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Ob-Gyn: The two futures for Iowa women

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In the next 10 days, the seven justices of the Iowa Supreme Court will issue a ruling in the misnamed “Fetal Heartbeat” ban. This legislation is the third iteration forced through the Iowa legislature in six years. It seeks to ban abortion at the instance of embryonic cardiac impulse at six weeks, well before most women know they are pregnant. The Supreme Court decision will either allow the ban to become law or permanently block it. Either way, a large portion of the electorate will be anguished, disappointed or even angry.

I cannot say which way they will decide. So instead, I will paint a picture of two possible futures for my patients and for myself as a woman’s health physician (an obstetrician gynecologist). I care for women before, during and after pregnancy.

At the earliest, pregnancy can be detected at four weeks after a period, around two weeks after fertilization of an egg by a sperm. Pregnancy tests often cannot detect a pregnancy until later, however, because of the delay in enough hormones reaching the bloodstream. Additionally, early symptoms of pregnancy (nausea, fatigue, breast tenderness or a missed period) are easily missed. These same symptoms can come from being ill, busy, nearing one’s menstrual cycle, or having medical conditions that affect the timing of a period. Most women do not make their first medical appointment for weeks. Ideally, women would get to a doctor sooner. But that’s hard to do in Iowa, particularly in rural areas. Iowa has the lowest rate of Ob-Gyn doctors in the entire U.S. And the situation is getting worse: Iowa is among the top five states with the biggest losses in OB care access. When a pregnant patient is able to establish care and confirm pregnancy, it is likely to be beyond six weeks.

Obstetric care is generally divided into trimesters, and in the U.S. more than 90% of abortions take place in the first trimester. That said, women who experience an unplanned pregnancy are very likely to choose to raise the child. For many decades, approximately 60% of women have chosen this. But for the 40% who would choose to end a pregnancy, they commonly report that they cannot afford another child, they have many responsibilities already, their families are complete. Not only might continuation of a pregnancy risk their life, but it might risk their livelihood, their ability to care for other children or aging parents. These are deeply personal decisions.

You might argue that prevention of unplanned pregnancies is the winning strategy. Unfortunately, places without obstetric care in Iowa also lack comprehensive contraceptive care. In rural areas, there are often no clinics to provide procedures or pharmacies to dispense medication. Both rural and urban patients may lack transportation to attend appointments. Low-income patients or the underemployed may still lack insurance. As someone who treats these very patients, I see how their unique hardships interfere with decisions to access all kinds of preventative medicine, including reliable contraception.

Even when a pregnancy is planned, the second trimester — approximately 13 through 26 weeks — is one filled with tremendous discovery. The fetus develops structures that can first be seen on ultrasound. An anatomy ultrasound, around the 20th week, screens for these developments and the fetus’s well-being. This ultrasound can detect some developmental anomalies, as well as life-limiting or life-threatening medical conditions, such as undeveloped kidneys or openings in the neurologic system. These are crushing moments for families filled with decisions about whether to subject a neonate to painful, costly and sometimes futile medical care in the hope of prolonging life.

Terrible maternal health complications also occur in the second trimester, making decisions more difficult. When the bag of water that surrounds a fetus ruptures too soon, patients can experience sudden catastrophic sepsis and require swift intervention. HELLP syndrome, a severe form of hypertension in pregnancy, can rapidly threaten nearly every organ system a woman has and is only remedied by delivery of the placenta. A miscarriage in the second trimester, when the placenta has developed, can lead to severe ongoing blood loss, or hemorrhage — a leading cause of death in pregnancy. Even for my young, healthy patients, pregnancy is the most dangerous condition a woman can have. When patients’ lives are at risk, the last thing I want to consider is if I have enough evidence to provide medical care and still avoid legal consequences for my patients and myself.

If, in the coming days, the Iowa Supreme Court decides to uphold the law, there will be more unplanned, and undesired, children born in Iowa, in our communities. We know their families will struggle. Research has indicated that existing children in families denied abortion care meet fewer of their developmental milestones. Babies born in unplanned and undesired pregnancies are less likely to experience bonding with their parent. And families that are denied abortion services are three times more likely to live beneath the federal poverty level five years later.

Or, in the coming days, the Iowa Supreme Court could decide to honor liberty, to recognize and preserve Iowa’s moderate existing abortion laws, and keep the government out of exam rooms. They could decide to let patients and families make their own personal medical decisions. They could honor the unique responsibility to bear and raise children — and the imperative right to decline to do so.  I anxiously wait to see how they will rule, and how my patients will fare.

Dr. Emily Boevers is an obstetrician-gynecologist who lives and practices in Waverly. Comments are her own and based on publicly available data, her decade of medical training and clinical expertise. This piece was originally published in the Waverly paper.

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