When Is Abortion Considered Medically Necessary?

Some restrictive abortion laws have exceptions for "medical emergencies"—here's what that really means.

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The Supreme Court has overturned Roe v. Wade, a long-standing precedent that gives pregnant people the constitutional right to access safe and legal abortions in the United States.

At the center of this ruling stands Mississippi's Gestational Age Act, a law banning all abortions past 15 weeks' gestational age, except "in a medical emergency or in the case of a severe fetal abnormality."

The Mississippi law—along with other restrictive abortion laws, like SB 8 in Texas and a 15-week abortion ban in Florida set to go into effect in July—don't specifically define what could constitute such a "medical emergency." Instead, states may just identify it as a "physical disorder, physical illness, or physical injury" that could cause "substantial and irreversible impairment" to the pregnant person, should the pregnancy continue.

To help clear things up a bit, here's what a medical emergency that would require an abortion can look like—and how overturning Roe will impact these medically necessary abortions.

Medical Emergencies That Can Require Abortion

Many people don't quite understand what could be considered an emergency during pregnancy that necessitates an abortion—and the language of the law certainly doesn't help clear it up.

"I think what's unfortunate is people don't understand medical necessity until it's their situation, and that's when it suddenly becomes very clear and apparent that a medical decision should be made between a patient and their doctor," Cindy Duke, MD, PhD, a dual board-certified virologist and OB-GYN, and medical director and owner of the Nevada Fertility Institute, told Health.

According to Dr. Duke, a medical emergency is determined by a physician or health care professional, not by the state, and there are multiple medical conditions that could result in a medically necessary abortion.

One common reason is the effect of pregnancy on the heart, specifically the tremendous strain it can place on it by disrupting blood flow and increasing the risk of blood clots from elevated hormones. "Some people are medically in conditions where that would be too much for their system and so it's either terminating a pregnancy or basically signing a personal death warrant," said Dr. Duke.

Ectopic pregnancies—during which a fertilized egg implants itself outside of the uterus (mainly in one of the fallopian tubes)—are another example of medical emergencies. Ectopic pregnancies only occur in 1%-2% of pregnancies, but make up about 2.7% of all pregnancy-related deaths. A fetus cannot survive an ectopic pregnancy, which, left untreated for too long, can be harmful or fatal for the pregnant person.

According to the Kaiser Family Foundation, other life-threatening conditions for the pregnant person include: severe preeclampsia, newly diagnosed cancer that needs treatment right away, and an intrauterine infection known as chorioamnionitis following a premature rupture of the amniotic sac. A placental abruption, in which the placenta separates from the uterine lining, may also be considered a medical emergency in some cases of extensive bleeding.

Still too, lethal fetal abnormalities may lead to a nonviable pregnancy during which abortion may be preferred. According to Dr. Duke, when health care providers discover abnormalities that would make the fetus incompatible with life, parents may choose to compassionately terminate the pregnancy to prevent the fetus from being born only to pass shortly after. These fetal abnormalities—which may only be detected on a 20-week fetal anatomy scan—include anencephaly (an underdeveloped brain and incomplete skull), renal agenesis (absence of one or both kidneys), and hydrops fetalis (extensive fluid build-up and swelling).

How Overturning Roe v. Wade Will Affect Medically Necessary Abortions

With Roe overturned, doctors may not be able to do everything in their power to protect patients, Josie Urbina, MD, an OB-GYN and fellowship-trained abortion specialist at the University of California San Francisco, told Health.

The COVID-19 pandemic—and the cases in pregnant women—is a key example of how medically necessary abortions might be affected: "When pregnant patients were admitted for COVID, sometimes to help them breathe better because of respiratory failure, we would have to do medically necessary abortions to free up lung space," said Dr. Urbina. But without Roe, "we won't be able to do these types of interventions," she added.

And overturning Roe will not stop abortions altogether. Instead, there may be a rise in unsupervised self-induced abortions. "Abortions will still occur but people may become desperate and have them under unsafe circumstances," said Dr. Urbina, who explained that in a pre-Roe world, people would insert different instruments into their cervix and uterus to cause an abortion, or take unregulated medications, which would lead to a host of health complications.

Data shows the reality of this risk: a 2017 study in The Lancet found that globally, there were 25 million unsafe abortions every year between 2010 and 2014, with most unsafe abortions occurring in countries with restrictive abortion laws. And a 2019 article published in The New England Journal of Medicine recounts many cases before Roe where self-induced abortions or abortions from doctors working the black market led to death of both the mother and fetus.

It's important to note too that communities with less access to health care, such as immigrant populations, those without insurance, or people with insurance but high deductibles, are more likely to be affected from abortion bans, said Dr. Urbina.

People of low socioeconomic status, who are disproportionately Black, Latinx, and Native American, are more likely to need a medical abortion because of health complications. "Conditions like asthma, obesity, diabetes, high blood pressure, and thyroid problems [tend to] affect people of lower socioeconomic communities," Dr. Urbina added. "Banning medically necessary abortions is going to affect the most oppressed and historically marginalized communities in our country especially those living in restrictive states."

Overall, the medical necessity of abortion in some cases is clear—despite the often indeterminate language of certain laws.

"There are situations where pregnancy termination in the form of the abortion is the only medical intervention that can preserve a patient's health or save their life," the American College of Obstetricians and Gynecologists and Physicians for Reproductive Health wrote in a 2019 joint statement. "As physicians, we are focused on protecting the health and lives of the patients for whom we provide care. Without question, abortion can be medically necessary."

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