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Abortion-ban exceptions won't provide much relief for Iowa women. Here's why. [1]
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Date: 2024-07-28
The Register's editorial
Des Moines Register
Rape, incest rules give little regard to trauma or doctors' role
Fetal abnormality exception defines little, discourages care
'Medical emergency,' too, can be in the eye of the beholder (or of the regulator)
Cautious optimism on treatment after miscarriage
Court battles and private support continue, but only elections can restore equality
Six years of trying will pay off Monday for Gov. Kim Reynolds and Iowa Republicans: A law that bans almost all abortions will take effect.
And “almost all” means “almost all.” Tying the abortion prohibition to the detection of cardiac activity means many girls and women won’t realize they are pregnant before it’s too late to seek care.
But Iowa’s law also notes five types of exceptions under which a girl or woman might, in theory, be able to terminate a pregnancy a little bit later.
Earlier reports in the Register and other outlets have illuminated how those doors might not be open as wide as they appear on first reading. But as reproductive freedom in the state comes to an end, it’s worth underlining how unyielding the supposed exceptions really are.
Some Republicans are talking about drafting a complete “life begins at conception” bill to fully outlaw abortion. But this law, now blessed by the courts, is already almost there.
More:Inside an Iowa Planned Parenthood clinic before abortion ban takes effect
Rape, incest rules give little regard to trauma or doctors' role
The new law prohibits abortion whenever an unconventional ultrasound can detect electrical activity inside a fetus, usually about six weeks after a woman’s last menstrual period. Survivors of rape and incest can receive care later — if they meet strict deadlines and other rules for reporting the attack that resulted in pregnancy. After they are sexually abused, survivors have exactly 45 days to tell police or a doctor. Survivors of incest have 140 days. To perform an abortion without risking professional discipline, doctors must document the attack in detail and judge the girl's or woman’s credibility, according to Iowa Board of Medicine rules.
If all of that happens, abortion is legal until 20 weeks after fertilization.
Neither the rape timeline nor the demand for sharing exacting detail with strangers comports with what many sexual abuse survivors actually experience.
“If you just look at statistics now, most survivors don't report,” said Tamika Payne, interim executive director of the Iowa Coalition Against Sexual Assault. “When the state … limits the options and choices that survivors of sexual violence have, you're effectively reinforcing the victimization they've just endured. You are telling them, you do not have control over your body. You just have the most heinous violations happen where you had no control. And now, in response, they're taking that control away.”
Dr. Emily Boevers of Iowans for Health Liberty, an OB-GYN who practices in northeast Iowa, said that, while she prefers to focus on harms to survivors, doctors will face new strains, too.
“It puts physicians in a position of having to be investigators for legal purposes, rather than just medical care providers,” Boevers said. “That patient-physician relationship is so precious. Spending our clinic time querying patients about dates of assaults, who perpetrated the assault, whether they had already reported it to appropriate authorities – these are nonmedical details, and we're asking them for nonmedical reasons. … It's a betrayal of the patient physician relationship.”
Payne said that abortion is necessary medical care and that restricting it in this way is a denial of human rights. “That's like somebody going to the ER and being (told), ‘Well, we can't mend your broken arm unless you were actually assaulted,’” she said.
“Rape” is a word that didn’t appear in Iowa Code until this law was passed, so one of doctors’ tasks is mapping patients’ experiences onto laws that criminalize sexual abuse. And the survivor has to start the process by reporting within 45 days.
“This is a patient who is perhaps already in a vulnerable situation,” Boevers said. “She may not have rapid or accessible transportation to either a police station or somewhere that she could report this or to a physician to seek care for it. … While what has happened to them is a form of sexual trauma, they may not recognize it in real time.”
Fetal abnormality exception defines little, discourages care
Ambiguity dominates this exception, which allows abortion in case of “a fetal abnormality that in the physician’s reasonable medical judgment is incompatible with life.” What is incompatible with life? A zero percent chance of survival? What about 0.1%? Who’s calculating the probabilities? What is “life” — does it include a couple of minutes inside an operating room before a doctor formally pronounces death?
“There is no standard definition in medicine of what that means,” said Dr. Andrea Greiner, who’s also part of Iowans for Health Liberty. “I think because of that ambiguity, it just adds more fear. And it's going to cause people to be very conservative.”
Instead of answering obvious questions, the rules for this law follow a pattern of being, as Greiner noted, sufficiently vague to incentivize care providers against abortion care. The alternative, in a case where someone somewhere might have a different opinion, is to risk a complaint that sets up a potentially career-ending hearing before the Board of Medicine.
“It just puts a ridiculous amount of emotional burden on the patients to have to have in an already very difficult situation, to grieve a pregnancy that is not what they thought it was going to be,” Greiner said.
More:‘It was just despair’: Abortion bans leave doctors uncertain about care - even in emergencies
'Medical emergency,' too, can be in the eye of the beholder (or of the regulator)
Abortion has been and will remain permissible in Iowa when the mother’s “life is endangered” or if she faces “substantial and irreversible impairment of a major bodily function.” Harsh abortion bans in other states have produced dozens of stories of women suffering permanent, avoidable injury because lawyers and doctors judge that a so-called exception in the law did not indisputably apply to the women’s cases.
Iowa Supreme Court Chief Justice Susan Christensen, dissenting from the court’s 4-3 reinstatement of this abortion ban, relentlessly catalogued scholarship and journalism that demonstrates the inhumanity.
“Does that mean there is no exception even in cases where a woman will be forced to endure a hysterectomy because she could not obtain a timely abortion under this law?” Christensen wrote. “The board’s rules offer no additional insight into what constitutes a ‘medical emergency’ under the exception. Nationwide, this lack of guidance into what constitutes a life-endangering medical emergency in states with similar statutes continues to perplex physicians at the expense of the pregnant women seeking their care.”
More:Iowa's six-week abortion ban takes away girls' and women's dignity. Vote out its authors.
The situation, Christensen pointed out, fully undermines one of the state’s purported purposes in enacting the law, to protect maternal health. Greiner described a potential dilemma: “Is it a medical emergency right now? Or could it become an emergency in two hours? For example, sepsis, which is abnormal functioning of the entire body, organs, due to overwhelming infection; that is not a binary process, like, you have sepsis or you don't have sepsis. It's an evolving medical condition. Initially, you may just have some low blood pressure and high heart rate, but two hours from now, that person could be in renal failure or liver failure or respiratory arrest or cardiac arrest. So, is it a medical emergency right now, just when their heart rate is fast, their blood pressure is low? Or do we have to wait?”
Boevers said the result will be reticence to perform abortions that might be legal.
“I think that we're going to see a lot of physicians and a lot of hospitals that are reluctant to provide care under these exceptions, no matter what, because of fear of having that scrutiny brought back to them and questioning whether they have met the criteria,” she said.
Cautious optimism on treatment after miscarriage
Greiner said that the wording of Iowa’s law is less concerning than the restrictions in other states where women who had indisputably miscarried have been forced to continue a potentially deadly, doomed pregnancy instead of receiving an abortion-like “D&C” procedure.
But Boevers pointed out that obstetricians who can even perform those and other specialized procedures are already hard to find in some parts of rural Iowa. She said she expects the problem to get worse because the abortion law will make Iowa a professionally risky and undesirable place for OB-GYNs to practice.
Iowa’s law makes plenty illegal. But a continued OB-GYN exodus — Iowa’s per-capita rate is already the nation’s worst — could mean that one result of the ban is that it becomes impossible to obtain legal care locally.
Court battles and private support continue, but only elections can restore equality
The litigation over the law and accompanying administrative rules is still far from over. Christensen noted in her dissent that specific portions of the rules could be challenged in isolation. But the window for preserving robust reproductive rights has closed
Volunteers and professional women’s health advocates have pledged to assist girls and women as much as possible in procuring necessary care here or outside Iowa.
The bigger picture won’t change unless a reconstituted Iowa Legislature repeals this law, which offends human rights and, as measured by polls, the wishes of Iowans. Voting for Democrats who promise to take this step in the Iowa House and Iowa Senate is crucial.
More:Iowa Poll: Over 60% support legal abortion as state Supreme Court considers restrictions
This call goes beyond preferring one party’s view on relatively mundane matters. It isn’t a matter of ousting lawmakers for, say, incompetent management leading to tax increases or holding the wrong view on speed-limit cameras. It’s about restoring the ability of girls and women in Iowa to fully participate in society, to be safe and to be treated with basic respect.
Lucas Grundmeier, on behalf of the Register’s editorial board
More:These 12 enduring principles guide decisions of the Des Moines Register editorial board
This editorial is the opinion of the Des Moines Register's editorial board: Carol Hunter, executive editor; Lucas Grundmeier, opinion editor; and Richard Doak and Rox Laird, editorial board members.
Want more opinions? Read other perspectives with our free newsletter or visit us at DesMoinesRegister.com/opinion. Respond to any opinion by submitting a Letter to the Editor at DesMoinesRegister.com/letters.
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