Republicans’ new 12-week abortion ban will impose unnecessary barriers to care, increase maternal death rates, and further strain the state’s health care system by forcing clinics to close, North Carolina doctors say.
When North Carolina Republicans released their 12-week abortion ban last week, they called the 46-page bill a reasonable compromise, a text of common sense. Within 48 hours, the bill had passed the House with limited debate and made its way to the Senate, where senators with objections were given only 10 minutes each to make their case.
Sen. Jay Chaudhuri, a Democrat, spent his time asking questions of the bill’s authors.
The bill requires doctors to report every miscarriage and abortion to the state. Chaudhuri asked Sen. Joyce Krawiec, one of the Republican sponsors, if that element of the bill was new.
“I’m not certain,” she said.
What about the part that says doctors must run extensive blood and diagnostic tests on women seeking a medication abortion? Or the part that requires three in-person visits for the medication? Are these new?, Chaudhuri asked.
“I do not know,” Krawiec said.
“This is a 46-page bill,” Krawiec added. “I read it yesterday just like you did, and I don’t remember all the parts of it.”
The bill quickly passed the Senate and was sent to Gov. Roy Cooper, who will veto it Saturday during a large reproductive rights rally. Republicans have the votes to override the veto, but if one Republican changes their mind, the bill will fail.
While the bill’s supporters may have been unsure about the specifics, the doctors who actually provide abortion care know exactly what it will mean for North Carolinians.
We spoke with several family medicine doctors over the last week, including physicians who offer abortion services, and they were unanimous: The “Care for Women, Child, and Families Act,” as the new bill is known, will increase maternal death rates, further strain the state’s health care system and cause extensive damage in ways that have yet to get much attention.
“As researchers with extensive experience related to women’s, children’s, and family wellbeing, we are deeply concerned that this bill does exactly the opposite of what its title suggests,” a group of eight doctors and scholars wrote this week in an op-ed for Cardinal & Pine.
Nearly every major medical society in the world sees abortion bans as dangerous meddling in fundamental healthcare. And more than 1,400 medical professionals in North Carolina wrote an open letter to lawmakers in February urging them to listen to doctors and leave the state’s current laws, which allow abortion up to 20 weeks, in place.
GOP leaders have said they consulted doctors when crafting the bill.
“That wasn’t a lie,” Dr. Erica Pettigrew, a family medicine doctor who helped organize the open letter effort, told Cardinal & Pine. “We’ve been speaking with them for almost a year now to educate them.”
“They just didn’t listen.”
Here’s what the doctors tried to tell lawmakers over the last year and what they hope at least one Republican will hear before the final vote.
The main provisions of Senate Bill 20 fit easily into bullet points.
- Bans abortion in North Carolina after 12 weeks.
- Includes exceptions for rape and incest up to 20 weeks.
- Includes exceptions for “life-limiting” fetal anomalies up to 24 weeks.
- Includes full-term exceptions for the life and physical health of the mother.
These policies, Republicans argue, are reasonable. Just look at the other states in the South, with their full bans and no exceptions of any kind, they said.
But the lesser publicized provisions, doctors told us, show that these bullet points obscure vague, confusing and medically unnecessary restrictions that push this bill far closer to a complete ban than a grand compromise.
Barriers to Care
The 12-week ban imposes “an array of medically unnecessary hurdles, including three in-person office visits for medication abortions and in-person counseling 72 hours before all abortions,” the group of doctors and scholars wrote. These regulations “make it harder and more expensive for women to get early abortions.”
In many cases, the bill will ensure that even a patient who does everything this law says they’re supposed to do will still not be able to get an appointment in time to have an abortion before 12 weeks.
“It’s a horrible purgatory that patients are in,” Dr. Pettigrew said. “It’s dangerous and it’s absolutely not in the best interests of the health of North Carolinians.
The bill also adds new licensing requirements for many abortion providers that could shut down all six existing Planned Parenthood clinics in the state. There are only 14 abortion clinics total operating in North Carolina, meaning nearly half of them could be forced to close. This would make it much harder for North Carolinians to get an abortion during the first trimester, even if it’s technically legal under the bill.
The Dangers of the Bill
Many other bans do not include the exceptions for the life of the mother, “life-limiting” anomalies, and cases of rape and incest.
But the exceptions in North Carolina’s bill are far more limited than they seem, doctors say.
Women seeking abortions under the incest and rape exceptions during the first 20 weeks of pregnancy will encounter the same problems and delays faced by women under current law. . Some women will be denied an abortion simply because it took them so long to get an appointment.
“There are all kinds of scenarios where, you have an 11-year old who doesn’t understand what missed periods mean or who is so absolutely frightened or doesn’t have a trusted adult in their life to confide in of what changes seem to be happening in her body,” Dr. Pettigrew said.
“So she may not realize what’s going on, or people around her may not realize what’s going on until after the 20th week.”
And those life-limiting anomalies? They must be “uniformly diagnosable,” the bill says, meaning all the doctors present must unanimously agree. Many conditions are widely diagnosable, but few are uniformly so, the doctors said.
“We don’t know how the language in this bill will play out in real life,” Dr. Pettigrew said. “It’s not medical,” she continued. “There’s no precedent, there’s no clarity.”
The bill’s vagueness also makes emergencies even more dangerous. Lawyers are risk-averse, Dr. Pettigrew said, and will encourage doctors to wait on care if there’s just the slightest medical uncertainty, even if the doctor knows what to do and doesn’t have much time to spare.
“They’re literally asking the doctor to tell the patient to wait until they’re closer to death before we can intervene,” Dr. Pettigrew said. “I’ve seen colleagues in Florida, in Tennessee, in all kinds of other states where patients are being told, ‘take your temperature and once you start to become [feverish], then we can consider you close enough to death to treat you.’”
This bill makes it clear up front that abortions would be considered lawful in medical emergencies, but its definition of an emergency is not clear at all, doctors said.
“It all comes down to how it ends up being interpreted,” Dr. Pettigrew added.
In the other states that have enacted abortion bans, a major study shows, the maternal death rate is 62% higher.
“It’s so horrible that we’re playing games with people’s lives.”
The Impact on Rural Communities
The in-person visits requirement will be especially difficult for women in rural communities and those with kids and jobs.
“We only have nine counties in North Carolina that actually have access to abortion care currently,” Dr. Michaela McCuddy, a family medicine doctor in Chatham County, told us. “So our patients are traveling two to three hours just to get an appointment.”
Transportation. Childcare. Time off work. And each visit is expensive.
“Imagine forcing that person to do that three separate times,” Dr. McCuddy said, “without any evidence to justify the medical necessity for those appointments.”
But this burden will not fall just on patients seeking an abortion, Dr. McCuddy added.
The ban will make physician shortages and long delays worse for everyone. Many rural areas are healthcare deserts, especially for pregnant women. In all of Western North Carolina, there are less than 10 hospitals that deliver babies.
“When you add this additional strain of these unnecessary bans, it strains that system even further,” Dr. McCuddy said.
Dr. Avanthi Jayaweera, a family medicine doctor in Caswell County, agreed.
“This is going to overburden our emergency departments,” she said.
The ban will also worsen the shortage of doctors, they added.
Many doctors already in rural maternal care centers, including family physicians, will leave if they are not allowed to provide their full scope of care. Abortion bans also make it harder to recruit and retain providers, the doctors said, especially young resident physicians.
Dr. Jayaweera, who is also a board member of the American Medical Student Association, said young physicians are turning away from states with restrictions.
“We are already seeing a 10% decrease in OB-GYN applicants to residency programs in states with restrictions already in place,” she said.
The Falsehoods in the Ban
The bill paints a dark picture of abortion as psychologically and physically unsafe. It spells out a long list of potentially abortion-related complications the doctor must tell a patient. But medical evidence shows that nearly all of the listed complications are far more common during pregnancy than abortion, Dr. Pettigrew said.
“Women are 14 times more likely to die from childbirth than from an abortion in the first trimester,” she said. “And so this is really meant to be a scare tactic, and an insult to the medical community because we already do that. Of course, we want our patients to be informed and make the right decision for themselves.”
Doctors have also studied for decades whether abortion care caused patients psychological harm, Dr. Pettigrew said. “The evidence is very clear that having an abortion does not increase your risk of mental health conditions or psychological issues.”
Denying someone a wanted abortion, however, does cause severe psychological trauma.
Women denied an abortion are more likely to face increased household poverty and to stay in contact with a violent partner, according to a major study.
The bill also suggests women get abortions because they are lied to or coerced into doing so, but that’s not how it happens, doctors say.
The bill “creates a false narrative that doctors are the ones pressuring patients into having abortion care or not offering them alternatives, ” Dr. Jonas Swartz, a Duke Health obstetrician and gynecologist, told reporters in a conference call last week.
“That is insulting. That’s not the way we care for patients,” Dr. Swartz said.
“I’ve had patients who have already approached me who were nervous to even ask about their options,” Dr. Jayaweera added.
Any doctor found in violation of the provisions in the bill can be referred to the North Carolina Medical Board to be disciplined. But violating a patient’s confidence, denying them the best care at a given time and lying to them about the risks of an abortion also clashes with the board’s stated principles, Dr. Pettigrew said.
If the bill was presented to the medical board, she said, it would be viewed as “medical malpractice, as unethical behavior, as unprofessional behavior.”
The bill also turns trusted doctors into spies.
“It creates a completely new legal mandate for all doctors, not just abortion providers” to report any conditions to the state they think may be related to an abortion, Dr. Pettigrew said.
Any urgent care doctor who thinks certain symptoms could be related to a hidden abortion has to interrogate the patient on where she might have gotten the pills.
“It’s horrendous on so many levels. This is creepy, what it creates, it’s downright creepy,” Dr. Pettigrew said.
‘There’s So Many Things That Are Wrong With This Bill’
Dr. Pettigrew, who also has a law degree, stayed up until 2 a.m. reading the bill the night it was released, writing notes in the margins.
“There’s so many things that are wrong with this bill that we haven’t even talked about,” she said.
Despite her thorough reading, she didn’t catch every detail.
She missed, for example, that the bill makes it illegal to “advise” an abortion after the 12th week, even if that care in another state is the best medically necessary course for a patient.
When it was pointed out to her recently, she was at first at a loss for words.
“That is not good,” she said, “I don’t know what to say about that.”