After Roe is gone, even your prenatal care will depend on what state you live in

After Roe is gone, even your prenatal care will depend on what state you live in

Most people who’ve had kids know the routine (some of us know it several times over): At certain points during pregnancy, tests are administered at various intervals to determine the existence of any abnormalities or unusual conditions. Tests for Down’s syndrome, Edwards’ syndrome, Patau’s syndrome, and spina bifida are typical. These blood and genetic tests are usually punctuated by recurrent ultrasounds in which the fetus’ development is analyzed by physicians for any physical problems or deformities, even missing body parts like a fully formed skull, or absent fingers, toes and limbs.

As explained by Sarah Zhang, writing for The Atlantic, the legality of abortion in this country—even if restricted in some states—has typically permitted those who are pregnant the right and option to terminate their pregnancy at its early stages based on such information, particularly information indicative of severe genetic issues. The fact that this is permitted only to a certain degree in several states is a reflection of the restrictions on terminating a pregnancy that already exist; however, if and when Roe is overruled and states are free to ban abortions in their entirety—a possible certainty for many states at this point—as Zhang observes, “Routine parts of prenatal care could start to look quite different in states that ban abortion than in states that allow it.”  The implications of such changes will be profound and rather disturbing.

As Zhang explains, in the 12 states which now prohibit most terminations of pregnancies after 20 weeks, obstetricians and genetic counselors who treat people who become pregnant are already scheduling routine tests on time frames earlier than medically optimal in order to obtain and provide as much information to prospective parents as soon as possible.

These preemptive diagnoses, however, sometimes collide with the reality of fetal development. As Zhang explains:

[T]he earlier the scan, the less doctors can see. Certain brain structures, such as the cavum septum pellucidum, might not develop until week 20, says Chloe Zera, an obstetrician in Massachusetts. Being unable to find this structure could indicate a brain anomaly, or just that the scan was done too early. Doctors might also pick up evidence of a heart defect but not know how severe or fixable it is. At 20 weeks, the heart is only the size of a dime.

Six states currently ban or restrict abortion on the basis of genetic anomalies, some, such as Tennessee’s statute, specifically reference Down syndrome. But others, such as North Dakota’s, extend broader prohibitions based on potentially even more severe conditions than Down syndrome. Zhang notes that these can include conditions such as Trisomy 13 (Patau syndrome), a severe genetic disorder that is usually fatal within a child’s first year.

This is where the existence of Roe becomes important. Zhang discusses the existing medical and ethical implications for doctors and patients in a state that restricts such abortions:

In states that currently restrict abortion based on genetic anomalies but still allow it for other reasons under Roe, patients can get an abortion if they do not mention the genetic anomaly. This puts doctors and genetic counselors in a bind. For instance, says Leilah Zahedi, a maternal-fetal-medicine physician in Tennessee, what if doctors see a severe heart defect on an ultrasound? The underlying cause of many such heart problems is Down syndrome. But Tennessee restricts abortions specifically on the basis of trisomy 21 [Down’s syndrome]. Should doctors tell patients about the connection to Down syndrome? Should they do the genetic testing? It could help parents prepare for everything else that comes with Down syndrome. But it would make it harder for them to get an abortion, if they chose to have one. They would need to go to a different doctor who does not know about the diagnosis, and take care not to reveal it.

So in Tennessee you already have doctors feeling compelled not to provide complete medical information to patients because Tennessee’s statute specifically prohibits abortions based on Down’s syndrome (which most pregnant people choose as the option), because they might not be able to obtain one otherwise. How would a patient feel about not getting complete information, or, alternatively, getting such information only to find out that getting it completely eliminated their option to terminate their pregnancy?

As Zhang explains, many states have so-called “trigger laws” (set to go into place when Roe is overruled) which contain the sole exemption of allowing abortion only in which the life of the mother is threatened or the condition is absolutely fatal to the fetus, another problem arises:

When it comes to fetal anomalies, “it’s very rare we can say, ‘This is universally fatal,’” Zera told me. For example, in the case of a massive brain hemorrhage that destroys most of the brain tissue but leaves the brain stem intact, the baby can breathe at birth but will need other medical care. Does fatal mean fatal in the absence of certain medical interventions? Which ones? And does an anomaly have to be fatal immediately, or within some period after birth?

Likewise, a condition that is potentially life-threatening to the mother can be equally ambiguous. Zhang references triploidy, a lethal chromosome abnormality that “can” cause pre-eclampsia (a complication of pregnancy that can produce high blood pressure and organ damage). Is high blood pressure always fatal? No, but it can be, depending on the patient, which is why physicians in Texas (whose statute only permits abortions in the case of “medical emergencies”) must now “wait” until the mother’s life is truly at risk in order to justify terminating the pregnancy.

Zhang cites anecdotally a patient in Tennessee whose doctor told her that genetic testing was now pointless. She also suggests that insurance companies may decide not to cover genetic testing if abortion becomes illegal in most states, as appears to be likely. From insurance company’s perspective, the whole point of covering such tests is to potentially forestall the extreme medical costs of caring for a critically ill newborn. What’s the point of paying the (enormous) costs of such testing and thus informing the potential parent if they can’t do anything about it, anyway?

[W]ill insurance companies, especially regional ones, want to continue covering these tests? Or will patients have to pay for them out of pocket? These tests are currently routine for pregnant women, but whether they stay that way in the future could depend on where you live and what you can afford.

The Republicans who passed these simplistic, draconian laws never bothered to examine the medical nuances or implications of what they were passing. They simply rubber-stamped them without the slightest thought of what the consequences would be. Because it bought them votes and kept them safely in office.

And now millions of those who become pregnant will be forced to deal with those consequences.

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