Harnessing MFM Expertise to Optimize Maternal Health After Dobbs

By Ashish Premkumar, MD, PhD

Navigating abortion care restrictions and barriers has long been a challenge for our patients and for us, as physicians. The 2022 Dobbs v. Jackson Women’s Health Organization decision increased state legislative interference and has created a rapidly changing and increasingly complex healthcare landscape, further complicating the ability to provide and to receive abortion care. Uncertainty about what reproductive care is permissible within a given state or institution can lead to delays in treatment and barriers to providing standard-of-care, evidence-based medicine. We have clear evidence that abortion restrictions harm our patients.

As experts in severe obstetrical complications, we, as MFMs, often take the lead when questions arise about abortion restrictions in relation to a specific patient’s clinical condition. All of us who care for pregnant people at high risk for morbidity and mortality must remember that the clinically appropriate options for care do not change based on where a patient lives or receives care, whether in a restrictive state or at a hospital with formal or informal policies that restrict the provision of care beyond what is required by law or regulation.

To make sure our patients have access to the care they need and deserve, we must work with allies across all medical specialties, as well as legal counsel. In my practice, our complex family planning partners work with our labor and delivery nursing staff to set the context around later abortion procedures. Providing this background helps parents, families, doulas, and nurses on the floor understand and feel more comfortable with the care, focusing on patient needs and outcomes.

With the new SMFM Special Statement: Considerations for management of high-risk pregnancies when abortion care is restricted, the SMFM Reproductive Health Committee outlines strategies for MFMs and their clinical and administrative colleagues to consider regarding potential scenarios around abortion care and how to address them within their institutions. Many of these strategies have been used by MFMs and their colleagues since the Dobbs decision to help preserve our ability to provide safe, evidence-based, medically appropriate care to pregnant people in states and institutions that restrict abortion care.

Specific approaches that have improved care include:

• Communication and consensus-building. Working with others in your institution, community, state, and region to discuss the impact of abortion restrictions on specific, common clinical scenarios and reach a shared understanding of what care is legally permissible. At the institutional level, MFMs can create an advisory group to think through clinical questions and the logistics of care, including education and training. A task force can be created to take on challenging scenarios as they arise to determine the immediate next steps. Resources supporting collaborative efforts to improve access to care can be found on the SMFM website.
• Reaching beyond your institution. Consult and partner with legal experts within and outside of your institution. Establish referral networks to ensure all patients have access to the care they need. Create and utilize a toolkit for care teams that brings together clinical, legal, and educational information. Free legal support is available for SMFM members, and trusted patient support resources also exist in all states.
• Improving access. Within your institution, advocate for providing comprehensive reproductive healthcare, including access to all contraceptive options and abortion care within the legal limits of your state.

In an effort to provide comprehensive reproductive care, shared decision-making and patient preferences are key. In my experience as an MFM focused on prenatal management of congenital anomalies, I have learned not to make assumptions about what a patient wants. It is not uncommon for a patient to choose abortion care in the setting of fetal anomalies even if maternal-fetal therapy is an available intervention. On the other hand, there is a perception that once a patient chooses maternal-fetal therapy, they will not consider abortion care if the situation evolves if the situation evolves.

Although it can improve perinatal health outcomes, maternal-fetal therapy is rarely a cure. Even in the best-case scenario, maternal-fetal therapy may limit the morbidity inflicted by an ongoing pathology. As individual clinical and patient circumstances change throughout pregnancy, patients deserve to remain fully informed and supported, which means continuing to counsel them about all options, including abortion, even after maternal-fetal therapy.

We must help our patients understand all their reproductive care options, especially considering ongoing abortion restrictions and barriers. Doing so requires us to pair our clinical expertise with thoughtful collaboration, patient-centered care, and institutional leadership to advocate for and advance reproductive justice within our own institutions and healthcare systems.

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Ashish Premkumar, MD, PhD, an MFM subspecialist, is an Associate Professor of Obstetrics and Gynecology, and the Interim Section Chief of Maternal-Fetal Medicine at the Biological Sciences Division at the University of Chicago. He is also a member of the SMFM Committee on Reproductive Health.