NEW ORLEANS —— During pregnancy, the amount of blood in the body increases 50%. But it can dip to low – and deadly – levels within minutes.
Pregnancy complications, most often during delivery and miscarriage, can trigger critical, excessive bleeding. That bleeding, postpartum hemorrhage, is the leading cause of maternal death worldwide.
To combat it, doctors routinely reach for the medication misoprostol.
“I have it in every single delivery room,” said an obstetrician who’s practiced in New Orleans since 2017. “ I can have it in 45 seconds.”
He needs it that fast, he said, because obstetric hemorrhage can progress quickly, making it possible for a patient to lose a significant amount of blood in a short amount of time. “It’s terrifying,” said the obstetrician, who asked that his name not be used because of the divisive politics of abortion in Louisiana.
To him, misoprostol at the bedside is “tantamount to maternal health.”
Come October 1, that will change.
Determined to eliminate medication abortions, anti-abortion Louisiana lawmakers reclassified misoprostol and mifepristone – the two prescription drugs needed for those procedures – as Schedule IV controlled substances.
Misoprostol, which was approved by the Food and Drug Administration 20 years ago for a number of medical uses, has been used increasingly to terminate pregnancies of up to 10 weeks. In 2001, medication abortion made up only 6% of all abortions. But in 2023, the proportion of medication abortions had risen to 63% of all U.S. pregnancies, according to the Guttmacher Institute. Most common is the two-drug regimen with misoprostol, which prompts uterine contractions, causing the uterus to empty.
Both drugs have also been used routinely in maternal healthcare. Now that is also threatened.
In New Orleans, city officials and medical professionals have been scrambling to respond.
The concern is that the new law limits not only people’s reproductive rights, but their very ability to survive common life events, like a miscarriage or the delivery of a child.
‘Anxious my whole pregnancy’
Earlier this year, a 38-year-old New Orleans woman, who asked that her name not be used, miscarried during the early part of her first trimester.
She’d had a previous miscarriage a few years ago, before she gave birth to her son, now a toddler.
But this time, Louisiana had already banned abortion statewide – and healthcare providers were leery of providing the abortion-inducing medications that are also used for miscarriages.
“I was very lucky,” she said.”It happened on its own at home.”
All she could do was feel grateful that she was physically okay and not subject to a now-controversial visit to a doctor’s office or emergency room.
“I had this sense of relief that I didn’t have to go to the hospital, because I was terrified that I wouldn’t get the proper care,” she said.
For her first miscarriage, doctors were able to treat her using all available methods. And instead of her current anxiety, she remembers feeling sorrow. “I was able to grieve appropriately,” she said.
Now, she is pregnant again.
And soon, her doctors will be hamstrung by the state’s newest restrictions, the new controlled-substance labels. Unlike many women, she is fortunate to have midwives and a doctor who assure her that they will be able to keep her safe.
But what if she suffers another miscarriage? What if her doctors detect something wrong that would require an abortion?
Deep South legislators have threatened to track pregnant women who go out of state to seek medical attention. So she and her husband were nervous to make an online announcement or anything else that publicly “documented” the pregnancy.
She was terrified – at first – to even text about her pregnancy. “I had all my apps on anonymous mode.”
Now, as her pregnancy has progressed, some of those initial fears have lessened. But she is still concerned that her care could be curtailed if she gives birth in Louisiana.
“It has been a completely different experience,” she said. “It’s really taken away from the joy of this pregnancy.”
“I’m happily pregnant,” she said. But the new policy restrictions and lawmaker threats affect her every day. “It has made me anxious my whole pregnancy.”
Difference between life and death
Because of Louisiana’s new controlled-substances label, misoprostol will have to be stored in a locked container that, in most hospitals, will be far from the arm’s reach of the attending doctor — often, down a hospital hallway or even on another floor.
“You never want to leave the bedside of a crashing patient. (But) someone will have to leave and run down the hall or wherever the cabinet is located and do a series of steps to access the medication and bring it back,” Dr. Jennifer Avegno, the city’s doctor, told the New Orleans City Council last week. “Even if that adds four or five minutes to the time – that four or five minutes can be the difference between life and death,” she said.
And it’s not as though the runs to locked cabinets will be rare – especially in Louisiana, which has some of the worst maternal outcomes in the nation.
In the United States, nearly 5% – 1 in 20 – pregnant women experience postpartum hemorrhage. In a study done in a south-central Louisiana hospital, the rate of postpartum hemorrhage stood at double that, at 12.3% – more than 1 in 10 women.
Louisiana’s move to lock up misoprostol and other critical-care medications goes against the “standard of care for women,” because it will inevitably increase maternal mortality, Avegno told the Council.
“Postpartum hemorrhage is incredibly common in America and it has gotten worse in the last 20 years,” Avegno said, noting it can be hard to predict hemorrhage, because patients can lose a lot of blood before the symptoms become apparent.
As recently as 2016, data showed that postpartum hemorrhage caused nearly 1 in 5 maternal deaths in Louisiana, with deaths higher among people of color, with disparities that persist throughout economic and social factors, including education and income, pointing to the roles that racism and discrimination play in maternal outcomes, according to KFF, (formerly known as the Kaiser Family Foundation,) a nonprofit health policy research, polling and news organization.
“It is profoundly inequitable,” Avegno said, of postpartum hemorrhage. “Black women in particular have a risk over three times of white and Hispanic women.”
From a racial-equity lens, the state’s overall maternal-mortality statistics are also stark: 13 of 15 pregnancy-related deaths were Black patients, according to the state’s most recent Pregnancy-Associated Mortality Review Report, released in April.
As a result, the new laws — like the anti-abortion laws that came before them — will inevitably have disproportionate effects. “While these laws hurt everyone they disproportionately hurt people who are systemically suffering from oppression already,” said Dr. Anitra Beasley, the medical director for Planned Parenthood Gulf Coast, which covers Louisiana and parts of Texas.
‘Backsliding’
For 49 years, from 1973 to 2022, the U.S. Supreme Court invalidated state laws that went too far in limiting a woman’s right to abortion, as protected by the 14th Amendment right to privacy.
Yet, through restrictive state laws, Louisiana and other states had, for years, chipped away at federal abortion limitations. Legislators enacted “trigger laws” to automatically ban abortions if the U.S. Supreme Court overturned the landmark case Roe v. Wade – as the high court did in 2022.
The moment the Roe decision was overturned, elective abortion procedures were banned in Louisiana and abortion clinics shuttered.
Medication abortions were already hard to access through a traditional doctor’s office in Louisiana, where doctors operating outside of an abortion clinic faced stringent abortion legal restrictions and could perform a limited number of annual terminations, documented carefully with the state.
So Louisiana residents who accessed medication terminations typically went through abortion clinics or out-of-state mail-order providers, who would schedule telehealth appointments and send mifepristone and misoprostol by mail to patients, who could terminate pregnancies by administering the drugs themselves in home by mouth or vaginally.
Because of the political climate around reproductive rights, most New Orleans doctors were wary of prescribing the two-drug regimen, even for pregnancies where the mother’s life was in danger or the fetus wasn’t viable.
The loss of the at-home, two-drug regimen hit especially hard on low-income Louisiana patients who could not afford to travel out of state for an abortion — and for those who might experience an unwanted pregnancy while on probation and parole, who can only travel out-of-state with the permission of their supervising officer, according to the Prison Policy Initiative.
To put a certain halt to all medication abortions, abortion opponents within Louisiana first put their hopes in the U.S. Supreme Court. But in June, the court threw out a lawsuit designed to take mifepristone off the market.
Despite its very conservative use across the state, anti-abortion legislators who viewed medication abortion as a loophole made an unprecedented move this spring, voting to become the first state in the nation to label the two drugs as controlled dangerous substances.
During the same session, lawmakers rejected a law that would have allowed two abortion exceptions, for rape and incest.
Gov. Jeff Landry signed the labeling bill into law in May. It takes effect on Tuesday, October 1.
People who possess the two drugs without a prescription could now face fines totalling thousands of dollars and up to five years in jail. Though pregnant people intending to use the pills themselves cannot be prosecuted, the statute could lead to arrest for anyone – including volunteers or parents – who help to obtain the pills.
It’s not uncommon in today’s reproductive environment for non-pregnant people to order the medication for themselves through the mail to have on hand to end a pregnancy or to manage a miscarriage — “just in case.” Now, Beasley said, those people are also left to wonder: “Am I going to get in trouble for having these drugs sent to me?”
The move, which likely will be mimicked in other conservative states, opens a new line of combat in the nation’s abortion battle.
In New Orleans, City Council orders Health Department to track any delays in care
Doctors say that the new “controlled substance” labeling will delay lifesaving care and had testified in opposition, believing that the classification was a gross misinterpretation of legislators overstepping their knowledge — or lack thereof — of the medical world.
Thomas Pressley, a Republican state senator, was motivated to sponsor the bill because of a personal tragedy: his sister’s husband put misoprostol into a drink in Texas, he said, causing her to cramp and deliver prematurely; her husband was charged in Texas and spent 180 days in jail and is on 10 years of probation.
“My sister’s story is clear proof that these drugs are being weaponized and are a risk to public health,” Pressly wrote in a statement.
But before the bill’s passage, more than 200 doctors sent a letter urging Pressly to re-think his legislation.
“Given its historically poor maternal health outcomes, Louisiana should prioritize safe and evidence-based care for pregnant women,” the letter said. “Misoprostol is regularly utilized for cervical ripening to begin the process of routine labor. In addition, it is a critical medication for the prevention of catastrophic obstetric hemorrhage following delivery of a newborn.”
That point elicits a nod from Avegno, the director of the New Orleans Health Department who is well-regarded nationally for her work leading the city through the pandemic. The two medications should not be classified as Schedule IV drugs along with fentanyl, morphine, Xanax, and other medications that can lead to “abuse and dependence,” she said.
Last Wednesday, she told the New Orleans City Council that the state’s self-imposed legislation will almost certainly harm women in Louisiana. On top of the delays, there’s the confusion of mischaracterizing as dangerous a drug that has long been used safely and routinely.
Though other drugs can be used to treat hemorrhages, many have “contraindications” — making them more dangerous for patients with conditions that are extremely common in Louisiana, including asthma and high blood pressure. Some of the other drugs that can trigger contractions also are more expensive or require refrigeration, where misoprostol is both affordable and stable at room temperature, a plus for rural or remote settings with more limited capacity.
The new labeling is likely to have deadly results, Avegno said, as it has in other states that have passed similar anti-abortion legislation.
Complications from postpartum hemorrhage, which already stand at alarming levels in Louisiana, will likely only get worse with the new law in place, Avegno said. “We run the risk of backsliding and we cannot afford to do that in a state that is consistently ranked in the bottom of maternal health.”
Doctors and nurses may also leave Louisiana to practice in other states as medication restrictions mount, as they face veiled legal threats for prescribing what are now “controlled substances” and increased barriers to store them onsite in clinics, according to City Council testimony last week.
As City Council President Helena Moreno made introductions, she asked her fellow Louisiana public servants to follow the council’s lead and yield to experts like Avegno.
“I’ve heard a lot of politicians say that there’s no problem with these restrictions,” Moreno said. “But we’re hearing something very different from the medical community.”
Avegno, in turn, welcomed the council’s motion, which ordered the health department “to investigate and study any delay of care issues related to the classification of Mifepristone and Misoprostol as dangerous Schedule IV controlled substances,” a role that could include surveying and consulting doctors, pharmacists, and patients; reviewing medical and electronic records “to determine whether quality and timeliness of care is impacted” by the new Louisiana statute.
The health department may also establish a “complaint-based reporting system” for its investigation, the council ordered.
In response, Louisiana Attorney General Liz Murrill — who ran for office as an “advocate for the unborn” — shrugged off the move by the council. “The New Orleans City Council is manufacturing a problem that doesn’t exist,” Murrill said last week.
Miscarriages – unwelcome in some ERs
Miscarriage is a common experience in New Orleans and across the country: roughly one-third of known pregnancies end in miscarriage, Avegno testified.
The risks of miscarriage in this post-Roe age have risen to widespread scrutiny and into the presidential race largely because of a Louisiana woman, Kaitlyn Joshua, who shared the story of her miscarriage on national television during the Democratic National Convention.
During her miscarriage in 2022, Joshua said, she sought care at two emergency rooms but couldn’t get doctors to perform a dilation and curettage or dispense medication to speed up the miscarriage.
Typically, when a woman realizes that she is miscarrying, she has three choices, doctors say.
She can choose to allow the miscarriage to continue naturally. Or she can opt for medication to allow the body to more swiftly expel the remainder of miscarried tissue. Medication also decreases the risk of surgery, the riskiest and most invasive way to end a miscarriage.
Without medication, women may have to wait for days or even weeks for a non-viable fetus to completely eject. That increases risk of infection and other complications and can stand in the way of women returning to work and caring for themselves and their families.
Dr. Emily Holt sees women weigh these choices all the time.
But now, when treating a patient for a miscarriage, Holt said she will no longer be able to provide misoprostol directly to her patients. As a single practitioner, it isn’t feasible for her to navigate the state hurdles to keep the medication on site – within her office, not within a locked case or otherwise, she told the City Council.
For fear of break-ins by people seeking known dangerous substances like opioids, she has a policy of not storing any controlled substances on her office property —- and does not want to start now, Holt said.
“These medications are not just abortion drugs. They are vital medications for practicing reproductive health care for women,” Holt said. “As a physician who practices in New Orleans I’m very worried for women in Louisiana.”
To Holt, the situation feels so serious that her concerns extend beyond her patients, to her patients’ kin —- “the families they leave behind if they die from a hemorrhage.”