Duke Physicians Warn that SB20 will Lead to More Maternal Death
CHARLOTTE, N.C. (WBTV) - Last week the NC Republican legislature passed a 12-week abortion ban. The bill provides exceptions after 12 weeks, capping abortions at 20 weeks in cases of rape or incest and 24 weeks for “life-limiting” fetal anomalies, and an existing exception for when the life of the pregnant woman is in danger would remain.
The Governor vetoed SB20 on Saturday. Republican lawmakers announced today that they plan on overriding the Governor’s veto.
As the politics play out in Raleigh, and Republicans promote SB20, OBGYNs from Duke Health say that the passing of SB20 will increase the maternal death rate and prevent doctors from doing their jobs — providing the highest level of maternal health care to their patients.
Dr. Brenna Hughes is the Vice Chair for Obstetrics and Quality at Duke and a maternal-fetal medicine specialist at Duke’s Birthing Center. She has helped deliver thousands of babies. She’s also a mom to six children.
“I like to say I do not know much about politics,” said Hughes.
“But I know a lot about medicine, and it is quite clear to me that we will see increased maternal mortality as a result of this bill.”
Experts say that the wording in SB20 is such that there are exceptions for maternal emergencies, but that the way they are interpreted by providers can vary significantly leaving doctors to decipher whether a patient is sick enough for them to provide life-saving medical care.
“We have seen in other states where people are forced to bleed to the point that they are unstable and can’t maintain their own blood pressure and need to be in the ICU before someone will terminate their pregnancies for fear of prosecution,” said Hughes.
The US already has a maternal mortality crisis ranking last among the world’s developed countries, and in North Carolina, the maternal death rate is even higher than our national average.
Dr. Hughes cites as a key contributing factor what she terms “maternal-care deserts,” rural counties where there are no hospitals. In North Carolina, 20 counties have no hospitals, and 38 counties have no labor and delivery hospitals.
Additionally, Dr. Hughes says that even under the current law – a 20-week ban – it has been particularly difficult to treat fetal anomalies, and she has already had to refer patients to other states.
Some patients seek abortions later in pregnancy after learning about a genetic or health condition in the fetus, many of which are not diagnosed until after the first trimester.
“We typically do anatomy, ultrasound, and pregnancy between 18 and 20 weeks gestation, " said Hughes.
“Oftentimes, severe anomalies may not even be diagnosed until close to 20 weeks. And if those anomalies require an amniocentesis to look for chromosomes, those results can take up to two weeks.”
Physicians Feel Shutout
Republicans say they consulted medical professionals but it’s worth noting not a single statewide medical organization has shown support for SB20. The North Carolina Medical Society, the North Carolina Obstetrical and Gynecological Society and the North Carolina Academy of Family Physicians all oppose the bill.
Some physicians say they’ve been left out of the democratic process and that SB20 was drafted without adequate consultation from medical experts.
“You may have been hearing legislators saying they’ve talked to doctors about this legislation,” said Beverly Gray, OB-GYN and Division Chief, Women’s Community, and Population Health, Duke University.
“Yes, we have tried to talk to as many legislators as will listen to us. Many of them just flat out would not talk to us about what we had to say about medicine, about evidence-based care, about the scenarios we see every single day.”
Doctors say the process to care for patients, particularly patients between the 12th and 20th week of their pregnancy, is complicated and poses many different decisions for a physician and that the body doesn’t always follow bullet points in a bill.
Dr. Jonas Swartz, OB-GYN and an Assistant Professor of Obstetrics and Gynecology at Duke Health says that the body doesn’t know that you’re 12 weeks pregnant and there’s an abortion ban so it can’t get sick anymore.
“The overall effect is it’s just going to have a chilling effect on care,” said Swartz.
“It’s going to make it so that North Carolinians have worse healthcare, and specifically, North Carolinian women have worse healthcare.”
The General Assembly’s Republican party issued a statement of its own about the bill last Friday. It is still unclear what medical experts Republicans spoke to before drafting the bill.
Today the ACLU of North Carolina and Planned Parenthood South Atlantic responded to Senator Joyce Krawiec, Senator Lisa Barnes, Senator Amy Galey, and Senator Vickie Sawyer’s statement.
Senate Bill 20 bans abortion after 12 weeks of pregnancy in most circumstances. Additionally, it creates more barriers for patients seeking abortion across the board. The ACLU of North Carolina and Planned Parenthood South Atlantic consulted medical and legal experts to analyze the bill language in an attempt to understand its impact on health care providers and patients.
Here’s what you need to know about the key points raised by anti-abortion politicians:
CLAIM: Senate Bill 20 doesn’t add any new restrictions to abortion before 12 weeks of pregnancy.
FACT: Senate Bill 20 adds a multitude of new measures that will restrict access to abortion across the board, including:
- Makes it harder to get a medication abortion — the most common form of abortion in the state — by: Preventing abortion providers from providing medication abortion after 10 weeks of pregnancy, cutting access to care by one week (from 11 to 10 weeks). Requiring patients to have at least 2 and potentially 3 in-person visits for a medication abortion, which will be a significant and potentially insurmountable barrier for many patients. This change is contrary to FDA guidelines that allow medication abortions to be prescribed via telehealth.
- Authorizes the imposition of new, medically unnecessary clinic facility rules that could be impossible for certain clinics to comply with and have a devastating impact on access to care.
- Forces patients to listen to state-mandated, non-scientific, anti-abortion counseling and creates more paperwork for the patient, neither of which have any medical benefit.
- Adds a requirement suggesting real-time ultrasound must be forced on the patient — even over the patient’s objection and even if the patient covers their eyes — a measure previously passed by the North Carolina General Assembly that has been permanently blocked by the courts.
- Creates myriad new reporting requirements that could compromise patient confidentiality and provider safety.
CLAIM: Senate Bill 20 doesn’t restrict the use of medication abortion after 10 weeks of pregnancy nor does it prohibit physicians from prescribing “abortion-inducing drugs” off-label, as long as it is during the first 12 weeks of a woman’s pregnancy.
FACT: Senate Bill 20 prevents doctors from providing medication abortion after 10 weeks of pregnancy due to the new requirement that the doctor shall confirm the pregnancy is less than 70 days (or 10 weeks) before providing the abortion. Currently, doctors in the state routinely provide medication abortions up to 11 weeks of pregnancy, in line with commonly accepted best practices for the medications. Additionally, Senate Bill 20 prevents doctors from using the medications commonly used for an abortion after 10 weeks, including in cases of medical emergency, rape, incest, or where the fetus has a “life-limiting anomaly” — even when this medication is used as part of the safest care plan for the patient, which may be true at later stages of pregnancy.
- In section 90-21.88A of the bill, the text plainly states that before a physician provides a medication abortion, they must examine the woman in person and they shall meet all of the conditions listed thereafter. Each of the conditions listed — including verification that the pregnancy exists, determination of blood type, and verification that the pregnancy is under 70 days — is a condition that must be met in order to provide the medication abortion. There is no doctor discretion written into the bill. As a result, under the Article, if the doctor cannot verify that the pregnancy is under 70 days because, for example, the ultrasound estimates that it is 73 days, they cannot provide the medication abortion. If the doctor cannot comply with all provisions of the bill (as stated in 90-21.83B(8), and again in 90-21.88A), they will be violating a provision of the Article and shall be subject to discipline by the North Carolina Medical Board.
- The language in the bill in section 90-21.88A uses the word “shall,” which medical and legal experts assert leaves no room for discretion or the use of medical judgment in providing an off-label medication abortion beyond the 70 days. Senate Bill 20 presents the gestational confirmation as a condition that must be satisfied in order to provide the medication abortion in compliance with the Article, and if the condition is not met, the physician shall be subject to discipline. The bill text plainly amounts to a mandate.
- Medical evidence demonstrates that medical providers may safely and effectively provide medication abortion for up to 77 days (11 weeks) in a pregnancy. Providers at Planned Parenthood South Atlantic currently have the option to recommend a medication abortion to patients up to 11 weeks of pregnancy.
- Additionally, Senate Bill 20 also impacts hospital-based care for any abortion allowed to occur after 12 weeks of pregnancy. The bill may prevent doctors in a hospital from using medications, including mifepristone and misoprostol, to assist with procedures later in pregnancy, including in cases where the patient or fetus has a serious medical condition. Senate Bill 20 would remove those medication options which are routinely used, potentially forcing doctors into a course of care or unnecessary surgery that is against the patient’s wishes or doctor’s recommendation.
- Some patients — for example those having an abortion for a wanted pregnancy with life-limiting anomalies — prefer a labor induction abortion with medications instead of surgery because they want to see and hold their baby. Patients in North Carolina should have the full range of evidence-based options available to them as they would if they were in a different state. Senate Bill 20 takes away these options, putting patients’ health and liberty in jeopardy.
CLAIM: Senate Bill 20 only requires two in-person appointments for a medication abortion.
FACT: Senate Bill 20 requires doctors to make three appointments for a patient seeking a medication abortion.
- While the first two appointments are explicitly required as a condition for the abortion for the patient, the bill also dictates that the provider must “schedule a follow-up visit for the woman at approximately seven to 14 days” after the abortion and must “make all reasonable efforts to ensure that the woman returns for the scheduled appointment.” The bill specifies that the provider must document in the patient’s medical records a description of the efforts made to bring the patient back for the follow-up appointment.
- In this way, the bill goes far beyond current standard practices for follow-up appointments. While it is true that the patient will not be penalized for not attending the third follow-up appointment, the patient may not know that they aren’t required to make a medically unnecessary third trip to a clinic.
CLAIM: This bill does not intend to shut down clinics.
FACT: In a memo to press, Senator Joyce Krawiec, Senator Lisa Barnes, Senator Amy Galey, and Senator Vickie Sawyer stated that Senate Bill 20 “requires clinics that offer surgical abortions to have the same healthcare standards as ambulatory surgical centers.” It is not medically necessary or recommended for clinics to meet the requirements of an ambulatory surgical center according to medical experts, so no abortion clinics in the state currently do. If these standards are ultimately imposed on clinics — despite not offering any health or safety benefit to patients — many of them would be unable to meet the new license requirements and may be forced to close.
- Senate Bill 20 directs the NC Medical Care Commission to rewrite regulations on clinics by October 1. It is within this regulation revision process that the Commission could impose further restrictions on clinics, potentially even going so far as to require clinics to have an ambulatory surgical center license aka “ASC” license. The Commission has the latitude to rewrite any regulation of abortion clinics (adopt, amend, and/or repeal), up to a ceiling of ASC standards, even if these regulations do not have any benefit to patients.
- ASC standards are even more onerous than the current regulations for abortion clinics (which are already medically unnecessary, expensive, and onerous themselves). The Commission does not have to go that far, but they could — and if they were to do so, it would have an even more devastating impact on access to care in the state.
- Planned Parenthood South Atlantic does not have any health center in North Carolina that currently meets all of the requirements of an ASC license, and many facilities will not be able to meet them in the near future (and they may be forced to close). It entirely depends on what the Commission ultimately does.
CLAIM: This bill protects access to abortion for patients in vulnerable situations, including survivors of rape and incest and diagnoses of a “life-limiting” fetal anomaly.
FACT: Any abortion provided after 12 weeks of pregnancy must occur in a hospital. As a result, people who live in rural parts of the state and/or people with low incomes will have significant barriers to obtaining an abortion after 12 weeks of pregnancy.
- Under Senate Bill 20, people who qualify for the limited exceptions presented in the bill, including survivors of sexual assault and patients who have received a diagnosis of a “life-limiting” anomaly, must seek care at a hospital. 20 counties in North Carolina do not have a hospital. According to the Center for Healthcare Quality and Payment Reform, 17 hospitals in the state are at risk of closing.
- Under Senate Bill 20, even abortions that are done for medical emergencies or for “life-limiting” fetal anomalies would have to be done using methods many physicians in hospitals lack the training to perform, which would severely compromise access, especially in rural areas in our state.
- This change in the law will have a direct impact on people living in rural parts of the state who will be forced to travel long distances to get to the only place that can provide this time-sensitive health care. Additionally, a hospital visit will cost more for the patient than a visit to an abortion clinic, creating an additional financial barrier for many patients.
- Currently, patients may seek an abortion at an abortion clinic up to 20 weeks of pregnancy.
CLAIM: Senate Bill 20 will improve patient safety.
FACT: Abortion — both medication and procedural — is overwhelmingly safe. Abortion is one of the safest medical procedures performed in the United States. Bans on abortion care, however, lead to substandard medical care and higher rates of maternal and infant mortality.
- Data, including from the CDC, shows that abortion has over a 99 percent safety record. Abortion procedures can be safely provided in doctor’s offices and outpatient health centers, and are similar, in terms of level of risk, to other gynecological procedures that take place in doctor’s offices every day.
- The National Academy of Sciences, Engineering, and Medicine concluded that restrictions on abortion do nothing to make the procedure safer, they only make it more difficult to access.
- Mifepristone, one of the two drugs in the typical medication abortion regimen, is safe, effective, and has been used by more than 5 million people in the U.S. since the FDA approved it more than 20 years ago. Mifepristone has allowed patients to make their own private medical decisions, and expanded access to reproductive health care.
- Senate Bill 20 is opposed by the North Carolina Medical Society, the North Carolina Obstetrical and Gynecological Society, and the North Carolina Academy of Family Physicians.
- About 1 in 4 women in the U.S. will have an abortion by the time they’re 45 years old.
CLAIM: Democrats refuse to oppose third-trimester abortions.
FACT: Deliveries occur in the third trimester, not abortions.
- Discussion of third-trimester abortion is completely irrelevant. Doctors define the third trimester as beginning at 28 weeks gestation. North Carolina has a 20-week gestational age limit currently. We do not need further regulation of third-trimester abortion in this state because it is already illegal.
- When pregnant people have health conditions requiring delivery beyond fetal viability, doctors — including those who provide abortion — go to heroic efforts to save the life of the woman and the baby. This bill is about rolling back rights from 20 weeks to 12, and making abortion unreachable for many, even in the first trimester. It has nothing to do with later abortion care.
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