Here on The Pulse, we have been exploring the United States, state by state, region by region, because of the Supreme Court of the United States (SCOTUS) decision last June. This was a decision on the Dobbs versus Jackson Women’s Health Organization case on abortion. The SCOTUS upheld a Mississippi law prohibiting abortion after 15 weeks of pregnancy. This means 15 weeks counting from the first day of bleeding of the last menstrual period. Although six of nine justices voted to uphold the Mississippi law, this was not the end of it. Rather, five of those six justices also joined onto a majority opinion written by Associate Justice Samuel Alito overturning the 1973 Roe v Wade decision that protected the right to choose. As a consequence, the US is now a patchwork of different situations, when it comes to the legality of abortion and access to abortion. States that are extremely hostile to abortion include Mississippi, Tennessee, Georgia, Alabama, Arizona, and Missouri. In such states, there also are implications for pregnancy care overall and in some cases fertility treatment is being threatened as well. There also are states that, despite presence of strong majorities of anti-choice Republican politicians, have upheld abortion rights, because of the state constitution, or because of the court system. Such states include Kansas, Alaska, Montana, and Ohio.
Meanwhile, states that are very supportive of abortion and reproductive rights include New York, Connecticut, Illinois, Oregon, New Mexico, Washington, and North Carolina, and various others. Of such pro-choice states, many protect the right to choose up to the point of fetal viability (24-26 weeks gestation) or close to that point. Today’s highlighted state, California, falls into this category.
Even prior to the SCOTUS overturning Roe v Wade, Governor Gavin Newsom signed a bill that now requires health insurers in the Golden State to pay all abortion costs for patients. California also has a law that protects abortion providers from civil liability in cases when anti-abortion states attempt legal action for treating women who travel to California for abortion care. Also, on November 8, 2022, Californians voted to modify the California Constitution so that it guarantees, explicitly, access to abortion and contraception.
In California, not all medical professionals are permitted to perform a procedural abortion, also known as surgical abortion. Meanwhile, physicians as well as licensed nurses, nurse practitioners, nurse midwives, and physician assistants are authorized to administer medication abortion, which you can have up to 77 days (11 weeks) gestation. One type of procedural abortion that can be used for an abortion is called a D&C, which stands for dilatation and curettage. Curettage is a kind of scraping of the inner lining of the uterus. Extracting a pregnancy, either viable or not, is only one of several reasons for performing a D&C. D&Cs can be performed for diagnostic reasons, such as when there’s a suspicion of abnormal cell growth in the endometrium. Therapeutic D&Cs can be performed for removing products of conception, but also for removing overgrowth of the uterine lining.
D&C by itself is adequate only early in pregnancy, so after a certain point the next option is dilatation and suction. This means that, after the cervix is dilated, the doctor suctions out the products of conception. Sometimes this can be done with a syringe, but often it requires power suction. A tube called a cannula is inserted through the opened cervix. Cannulae come in a range of sizes that are chosen based on how far along the pregnancy is, or was before it became inviable. In some cases, following suction, the doctor may then perform some curettage to extract any remaining products of conception.
At some point during pregnancy, generally around the midpoint, suction is not enough to extract either a viable or inviable fetus. In such cases, the OB/GYN must use instruments to grab onto the fetus, or parts of the fetus. Such a procedure is known as a D&E, which stands for dilatation and extraction. The extraction includes not only the fetus, but also the placenta, as well as the membranes. All the products of conception must be removed and accounted for, because products that remain inside the uterus can become infected. In discussing these techniques, notice how we have switched back and forth between mentioning elective and non-elective procedures. That’s because performing any of these procedures requires the same set of skills regardless of whether it’s a medical necessity, such as removal of retained products after a missed abortion, or it’s an unwanted pregnancy.
In California, minors seeking abortion care are treated as adults. This means means that they do not need to obtain consent of a parent or guardian, nor even must a parent or guardian be notified of the minor’s decision to have an abortion