Delays, confusion, adaptation mark first two years of NC’s stricter abortion law
By Lisa Worf
Co-published with WFAE
In the past two years, North Carolina’s stricter abortion law has changed the way Jamila Wade treats a small portion of pregnant patients she sees in the emergency room. They’re clearly losing their pregnancies, but the pregnant patient’s vital signs are still stable.
Wade, head of the OB-GYN department at Iredell Memorial Hospital in Statesville, said she’s had to delay care in a few cases because procedures that were standard treatment not that long ago are now banned practice. Distinguishing between the two can be fraught with uncertainty for many providers as they adapt to the new reality.
The treatment for a miscarriage often requires a doctor to empty the uterus to prevent life-threatening infections or hemorrhages for the pregnant patient. If the fetus has not yet died, in effect, this is an abortion.
The state’s 2023 law allows for abortions after 12 weeks when a doctor finds there’s a “medical emergency” that requires an “immediate abortion…to avert” the patient’s death — or there’s a serious risk of substantial “impairment of a major bodily function.”
In one instance, Wade recalled a patient who had come to the ER who was 18 weeks pregnant and miscarrying.
“The baby was partly out of the uterus but had not completely delivered, but the baby still had a heartbeat, so we literally could not do anything,” Wade said.
She said the patient’s husband was furious and demanded that she and her staff intervene.
“He’s like, ‘My wife, she’s in pain.’ And I was like, ‘I know she is in pain. I’m trying as much as I can to control her pain and make this more comfortable for her. But unfortunately, because of the law, I am kind of forced not to act in this situation unless she becomes more unstable,”’ Wade said. “He just felt helpless for his wife, and he just wanted us to end this process for her.”
Wade said she consulted with hospital administrators and attorneys who agreed with her assessment. It took more than 12 hours for that fetus’s heart to stop beating, she said.
Before the law, Wade said she would have given the patient the option to complete the miscarriage earlier by taking medication to hasten the delivery or performing a procedure to empty her uterus. Both are considered abortions.
Wade said she’s had to delay care in a few situations like this — not because of confusion about the law, but because of its restrictions.
“They were frustrating for us because it limited what we do and how we care for our patients,” Wade said.
Other OB-GYNs whom WFAE and NC Health News spoke with did say confusion was a factor in delays in care where abortions appear to fall within the law. Several physicians said they’d seen how vague legal language and the threat of losing a medical license have caused doctors to hesitate to help patients make the best medical call.
Measuring the law’s impact
It’s hard to tally the impact of North Carolina’s new abortion law on patients with urgent pregnancy complications.
The state health department tracks doctors’ reports of pregnant patients who develop serious and life-threatening complications during their deliveries. The statewide rate for these complications in 2024 was up 23 percent from 2022, the year the U.S. Supreme Court overturned Roe v. Wade. North Carolina’s ban on most abortions after 12 weeks took effect a year later on July 1, 2023.
How much of that reported increase is related to physicians and hospitals attempting to interpret the law’s language in a medical setting is not clear.
WFAE/NC Health News asked a dozen OB-GYNs across the state about delays in care in urgent situations. None said they had heard of any deaths. Routine maternal mortality reviews performed at the state level could pinpoint fatalities, if they’ve occurred. But those reviews are years away from completion.
“Do I think there’s going to be a change with an increase [in fatalities]? I don’t want to say it, but I do think there will be,” said Maria Small, who treats patients with high-risk pregnancies at Duke Health and is the immediate past chair of the review committee. “I pray I am wrong, but this is my fear.”
Nine of the physicians we spoke to said they had seen or heard of delays. Many brought up delays specifically for the treatment of miscarriages.
One reason for delay could be that rural hospitals are closing or reducing obstetric units. Twenty-seven North Carolina counties now don’t even have an OB-GYN, much less a full maternity unit. This means women are referred farther from home to get care.
Beverly Gray is an OB-GYN with Duke Health, a system that receives many patient referrals. She said delays don’t have to be deadly to be serious.
“People have complications, or people have trauma, or people just have their care mismanaged,” Gray said. “[Those complications are] really important for patients and their families — and those happen on a weekly basis.”
One doctor called the delays not “anything lengthy” and said they came initially from confusion in the face of a new law. Another doctor said she couldn’t think of a delay that was “extremely risky.” Several said they saw delays in which patients “had gotten sicker,” given that serious health risks can increase when physicians wait to deliver care. Even now, two years into the law, some doctors said delays continue to pop up.
Confusion around the law
Rebecca Pollack has heard from OB-GYNs who still aren’t sure how to treat a patient while complying with the new law. She’s a doctor in the Charlotte area who specializes in high-risk pregnancies.
Pollack said she encounters cases “fairly often” where a patient’s water has broken several weeks before the fetus is viable, the patient is bleeding, and her cervix is dilated. Maintaining such a pregnancy greatly increases the risk of infection.
“I’m usually the one getting called into these situations to give an opinion and an assessment that, yes, there is no way we can salvage this pregnancy,” Pollack said.
Some maternal-fetal medicine specialists in North Carolina say they’ve been placed in this position more often in the past two years, typically taking calls from doctors in smaller communities. These days, Pollack fields two to three of these calls a month. She said there’s always been some degree of uncertainty with decisions involving ending a pregnancy, but that’s increased since the state’s stricter abortion law took effect.
“Because of that unease, women are being left to linger in that condition — even though there is no way that pregnancy is going to stay intact for weeks more,” Pollack said.
Pollack said she has heard of patients early in their pregnancies seeking help for heavy bleeding. Those symptoms show they’re miscarrying, she said, and yet patients have been told they’ll have to wait till there’s an acute threat to their health and life before doctors can intervene.
Pollack says there’s no need to wait.
“The law has nothing to do with that, but it’s this kind of vagueness and unsureness about what the law actually says,” she said.
The new law doesn’t change the definition of a “medical emergency,” but it does require physicians to file paperwork with the state each time they perform abortions in these situations.
Doctors who are found to have violated the law could be stripped of their medical license. The new law doesn’t create additional criminal penalties — but two laws from 1881 do designate providing unlawful abortions as low-level felonies.
“These legal conditions certainly make us pause and take a moment,” said Amelia Sutton, an OB-GYN who works with high-risk pregnancy patients in the Charlotte area. Some of Sutton’s patients come from South Carolina and other surrounding states that have more restrictive laws. Such patients are increasingly traveling to North Carolina for abortion care that is no longer available in their home states.
“I think all of us have those thoughts in the back of our mind: ‘I know I’m doing the right thing for this patient. However, will I lose my license, lose my livelihood? Could I even be prosecuted criminally?’” Sutton said.
Nationally, no doctor has been convicted and jailed for providing an abortion since Roe v. Wade was overturned, according to KFF, a nonprofit that tracks health policy issues in the United States. Texas and Louisiana attorneys general have targeted a doctor in New York for mailing abortion pills to residents in their states, where near-total bans are in effect.
North Carolina’s medical board hasn’t publicly disciplined any doctors for providing abortions outside the law or for delaying care in cases that meet the state’s exceptions.
Handing off patients
Pregnant patients with complications may receive different care, depending on the location of the hospital and its size. That’s always been the case; bigger hospitals have more specialists and equipment to handle high-risk patients. But several doctors we spoke with say that, especially in smaller communities, they’ve seen how the state’s abortion law has introduced hesitancy around providing care where the standard treatment would be an abortion.
Doctors, uncertain of what to do, send patients to bigger hospitals.
“Within North Carolina, tertiary care centers that have more robust legal support … that have, like, a team that provides us care routinely, are often getting transfers from smaller hospitals of patients needing that care,” Gray said.
These transfers are taking place even though physicians in larger institutions have reassured staff at smaller hospitals that the law allows them to care for these patients.
“They may say ‘We would feel more comfortable if we could transfer them to you,’” said Clayton Alfonso, a physician from Duke Health and the vice chair of the North Carolina section of the American College of Obstetricians and Gynecologists.
He said these transfers increase costs and delay the timeliness of care.
The state’s abortion law has introduced hesitancy around providing care where the standard treatment would be an abortion. Doctors, uncertain of what to do, send patients off to bigger hospitals. Credit: Steve Harrison / WFAE
Alfonso said he’d heard of a handful of cases “early on” after the law took effect, where patients “had gotten sicker” waiting for a transfer.
Over the past two years, Wade, the OB-GYN from Statesville, said she’s transferred stable patients who appear to be having what she calls “an inevitable abortion” in the second trimester to larger hospitals. Wade said, the law requires them to wait till the fetus has died or the patient becomes unstable.
“But we don’t know how long this process is going to take. And, then, while we’re waiting for this process to occur, for eventually this baby to pass, or for the patient to just deliver — is she going to become unstable? Will she get infected?”
In those cases, it’s not confusion, the need for a bigger legal department or more expertise that prompts her to call for a transfer.
“It’s mainly a matter of blood,” Wade said.
Bigger hospitals have larger blood banks to treat patients who may begin to hemorrhage.
Hospitals in Charlotte also receive many pregnant patients with complications from South Carolina and other states with near-total bans on abortions. A doctor who treats high-risk patients in Charlotte said she was able to convince a South Carolina hospital not to transfer a patient after her water broke early in her pregnancy, but to instead perform an abortion there.
That OB-GYN spoke on the condition of anonymity because of the sensitivity of the topic.
“I thought it would be best for her, also for future patients, to have these providers become more comfortable with practicing within the law and safely,” the doctor said.
She said that’s better for patients across the border in North Carolina, too, since the area’s growth and more referrals from other states have made for fuller maternity units.
Another concern that cropped up among a few OB-GYNs is doctors transferring patients because of their anti-abortion beliefs or those beliefs prompting someone on their medical team to find fault with their care.
Hospitals reluctant to publicly release guidance
It’s hard to figure out what guidance health care systems and hospitals have been giving doctors about how to treat patients and comply with the state’s new abortion law. The North Carolina Healthcare Association, which represents the state’s hospitals, told WFAE and NC Health News it doesn’t monitor this, nor has it convened its members to discuss it.
WFAE and NC Health News surveyed a dozen health care systems — the state’s largest ones and a few smaller hospitals. We asked them about the guidance they offer doctors who treat pregnant patients, how the guidance is communicated, and what the protocol is when doctors are unsure if they can legally provide abortion care in an emergency situation. Eight of them responded, and most answers were brief.
A Cone Health spokesperson simply wrote, “Cone Health follows the law in caring for our patients.”
Duke Health emphasized the expertise of its doctors and wrote that all of their clinicians are advised to manage abortion care and emergencies “based on their medical expertise, the medical standard of care, and in compliance with all applicable laws.”
UNC Health said doctors “exercise their expert medical judgement based on established, evidence-based care guidelines.” UNC Health’s legal and risk management teams are available to answer questions about the law, the response said, “but lawyers don’t tell physicians how to practice medicine.” Attending physicians can seek opinions from colleagues, but they’re “the ultimate authority.”
Novant Health gave the most detailed response. A spokesperson said the health care system notifies clinicians through “written communications, one-to-one consults, and in-person forums where team members can share thoughts and questions.” When doctors are unsure of how to proceed, they can consult colleagues, “designated physician leaders and other system-wide supports.” Novant said, “physicians are responsible for clinical decision-making,” but staff can request a legal or ethical review to support treatment decisions.
OB-GYNs with North Carolina’s largest health care systems say their systems have been clear about guidance on the abortion law and that they have the support to make calls that are consistent with their training as OB-GYNs.
But Small, the OB-GYN at Duke Health, said she’s heard from colleagues in other parts of the state who’ve had a different experience.
“They feel they have had delays and that there is a level of confusion about what can be done occasionally in the setting of emergency management,” Small said.
Looking toward Georgia
After two years, doctors in North Carolina are adapting to the law, nonetheless there are varying views on how much confusion still exists.
“There was initially some confusion and some concerns on the part of physicians,” said Jeffrey Wright, who treats patients with high-risk pregnancies in Wilmington. He said a lot of that had to do with a misunderstanding that the patient must be “absolutely on death’s door before the pregnancy is terminated.”
Gov. Josh Stein speaks at a press conference on Jan. 16, 2025 announcing his executive order to protect women’s freedoms and privacy. Credit: Gov. Josh Stein Facebook Page
Wright said he thinks educational programs by hospitals and other groups have alleviated those concerns.Doctors WFAE and NC Health News spoke with — who have performed emergency abortions — say they haven’t received any pushback from the state. North Carolina Gov. Josh Stein issued an executive order in January to protect clinicians providing “lawful reproductive health care services” against prosecution. N.C. Attorney General Jeff Jackson, along with other Democratic attorneys general, reminded hospitals in June that the federal Emergency Medical Treatment and Labor Act requires them “to provide access to abortion care if it is the treatment necessary to stabilize pregnant patients with an emergency medical condition.”
That takes some pressure off, but many physicians in the state still worry — particularly after state legislators proposed in April a bill banning abortion from conception onward except to save the life of the mother.
That bill went nowhere, and legislative leaders said they weren’t eager to enact more restrictions.
Efforts in Georgia to create guidance for hospitals treating patients who meet medical exceptions under the state’s six-week abortion ban are attracting attention from OB-GYNs in North Carolina.
One woman died in Georgia as a result of a delay in care in 2022 — after that state’s ban went into effect — a ProPublica investigation alleged. That state’s law, which includes prison time as a penalty, has created “a huge amount of fear and confusion,” said Nisha Verma, an OB-GYN practicing in Georgia and the senior adviser for reproductive health care and advocacy at the American College of Obstetricians and Gynecologists.
A group of Georgia clinicians, attorneys and hospital administrators convened by ACOG met over the past year. Verma said they’re having “success” in working with hospitals.
“A lot of our hospitals are really eager to have guidance and help and support from legal and clinical colleagues to create a system that supports them in providing that maximum amount of care and protecting their doctors in doing so,” Verma said.
Alfonso, the vice chair of ACOG’s North Carolina section, said if those efforts work well he’d like to see hospitals in North Carolina come up with shared guidance of their own.
“I would really hope that our state would band together,” Alfonso said. “There’s always strength in numbers, and I think there’s always strength in the consistency of care that we provide.”
His hope is that it would allow hospitals and doctors to feel safer treating patients under the law. But he also worries that a set of guidelines could create a target for lawmakers to further restrict abortion care, a sentiment expressed by multiple providers.
Two years after North Carolina’s new restrictions took effect, OB-GYNs in the state are finding their footing on how to adjust to the changes in the law. But Amy Bryant, an OB-GYN in the Triangle, said there will always be uncertainty when doctors are asked to trade their medical judgment for vague legal language. Doctors don’t want lawmakers to create a list of exceptions. They do want assurance that they won’t be penalized for practicing medicine as they were trained.
“I’m sure there is some level of comfort people have come to,” Bryant said. “But this is the thing about medicine — you can’t account for all the scenarios that are going to occur.”
NC Health News reporter Rachel Crumpler contributed to this report.
Reporter Lisa Worf has covered North Carolina and the Charlotte area since 2006.
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