Mike Wolanin | The Republic A bright red sign points to the emergency entrance to Columbus Regional Hospital in Columbus, Ind., pictured, Tuesday, March 31, 2020.
Columbus Regional Health officials say they are prepared to comply with Indiana’s near-total abortion ban but expressed concern about some potential unintended consequences of the new rules, which are set to take effect in a little over two weeks.
The ban, which is expected to take effect on Aug. 1 after the Indiana Supreme Court recently struck down an injunction blocking the law, prohibits the vast majority of abortions even in the earliest stages of a pregnancy except in cases of rape and incest before 10 weeks post-fertilization, to protect the life and physical health of the mother and if the fetus is diagnosed with a lethal anomaly.
Since last summer, CRH officials have worked to clarify certain aspects of the law that would impact the hospital system even though they only perform procedures to terminate pregnancies when the life or health of the mother is at risk. Patients seeking to end their pregnancies for non-medical reasons generally are referred elsewhere.
While the new rules won’t impact the range of procedures that CRH offers or under what circumstances doctors would perform them, the law has some implications related to miscarriages and other aspects of pregnancy besides abortion, including a provision that attending physicians certify in writing the reason why a pregnancy is being terminated — including during a medical emergency — before the doctor performs the procedure.
The hospital system, for its part, has put in place a system that includes pre-written templates that document why the pregnancy is being terminated that can be quickly inserted into a patient’s medical record as needed, said Dr. Rachel Reed, CRH vice president and associate chief medical officer.
Earlier this month, CRH leadership met with their OBGYN providers to ensure they had access to the system and other resources they need and knew how to file the required documentation with the state.
“We’ve put together a couple different ways in order to help our physicians be able to do it in a way that is compliant but also not burdensome, too time-consuming or anything,” Reed said. “…It should surely only take a few minutes. (That) would be our goal so that they’re able to provide the care quickly as needed.”
Unintended consequences
The ban is poised to dramatically reshape the landscape of female reproductive healthcare in Bartholomew County and the state and could have some unintended consequences.
Some of those potential consequences include whether there are enough resources in the community to handle what local health officials expect to be an increase in births, as well as an expected increase in people who may not be able to travel out-of-state to get abortions turning to unsafe methods to end their pregnancies, including attempts to self-induce abortion.
“I think we could anticipate an increase in the birth rate,” Reed said. “(At CRH), we’re more than capable of caring for some additional patients, but I do wonder about the community in general. Do we have the resources in place to provide care to these patients as they are having to continue a pregnancy that they may not otherwise would have? I think there is a concern that we may see an increase in attempts at self-termination of pregnancy, which can be very dangerous.”
New data from the Indiana Department of Health suggest that the landscape of female reproductive health care is already changing, with the number of abortions being performed on local residents increasing last year but steeply declining during the first three months of this year.
A total of 79 abortions were performed on Bartholomew County residents last year, up from 76 in 2021, according to the Indiana Department of Health. At the same time, abortions performed on Jackson County residents rose from 28 in 2021 to 38 in 2022.
But just 14 abortions were performed on Bartholomew County residents from this past January to March, state records show. If that pace were to continue despite the ban going into effect, the county would be on pace for 56 abortions this year.
Only five abortions were performed on Jackson County residents during the first quarter of the year.
However, these figures don’t include any local residents who may have traveled out of state to have an abortion.
There are several abortion providers within a five-hour drive of Columbus, including in Champagne, Illinois, the Detroit metro area, and even in Windsor, Canada, just across the border from Detroit, which is slightly more than a five-hour drive from Columbus.
Previously, abortion services could be obtained in Bloomington and Indianapolis.
Vague language
Attorneys in Indiana also have raised concerns about some of the implications that the ban — including what they describe as vague language — could have on healthcare providers and patients.
Currently, there is no legal precedent that establishes, in the context of Indiana’s abortion ban, what constitutes several criteria listed in the law’s exemptions, including “reasonable medical judgment,” “serious health risk to the pregnant woman” or substantial and irreversible physical impairment of a major bodily function,” according to an analysis by Indianapolis law firm Quarles & Brady LLP provided to The Republic by healthcare attorney Kaytie Ravega.
Where courts draw the line on what these provisions mean would get ironed out in subsequent court challenges after the law takes effect, the law firm said. However, the legal standard will likely hinge upon the doctor’s medical judgment, though physicians “should be prepared to defend” their determinations, possibly in court, the attorneys said.
Though the law includes an exemption for when the life or health of the mother is at risk, it does not specify how close to death the patient has to be before a doctor can legally intervene and end the pregnancy.
And the recent Indiana Supreme Court decision to strike down an injunction blocking the ban, the ruling “did not provide any overarching clarifications concerning the abortion restrictions,” Ravega told The Republic this past week.
Reed, for her part, said the Indiana Hospital Association has provided guidance to CRH, though she characterized the exemptions as “very nebulous.”
“Guidance from the Indiana Hospital Association has led us to define it … as if the patient were at risk of death or substantial or irreversible physical harm,” Reed said. “However, it does not include psychological or emotional mental health-type conditions. Basically, it’s that the physician makes this decision based on reasonable medical judgment. So it is left very nebulous.”
Reed said some potential situations that could arise at CRH would be providing care for an ectopic pregnancy, certain heart conditions, as well as cancer treatments for the mother that would be dangerous to the fetus. However, CRH typically would refer patients who would meet the criteria for exemptions under the ban elsewhere, as long as it wasn’t a medical emergency.
“Unless there was an immediate, like an emergent need, typically at CRH we would not have provided the service for even any of those circumstances,” Reed said. “Generally, we would refer those patients, as long as the patients were medically stable, to a higher-volume provider. Where the law really affects us is actually in the case of care for an ectopic pregnancy, which is relatively common, and then in the potential case of miscarriage care … essentially (a patient who is) in the process of a miscarriage or delivery that can’t be stopped.”
What’s next?
Despite taking effect again, the ban is still facing a legal challenge even after the Indiana Supreme Court struck down the injunction blocking the ban.
The split ruling from the high court last month also has “subtly” invited additional legal challenges, though the outcome of any future challenge is impossible to predict, according to attorneys.
“The court did not consider and the decision does not address the ultimate and total constitutionality of the statute,” Ravega said. “That will be addressed, however, in other cases that have been or will be filed. …The law still contains high penalties for noncompliance even though its provisions about how to comply and what is required are vague. This situation poses risk to providers and patients throughout the state.”
