Pro-life doctors disagree on complex cases

When Dr. Kathryn Carnahan started seeing memes on social media last year about how women were going to die from ectopic pregnancies or sepsis due to laws protecting unborn babies, she rolled her eyes. “I thought no one would take this kind of stuff seriously,” said Carnahan, an OB-GYN at a faith-based inner-city hospital near Milwaukee. But she soon discovered she was wrong: “I have seen those fears come into my office with my patients.”

After the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization in June 2022, a pro-life law in Wisconsin took effect, protecting babies from abortion except to save the mother’s life. Since then, Carnahan has regularly seen pregnant patients who worried they would die because the state’s pro-life laws would prevent them from receiving proper treatment. “The worst part is that they have no reason to be scared,” Carnahan said.

Wisconsin is one of several states where lawmakers have introduced legislation to clarify the medical emergency exceptions in abortion laws, particularly as they relate to a condition known as previable premature rupture of membranes (PPROM). In that condition, the amniotic sac that holds the baby tears and leaks fluid, also described as the mother’s “water breaking,” before the baby can survive outside the womb. According to the American College of Obstetricians and Gynecologists (ACOG), the condition occurs in less than 1 percent of pregnancies.

Abortion supporters often claim that pro-life laws endanger the lives of women who experience PPROM. Among pro-life physicians, opinions vary about the best course of treatment when a mother’s water breaks too early in pregnancy. But they agree that existing pro-life laws allow doctors to provide life-saving care to women, even if it involves ending the pregnancy. A broken amniotic sac leaves a woman vulnerable to infections including sepsis, a deadly blood infection. The law allows abortions when “necessary … to save the life of the mother” and does not stipulate that the risk to her life has to be immediate. Carnahan believes doctors would not face prosecution for aborting the baby before the mother actually shows signs of infection.

According to a practice bulletin from ACOG, doctors should give women whose water breaks before the baby is viable two options for treatment: expectant management or immediate delivery. In expectant management, medical staff closely monitor the woman for signs of infection while giving the baby time to continue developing. The bulletin defines immediate delivery as “termination of pregnancy by induction of labor or dilation and evacuation,” also known as a dismemberment abortion.

Carnahan said both options are appropriate medically. “Ethically,” she said, “there are lots of us who would say, well, if a woman is stable—she doesn’t have any signs of an infection that could progress to a circumstance that would threaten her life—then there is no indication to end the pregnancy at that point. And so it’s not ethical to terminate the pregnancy at that time.”

Carnahan said her conscience and the policies of her hospital would prevent her from inducing labor under these circumstances. But because offering both choices is considered best practice, Carnahan said she would still let women know that they could go elsewhere to end the pregnancy.

As long as the patient remained under her care, Carnahan said she would encourage her to wait and would provide careful monitoring. She said she’s seen patients stay “stone cold stable” for weeks without any sign of infection. “That tells you this baby’s got a shot,” Carnahan said. “Why would I end this pregnancy?” The moment a woman’s water breaks, she said, is too early to know the outcome. “If there’s not a clear answer right away, then I think time is a tool that we use to get more information,” she said.

At the first signs of infection, though, Carnahan said she would induce labor without question. “You don’t get any ethical pushback on that,” she said. “I don’t think you would ever get any legal pushback on that. And that is well before a woman would be in a circumstance where she would be unsafe.”

Not all doctors who oppose elective abortion agree with Carnahan’s view.

“The counter to that, though, is that once they get sick, sometimes they get sick very rapidly,” Dr. Ingrid Skop, vice president and director of medical affairs at the pro-life Charlotte Lozier Institute, told me earlier this year. She works in obstetrics at a hospital in Texas, where state laws also prohibit abortion except to save the life of the mother. Skop said she would offer expectant management as well as an abortion procedure or induction of labor upon diagnosis of something like PPROM.

Skop, who ran a private practice in San Antonio for 25 years, said she has never performed an abortion on a live baby. She thinks that’s because, when a patient with a condition such as PPROM decides against expectant management, she has steered those women towards inducing labor. “If we induce, she has a baby to hold,” Skop said. “It’s a much more compassionate way to allow her to mourn her child than to dismember the child.” She added that a dilation and evacuation is also complicated and a “horrible” experience for the doctor “because they’re dismembering a baby.”

Skop agreed that doctors don’t have to deliver the baby early if the mother doesn’t want that—as long as she’s not infected. But she estimated that about half of the time, her patients in these circumstances chose induction over waiting. Often, that decision hinged on how far along the baby was. “If she is only 18 weeks she is likely to choose induction knowing she is unlikely to reach viability,” said Skop.

Dr. William Lile, an OB-GYN in Pensacola, Fla., speaks at pro-life events across the country as the “ProLife Doc.” He said even inducing labor in these conditions—before the first signs of infection—is wrong.

“There’s a big difference between, you know, having the risk factor of developing an infection and actually being infected,” Lile told me earlier this year. “And if you’re inducing a healthy mom and a healthy baby at 18 weeks gestation—the baby has absolutely zero chance of surviving—then you’re not, by definition, ‘pro-life.’” He said as soon as the woman has a fever or an elevated white blood count, the doctor has to induce labor no matter how far along the pregnancy is.

The Christian Medical and Dental Associations (CMDA) and the American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG) are leading voices for pro-life healthcare professionals in the United States. According to senior vice president of bioethics and public policy Dr. Jeffrey Barrows, CMDA does not have an official position on the treatment of PPROM. He said CMDA does not make treatment recommendations because “there are so many clinical factors that need to be considered, it’s very difficult to make good recommendations.” AAPLOG said it supports giving women the choice of expectant management or induction of labor before infection and recommends induction over a dismemberment abortion.

“Where we have concerns is that some obstetricians don’t seem to have been trained in how to do expectant management and move to induction quickly,” the group said. It added that AAPLOG “wants to ensure women have a thorough informed consent regarding maternal and fetal risks before a decision is made.”

Carnahan said she’s seen this disagreement among doctors regarding the appropriate response to these cases and believes it boils down to the individual doctor’s level of comfort with risk-taking. In her mind, there’s enough uncertainty about the risks and benefits of continuing the pregnancy in the moment that someone receives a diagnosis of PPROM that she would want to wait and see. But she knows other doctors are more risk averse and not as willing to wait.

“With this particular condition, that’s where a lot of the disagreement about management comes from, is that we all have different tolerance for risk,” said Carnahan. “And even within the pro-life community, we’ll all kind of feel a little differently about that.”