As doctors grappled with the risk of criminal prosecution in states where abortion is banned, hospital leaders and lawyers left them to fend for themselves with minimal guidance, sometimes “obviously,” according to a 29-page report released Thursday. Deliberately silent”. Presented by Senate Finance Committee Chairman Ron Wyden. The report concluded that poor guidance resulted in delays in emergency care for patients facing pregnancy complications.
Oregon Democrats launched an investigation in September into ProPublica’s reporting on preventable maternal deaths in states that ban abortion. Wyden requested documents from eight hospitals to determine whether they were complying with federal law requiring them to stabilize or transfer emergency patients; his committee has regulatory authority over enforcement. The report also draws on roundtable discussions with doctors in states that restrict abortion.
The resulting committee staff report sheds new light on the chaotic and dysfunctional hospital landscape in states with abortion bans, as well as new opportunities for hospitals to consider reforms and provide proactive and transparent guidance to patients and physicians.
Doctors who spoke on condition of anonymity described how hospital lawyers “refused to meet with them” for months, made it “nearly impossible” to contact them in “life-and-death” situations and offered little other than “reflection” on the law. help. Doctors described how other doctors gave false and potentially harmful messages that patients could not legally choose their own treatment options and that doctors could not legally treat ectopic pregnancies, a potentially fatal complication in which an embryo develops outside the uterine cavity.
“Doctors play lawyers, lawyers play doctors,” Wyden said in an interview. As a result, “women are being harmed, they are suffering, they may die, and we want to sound the alarm so that they are better protected and know what their rights are.”
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The Biden administration is telling hospital officials that under the federal Emergency Medical and Labor Act, or EMTALA, they have a duty to stabilize any patient who shows up in the emergency room, even if that means doing so would conflict with state abortion laws. If they cannot, in line with government guidance, they must transfer the patient to a hospital that is capable. Some states have fought this. In Texas, a court ruled that government guidance could not supersede the state’s abortion ban, and the Supreme Court rejected an appeal.
The investigation found that hospitals often did not write down information about how to handle legal conflicts between the ban and federal law, and in some cases provided it only on a “need to know” basis. One doctor in Idaho said nurses who were not included in the same email did not trust themselves to treat patients, adding that doctors were left to “figure out the second or third best option” on their own. One emergency physician who once worked in Texas said they encountered obstetricians and gynecologists who were afraid to help provide care. Another said colleagues “just want to get these patients out” because they fear the professional and personal risks of treating them.
The report describes five preventable deaths reported by ProPublica as examples of the deadly consequences of abortion bans. It also adds to the growing number of patients in crisis who are being denied treatment. Doctors shared some examples such as:
- A patient in Idaho had his placenta “snip” off one side of his uterus, causing massive bleeding; the patient was sent home from the emergency room four or five times with the bleeding. Doctors said it was only at the moment they were “on the verge of losing blood” that the hospital believed they were legally allowed to stabilize the patient.
- Another Idaho patient, who was 19 weeks pregnant, developed cramps and spotting but was sent home under the guidance of a maternal-fetal medicine specialist until she “went into an emergency.”
- In one patient, the amniotic fluid ruptured at 21 weeks and the fetus was not viable. Doctors refused to remove the fetus until her heart stopped, first sending her home and then, upon her return, asking her to wait more than six hours before agreeing to induce labor. ProPublica reported on a similar case in Texas, where a woman died of a fatal infection after waiting 40 hours for her fetus’ heart to stop.
Wyden was able to obtain documents and answers from the hospital that are rarely made available to the public. In December, ProPublica asked 50 Texas hospitals, which account for about half of the state’s births, to provide abortion care options, according to Texas hospital discharge data. Almost everyone refuses to offer them. Researchers who attempted a similar survey in Oklahoma last year encountered similar resistance after trying to get hospitals to share their policies for treating pregnancy complications amid the state’s ban, according to a study by Physicians for Human Rights.
The senators requested documents from eight hospitals across the country that had reported that emergency care for pregnancy complications was delayed or denied. He asked about their “policies, processes and procedures related to state abortion laws and emergency reproductive health care.” All eight responded, sharing hundreds of pages of documents and answers that the committee released with the report. The documents provide a rare and detailed look into the workings of a private health care system that could give hospital doctors and ethics committees new insights into the actions of others in response to the law.
The response showed many hospitals were relying on guidelines that were in place before the abortion ban was introduced, the report said. In most cases, doctors were given basic EMTALA guidance, but there was no discussion of how to handle the new abortion restrictions and were told to contact legal or ethics advisors with questions. Only a handful of hospitals have developed proactive guidance to help their providers respond to the new situation, and only two of these hospitals explicitly discussed conflicts between abortion bans and EMTALA and how to deal with them. It’s unclear whether the directives were made before media reports about the denial of care.
Freeman Health System in Missouri was found by federal investigators to have violated EMTALA after doctors told a patient whose amniotic fluid broke when she was nearly 18 weeks pregnant that they could not induce labor because of the state’s new abortion law. It submitted a strong protocol to the committee that included an intake flow chart for pregnant patients and an informed consent document informing patients of high-risk pregnancy complications that constitute an “emergency medical condition” under EMTALA. The Missouri hospital system is the only one of eight that says it provides comprehensive civil and criminal defense to any provider sued under state abortion laws, the report said.
Also under investigation is the Georgia hospital system that treated Amber Thurman. Doctors at Piedmont Henry Hospital discussed but did not provide procedures for clearing the uterus in a timely manner, according to a report from the state Maternal Mortality Review Commission, which concluded her death was preventable.
Piedmont told Wyden it had formed a task force after the state’s abortion ban took effect. The hospital said it has provided educational materials to health care providers about possible conflicts caused by the abortion ban, including a “decision tree,” a statement from the American College of Obstetricians and Gynecologists on how to handle exceptions to the abortion ban and guidance on complying with legal documentation requirements . (ProPublica reported in September that the task force provided education in the months after Thurman’s death.)
Piedmont, Freeman and the five other hospitals named in the report did not respond to requests for comment. Dr. R. Cliff Moore, chief medical officer and maternal-fetal medicine physician at Louisiana Women’s Hospital, said that when the diagnosis of early miscarriage is unclear, doctors “will wait for more information as long as the patient is stable.”
“There have been no changes to Women’s Hospital’s policy, evaluation, treatment and care for early pregnancy abortion,” he said.
To safeguard emergency reproductive care, the report calls for the re-establishment of abortion services nationwide and for the federal government to enforce EMTALA “to the fullest extent of the law.”
But with Republicans taking control of all branches of government next session, Wyden acknowledged that is unlikely to happen.
“More importantly, hospitals and provider groups should step up and do whatever they can to ensure patients get the health care they need,” he said. “That means making it clear that patients have a federal legal right to emergency care. , no matter where they live, and should not be on the verge of death to receive emergency care.”
The report makes four recommendations:
- It calls on hospitals and hospital associations to work together to provide doctors with training, guidance and resources to ensure they provide emergency pregnancy care in abortion-ban states.
- It said professional medical organizations “should publish guidance and publish standards that clearly define appropriate clinical care in obstetric emergencies.”
- It encourages hospitals to support all doctors, from obstetricians and gynecologists to family physicians, in becoming certified to prescribe mifepristone, which is part of a two-pill abortion pill regimen.
- Doctors should counsel patients about their rights under EMTALA and how to report violations, the report said.
