By Rachel Crumpler
Beverly Gray, an OB-GYN at Duke Health who provides abortion care, expects that turning away people seeking abortions in North Carolina will be a daily occurrence beginning tomorrow, when the state’s new restrictions passed by Republican lawmakers take effect.
Overnight, abortion access will significantly diminish as the time frame for seeking most abortions in the state drops from 20 weeks of pregnancy to 12 weeks.
Gray said cutting weeks of access in the state will make turning patients away from care — which already happened under the 20-week ban — more frequent.
That’s devastating to her, to her colleagues and to many women, she said.
“I think about when we turn someone away, will they be able to make it to another state?” Gray asked. “And if they can’t, what is their life going to be like? What is their child’s life going to be like?”
It’s not lost on Gray why she will be turning more people away — timelines set by North Carolina lawmakers over the objections of medical professionals and a veto by Gov. Roy Cooper. Gray still has the same skills to help patients in an array of situations, but her hands will be newly tied — taking previously available options for reproductive health care off the table.
Amy Bryant, another OB-GYN and abortion provider, knows the new North Carolina law will put care out of reach for many patients, such as a 17-year-old whom she treated a few weeks ago. The teen, who was just finishing high school, sought an abortion when she was 13 weeks and one day pregnant. Tomorrow, that patient would be left to carry the pregnancy to term or travel out of state.
“That’s just going to happen so much more,” Bryant said. “It’s just unfair.”
While most abortions occur before 12 weeks, Bryant said, there are plenty of scenarios when that’s not possible. At least 1,878 North Carolinians obtained abortions after 12 weeks of pregnancy in 2021 out of a total 27,305 who had abortions, according to the latest data available from the state health department.
North Carolina’s new law does provide some exceptions — for rape, incest, fetal anomalies and risk to the mother — that allow an abortion after 12 weeks. Still, Bryant said, some of the most vulnerable patients will be outside the window of care, such as teenagers with irregular periods who often identify pregnancy later, or those who need more time to pull resources together.
Gray has similar concerns about access to care.
“There are a lot of complex social reasons that impact why people need care,” Gray said. “I think a lot of those patients don’t fall into the exceptions — patients who may be living in poverty, who are working multiple jobs, who already have kids, who have delays in care because they at baseline don’t have access to health care.”
As a result of the new restrictions, Bryant anticipates that North Carolina will face increased birth complications and elevated maternal and infant mortality rates — trends seen in other states with restrictive abortion policies.
“My colleagues and I want to abide by the laws, and we want to provide the best possible care,” Bryant said. “There are times where that really does come into conflict, and it’s gotten worse.”
New era of care
Since the Supreme Court’s Dobbs decision in June 2022 handed the authority to regulate abortion back to states and their elected officials, North Carolina providers working in reproductive health care have faced a challenging year navigating the shifting legal landscape. Tomorrow, they will enter a new era, adjusting their practices to conform to the added constraints on their work.
In addition to cutting by eight weeks the time window allowed for most abortions, lawmakers placed more requirements on women seeking abortions and on their providers.
One of the biggest changes is requiring an in-person appointment for state-mandated counseling at least 72 hours before an abortion. Previously, this pre-procedure counseling could occur over the phone or online. Gray said for patients and providers, this will be one of the most difficult requirements to adjust to and, she emphasized, it’s not medically necessary.
As a result, patients will be required to visit clinics at least twice — many needing to travel long distances to reach one of the state’s 14 abortion clinics spread over nine counties. The additional appointment will necessitate extra time off work, miles driven, hotel stays and child care costs.
“We expect that to be a significant barrier for many patients, and probably an insurmountable one,” Molly Rivera, Planned Parenthood South Atlantic spokesperson, told NC Health News in May. “Especially for folks in rural parts of the state who have to already drive hours to get to an abortion clinic. Especially for folks that don't have paid time off of work. Especially for people who already have kids at home.”
For providers and clinics, adding an extra appointment to an already busy workload will create another layer of complexity to scheduling. There also are new reporting requirements that physicians say will be burdensome.
“I would rather spend that time with my patient and their family,” said Caledonia Buckheit, an OB-GYN in the Triangle. “I don't want my time and effort to be towards paperwork and legal — these things that are not patient-centered.”
Several other provisions in Senate Bill 20 are being challenged by Planned Parenthood South Atlantic and Gray in a lawsuit that was filed June 16 in U.S. District Court. The health care providers argue that specific provisions are so vague or contradictory that doctors are uncertain about what’s lawful.
After the lawsuit was filed, lawmakers at the General Assembly revised several of the challenged abortion provisions this week by passing amendments to a separate bill. For example, one revision clarified that medication abortions are permitted up to 12 weeks in the state. Previously, language in Senate Bill 20 stated in one place that the age of the fetus could be “no more than 70 days,” or 10 weeks.
Gov. Cooper signed the revised provisions into law Thursday afternoon, less than 48 hours before the new restrictions take effect.
"In addition to being dangerous for women, the rushed abortion ban was so poorly written that it is causing real uncertainty for doctors and other health care providers,” Cooper wrote in a statement about signing House Bill 190. “This bill is important to clarify the rules and provide some certainty, however we will continue fighting on all fronts the Republican assault on women’s reproductive freedom."
At a federal court hearing for the lawsuit heard in Greensboro on Wednesday, the plaintiffs and defendants agreed that the new language resolves issues with several provisions. However, the passage does not resolve the entirety of the lawsuit. The remaining differences likely will be addressed through future legal proceedings.
“Our lawsuit was never going to be able to give North Carolinians the bodily autonomy that they deserve,” Rivera said after the court hearing. “This law passed. It's happening. But we did come to the court to get clarity so that we know how to comply with this sweeping law so that we can help patients navigate this reality.”
Other portions of the bill, such as the mandate that any abortion after 12 weeks be provided in a hospital and the implementation of any new, potentially stringent licensing rules on the state’s abortion clinics, will not go into effect until October.
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How sick is sick enough?
The new law about abortion does provide some exceptions for rape, incest, fetal anomalies and risk to the mother that allow abortions later in pregnancy, but physicians have concerns about how workable those are in practice.
Lisa Carroll, a high-risk pregnancy OB-GYN worries about her patients — many of whom have chronic illnesses that are exacerbated by pregnancy. Many conditions are not immediately life-threatening, but pregnancy could cause long-term health risks.
For example, Carroll recently treated a pregnant patient with kidney disease. Carrying the pregnancy caused significant dysfunction to the woman’s kidneys, for which she required dialysis. Carroll had a long conversation about her options to continue the pregnancy or terminate. The patient chose to continue the pregnancy, but Carroll said she’s unsure if the same situation presented next week would be considered life-threatening enough to meet the law’s exception.
Carroll spends most of her time screening for and diagnosing fetal anomalies in pregnancies, and the law allows abortions up to 24 weeks in cases where a “life-limiting” anomaly is found.
Medical professionals have voiced concern over the phrase “life-limiting” anomaly, calling it broad and open to interpretation.
“What is life-limiting?” Carroll asked. “Does that mean that the fetus isn't expected to live a month after birth? Isn't expected to live a year after birth? Isn't expected to live to the age of 10?”
Rachel Veazey, a reproductive genetic counselor in the Triangle, agrees that “life-limiting” is ambiguous.
“It’s really particular wording that, I think, is going to throw our field for a loop,” Veazey said.
Veazey explained that very few conditions are considered definitively lethal — or always causing a newborn baby to die. Many fetal anomalies are a spectrum that often catch expecting parents by surprise. Often, she said, they result in a child with such profound disabilities that their quality of life is severely diminished.
“With a lot of families, we end up having conversations about quality of life versus life-limiting,” Veazey said. “There's a lot of anomalies or genetic conditions that very much alter the picture of what families imagine when they enter into a pregnancy that is not compatible with their life, and they would view it as life-limiting. But we know that's not what the rough definition of what the law is going for.”
In some ways, though, Carroll said not having a definitive list of conditions is helpful because individual physicians and health care institutions can determine what they are comfortable deeming life-limiting based on the context of each individual case.
Operating in this gray area is also problematic, she said.
“It is good to allow for physician judgment, but the problem is that physician judgment is now open to criminalization,” Carroll said. “If there are other physicians who disagree, or who say that it's not life-limiting, or it's not life-limiting in all cases, or wasn't life-limiting in that particular case — then I may be criminalized for that individual judgment.
“That is not something that is normal or appropriate or fair in the practice of medicine, and it may lead physicians to be counseling patients based not on the patient's best interest or the fetus’ best interest.”
Veazey said the patients she counsels with identified fetal anomalies regularly choose to terminate the pregnancy. While she expects a good portion of fetal anomalies to be detected by 24 weeks, it will not encompass all conditions, nor necessarily account for those who are delayed starting prenatal care or who face delays due to the state’s new abortion restrictions. That’s why she believes her job may become more focused on grief counseling in the months ahead as she sees more patients who may be carrying pregnancies to term who would have — in a different legal landscape — opted for abortion.
“A lot of the conversations we have with families that are continuing with pregnancy are helping them understand what the health care management looks like for that child or individual with a birth defect or genetic condition,” Veazey said. “Imagining doing that with or for someone who wouldn't have on their own volition decided to continue a pregnancy is a different kind of counseling.”
Although medical professionals see potential ambiguity with other conditions, the law does make one thing clear in regard to fetal anomalies: New language bans abortions at any gestational age due to the identification of the fetal abnormality of trisomy 21, known as Down syndrome — one of the most common genetic differences in a human embryo.
“It's going to create a very strange counseling conundrum for high-risk OB doctors, for all general providers, anybody who provides prenatal care,” Carroll said.
Loss of options
Tomorrow North Carolina will join the ranks of about 20 other states across the country that have banned or increasingly restricted abortion access since Dobbs. Before this legal change, the state served as one of the last remaining abortion access points in the South.
In states with new restrictions, there were fewer abortions, while the numbers show that many women traveled to other states for procedures. In sum, though, the Society for Family Planning has collected data on abortions across the country and found that in the first nine months after the Supreme Court overturned Roe, there were a cumulative 25,640 fewer abortions in the U.S.
“We know that bans or restrictions on abortion care don't stop abortions from happening,” Rivera from Planned Parenthood South Atlantic said. “They just make it harder for people to do it, which inevitably pushes them further into their pregnancy.
“So even a patient who has decided long ago that not only did they realize they were pregnant but they decided they didn't want to be, they are not able to get an abortion right away. They first have to figure out whether or not they can get it in their home state. And if they learn that they cannot, they have to figure out where to get it next. And that's complicated.”
Gray wishes that lawmakers would trust women to make their own reproductive health decisions.
“Patients are really the experts of their lives, and they know what they're able to handle and not able to handle,” Gray said. “I think they make really thoughtful decisions, and this law makes it harder for them to be thoughtful. It makes it harder for us to provide evidence-based care and just creates chaos for an already busy and taxed medical system. It doesn't improve care.”
Tell us your story about abortion access
NC Health News will be continuing to cover the effects of increased abortion restrictions in the months ahead and the best way for us to do that is with your help — hearing concrete examples of how you are navigating the new law. Have you been affected by new abortion restrictions as a medical professional or a patient? NC Health News is interested in hearing your experience.