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Stroke, hemorrhage, sepsis: Idaho doctors detail ways abortion ban risks patients’ health

Jamie Richmond, Boise, dressed as a pregnant Statue of Liberty during a rally at the Idaho Capitol in Boise, Idaho, on Sunday, April 21, 2024. Hundreds gathered to support women and health care workers caught in the legal gray areas of Idaho's strict abortion legislation.    (Darin Oswald/Idaho Statesman/TNS)
By Nicole Blanchard Idaho Statesman

BOISE, Idaho — Dr. Becky Uranga has always loved working in emergency obstetrics. As an OB-GYN, she and her colleagues at OGA Women’s Health rotate emergency shifts, when Uranga spends 24 hours covering labor and delivery and caring for Treasure Valley patients with urgent medical needs.

For the last several months, those shifts have come with a new challenge. In January, a U.S. Supreme Court order allowed one of the strictest aspects of the state’s abortion law to take effect. Since Jan. 5, Idaho doctors have not been able to perform abortions to protect their patients’ health in a medical emergency.

Uranga told the Idaho Statesman that in some of those emergency situations her practice deals with, an abortion is the standard procedure to stabilize the patient and prevent infection, kidney failure, hemorrhaging or loss of fertility.

She recently saw a patient with previable preterm rupture of membranes — the patient’s water broke before her fetus was able to survive outside of the womb. Uranga said it’s a “classic case” for which abortion is the recommended treatment. Without it, the pregnant patient risks serious infection, detachment of the placenta from the uterine wall and other complications.

But Idaho law meant Uranga couldn’t offer her patient the treatment she needed.

“I remember going to see the patient in the ER, and then coming back to labor and delivery and ugly crying because there was nothing I could do,” Uranga said in an interview.

The patient ended up seeking an abortion in Oregon. She delivered her baby while en route to Portland.

Idaho physicians like Uranga told the Idaho Statesman how January’s Supreme Court order is impacting them and their patients, sharing heartrending details of medical emergencies, compounded by the fear that they could be criminally prosecuted for performing an abortion that doesn’t meet narrow exceptions. Emergency out-of-state transports of pregnant patients are on the rise, and several doctors told the Statesman they feel their hands are tied and their patients are receiving worse care.

“For decades we’ve been making health care better little by little, and it feels like it all got wiped away,” Uranga said.

The Supreme Court on Wednesday will hear oral arguments from Idaho and the U.S. Department of Justice to determine whether federal emergency medicine requirements take precedent over Idaho’s abortion law. Doctors said they fear what will happen if the court rules in Idaho’s favor.

Doctors in limbo after Idaho abortion ban

Since Idaho’s total abortion ban took effect in August 2022, physicians have faced uncertainty around how they can care for their patients. The law has just a few exceptions for reported instances of rape or incest, for nonviable molar or ectopic pregnancies and for preventing the death of a pregnant patient.

Absent is an important distinction: preserving pregnant patients’ health. Shortly after the ban became Idaho law, the Department of Justice sued the state and said this missing provision violates a decades-old federal law called the Emergency Medical Treatment and Labor Act, or EMTALA. The law requires any hospital that accepts Medicare funding to stabilize patients experiencing a medical emergency, regardless of their ability to pay for treatment.

For more than a year, an injunction from the U.S. District Court of Idaho kept EMTALA in effect, allowing physicians to perform abortions as needed to stabilize emergency patients. Last fall, the 9th Circuit Court of Appeals reversed that injunction, then swiftly reinstated it. In January, at the urging of Idaho Attorney General Raúl Labrador, the U.S. Supreme Court agreed to take on the case. It quietly issued an order allowing Idaho’s ban on emergency health-preserving abortions to resume.

Uranga remembers exactly how she felt. She was hiking in McCall when she found out about the order through a group chat with other doctors.

“I knew how bad things were already, and I thought they couldn’t get any worse,” she said.

Dr. Mike Schneider, a maternal-fetal medicine specialist from Boise, told the Statesman in an interview that his entire team felt “completely deflated” by the Supreme Court order.

“It was like, ‘Why are they doing this to our patients? Why are they doing this to us as providers?’” Schneider said.

‘This is not theoretical’

In Statesman interviews and Supreme Court filings, physicians, medical associations and Idaho’s largest hospital system emphasized that emergency obstetrics cases are not just fodder for legal debate.

“This is not theoretical,” Uranga said. “This is actually happening.”

So far this year, she has treated two patients with previable preterm rupture of membranes. One was the patient who delivered while traveling to Portland. The other didn’t want to leave the state for an abortion procedure.

Uranga said the patient “really believed they would be fine. I don’t know what happened to her, but I think about her a lot.”

Several doctors detailed the cases they’ve seen in a document compiled by Physicians for Human Rights. The organization submitted that document, with the doctors’ accounts anonymized, along with an amicus brief — an outside testimony meant to add context and illustrate the legal impact of a court case — to the Supreme Court.

In it, one doctor in Oregon recounted treating an Idaho patient with a history of kidney disease who had a type of preeclampsia called HELLP syndrome, which includes low platelets and elevated liver enzyme levels and can lead to hemorrhage. The recommended treatment is immediate delivery of a pregnancy, or, if the pregnancy is not yet viable, abortion.

The woman, who was 18 weeks pregnant with twins, had spent years on dialysis and had a donor kidney. Her emergent condition put her at high risk of kidney failure. The physician who cared for the patient after she was transferred out of Idaho told Physicians for Human Rights that Idaho doctors didn’t feel they could do an abortion, even though one of the patient’s fetuses died while she was still at an Idaho hospital.

Instead, she was transferred to Oregon, where the second fetus died before doctors could terminate the pregnancy.

“She was young and the whole thing was incredibly traumatic for her,” the Oregon doctor said in the document. “After we removed the two dead fetuses, she had to stay with us for a while. After all this, we had to coordinate transport back afterwards, after she had not gotten appropriate treatment for a long time and was in a terrible state.”

In its own amicus brief, St. Luke’s Hospital System told the Supreme Court that patients who are forced to continue their pregnancies “will suffer — potentially gravely.” It said conditions that call for termination can cause extreme pain and health complications, including liver hemorrhage, kidney failure, stroke, seizures, pulmonary edema and more.

The Physicians for Human Rights brief included several other stories of obstetric emergencies in Idaho, from more cases of previable preterm rupture of membranes to a refugee patient with a history of sexual assault who was too traumatized to push when she was in preterm labor.

Boise OB-GYNs say transfers add more risk

The emergency obstetrics cases outlined by the amicus briefs aren’t isolated incidents. In a panel hosted by the American Civil Liberties Union last week, Dr. Jim Souza, chief physician executive for St. Luke’s, at a news conference said the hospital system last year saw 54 cases of previable preterm rupture of membranes.

“That’s one a week,” he said. “There’s a lot of second-guessing and hand-wringing. When the guessing game gets too uncomfortable, we transfer the patient out of state at great cost.”

In 2023, when the injunction was still in place, St. Luke’s transferred a single patient out of state for obstetric emergency, Souza said. Since January, six such patients have been transferred to other states for care.

Doctors said their patients are getting worse medical care as a result of the reinstated ban on emergency health-preserving abortion. Since the law allows abortion when a patient’s life is at risk, some doctors said they feel they have to let their patients’ condition decline to a point where the life-saving exception is more certain.

“It’s not good medicine to wait till someone’s at death’s doorstep and then try to pull them back,” Dr. Stacy Seyb, a maternal-fetal medicine specialist at St. Luke’s in Boise, told the Statesman.

Seyb and others noted that even when they transfer a patient out of state, they’re causing care delays and risking potential accidents or other problems. Many now advise their pregnant patients to carry insurance for air ambulance transports, which can cost tens of thousands of dollars.

Before the abortion ban, physicians were able to proactively prevent serious illness, whereas “now we are delaying care,” Schneider said. “So patients are becoming sick, or we’re delaying their care by transferring them out of state. And that causes just a tremendous potential for harm — maternal health harm, emotional harm and financial harm — to these patients and their families.”

Potential criminal charges worry physicians

Doctors told the Statesman their first concern is for their patients. Their second is for themselves and their careers.

Idaho’s abortion ban doesn’t just outlaw the procedure, it criminalizes it. Health care providers face two to five years in prison and the revocation of their medical license if they perform an abortion that doesn’t fit the law’s few exceptions.

In an interview with the Statesman, Souza said the line between preserving someone’s health and preserving their life is never clear. That makes for uncertainty over which emergency abortions may be legal.

Souza said in a patient’s “hour of greatest need,” a doctor may not feel comfortable making the right medical choice because they have to fear for themselves. He called it a “very dangerous mix in medicine.”

“Your doctor has to worry about their own profession and their own interests,” Souza said. “It runs 100% counter to the fiduciary relationship we commit to in our profession.”

St. Luke’s amicus brief called such situations “an impossible choice.” In its own brief, the Idaho Coalition for Safe Healthcare — a group formed in the wake of the Dobbs decision — said its members “have been at a loss for what to do” since January.

“At nearly every turn, Idaho’s doctors have been warned that they are being tracked and scrutinized and they should fear prosecution for providing an abortion under any circumstances — even when medically necessary,” the group’s brief said.

Dr. Sara Thomson, a Boise OB-GYN, told the Statesman in a written statement that she and her colleagues are facing a crisis of conscience.

“The threat of incarceration for five years for patient care is a heavy burden, and being told that no physician has been prosecuted in our state yet or that a case of medical necessity is unlikely to be prosecuted is not adequately reassuring,” Thomson said.

‘I have to be hopeful’ about SCOTUS decision

Since August 2022, Idaho doctors have rallied in support of abortion access. More than 600 physicians joined the newly formed Idaho Coalition for Safe Healthcare. Doctors have contacted their patients to explain the potential impacts of the state’s laws. They’ve testified about their concerns in front of the Idaho Legislature and now the U.S. Supreme Court.

It’s been hard work, they said. And many feel like no one is listening.

Souza said that’s why it was important for St. Luke’s to weigh in on the EMTALA case.

“Very early on this issue, we asked ourselves how loudly we were going to speak up about this as a health care system,” Souza told the Statesman. “And very quickly, when we saw what the language of the law that was going to be implemented, we recognized that it was going to be in conflict with health care.”

Souza said the brief was a chance for St. Luke’s to show its doctors that it stands with them, hears their concerns and will continue to push for an abortion law exception to preserve patients’ health.

Seyb, who works for St. Luke’s, lent his voice and experience to the hospital’s brief. He said it felt important to advocate for patients and their right to get adequate care at home.

“I see patients in these moments that make me feel like somebody’s got to help them,” Seyb said. “And to not speak up, it would be a failure on my part.”

Wednesday’s oral arguments won’t give physicians the answers they need. The Supreme Court is expected to issue its decision in the case in June or July. That leaves doctors and their patients in a holding pattern, and the justices could ultimately rule that this is the state of Idaho health care.

“Six months of hoping is better than nothing,” Uranga said. “I choose to feel hopeful. I have to be hopeful; otherwise, I wouldn’t be able to see patients.”