Questions to Help Hospital Systems Prepare for the Widespread and Devastating Impacts of a Post-Roe Legal Landscape

For decades, people across the U.S. have faced countless barriers to accessing abortion care. Today, the Supreme Court ruled in Dobbs v. Jackson Women’s Health Organization to overturn Roe v. Wade. With this decision, we know abortion access will become significantly more restricted in many parts of the country. Therefore, it is important for clinicians to work with their hospital systems to prepare to address the wide spectrum of medical care that will be affected by restrictions on abortion access. 

Notably, hospitals in states expected to ban or further restrict abortion access need to consider whether and how they can connect patients with care in their state or surrounding states. Hospitals in states expected to preserve or expand abortion access will need to plan around potential increases in volume. To help clinicians and hospital systems prepare for significant and devastating changes to the legal landscape around abortion, ACOG has developed the following list of questions. These questions are modelled on an emergency response framework, which has been developed to guide responses to public health events and emergencies with major health consequences, as we expect in this post-Roe world. These questions were developed by ACOG for clinicians to use when preparing for the shifts in abortion access with their hospital administrators and leadership.  

What resources can clinicians use when they are unsure what care they can provide a particular patient under a state’s laws?

Experts predict that up to 26 states around the country will completely or almost completely ban abortion in the post-Roe landscape. Some state laws banning abortion may have exceptions for “medical emergency,” “life endangerment,” or “medically futile pregnancy.” Given clinicians often practice and make medical decisions in grey areas, it may be unclear whether they can perform an abortion for a particular patient under their state law’s exceptions. For example, for a patient who presents with active bleeding and a fetus with cardiac activity in the early second trimester, how much bleeding warrants a “medical emergency” in which clinicians are able to intervene? Just as many institutions did during the COVID-19 pandemic, we recommend that hospitals create a task force to help clinicians make these decisions and designate a representative who can be on call as questions arise in real time.

Who should be on our hospital’s task force?

If possible at your institution, it will be helpful to include a lawyer and a clinician with family planning expertise on your hospital’s task force. It may also be helpful to include a maternal-fetal medicine specialist. For smaller or community hospitals, it may be helpful to collaborate with other institutions or academic centers in your area. Hospitals should, to the extent possible, provide legal protection for those serving on task forces, similar to that provided for credentialing committees, ethics committees, and maternal mortality review committees.

For institutions in restrictive states: What is our hospital doing to prepare to potentially transfer and refer patients we are unable to care for at our institution due to state laws or personnel availability?

Clinicians practicing in states where abortion is restricted may already have systems in place to assist with transfers and referrals for patients experiencing obstetrical complications and needing abortion care. Likely, as the legal environment becomes more restrictive, hospitals will have to develop, expand, and adjust these systems to allow patients to continue to obtain the healthcare they need. Hospitals should consider legal questions that may arise when attempting to refer or transfer patients, particularly patients who are experiencing serious pregnancy complications but may not be considered “sick” enough to qualify for care under a state’s existing abortion restrictions. For example, can a clinician directly transfer a patient to an institution in another state or provide a “warm” referral to facilitate care? How are clinicians able to help patients get care in their state or other states without exposing themselves or their patients to potential criminalization?

For institutions in protective states: What is our hospital doing to prepare for a potential surge in patients attempting to access abortion care at our institution?

Hospitals in protective states may face a surge of patients attempting to access abortion care at these institutions. It is important for these hospitals to prepare for how they can best provide care for increased volumes of patients. For example, are there systems that can be set up to facilitate accepting transfers and referrals for abortion care from clinics and hospitals in restrictive areas? Can clinician schedules be adjusted to allow more reserved appointment slots for people seeking abortion care? Can cash pay options be established for abortion services to facilitate access for people who may not have insurance, or whose insurance plan may not cover abortion services?  

What is our institution doing to help protect clinicians and their pregnant patients who present for care? Does our institution have a policy and plan to protect healthcare professionals who intervene in life-threatening situations with appropriate medical care from the consequences of abortion bans? What does liability coverage look like in these situations?

Legal restrictions on abortion are and will continue to affect a wide spectrum of patient care. For example, in states with laws criminalizing abortion provision, clinicians may be nervous to provide pregnant patients with needed diagnostic tests (i.e. radiology imaging) or interventions (i.e. anesthesia or surgical intervention for a ruptured appendix during pregnancy) due to fear of inadvertently causing a pregnancy loss. They may also be confused about the impact of abortion restrictions on miscarriage and pregnancy of unknown location management. In addition, they may be uncertain about what they should document in the medical record when caring for particular patients. There may be scenarios when a healthcare professional acts in an evidence-based and lifesaving way but is still pursued by the state for violating an abortion ban law. 

It is important that clinicians feel supported by their hospitals to provide and connect pregnant patients with necessary care. This may involve setting up meetings between clinicians and the hospital’s legal counsel to review risks and discuss how the hospital will support and protect clinicians. It may also involve establishing hospital policies emphasizing clinicians’ responsibility to provide compassionate, evidence-based, and non-judgmental care to their patients in whatever way they can. Institutions can also bring in trainers to help clinicians understand best practices for preventing criminalization of pregnant patients who may present, for example, after self-managing an abortion.