How reversing Roe v. Wade will affect physicians and patients [PODCAST]

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“These changes on the horizon for our country are unlike anything we have ever experienced. We have only experienced an expansion of rights for those who have been denied fair treatment. Going backwards only infringes our ability to pursue life, liberty, and the pursuit of happiness. Future laws that could be overturned include Griswold v. Connecticut, protecting the right of marital privacy against state restrictions on contraception.

As an experienced physician with a strong interest in patient safety, I feel the need to educate our patients about potential changes in their health care because of this possible decision and ask for their partnership in getting out the vote for candidates that would support women’s rights. Time is of the essence.”

Susan Mann and Haywood L. Brown are obstetrician-gynecologists.

They share their stories and discuss the KevinMD article, “Reproductive and abortion care is health care.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Susan Mann and Haywood Brown. They are obstetrician-gynecologists. Dr. Brown is past president of the American College of Obstetricians and Gynecologists, and together they wrote the KevinMD article “Reproductive and abortion care is health care.” Susan and Haywood, welcome to the show.

Susan Mann: Thank you.

Haywood L. Brown: Thank you, Kevin.

Kevin Pho: So we’ll get into the article in a little bit. We’re going to ask each of you to briefly share your story and journey to where you are today. Susan, why don’t you go first?

Susan Mann: Sure. I’m a practicing obstetrician-gynecologist. I’ve been at the Beth Israel Deaconess Medical Center in Boston for the past 32 years. I’m originally from the Midwest, from Missouri actually, and I chose to move to Massachusetts because I believe strongly in women’s rights and women’s health care. It has been a wonderful journey to support women all these years, and I’m just really concerned about what’s on the horizon.

Kevin Pho: And Susan, what would you say is one of your greatest rewards as a practicing obstetrician-gynecologist?

Susan Mann: Well, I’ve delivered probably over 5,000 babies, but that’s kind of what we do. The other area: Around the year 2000, I became very interested in patient safety and communication, and my background is training with the Department of Defense to improve communication among providers. That’s really where my interests have lain in the past 20 years, to help the communication flow better, both among providers, doctors, nurses, obstetricians, and anesthesiologists, and also with our patients. It’s been a wonderful journey.

Kevin Pho: And Haywood, briefly share your story and journey to where you are today.

Haywood L. Brown: Absolutely, Kevin. I have been involved in women’s health care, obstetrics and gynecology, and preventive care for 40 years now, and my career has been in different states and different institutions. I started my career, basically after my fellowship training, really focusing on health equity and health disparities. I did all of my first academic jobs at large charity care-type institutions, including LSU New Orleans, Indiana, and so forth and so on. So my focus has always been on all of the things encompassing women’s health and women’s health care.

My rise to become president of ACOG was really focused on that agenda, particularly over the last decade and a half, really focusing on health disparities but also quality care. In fact, Susan and I met because we were doing several quality initiatives together, really to impact and address maternal mortality and maternal morbidity. And of course, my journey has always been one where I’ve championed, as Susan has, access to a full range of reproductive services, including abortion services. Fortunately for me, I’ve never experienced in my professional life a period where I could not advocate for those services or have the ability to provide those services to women. What this does currently is really put us back, you know, maybe not just 50 years, but maybe 130 years, if we think about the implications of what we’re going to see with the other attacks that are coming on patient-physician relationships and privacy.

Kevin Pho: All right, so let’s talk about that article both of you wrote. It’s titled “Reproductive and abortion care is health care.” Susan, for those who didn’t get a chance to read that article, can you just briefly walk my audience through it and share the story of why you and Haywood decided to write it?

Susan Mann: Absolutely. Thank you, Kevin. When the leak came out about what was coming potentially from the Supreme Court in terms of limitations on abortion, many of us that provide care thought that things might be scaled back, that maybe it might be reduced to 15 weeks. But I think pretty much universally, it was just such a gut punch to think that all abortions could be taken away from women and returned to states’ rights. What that means is the day it is signed, there are 26 out of 50 states that have laws either already on the books or that will take effect again where a woman can’t get these services, period.

When you’ve practiced for so long, you know, when that door closes in the exam room and it’s you and the patient, you hear their stories and their concerns and what they’ve been through, whether it was a sexual assault, whether it was a very desired pregnancy and now the baby has congenital anomalies that are not compatible with life, or whether it is a problem with the placenta, all types of things that we see in our practice. You know, 95 percent of the time, people think I have the best job in the world. Delivering babies is great. But you know, there’s about two and a half to five percent of the time that it is one of the worst jobs, to have to deliver news to people.

And to think that there are men, predominantly men, that have no medical training, that are making decisions that no longer allow people, couples, and women to make these decisions for themselves when their lives are at stake. I can’t think of any other time in medicine where the desires of others are imposed on me and my patients in our exam room, talking about options that, for the most part, are really difficult options for patients to take on board. And now not to be able to give them options, to be able to look them in the eye and say, “You know, last month we could have taken care of this, but this month your life is now at risk.” It was just so fundamental to my nature that I had to take up the pen, that I had to really sound the alarm for my physician friends. You know, there’s just so much going on in our world right now. We can’t let this just be one more thing that we absorb and move on. We have to pay attention to this.

Kevin Pho: So I’m going to ask both of you the same question, and that’s: Take us into the exam room. Assuming that there are no changes to the draft opinion, can you give us an example or a case study of how this would affect your life as a physician? Susan, why don’t you go first?

Susan Mann: You know, I’m very fortunate. I practice in Massachusetts. Massachusetts has tried to strengthen their abortion rights laws, so I feel that I will be able to continue my practice for now, and I say “now” with a line under it. The line is under it because you’ve heard Senate leader McConnell say, “No, actually, if the Republicans come into power, we want to make this law the law of the land, regardless of what state you’re in.”

So if you then take it to that degree, how would it affect my practice? I almost can’t quite wrap my brain around it. Take somebody, and we’ve seen these cases, who has a placenta abnormality where it’s overlying the cervix, and the patient starts bleeding at 17 weeks, and you’ve had to transfuse them one or two units, and you know that there’s potentially 20 more weeks to go of their pregnancy before you could perhaps take care of this problem. It just puts her at risk, so much risk, and you would have to, I guess, wait until 24 weeks to deliver the baby. I can’t even work out the algorithm of how you would care for these people. It is just so frightening to me, what is potentially on the horizon.

Haywood L. Brown: Kevin, I’m going to take you into the exam room of three previous cases I’ve had to deal with where the woman made a decision to not continue their pregnancy. These are from the past, from my history, but what would happen if those women were coming into the exam room now with the limited options?

Let me take the serious one of a woman who finds herself pregnant with stage 4 breast cancer, having to make a decision about treatment. Let’s say, like my patient, she was already at 11 weeks with a very desired pregnancy, but really having to postpone her treatment now for another 30 weeks or 20 weeks before she could literally deliver. Tough decision. She made a decision to terminate the pregnancy because she needed to undergo major radiation, chemotherapy, and surgery. And fortunately, as I know the story goes, she later had another child that we were able to take care of.

Or take you into the exam room of a 12-year-old who’s pregnant, who’s brought in by her mother. She’s now 15 to 16 weeks, just found out she was pregnant, and she is now in a situation where she is pregnant because the boyfriend raped her. Period. We have states now who are saying that there should be no exception for rape or incest. So how can you say that you’re pro-child if you can’t think about that 12-year-old that I had that many years ago, who really could not, would not have been able to exercise the option of a pregnancy termination?

So those are just two examples. And I think, to ignore the long-term issues of things like the psychological stress, the emotional stress that we now follow. As soon as I’ve seen these women, we’ve followed them for years, with the trauma that they’ve endured, not just from the rape, but just from the pregnancy and having it. So these are real scenarios. These are real issues now that we would have to deal with, and we would have to try to figure out ways to help these women navigate that process if they were in a state that had a trigger law that said an absolute no.

Because we’ve heard politicians say, “Well, you know, it was conceived by rape in a 12-year-old, but it’s still a baby.” And so, ignore the mother, the 12-year-old, but take the side of the embryo. What kind of logic is that? And so this is what I think we’re dealing with today, and we have to be concerned about that. We must be concerned about it. Women need to be concerned about it. Men need to be concerned about it. Churches need to be concerned about it. Communities need to be concerned about it. This is where we are.

Susan Mann: And Kevin, the truth is, you know, in these states, people that have means will find a way to travel, be it to Massachusetts, New York, California, or Colorado. But people without means, and we see so much when you look at the studies of what has happened with abortion over the last few years. If you used long-acting contraceptives, we’ve seen the rates of abortion and teen pregnancies go down, and we’re worried that the future is that these types of contraceptives are at risk as well.

But if you have means, you’ll travel to Massachusetts, and if it becomes a law of the United States, you’ll go to Canada or South America. Mexico now allows abortion. But if you don’t have the means to take on one more child and try and support one more child when you’re already financially strapped, you just have to wonder, what are we doing for these people? What are their lives and the quality of their lives? It’s just yet again an example of the unfairness that exists in our health care system. And we also know, if you then flip it on its head, maternal mortality is three to four times higher in a Black woman or in a Native American woman than that of a white woman. It just doesn’t stop. This just keeps compounding.

Haywood L. Brown: Well, Kevin, let me give you a historical perspective, because if this decision is upheld to undo Roe, it really undoes Planned Parenthood v. Casey, which may not mean anything to anyone, other than that was the original challenge that produced undue burden. And so undue burden is really about a person having to travel more than 100 miles to get a pregnancy termination. So basically, Roe undoes Casey. Well, perhaps Roe also undoes Griswold, which is a right for married women and men to use contraception.

And so, getting back to Susan’s point, there are certain contraceptive methods that are proven to be the most effective for pregnancy prevention that could be challenged, and that includes intrauterine devices, because there’s, quote, a small minority of individuals who believe they prevent implantation. As long as that mentality is there, rather than the fact that they are hormonal and so forth and so on, you’re going to have people who will go after those.

So who’s to say to me, now in my room, when I have a woman who wants to have an intrauterine contraceptive device, a long-acting contraceptive method, “You can’t have that, because the law says that this may cause the pregnancy not to implant”? It’s the most effective method of contraception that we have for pregnancy prevention. There are people out there who want to do that because they have personalized the conception. That’s how tragic this is and how demeaning it is to women’s reproductive rights.

Susan Mann: And it goes on even further, Kevin, if you take it to where a subset of our population wants to go: Personhood begins when the egg is fertilized. So take women that undergo IVF, which has been a godsend for so many women and allowed women and men to have families. IVF is at risk, because if a woman conceives and has 10 embryos right now, she may freeze them, she may use them for a later pregnancy, or she may choose to discard them. But if you say that a fertilized embryo is a person, or give it personhood status, then there are three options. You can put all 10 back in the uterus. You can donate them to another family, but that’s kind of a difficult decision, whether you want your DNA spread across multiple families. Or you pay for refrigeration fees for eternity. But if the freezer breaks, then you’re at risk for committing murder in their eyes. And so that puts a complete chill on the IVF colleagues that perform these kinds of services.

So I just don’t think that the average physician understands what’s coming down the pike if this decision is really allowed to stand and some of these other add-on decisions come to fruition. The criminalization, you know, that goes along with some of these laws. I mean, like the Texas law, you know, bounty hunters out there saying, “OK, if you do this, you know, there’s a bounty on you.” Well, we’ve already seen people who provide abortion services have bounties on them and be killed. I mean, that’s been going on. It has happened several times for prominent physicians in their community. But you know, this is murdering someone to, quote, keep them from performing a service that women come for that’s legal. That’s legal.

So you know, now you have Texas with a bounty law, where you can be turned in, but a number of other states are actually going to trigger that too, where you begin to say, “Well, if you do perform this abortion on this person, we’re going to report you, and you’re going to jail.” That takes us back to the Comstock laws of 1893.

Kevin Pho: So, putting in context the political and societal climate that we live in, what do both of you anticipate the next few months to realistically bring? What can we expect in the next three to six months? Susan?

Susan Mann: I fear that the opinion that was leaked is going to become law of the land. I don’t think that there will be an expansion of the Supreme Court in the near future. I hope that it will galvanize women, and I hope that as physicians, I think it is OK to educate women in your exam room to get out the vote, because it is important for them to preserve their rights, for us to all work together. And if women don’t get out the vote and encourage their male partners to get out the vote. The only way that I see the situation changing is to elect officials that represent the majority’s view.

Haywood L. Brown: Well, I think the issue is how shortsighted, when you think about the immediacy of this. Keep in mind that we’ve been trying to work on this for 50 years, of overturning Roe. I mean, so it’s never going to be those individuals who are going to be completely cured. What I was hoping for was not a complete reversal of Roe, but really, the fact that the case that was being looked at was a 15-week limitation, with exceptions for rape and incest, and so, you know, all those types of things that may make more logical sense. But for those individuals who firmly believe that it’s all or none, it’s all or none, when the population is 70 percent in favor of women having the right to it, it ignores all that.

And so this is where we have to go. We have to be prepared to help women. We have to be prepared for helping women to exercise their options wherever they can. The biggest group that will be penalized, of course, is people who have access issues already, who have dollar issues already, who have counseling issues already, individuals that they can see. And so the idea of us being able to band together and look at where we can help a woman exercise their options those are really the things that I want to take home.

But I also want people to think, as Susan has said, about what the political implications are for the embryo. What are the implications? What happens to the millions of frozen embryos around the country? They’ve become wards where they’re being frozen. What happens to long-acting contraception? But ultimately, what happens to the physician-patient relationship and the right to privacy? Have we really now said that you have no right to privacy when it comes to exercising your reproductive rights? If we’re really saying to people you have no right to privacy, period, when it comes to pregnancy and this issue, and essentially, has that not been what has been said? That is what’s been said.

And people’s right to privacy, you can take it back to the original Constitution. I mean, women were not included in the original Constitution, but the right to life, liberty, and the pursuit of happiness. Well, forcing someone to carry a pregnancy after rape or incest doesn’t fall in any of those categories. Life of the mother at the time of a difficult pregnancy doesn’t fall into any of those categories. So why is it that we can revise it now based on the opinion of a few?

The last thing I would like to say is, when you present that to people, you would think they would be logical. But what I’ve heard a number of times on this issue, and even on the issue of maternal mortality, where we were fighting to improve the health of women in general, is a political person saying to me, “Well, if they die, it’s God’s will.” They don’t understand that my whole teaching is that God gave you talented, brilliant surgeons and people who would care for us, who evolved over the years. So it doesn’t have to be God’s will that someone dies. You know, we can save lives. That’s what we do. What I’m saying is that we are saving the lives of women, we’re saving the lives of many children, we’re saving the lives of the long-term health.

And I believe that it is so shortsighted, people forgetting about the fact that they have daughters, they have sons, and it’s really different when it’s yours. Trust me, I trained in the South, and I would tell you, when it’s your daughter, it’s different. You make different decisions, and that happens all the time. That’s the hypocritical aspect of it that’s just so hard to deal with.

Kevin Pho: Susan, I’m going to give you the last word. What are some of your take-home messages that you want to leave with the KevinMD audience?

Susan Mann: It’s really time to pay attention to this matter. This can’t just be, “Oh, it’s one more thing that’s going on in the world.” This is a stop-and-pay-attention, become-actively-involved issue, because if we don’t, the ramifications are just so significant for our lives as clinicians and for our patients’ lives.

Kevin Pho: Susan and Haywood, thank you so much for sharing your time and insight. Thanks again for being on the show.

Susan Mann: Thank you.

Haywood L. Brown: Thank you very much for allowing us to be on.

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