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reproductive health

Obstetricians are facing impossible dilemmas with abortion care in some states.

When the Dobbs decision overturned Roe v. Wade in the summer of 2022, experts warned that there would be medical consequences. Politicians have made abortion a black-and-white issue when it's a vast ocean of gray, and doctors are now stuck in dilemma after dilemma in states like Tennessee, which enacted some of the strictest abortion laws in the nation in the wake of Dobbs.

In Tennessee, it is now a Class C felony to perform an abortion. Exceptions are made for rape and incest, ectopic pregnancy, molar pregnancy, and if "the abortion was necessary to prevent the death of the pregnant woman or to prevent serious risk of substantial and irreversible impairment of a major bodily function of the pregnant woman."

But as OB-GYN Sarah Osmundson explained on Radio Atlantic, that last exception is "very gray." Working as a maternal-fetal specialist at Vanderbilt University Medical Center, Osmundson serves on the abortion committee that decides whether a doctor has the green light to perform an abortion to save a mother's life or bodily function. In an interview with Hanna Rosin, Dr. Osmundson shared how making those calls can feel like an impossible task as providers walk the line between ethical care and the threat of legal action.

Osmundson explained that it's unclear what the exceptions to the law even mean because there's no predictable line for when a patient will cross over into imminent death or permanent injury. "It is a continuum of risk," she said. "Where is the cut point that we have to decide some aspect of risk is too high?"

Some cases are cut-and-dried, she said, but others present a conundrum for those who are tasked with assessing whether the risk to a mother's life or health is high enough to warrant an abortion. There are no clear thresholds, especially since risk assessment isn't an exact science.

She offered an example of a patient who has diabetes combined with an autoimmune condition, but they're both currently well managed, on top of kidney disease.

"You know, these are the kind of cases where we’re really trying to guess at: What is their risk of death or serious morbidity?" she said. "And even when I see these patients in the office, like, I can’t sit down with them and say, Your risk is X percent. I don’t have data to drive that individual case. Maybe their risk of serious problems in pregnancy is like 5 percent."

Osmundson pointed out that some patients choose not to screen for chromosomal abnormalities with an amniocentesis because there's a 0.1% risk of complication and they decide it's not worth the risk. "So we don’t do certain things because of very low risk. How am I to say that a risk of 5 percent is too low of a risk?" she asked.

Dr. Lisa Harris, an OB-GYN and professor at the University of Michigan, posed a similar questions to NPR shortly after the Dobbs decision was announced.

"How imminent must death be?" Harris asked. "There are many conditions that people have that when they become pregnant, they're OK in early pregnancy, but as pregnancy progresses, it puts enormous stress on all of the body's organ systems – the heart, the lungs, the kidneys. So they may be fine right now – there's no life-threatening emergency now – but three or four or five months from now, they may have life-threatening consequences."

Osmundson gave a specific example along those lines that posed a problem for some doctors on her committee. A woman was 14 weeks pregnant with a fetus that had no skull, which meant it had no chance of survival but an increased risk of excessive amniotic fluid, which could threaten the mother's life. Osmundson thought the case warranted an abortion, but others on the committee wouldn't commit, with one saying they weren't "brave enough."

The doctors were concerned about the way the decision would be scrutinized and the potential legal consequences if someone brought the case to court. Dr. Louise King, an OB-GYN at Boston's Brigham and Women's Hospital, had warned of this scenario when Roe v. Wade was overturned.

"Laws will exist that ask [physicians] to deprioritize the person in front of them and to act in a way that is medically harmful," King told NPR. "And the penalty for not doing so will be loss of license, money loss, potentially even criminal sanctions."

The reality Osmundson described in the Radio Atlantic interview demonstrates how prescient that warning truly was.

"I feel like I’m making a decision thinking about: How would our attorney general interpret this? How would the optics appear? And it makes me feel really uncomfortable, as a physician, that I’m considering care for the optics, rather than for what is right and best for the patient," she said.

Legal abortion ban exceptions like "to prevent the death of the pregnant woman or to prevent serious risk of substantial and irreversible impairment of a major bodily function of the pregnant woman" may sound straightforward to the average person, in the reality of medicine, it's not. Doctors aren't magicians or oracles, they don't have a crystal ball that tells them if a patient is going to live or die or be irreparably harmed—they make their best guesses based on their deep well of knowledge and experience, which lawyers and politicians deciding on legal boundaries don't have. Abortion restrictions and exceptions like Tennessee's force doctors to think as lawyers and lawyers to think as doctors when they don't have the training for it, all while people's lives hang in the balance.

The ambiguity in risk thresholds also makes these legal questions impossible to navigate. As Osmundson pointed out, a 5% risk is actually quite high, especially when it's your own life on the line. That's a hard enough choice for a person to make for themselves, much less a choice we should expect a doctor to make for someone based on political decisions and legal judgments made by people with no experience in the intricacies of medicine.

The challenges are even causing some doctors to leave states where they feel they can't care for patients properly. Kylie Cooper, MD was a maternal-fetal specialist who moved from Idaho to Minnesota in the wake of the Dobbs decision.

“My husband and I would talk about this every day. It was consuming us,” she told the AAMC. “What if I lost my license? What would happen to our kids if I went to jail? What about my guilt if I didn’t help a sick patient to my fullest ability? It was a nightmare. I didn’t feel I could remain a health care provider in a place where I couldn’t help a patient sitting right in front of me. It was unbearable.”

And for many, it doesn't seem to be a matter of making the law clearer. There are simply too many factors on an individual patient basis for more clarity in the law to even be possible, much less helpful, while also preserving a doctor's ethical standards of care.

So what's the answer?

The simplest answer is medical privacy—the protection that was provided by Roe. v. Wade—which was argued for and passed by the majority of Republican-nominated Supreme Court Justices, by the way—for doctors and patients together to decide on healthcare decisions without government interference. We were warned by doctors of what would happen when abortion laws were left fully up to each state, and now we're seeing those consequences play out in state after state.

After going through various challenging scenarios, Osmundson summed up the crux of the issue with two questions that every person ought to consider: "Do you want your cancer doctor to be considering the opinion of an attorney general when they’re making recommendations about your cancer care? Why would you want those kind of external things involved in your care during pregnancy?"

Listen to Dr. Osmundson's enlightening Radio Atlantic interview here.

It was a cold, dreary day during my freshman year of college when the doctor said life-changing words:

“You have PCOS," she said unemotionally as she scribbled words on her notepad.

It wasn’t exactly a surprise. My older sister was diagnosed a few years before too, and we’d both experienced the same symptoms leading up to the diagnosis. Still, it wasn't a thrilling thing to be told.


Polycystic Ovary Syndrome (PCOS) is a hormonal endocrine disorder that affects between 1 in 10 and 1 in 20 women of childbearing age. As many as 5 million women in the United States could be affected, and many cases are undiagnosed. PCOS can cause irregular periods, infertility issues, and drastic changes in appearance, including acne, facial hair, and weight gain.

Being a teenager was already frustrating, but then my health decided to throw that curve ball.

So what did I do? I started running — a lot. Running eventually became my physical and mental refuge. It was a way to release my anger at what I thought was an attack on my womanhood and a way to tone up the parts of my body I had control over.

I completed the San Francisco Rock n' Roll Half Marathon in April 2015. Image from the author, used with permission.

I also changed the way I ate, and I started trying to find a therapist who wouldn't break my bank account.

But the most decisive and important things I've learned, and am still learning, aren't the things my doctor told me during that first appointment. Instead, this illness has taught me about the nitty-gritty of struggling with chronic illness, the gross and empowering things that medical textbooks won't teach you.

Here are some of those lessons that I — and many who have struggled with chronic illnesses — have learned during the journey.

1. My weight doesn’t define me.

Weight dominates women’s magazines. And every day, we’re given information about weighing too much or too little and which bodies are real and which aren’t.

You know what body is real? Yours.

When I found out I had PCOS, I trained for a half marathon, started doing yoga, and changed my diet, thinking that I could slim down to the dream image of my body I had in my head.

Ultimately, I lost a total of five pounds in one year. It was underwhelming, but I felt better than I’d felt during most of my young adult life during that year. My body, while large, gets me to work every day, runs half marathons in different cities, and does some pretty cool things in between. I’ve learned to be grateful for it, at all of its various shapes and sizes.

2. Just because it makes others uncomfortable, doesn’t mean I shouldn’t discuss it.

A lot of people don’t know about PCOS, and most of them don’t want to know more.

PCOS looks pretty different for everyone, but some commonly involved are weight gain, depression, body hair, and infertility. And those aren’t exactly pleasant. Unfortunately, there isn’t a lot of science out there on how to properly address PCOS just yet, leading to it being commonly misdiagnosed.

When I tried talking about my disease publicly, people were disgusted by it, and I also felt like they didn’t understand how a syndrome like mine could change my life so much. But here’s the thing:

When I talked about PCOS with friends who I trusted, I was more relieved and encouraged. Allowing the people I loved to help me through my health issues made a huge difference, and I’m better for it.

3. I don't need to be a doormat for terrible dates.

I grew up being told that I was intelligent and beautiful (because encouraging parents rock), but PCOS took a bit of a toll on my confidence when it came to dating. And sometimes, when I was getting used to my syndrome, I let society’s standards of worth dictate how I responded to romantic partners.

If someone indicated they were attracted to me, I felt like I had to be grateful for their interest. In turn, I became a doormat for terrible dates, and I accepted the love I thought I deserved because I thought I should be happy with what I got.

I learned quickly, though, that this couldn’t be further from the truth. But it took some heartache, self-reflection, and real talk from friends and family to get there.

4. Infertility is a big issue, but there are options.

I know, I know. Infertility probably isn't something a normal 18-year-old thinks about. But I've always known that I wanted a family of my own one day.

The great thing is there are plenty of resources, scientific breakthroughs, and support systems for people who struggle with infertility. Over the years, I have slowly found other women with PCOS who want to have kids. They are finding their own ways forward, whether that's through medicine, adoption, or in vitro fertilization.

There are options. There are almost always options. You just have to look.

5. Depression does not own me.

Depression is a common symptom of PCOS, and there are days when it's incredibly hard for me to get out of bed.

There are times, all too often, when my life seems amazing on the surface, but I’m crumbling inside. But here’s the thing I've learned: I have power.

I have the power to do things I know will improve my mood, like running, spending time with friends, and going to therapy. I've slowly learned (and am still learning!) the importance of self-care and the reality that self-care looks different for everyone.

Having power doesn’t mean there won’t be difficult days, but it does mean that eventually, I can get through my issues.

6. I enjoy food, and I should keep on enjoying it.

I’m a southern-raised American. I love good food. Like shrimp and grits, and spaghetti, and gelato! I still enjoy all those things and more. Unfortunately, PCOS isn’t exactly a fan of those foods or of carbs or sugar in general.

So while I indulge every now and then, I also focus on balance, and on keeping things in moderation. It keeps my hormones — and my taste buds — pretty happy.

7. I am not PCOS.

I have a syndrome. A frustrating syndrome. A highly under-researched syndrome. I have trouble losing weight, I have facial hair, and I struggle with depression daily.

But I am still not that syndrome.

I’m a writer, a reader, a runner, a traveler, and a Harry Potter fanatic. I am a multilayered person who laughs and drinks and has fun. I sometimes talk too much, put my foot in my mouth, and make really goofy mistakes.

I do all those things because I'm Kayla, not PCOS. And that is the most valuable lesson of all.