Moral Injuries

In September 2021, with Senate Bill 8, the Texas legislature banned all abortions after a “fetal heartbeat” is detected, often as early as six weeks. Patients from Texas began to pour into New Mexico for abortion care, leading to a tripling in patient volume across the state, according to Dr. Eve Espey, chair of the University of New Mexico’s OB-GYN department. The Dobbs v. Jackson Women’s Health Organization ruling in June 2022 brought patients from other states too—Louisiana, Oklahoma, Arizona—driving up wait times for appointments. Clinics reduced the number of contraceptive visits and expanded the number of abortion visits and providers; still, Espey says, providers are seeing a 70 percent increase in patient volume overall, and a 500 percent increase in second trimester care. Most patients come from Texas.

Espey offers abortion care at the university’s clinic and at Planned Parenthood. She discusses here the challenges abortion providers in New Mexico have faced over the past couple of years.

—Molly Montgomery

Our opening line is, “Where’d you come from today?” That actually helps us figure out whether we need to give additional doses of medication, whether we need to talk about how to mask the fact that the patient had an abortion, whether they know somebody in town in case they need to stay overnight or have a complication, and whether they can come back to the clinic if needed. It very much factors into the way we think about how to provide the best quality care for each patient. We’ve become expert logisticians. Most of our patients don’t receive regular medical care in New Mexico, so when they come in with a curveball—an adherent placenta, for example, that might require a complex surgery, like a hysterectomy—that requires an entire additional layer of internal discussion, negotiation, care conferences, the kinds of things that significantly increase the complexity of care. And it all needs to happen right now, because that patient drove fourteen hours from a town in Texas and usually has children and a job at home.

One of the major impacts of Senate Bill 8 was seeing patients who were diagnosed with their pregnancy at seven weeks, a week after a heartbeat was visible. It took them another four or five or six weeks to find the funds, take time off work and actually get an appointment for an abortion. People were making appointments in multiple states and multiple clinics. We’d talk to patients who, if they couldn’t get an appointment in New Mexico, would go to Louisiana, they’d go to Colorado, they’d go to Kansas. And over time, the number of states where people could legally get an abortion also shrunk—after Dobbs, states that had trigger laws instantly imposed abortion restrictions, which created even more of a crunch for patients.

Our days got significantly longer and much more stressful because we saw the real suffering that our patients were going through on top of the typical barriers to abortion—not being able to get a ride, not being able to get time off work. And now they were afraid of being sued, or seeing their friend who helped them get to New Mexico be put in jail. Nobody really understood the law, so people’s fears outstripped the actual content of the law. Patients didn’t understand that they themselves couldn’t get sued; because of the intentional confusion and chaos surrounding the law, they didn’t tell anybody. They’d come for abortion care all alone, with no money, and just incredibly distressed beyond the regular stigma that’s associated with abortion. They felt their state had basically turned its back on them. That moral distress translates into moral injury for the providers and staff who are taking care of them.

We are seeing far more patients with fetal anomalies, because it’s illegal to terminate these futile pregnancies in Texas. Just this last week I received a call from a former colleague who’s now working in Texas. He said, “We’ve got a patient who’s second trimester, who has a placental abruption and has a lethal fetal anomaly, and she’s bleeding pretty heavily. Because there’s a heartbeat, we’re not allowed to terminate the pregnancy.” This is a hopeless pregnancy, and a patient who’s medically very much at risk. This colleague is asking me how we can possibly figure out care for her.  Most of the time, we advise the provider to send the patient to us and we take care of them in New Mexico, but this patient was not stable for transport. So I’m racking my brain to think about how we can get around the fear that the hospital has of violating a law that would elevate an electrical impulse over the life of a human being.

Part of what’s so challenging, both for patients and providers, is that the landscape changes all the time. The North Carolina legislature just passed a ban on abortions after twelve weeks. The governor vetoed the ban, but the legislature may override the veto. North Carolina is currently a haven state where many of my colleagues are proud to offer care to numerous patients from surrounding restrictive states. It’s not clear they’ll be able to offer that care moving forward.

Abortion training in restrictive states is another casualty of restrictive laws. Almost half of ob-gyn trainees receive their education in restrictive states—they can no longer receive that training there. And it’s not just being able to perform an abortion, it’s being exposed to the people who can talk to medical students, nursing students and allied health professionals to help them understand why legal abortion is so important to individual and public health. I didn’t even have a lecture about abortion as medical student, much less perform one as a resident.

I was not super pro-choice as a younger person. My mom was anti-choice because she had worked in a camp for kids with Down syndrome and associated abortion with the kids she played with as a counselor. So that became my opinion as a young person. And then I had my own experiences—I had a teen pregnancy and was married briefly but raised my son as a single parent. While that derailed me a bit, I had the privilege of education and family support. In medical school, I had an unplanned pregnancy and an abortion and have never felt so free and relieved in my entire life. Through my own experiences, I got to the point where I “believed” in abortion, but felt that I could never provide the care myself. And then one day it occurred to me, wait a minute, I’m not a neurologist, this is my wheelhouse. I care for women and patients who can become pregnant; if I believe in this, how can I morally make a decision not to provide the care? Particularly after personally experiencing the huge change it made in my own life, allowing me to continue to pursue my career. But we see this all the time, people who don’t believe in abortion, who then have one and think it’s somehow different for them. Where it crystallized for me was in a teen clinic in Gallup that I helped run in my first job after residency. I became close to a particular patient who, like me, experienced an unintended pregnancy, but didn’t have the same options or the same advantages. After that experience, I decided to direct my career toward a focus on family planning, abortion and public health.

The reality is that it’s hard to prevent pregnancy for thirty years, which is what many people desire. As a physician trainee, you need role models and education—about contraception, abortion and public health—and I’m really worried about losing that in half of the country. That’s dire. We need to continue to focus on ensuring there will be people who understand the importance of the full spectrum of reproductive health care, provide that care and make sure we always center our patients and their reproductive freedom in the care we provide.