This week, we learned about the tragic and preventable deaths of two women in Georgia from ProPublica. In the case of Amber Thurman, the 28-year-old single mother and medical assistant traveled to North Carolina for legal abortion care after Georgia’s 6-week abortion ban went into effect in 2022.
A few days after receiving abortion medication, Thurman vomited blood and passed out back home in Georgia. An ambulance brought her to Piedmont Henry Hospital in Stockbridge. On presentation to the emergency department (ED), she had low blood pressure, tender abdomen, and doctors noted a foul smell during her pelvic exam — all evidence of abdominal infection. She had retained products of conception (when placental and/or fetal tissue remains in the uterus) and had an infection that needed to be treated. Her condition, though rare, is not unprecedented in pregnancy.
The doctors treated her quickly with fluids and antibiotics, yet it was 20 hours before she received the dilation and curettage (D&C) she needed to treat the source of her infection. She died on the operating table, and Georgia’s maternal mortality review committee recently deemed her death “preventable.”
Delays in Care
Georgia’s abortion law allows for, “Removing a dead unborn child caused by spontaneous abortion.” Because Thurman had taken abortion medications, it is possible the healthcare team was concerned about the legality of providing her with medically appropriate care since her pregnancy loss was not “spontaneous.” Even just deliberating that issue may have contributed to the delay that ultimately cost Thurman her life.
Notably, “Piedmont [Hospital] did not have a policy to guide doctors on how to interpret the state abortion ban when Thurman arrived for care.” The hospital’s lack of a policy to guide clinicians around decision-making left Thurman’s team with no direction, and no certain protection from criminal liability or loss of license. The committee recommended all hospitals implement policies “to treat a septic abortion on an ongoing basis.” Indeed.
Georgia is by no means unique. A lack of clear guidance around when abortion or miscarriage management can be performed to save a woman’s life has caused harmful and deadly delays worldwide in countries where abortion is illegal or restricted. In Ireland in 2012, the tragic death of Savita Halappanavar, a young woman denied abortion care for a 17-week fetus with no chance of survival, sparked national protests that led the country to overturn its abortion ban. In Poland last year, thousands protested the death of 33-year-old Dorota Lalik who died of sepsis 3 days after going to the hospital when her water broke 5 months into her pregnancy. El Salvador. Nicaragua. Kenya. The list of countries where women have been severely harmed after being denied proper abortion or miscarriage management care goes on. Increasingly often, this includes women in the U.S.
The Need for Clear Guidance and Protocols
Much of the public dialogue around Thurman’s case, and others like hers, has blamed and vilified physicians for failing to provide her with adequate, timely care. Yet it is clear her care team was struggling to provide treatment that met both legal and medical standards of care — standards that now appear in conflict with each other.
Abortion bans are written by legislators. Many bans have exceptions, but those exceptions are often ambiguous. So-called “life-saving” abortion clauses are often narrow or vague. Without legal guidance for healthcare professionals, such protections for women’s health remain hollow and ineffective. Patients too have been so fearful of criminal charges or civil actions against them that they may avoid EDs altogether.
Hospital administrators must take proactive measures to protect their staff and patients by enacting clear guidelines and practices to enable the highest standards of medical care. If they fail to do so, they leave medical practitioners in the lurch and patients in grave danger.
After the end of Roe, we have seen a wild west of restrictions on abortion that continue to hamstring and intimidate those who seek to provide quality reproductive healthcare. The resulting landscape has driven some ob/gyns out of hostile states and created mayhem for those practitioners who remain. Healthcare practitioners cannot be expected to serve as their own legal counsel and ethics advisors. Expecting physicians to practice their best medicine in an uncertain legal environment leads to confusion, expensive consultations, and potentially dangerous delays in care.
Despite this, some place the blame for patient deaths on practitioners, disingenuously claiming the laws are clear and even trying to shame healthcare workers for not proceeding in the face of uncertainty.
In the past 2 years, we’ve heard stories of uneasy physicians phoning hospital attorneys while a patient decompensated in front of them. The popular press is full of stories of patients being turned away from EDs for not being “sick enough” for a physician to feel certain that they can provide care under restrictive abortion bans. We’ve heard accounts of ectopic pregnancies, premature rupture of membranes, and now septic retained products that have all resulted in patient harm, loss of fertility, and even patient death. Such situations are now so common that they have become a theme of the presidential election.
Physicians themselves cannot be at the center of blame. It is physicians’ ability to do their job that has changed dramatically and must be fixed.
We have assembled a coalition of other concerned physicians and attorneys to work together to support hospital administrators and risk managers in aggressively protecting physicians nationwide. By working to identify individual hospital facilities that may have policies or effective management of ED protocols, we can create a blueprint to address these serious violations of medical ethics and human rights. Even facilities located in restrictive states can transform how healthcare professionals navigate the current atmosphere of uncertainty and fear to provide the best possible care.
Hospitals tend to be risk-averse and advise physicians to do less, not more, when concerned about the uncertain legal landscape. It’s time to reverse that approach. When it comes to care for pregnant patients, there is no clear warning about how long a patient has before death is certain.
It’s up to hospital administrators to assemble their risk management team, consult with their attorneys, and advise physicians to abide by the highest standard of care in their state. And to do so now before the next tragic case shows up on their doorstep.
Dara Kass, MD, is a practicing emergency medicine physician and healthcare consultant and former regional director at HHS. She is also the clinical director for Access Bridge, which works to improve reproductive healthcare in emergency medicine. Julie F. Kay, JD, is a human rights attorney and the executive director of the Abortion Coalition for Telemedicine. She is co-author of Controlling Women: What We Must Do Now to Save Reproductive Freedom.
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