Abortion care continues to be available in seven Indiana counties while the state’s near-total abortion ban is on hold. (Getty Images)
Indiana University Health said Thursday it was prepared for the state’s near-total abortion ban to take effect on Sept. 15, and its physicians across the state are ready to follow the law.
“We’re going to continue to provide abortion care – legal abortion care – in our state through our health system for our patients who need it. We know that abortion is safe, it is evidence-based and we will continue to provide that care within the parameters of the new law,” said Dr. Caroline Rouse, the medical director of maternity services at Riley Maternity Tower.
As the Indiana General Assembly passed the state’s near-total abortion ban on Aug. 5, leaders at Indiana University Health, or IU Health, met to create a game plan for the system, which has 689 locations in 43 cities around the state.
Under the law, physicians may only perform abortions if the patient’s life or health is at risk or if there is a fatal fetal anomaly. There is confusion in the law on whether those exceptions are limited to 20 weeks. The law provides rape and incest victims ten weeks to obtain an abortion.
Using the same sort of incident command structure initiated during the emergency outbreaks of infectious diseases like Ebola and COVID-19, a group of 60 senior leaders at the healthcare entity identified 80 issues in need of answers.
Five weeks later, the health system announced its plans to adapt to the state’s new abortion needs, anticipating a surge in demand for maternal-fetal services.
Dr. David Ingram, the executive vice president of IU Health who served as incident commander over the planning effort, said he felt the state’s largest health system needed to quickly formulate a plan following the ban’s passage.
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In particular, a requirement that all abortions occur within a hospital or ambulatory surgery center means IU Health will need to expand its abortion capacity, since most abortions previously occurred in outpatient clinics. Most of Indiana’s abortions — about 55% – are now done with medication, with the rest using suction to dispel the fetus.
Ingram, also the system’s chief medical executive and neonatologist who specializes in newborn healthcare, said IU Health expected to see an increased demand for its neonatal services.
“We anticipate increased pregnancies in the state and with that we also know that about 10% of pregnancies lead to an admission to either a special nursery unit or to a neonatal intensive care unit,” Ingram said.
But now, even before the ban, those intensive care units already ran at about 90-95% capacity, Ingram said.
“So that’s something we need to think deeply about,” he said.
Providing guidelines to physicians
Ingram said the abortion ban was “new territory” for many providers, who may feel increased anxiety and second-guess their medical decisions in fear of legal repercussions.
In response, he said IU Health would launch a 24/7 Rapid Response Team composed of clinicians, ethicists and attorneys to provide clarification to any doctor needing a second opinion, something other states have implemented following their abortion bans.
Rouse, also an assistant professor of obstetrics and gynecology, said she hoped the response team would decrease potential delays in care brought on by the law – though she acknowledged that other states had reported difficulties.
“With new legislation like this, it can be really difficult to implement that into individual patient situations. The law is broad and patient situations are very specific and unique,” Rouse said. “I worry that, potentially, the steps that (physicians) may take may be a little different than what they would have done prior to the law.”
Additional IU Health guidance to physicians included providing a medical screening exam for patients seeking an abortion due to rape or incest, two exceptions under the law, and referrals to appropriate social services agencies, such as the Department of Child Services.
Treating an ectopic pregnancy, which can be fatal to the parent, is not considered an abortion if performed before cardiac activity is detected, typically around six weeks. Otherwise treating an ectopic pregnancy is considered an abortion, and must be documented as such, after that benchmark, Rouse said,
“The additional documentation and reporting requirements are a time burden for providers and so that is certainly something that we have thought about as we’re developing our processes and workflows,” she said.
The doctors said they didn’t anticipate patients seeking abortion care from outside of Indiana but that the law didn’t prohibit them from advising patients to seek a legal abortion in another state.
Hindering efforts to teach, retain the next generation of doctors
Additionally, IU Health runs the only medical school in the state and one of the largest in the country with just over 1,400 students.
But the majority of those residents, 85%, indicated that passage of the abortion ban negatively factored into their consideration for post-residency employment, Ingram said.
The law also hinders the education available to those in the OB-GYN residency program.
“We do have a large OB-GYN residency program and given that the program needs to provide all access to the full spectrum of reproductive services, we’ve needed to make arrangements for out-of-state training for those who need it,” Ingram said.
Additionally, IU Health’s recruitment efforts have been hampered, with out-of-state candidates dropping out of the process following the law’s passage.
“(The law) has certainly increased our workload but we know how important this is to preserving our promise to provide the best care for patients,” Ingram said.
However, that care will be much more expensive – both for parents seeking abortion healthcare and patients giving birth.
“Services that are provided in hospital settings are definitely more expensive than outpatient settings so we do anticipate a rising cost from that perspective,” Ingram said. “The second piece of increased costs will certainly be the anticipated volume of patients that will be admitted to our neonatal intensive care units. Often, those are prolonged stays within those units and some of the most expensive care that we provide.”
Ingram didn’t have an estimated cost increase for the health system.
In a state with the third-highest maternal mortality rate, Ingram said he worried about the impact of the abortion ban, saying IU Health would be studying the public health impact. The system has not specifically addressed concerns about Hoosiers who may attempt to self-induce an abortion or seek emergency care after a botched illegal abortion.
“After five weeks of intense work with 60 senior leaders and hundreds of patient hours, we’re prepared and we feel that this process has served us well,” Ingram said. “The highest priority for us is to provide services to our patients to preserve the patient-physician relationship within the boundaries of the newly established law.”
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