs. Those suggestions included helping residents in restrictive states travel elsewhere to learn relevant procedures.
In Texas, Barker launched a course on reproductive health for EM residents and medical students that covers such topics as emergency contraception and initiating birth control in the ED. In addition, she started a project to better train EM physicians in providing medications for miscarriage management. “Miscarriage is truly a time-sensitive emergency, and it can be difficult to get those medications from pharmacies because they are also used for some abortions,” Barker says.
Still, some trainees say they would simply prefer to avoid restrictive states. “I don’t want to be constrained in the care I provide patients,” says Patel, pointing to an experience that drove the point home for her.
“I was working as a scribe in the ED, and a patient found out she was pregnant. She said, ‘I’m in an abusive relationship. I can’t have this baby.’ It was so heartbreaking to see how afraid she was. I don’t want a legislature to tell me how I can help a patient right in front of me.”
*Not her real name
