A Threatened Essential Procedure
Published Online:8 Aug 2022 https://doi.org/10.1089/gyn.2022.0062.editorial
It is impossible to practice obstetrics and gynecology right now without the incessant thought in the back of one's head: “What happens now that Roe v. Wade has been overturned?” I would like to extend an enormous Thank You to Mitchel S. Hoffman and the Journal of Gynecologic Surgery, for recognizing the importance of discussing abortion as essential, safe medical care by welcoming this Special Issue for publication. With the recent Dobbs decision by the Supreme Court of the United States (SCOTUS) that ultimately overturned Roe v. Wade, many physicians and patients are facing what is to be a new reality—one in which abortion is only accessible to patients living in certain states or to patients with the resources to travel to those states.
Abortion is one of the most commonly performed surgical procedures among reproductive-age women, with more than 250,000 performed in 2019. Despite this, many physicians do not provide abortions routinely, and abortion remains a highly regulated procedure. In this Special Issue dedicated to abortion, I hope readers will come to understand the legal history of abortion and what has led us to the current state of affairs, wherein legislators across the country are limiting access to this essential medical procedure. I also hope to frame abortion as a medical procedure, which, like all procedures, has risks, benefits, anesthesia considerations, and special situations in which the procedure may carry additional surgical considerations.
In her article on the history of abortion, Whittum describes the history of abortion regulations, highlighting the sharp increase in the last decade (pp. 000–000). While antiabortion laws predate the 1800s, history has shown that regulations did not actually stop abortions from occurring, rather, they led to an increase in illegal—and therefore often unsafe or criminalized—procedures. Only 1 decade ago, a woman living in Ireland was denied an abortion while experiencing a 17-week septic miscarriage, and she ultimately died as a result. The response was an international outcry and eventual legalization of abortion through the Health (Regulation of Termination of Pregnancy) Act of 2018.
While Christian countries (such as Ireland) are expanding abortion access, the United States has been restricting access further. During first 3 months of 2022, 519 abortion restrictions were introduced in 41 states. While the final SCOTUS ruling on the 15-week Mississippi abortion ban, Dobbs v. Jackson Women's Health Organization, was released in June 2022, a draft majority opinion leaked in early May showed that the SCOTUS was poised to overturn Roe v. Wade, which made abortions illegal in half of U.S. states.
Despite the passage of unprecedented numbers of abortion restrictions in the past year, the majority of Americans believe abortion should be legal in some or all circumstances. Rich and colleagues ethical discussion on abortion leads to the ultimate conclusion that abortion is a “moral good,” and that physicians providing these services should be lauded (pp. 000–000). By providing abortions, doctors are not only recognizing patients' autonomy, but also providing economic opportunities for such patients and creating improved health outcomes. As obstetricians/gynecologists, we see the toll pregnancy takes on our patients. We see the joy of delivering healthy, desired babies, but we also witness the anguish that abnormal and unintended pregnancies cause. We learned from The Turnaway Study that patients who attempt but were unable to obtain desired abortions faced risks—including eclampsia, postpartum hemorrhage, and death associated with pregnancy—that they would not have been subjected to if these patients were able to obtain abortions. As physicians, we have a moral imperative to help our patients live their healthiest lives, and we can do so by helping our patients avoid these preventable pregnancy-related outcomes.
While most obstetrician/gynecologists are well-versed in the risks associated with pregnancy, many of these clinicians may not be as familiar with the risks associated with abortion. In their article on abortion safety, Ralph, Norkett, and colleagues point out how incredibly safe abortion is, with a mortality rate of 0.3 per 100,000 at under 8 weeks, when the majority of abortions are performed (pp. 000–000). Because most complications are rare, many obstetrician/gynecologists may not be familiar with them. This review details the diagnosis and management of these complications.
Rarely, complications can be attributed to abnormally implanted pregnancies. Harken and Russo discuss some of these uncommon locations for pregnancy implantation, detailing both diagnostic criteria and management options (pp. 000–000). While rare, cesarean, cervical, and interstitial pregnancies are increasing in frequency, and recognition is important to avoid complications in patients presenting for abortion and other early pregnancy services.
The final article in this series, by Cansino and Brown, details anesthesia considerations for abortions (pp. 000–000). Anesthesia options can range from local anesthesia with accompanying verbal support to general anesthesia. Particularly, as states face restrictions and all-out bans on abortions, it will be essential for more physicians to begin to provide abortion services. Understanding anesthesia options will be key to increasing abortion provision.
We appreciate the opportunity to present abortion as an essential component of reproductive health care. This series has, we hope, shown that abortion, like many other gynecologic procedures, is extremely safe, and reviewing the rare complications can prepare us better to manage them when they do occur. Understanding abortion regulations from a historical lens allows us to understand better how we come to find history repeating itself.
In addition to the topics presented in this special issue, new questions will arise now that SCOTUS ultimately overturned Roe v. Wade. First, what happens to patients who are unable to obtain abortions? A 2021 study demonstrated that states enacting more abortion restrictions had higher total maternal mortality rates—a troubling finding that is likely to be replicated as more states create earlier gestational limits and total bans. There is concern that this will have a disproportionate impact on black women, who already have a threefold higher risk of dying in pregnancy than do white women. How can we help traverse the socioeconomic barriers that prevent patients from accessing safe, legal abortions, and therefore decrease their overall risk of mortality? Second, what happens to all of our trainees? Currently, access to abortion training is an Accreditation Council for Graduate Medical Education requirement for residency graduation; however, with half of U.S. states banning abortions, how will our trainees learn to perform them, and will they be less likely to choose to train in states where abortion access is restricted?
It is unclear what the future holds for abortions in the United States. One thing is clear—abortion is a safe, necessary medical service. I hope that this series encourages all clinicians who legally can provide services to begin doing so, as we attempt to continue providing the high-quality gynecologic care our patients deserve.
It is impossible to practice obstetrics and gynecology right now without the incessant thought in the back of one's head: “What happens now that Roe v. Wade has been overturned?” I would like to extend an enormous Thank You to Mitchel S. Hoffman and the Journal of Gynecologic Surgery, for recognizing the importance of discussing abortion as essential, safe medical care by welcoming this Special Issue for publication. With the recent Dobbs decision by the Supreme Court of the United States (SCOTUS) that ultimately overturned Roe v. Wade, many physicians and patients are facing what is to be a new reality—one in which abortion is only accessible to patients living in certain states or to patients with the resources to travel to those states.
Abortion is one of the most commonly performed surgical procedures among reproductive-age women, with more than 250,000 performed in 2019. Despite this, many physicians do not provide abortions routinely, and abortion remains a highly regulated procedure. In this Special Issue dedicated to abortion, I hope readers will come to understand the legal history of abortion and what has led us to the current state of affairs, wherein legislators across the country are limiting access to this essential medical procedure. I also hope to frame abortion as a medical procedure, which, like all procedures, has risks, benefits, anesthesia considerations, and special situations in which the procedure may carry additional surgical considerations.
In her article on the history of abortion, Whittum describes the history of abortion regulations, highlighting the sharp increase in the last decade (pp. 000–000). While antiabortion laws predate the 1800s, history has shown that regulations did not actually stop abortions from occurring, rather, they led to an increase in illegal—and therefore often unsafe or criminalized—procedures. Only 1 decade ago, a woman living in Ireland was denied an abortion while experiencing a 17-week septic miscarriage, and she ultimately died as a result. The response was an international outcry and eventual legalization of abortion through the Health (Regulation of Termination of Pregnancy) Act of 2018.
While Christian countries (such as Ireland) are expanding abortion access, the United States has been restricting access further. During first 3 months of 2022, 519 abortion restrictions were introduced in 41 states. While the final SCOTUS ruling on the 15-week Mississippi abortion ban, Dobbs v. Jackson Women's Health Organization, was released in June 2022, a draft majority opinion leaked in early May showed that the SCOTUS was poised to overturn Roe v. Wade, which made abortions illegal in half of U.S. states.
Despite the passage of unprecedented numbers of abortion restrictions in the past year, the majority of Americans believe abortion should be legal in some or all circumstances. Rich and colleagues ethical discussion on abortion leads to the ultimate conclusion that abortion is a “moral good,” and that physicians providing these services should be lauded (pp. 000–000). By providing abortions, doctors are not only recognizing patients' autonomy, but also providing economic opportunities for such patients and creating improved health outcomes. As obstetricians/gynecologists, we see the toll pregnancy takes on our patients. We see the joy of delivering healthy, desired babies, but we also witness the anguish that abnormal and unintended pregnancies cause. We learned from The Turnaway Study that patients who attempt but were unable to obtain desired abortions faced risks—including eclampsia, postpartum hemorrhage, and death associated with pregnancy—that they would not have been subjected to if these patients were able to obtain abortions. As physicians, we have a moral imperative to help our patients live their healthiest lives, and we can do so by helping our patients avoid these preventable pregnancy-related outcomes.
While most obstetrician/gynecologists are well-versed in the risks associated with pregnancy, many of these clinicians may not be as familiar with the risks associated with abortion. In their article on abortion safety, Ralph, Norkett, and colleagues point out how incredibly safe abortion is, with a mortality rate of 0.3 per 100,000 at under 8 weeks, when the majority of abortions are performed (pp. 000–000). Because most complications are rare, many obstetrician/gynecologists may not be familiar with them. This review details the diagnosis and management of these complications.
Rarely, complications can be attributed to abnormally implanted pregnancies. Harken and Russo discuss some of these uncommon locations for pregnancy implantation, detailing both diagnostic criteria and management options (pp. 000–000). While rare, cesarean, cervical, and interstitial pregnancies are increasing in frequency, and recognition is important to avoid complications in patients presenting for abortion and other early pregnancy services.
The final article in this series, by Cansino and Brown, details anesthesia considerations for abortions (pp. 000–000). Anesthesia options can range from local anesthesia with accompanying verbal support to general anesthesia. Particularly, as states face restrictions and all-out bans on abortions, it will be essential for more physicians to begin to provide abortion services. Understanding anesthesia options will be key to increasing abortion provision.
We appreciate the opportunity to present abortion as an essential component of reproductive health care. This series has, we hope, shown that abortion, like many other gynecologic procedures, is extremely safe, and reviewing the rare complications can prepare us better to manage them when they do occur. Understanding abortion regulations from a historical lens allows us to understand better how we come to find history repeating itself.
In addition to the topics presented in this special issue, new questions will arise now that SCOTUS ultimately overturned Roe v. Wade. First, what happens to patients who are unable to obtain abortions? A 2021 study demonstrated that states enacting more abortion restrictions had higher total maternal mortality rates—a troubling finding that is likely to be replicated as more states create earlier gestational limits and total bans. There is concern that this will have a disproportionate impact on black women, who already have a threefold higher risk of dying in pregnancy than do white women. How can we help traverse the socioeconomic barriers that prevent patients from accessing safe, legal abortions, and therefore decrease their overall risk of mortality? Second, what happens to all of our trainees? Currently, access to abortion training is an Accreditation Council for Graduate Medical Education requirement for residency graduation; however, with half of U.S. states banning abortions, how will our trainees learn to perform them, and will they be less likely to choose to train in states where abortion access is restricted?
It is unclear what the future holds for abortions in the United States. One thing is clear—abortion is a safe, necessary medical service. I hope that this series encourages all clinicians who legally can provide services to begin doing so, as we attempt to continue providing the high-quality gynecologic care our patients deserve.
Страницы не указаны (pp. 000–000), потому что журнал ещё не вышел
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