How Roe’s end would change prenatal care
Pregnancy, in the age of modern medicine, comes with a series of systematically recommended prenatal tests: at 11 weeks, a blood test and an ultrasound to check for conditions such as Down syndrome. At 15 weeks, another blood test, for abnormalities like spina bifida. From 18 to 22 years old, an anatomical ultrasound of the baby’s heart, brain, lungs, bones, stomach, fingers and toes. This is when many parents find out if they are expecting a boy or a girl, but the most pressing medical reason is to look for anatomical abnormalities, including serious abnormalities such as missing kidneys or missing parts of the brain and skull.
With Roe vs. Wade In place in America, women undergoing prenatal testing generally have the legal right to terminate a pregnancy based on the information they learn. But restrictions on abortion in some states — by gestational age or by fetal abnormality — have already begun to limit that choice. What if the Supreme Court overturns roe deer, as seems likely, it will be further reduced in some states. The routine elements of prenatal care might start to look very different in states that ban abortion than in states that allow it.
Even today, the laws of more than a dozen states that restrict abortion beyond 20 weeks change the use of second trimester anatomical analyses. “People are rolling back these tests, doing them earlier than is optimal,” says Laura Hercher, a genetic counselor at Sarah Lawrence College, who recently conducted a survey of genetic counselors in states where abortion is restrictive. But the earlier the examination is performed, the less doctors can see. Some brain structures, such as the cavum septum pellucidum, might not develop until week 20, says Massachusetts obstetrician Chloe Zera. Not finding this structure could indicate a brain abnormality, or simply that the scan was done too early. Doctors can also detect evidence of a heart defect, but don’t know how serious or repairable it is. At 20 weeks, the heart is only the size of a penny.
Six States also currently restrict abortions based on genetic abnormalities. These laws typically target Down syndrome, or trisomy 21, in which the presence of a third chromosome 21 can have a range of physical and mental effects, milder in some children than others. The laws of some states specifically mention Down syndrome; others to expand restrictions on a much wider range of genetic abnormalities, many of which are much more life-limiting than Down syndrome. In trisomy 13, for example, the physical abnormalities are so severe that most babies only live a few days or weeks. More than 90 percent do not survive beyond their first year.
In states that currently restrict abortion based on genetic abnormalities but still allow it for other reasons under roe deer, patients can have an abortion if they do not mention the genetic abnormality. This puts doctors and genetic counselors in a bind. For example, says Leilah Zahedi, a maternal-fetal medicine physician in Tennessee, what happens if doctors see a serious heart defect on ultrasound? The underlying cause of many of these heart problems is Down syndrome. But Tennessee restricts abortions specifically on the basis of Down syndrome. Should doctors tell patients about the link to Down syndrome? Should they do genetic testing? It could help parents prepare for everything that comes with Down syndrome. But it would be more difficult for them to have an abortion, if they chose to have one. They should consult another doctor who does not know the diagnosis and be careful not to reveal it.
Many of the current abortion restrictions contain exemptions for cases with the most dramatic medical consequences: fatal fetal abnormality or risk to the life of the mother. Yes roe deer is overturned, many of the “trigger laws” that will immediately ban abortion in certain states also contain such exemptions. But what is “fatal” for the baby and what risk is acceptable for the mother are not entirely clear criteria. “There are very few clear lines in medicine,” says Cara Heuser, a maternal-fetal medicine physician in Utah. “The laws really don’t allow for all the nuance that we see in medicine. They ignore uncertainty.
When it comes to fetal abnormalities, “it’s very rare that we can say, ‘It’s universally fatal,'” Zera told me. For example, in the case of a massive cerebral hemorrhage that destroys most of the brain tissue but leaves the brainstem intact, the baby can breathe at birth but will need further medical attention. Fact fatal mean deadly in the absence of certain medical interventions? Which? And should an anomaly be fatal immediately or within a certain time after birth?
There is also ambiguity in the exceptions for the life of the mother. A genetic counselor in Texas told me about a recent patient whose fetus was triploid, meaning it had a full extra set of 23 chromosomes. It is one of the universally fatal conditions. But triploidy also poses an additional risk to the mother, as these pregnancies are linked to preeclampsia, or dangerously high blood pressure. Texas currently limits abortions beyond approximately six weeks, except in “medical emergencies.” High blood pressure may not be an immediate medical emergency, but it can be. “What’s scary about being a pregnant person in Texas,” says the genetic counselor, whom I agreed not to name because that person feared legal retaliation in the state, is that many doctors will wait to provide treatment “until mom’s life is really in danger.” The fetus won’t survive, and the delay can only increase the risk to the mother, but “we have to wait until you’re sick enough to deliver.” These laws create a general climate where physicians who fear prosecution may be reluctant to treat the mother. “Sometimes,” Heuser says, “that hesitation can be fatal.”
Yes roe deer is canceled and abortion is banned in many states, testing could play a different role in prenatal care. Zahedi told me, anecdotally, of a recent patient whose doctor told her genetic testing no longer made sense. But she doesn’t really think abortion bans will change the use of tests, even if they limit what patients can do afterward. Most of her Tennessee patients already don’t choose abortion, she said, but the tests can provide information that informs obstetric care and prepares parents for what’s to come.
Others raise the possibility that insurers will eventually drop coverage for prenatal tests. Cumulatively, “all of these types of screenings and tests are incredibly expensive,” Hercher, of Sarah Lawrence, told me. Insurance currently has a financial incentive to cover them, because preventing the birth of a child with severe medical needs saves costs down the line. But if abortion is illegal in many states, Hercher asks, will insurance companies, especially regional ones, want to continue covering such tests? Or will patients have to pay for them out of pocket? These tests are currently routine for pregnant women, but whether they will remain so in the future will depend on where you live and what you can afford.