Emergency care for pregnant women at stake in Supreme Court case, Missouri doctor warns

When a woman experiencing a second trimester miscarriage came into the hospital bleeding through her clothes, Dr. Jennifer Smith couldn’t immediately help her. 

Not while her fetus still had a heartbeat.

Too scared to wait for the miscarriage to progress far enough to be admitted to the hospital in Missouri, the woman and her husband drove to Illinois where she could obtain an abortion. 

Until the situation is life-threatening to the mother, her hands are tied, said Smith, an OB-GYN in St. Louis. But at least in the worst emergency cases, Smith knows she can help thanks to a federal law called Emergency Medical Treatment and Active Labor Act (EMTALA).

“It’s just hard to imagine that we’re living in a time where that actually may not be true,” Smith said. 

The U.S. Supreme Court will soon decide whether a federal law mandating hospitals treat and stabilize every patient, regardless of their ability to pay, includes providing abortions where they are otherwise illegal.

In the case, the Biden administration sued Idaho to block enforcement of its abortion ban, arguing that it violated EMTALA by denying women abortions in emergency situations. Idaho bans abortions in almost all cases, with exceptions to save the life of the pregnant woman or when the pregnancy is the result of rape or incest. 

In response, Idaho argued that the federal law only requires “stabilizing treatment for the unborn children of pregnant women.” Idaho is asking the court to lift a temporary injunction blocking enforcement of its abortion ban in hospital emergency rooms.

The government is arguing that EMTALA requires hospitals to provide abortions needed to stabilize or save the life of a pregnant patient It also protects doctors from prosecution.

Without the law, hospitals and health care workers would have to wait until a mother is actually dying to proceed with a life-saving abortion, Smith said. St. Louis area hospitals still perform abortions for ectopic pregnancies, a nonviable pregnancy that if left unaddressed can be life-threatening to the mother, Smith said. But without EMTALA, she’s not so sure.

“It leaves every person involved in the care open to be prosecuted,” Smith said.

In May, nearly 6,000 physicians across the country signed a letter on behalf of the Committee to Protect Health Care asking the Supreme Court to uphold the federal law. 

Smith was among 32 Missouri doctors to sign on.

In June 2022, Missouri became the first state to ban abortion following the Supreme Court case overturning the landmark Roe v. Wade decision. The ban was triggered under a law passed in 2019 that made it effective with the Supreme Court action.

The 2019 law states abortions will only be permitted in cases of a medical emergency when “a delay will create a serious risk of substantial and irreversible physical impairment of a major bodily function.”

Health care providers who perform abortions not necessary to save the woman’s life can be charged with a class B felony. If convicted, they would face up to 15 years in prison and their medical license could also be suspended or revoked. 

Because of this ban, some doctors and hospitals in Idaho recently stopped admitting pregnant patients who came into the emergency room, potentially needing abortions to save their lives. Instead, women are being transferred to other states for treatment during emergency situations. 

Since Roe was overturned, a Missouri hospital became one of the first in the nation to be cited for violating EMTALA by denying a pregnant woman emergency care. 

In August 2022, Mylissa Farmer entered a Joplin emergency room after her water broke at about 18 weeks pregnant. Even though the pregnancy was no longer viable, because the fetus had a heartbeat, and because Farmer’s condition wasn’t immediately life-threatening, she was turned away. She returned the next day, was kept overnight and then released without additional treatment.

Freeman Health in Joplin was later cited for being in violation of federal law. 

“Although her doctors advised her that her condition could rapidly deteriorate, they also advised that they could not provide her with the care that would prevent infection, hemorrhage, and potentially death because, they said, the hospital policies prohibited treatment that could be considered an abortion,” the report from the U.S. Secretary of Health and Human Services stated. “This was a violation of the EMTALA protections that were designed to protect patients like her.”

Smith said that while she and her colleagues often aren’t able to immediately help patients who experience situations like Farmer, she can at least direct them to care a short drive away in Illinois. 

Prior to the Dobbs decision that overturned Roe, Smith said if a pregnant patient experienced premature rupture of the membranes, they could deliver the baby so the family could have some memories to hold on to. 

Often parents would get copies of their child’s footprints and say their goodbyes.

Now, since they can’t act while the fetus has a heartbeat, Smith said she refers patients to abortion clinics in Illinois where they can receive a surgical abortion. But as a result, they don’t get to hold their baby, and often have to navigate anti-abortion protesters on the way. 

To Smith, it’s not worth risking the mother’s life and well-being to wait for her condition to deteriorate. 

“To delay the care of the mother based on the beating heart of the baby is so counterproductive,” she said. “ … It just takes one emergency that we don’t act on or that we delay to change the life of a whole community.”

A decision in favor of Idaho could impair care for pregnant patients with serious injuries from car accidents or gunshots, or who suffer a stroke, Smith said. In those cases, saving the mother sometimes isn’t possible without first delivering the pregnancy, whether viable or not. 

Pregnant women can quickly lose blood in emergency situations, potentially putting the mother and child’s lives at risk, she said. 

“Unless you’re a trauma physician, it’s an amount of blood that nobody else in the hospital deals with. It’s an unbelievable amount and it can happen so fast,” she said. “If you have to wait and question your legal standing, the likelihood of saving that patient intact, saving the baby, saving her uterus, all of it, it just goes down all the time.”

The Supreme Court could rule on the EMTALA case as early as next week. Until then, doctors continue holding their breath. 

“They’re just singling out pregnancy at this point,” Smith said. “But once you start chipping away at rights, it’s really unclear where the end point is.”

This story was originally published by the Missouri Independent