Navigating EM Post-Dobbs

Monica R. Saxena, MD, JD, assistant professor of emergency medicine, developed a protocol to offer medication abortions to patients in the Stanford Hospital emergency department (ED), in collaboration with Carl Preiksaitis, MD, emergency medicine fellow, and Andrea Henkel, MD, MS, assistant professor and complex family planning subspecialist in the Department of Obstetrics & Gynecology. A patient wishing to terminate a pregnancy receives comprehensive options counseling and if they are less than ten weeks along, they are offered the option to initiate a medication abortion in the ED.

The protocol was developed in the year leading up to the 2022 Supreme Court decision Dobbs v. Jackson Women’s Health Organization ruling that overturned Roe v. Wade. Saxena discussed what she has been doing lately to safeguard emergency medicine’s role in women’s health and reproductive options.

How do abortion restrictions in certain states potentially impact emergency medicine physicians?

Saxena: California is an abortion permissive state. However, 14 states have banned all or most abortions and an additional seven states have varying restrictions. An emergency medicine physician could encounter restrictions in treating a pregnant woman facing a medical emergency. We’ve seen reports of physicians having to decide whether should they uphold our emergency medicine ethos to provide care to anyone, anywhere, anytime, or withhold treatment according to state law.

I think as a specialty, we have to look at how we keep our doors open for all patients, especially those patients in abortion-restrictive states who are facing medical emergencies within our scope of practice. The standard of care is constant but the care provided can be impacted by varying state laws. Compounding the issue, a lot of those states have care deserts, which means emergency physicians are dealing with patients who are potentially sicker and farther along in their medical emergency.

In what ways can the approach to abortion services mirror the existing practices of emergency medicine?

Saxena: In the ED, we treat life-threatening emergencies, but we also provide medical services to patients with all sorts of non-threatening medical complaints. We provide options counseling — informing patients about their choices when facing important healthcare decisions. In a similar vein, pregnant patients facing a decision to terminate pregnancy are provided options counseling.

What role does administrative support play in the successful implementation of the medication abortion program?

Saxena: Stanford has been incredibly supportive, and I give a lot of that credit to our department chair and our faculty for implementing the protocol. The risk management concerns in California were a lot different from what they would be somewhere else. We have seen a couple of other hospitals try to implement the program we’re doing with varying success. In restrictive states, there’s some reluctance to implement a medication abortion program and there are places where it likely won’t happen.

What strategies can be employed to ensure a more comprehensive focus on women’s health issues within emergency medicine?

Saxena: I think we need to incorporate more about women’s health into the training of our emergency medicine residents, not only about abortion but also women’s cancers, maternal mortality, and maternity care deserts. There’s a gap in emergency medicine when it comes to exploring and improving reproductive health or even women’s health in general. Look at cardiovascular disease — the majority of research is on white men. One of the few areas where they’ve successfully secured resources and attention for a women’s health issue is breast cancer. I believe research and training regarding the rest of women’s health is lagging and it’s frustrating.

What is your current focus in the context of evolving legal landscapes post-Dobbs? Saxena: I’m evaluating the PostDobbs landscape for women’s health and treating ectopic pregnancies in abortion-restrictive states. 


Spring 2024