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American Journal of Kidney Diseases

Overturning Roe Will Do Harm to Our Patients

Published:September 22, 2022DOI:https://doi.org/10.1053/j.ajkd.2022.08.006
      We dissent.
      On June 24, 2022, the US Supreme Court overturned precedent established by Roe v Wade in 1973 and Planned Parenthood v Casey in 1992, which eliminated the constitutional right to abortion. In the wake of this decision, individual state laws govern the legality of abortion. Thirteen states have “trigger” laws that ban abortion at a specified time after the overturning of Roe, and another 7 states have pre-Roe laws banning abortion that remain on the books but have not been enforced since 1973.
      Abortion Policy in the Absence of Roe. Guttmacher Institute.
      In discussing a patient’s fate, dissenting justices stated that with the Court’s opinion, “a state can force her to bring a pregnancy to term even at the steepest personal and familial costs.”
      • Kagan E.
      Dissenting opinion. Dobbs v. Jackson Women's Health Organization. No. 19-1392, 24 June 2022, p. 149. Supreme Court of the United States.
      Access to abortion is particularly salient for those with chronic kidney disease (CKD), whose health and childbearing experiences are more nuanced than these laws can acknowledge. Owing to an altered hypothalamic-pituitary-ovarian axis, erratic menstrual cycles are common in people with CKD
      • Holley J.L.
      The hypothalamic-pituitary axis in men and women with chronic kidney disease.
      ,
      • Reynolds M.L.
      • Poulton C.J.
      • Blazek L.N.
      • Hogan S.L.
      • Falk R.J.
      • Derebail V.K.
      Subfertility and early menopause in women with glomerular disease.
      and may impair awareness of pregnancy, limiting the ability to find abortive services within 6 weeks’ gestation, a timeline currently set in 4 states.
      Abortion Policy in the Absence of Roe. Guttmacher Institute.
      Exemptions in instances where abortion will save a pregnant person’s life or preserve health are heterogeneously applied across states, and in some states exemptions do not exist. In Missouri, abortion is now banned “except in cases of medical emergency.”
      Missouri Revisor of Statutes, Mo. Rev. Stat. § 188.017 (Eff. 24 June 2022).
      In Michigan, a law passed in 1931 prohibits abortion unless it “shall have been necessary to preserve the life of such woman.”
      Michigan Compiled Law, Mich. Comp. Law §750.14 & 750.15 (Eff. 1931).
      Analysis by the Guttmacher Institute details that exceptions for health have generally permitted abortion in instances of “substantial and irreversible impairment” or “imminent peril” of a “major bodily function.” In such cases, it is the physician’s responsibility to prove this.
      State Bans on Abortion Throughout Pregnancy.
      In this post-Roe era, where and by whom will the line be drawn between health and life for pregnant people with CKD to justify an exception? Is a patient with a severe lupus nephritis flare at 14 weeks’ gestation, for whom termination of pregnancy would facilitate more treatment options, in “imminent peril”? Does accelerating the need for dialysis by several years in a patient with CKD stage 4 constitute “substantial and irreversible impairment”? When a pregnant patient on dialysis is advised that optimal pregnancy care would include increasing to 36 hours per week of hemodialysis, straining their ability to work or care for other children at home, is this sufficient disruption of “bodily function?” For our patients, these decisions influence not only their health, but their functionality and livelihoods. Each person with CKD deserves the right to draw their own, highly personal line, weighing the risks and benefits of continuing a pregnancy. To support patients in their reproductive goals, it is imperative that nephrologists become familiar with our state laws, which may evolve, so that we may advise our patients about the safest available treatment options and nearest resources.
      Abortion Policy in the Absence of Roe. Guttmacher Institute.
      Historically, pregnancy was discouraged in people with CKD owing to risks of maternal morbidity, death, and poor fetal outcomes. With advancing neonatal care, more recent evidence suggests that live birth rates have improved for people with CKD and that risks are decreased when pregnancies are well planned with optimized preconception blood pressure and disease stability on a regimen of pregnancy-compatible medications.
      • Hladunewich M.A.
      Chronic kidney disease and pregnancy.
      However, timing a pregnancy in the context of one’s kidney disease, whether it may be progressive or relapsing and remitting, as well as the myriad other personal, relational, social, and economic factors that influence family planning, is not always straightforward. Family planning challenges specific to CKD, as well as downstream challenges in pregnancy, now exacerbated by restricted abortion access, are summarized in Fig 1. Options for reliable contraception may be medically limited for some people with CKD, owing to the potential cardiovascular risks of estrogen-containing contraception,
      ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
      cost, or access to procedures for implantation and removal. Contraception use is low in both kidney transplant recipients and those on dialysis
      • Shah S.
      • Christianson A.L.
      • Thakar C.V.
      • Kramer S.
      • Meganathan K.
      • Leonard A.C.
      Contraceptive use among women with end-stage kidney disease on dialysis in the United States.
      ,
      • Shah S.
      • Christianson A.L.
      • Bumb S.
      • Verma P.
      Contraceptive use among women with kidney transplants in the United States.
      —2 of the most vulnerable populations to a high-risk, unplanned pregnancy. For those with a kidney transplant, conceiving while taking standard-of-care maintenance immunosuppression with mycophenolate mofetil increases the risk of spontaneous abortion and congenital malformations.
      • King R.W.
      • Baca M.J.
      • Armenti V.T.
      • Kaplan B.
      Pregnancy outcomes related to mycophenolate exposure in female kidney transplant recipients.
      Overall, there has been a reported lack of confidence from nephrologists in counseling about family planning and pregnancy owing to a lack of education and experience.
      • Hendren E.M.
      • Reynolds M.L.
      • Mariani L.H.
      • et al.
      Confidence in women's health: a cross border survey of adult nephrologists.
      Following the reversal of Roe, this patient-centered counseling is more critical than ever.
      Figure thumbnail gr1
      Figure 1Challenges in family planning, pregnancy, and the impact of restricted abortion access in patients with chronic kidney disease (CKD).
      CKD is currently estimated to complicate 3% of pregnancies.
      • Piccoli G.B.
      • Zakharova E.
      • Attini R.
      • et al.
      Pregnancy in chronic kidney disease: need for higher awareness. A pragmatic review focused on what could be improved in the different CKD stages and phases.
      Although risk is inherent in all pregnancies, it is particularly elevated in those with underlying CKD. The United States currently has the highest maternal mortality rate in the industrialized world and each year roughly 700 women die owing to pregnancy or delivery complications.
      • Hoyert D.
      Maternal mortality rates in the United States, 2020. NCHS Health E-Stats. 2022.
      In the United States, complications from pre-existing chronic conditions are the fastest-growing cause of maternal mortality, and are responsible for a third of all maternal deaths.
      • Creanga A.A.
      • Syverson C.
      • Seed K.
      • Callaghan W.M.
      Pregnancy-related mortality in the United States, 2011-2013.
      At the time of delivery, the odds of severe maternal morbidity and mortality are nearly 6 times higher and the odds of preterm delivery are 4 times higher when CKD is present than when it is absent.
      • Oliverio A.L.
      • Admon L.K.
      • Mariani L.H.
      • Winkelman T.N.A.
      • Dalton V.K.
      Health outcomes and health care utilization among obstetric deliveries with concurrent CKD in the United States.
      Compared to the general population, pregnant people with CKD have a 10-fold higher risk for preeclampsia,
      • Zhang J.J.
      • Ma X.X.
      • Hao L.
      • Liu L.J.
      • Lv J.C.
      • Zhang H.
      A systematic review and meta-analysis of outcomes of pregnancy in CKD and CKD outcomes in pregnancy.
      which increases the risk of subsequent cardiovascular disease. Those with chronic medical conditions are at nearly 50% higher risk of experiencing peripartum mental illness.
      • Brown H.K.
      • Qazilbash A.
      • Rahim N.
      • Dennis C.L.
      • Vigod S.N.
      Chronic medical conditions and peripartum mental illness: a systematic review and meta-analysis.
      In addition, pregnancy-associated progression of CKD was reported to occur in 80% of individuals who experienced pregnancy with a preconception estimated glomerular filtration rate of <60 mL/min/1.73 m2.
      • Wiles K.
      • Webster P.
      • Seed P.T.
      • et al.
      The impact of chronic kidney disease Stages 3-5 on pregnancy outcomes.
      In this recent cohort of patients with CKD stage 3-5, pregnancy accelerated the onset of kidney failure by an average of 2.5 years.
      • Wiles K.
      • Webster P.
      • Seed P.T.
      • et al.
      The impact of chronic kidney disease Stages 3-5 on pregnancy outcomes.
      Although CKD progression may not immediately threaten one’s life in pregnancy, it certainly affects health and can decrease longevity across a lifespan. These risks will be compounded in marginalized communities that are disproportionately impacted by the lack of access to abortion services owing to systemic inequities.
      • Brown K.
      • Plummer M.
      • Bell A.
      • et al.
      Black women's lived experiences of abortion.
      ,
      • Sutton A.
      • Lichter D.T.
      • Sassler S.
      Rural-urban disparities in pregnancy intentions, births, and abortions among US adolescent and young women, 1995-2017.
      Black women in the United States are 50% more likely to have a preterm birth than White women,
      • Schaaf J.M.
      • Liem S.M.
      • Mol B.W.
      • Abu-Hanna A.
      • Ravelli A.C.
      Ethnic and racial disparities in the risk of preterm birth: a systematic review and meta-analysis.
      and the maternal mortality is 3.5 times higher in non-Hispanic Black women than non-Hispanic White women.
      • MacDorman M.F.
      • Thoma M.
      • Declcerq E.
      • Howell E.A.
      Racial and ethnic disparities in maternal mortality in the United States using enhanced vital records, 2016-2017.
      Black people with CKD are also more than 3 times as likely as White people to initiate maintenance dialysis.
      • Norris K.C.
      • Williams S.F.
      • Rhee C.M.
      • et al.
      Hemodialysis disparities in African Americans: the deeply integrated concept of race in the social fabric of our society.
      The fall of Roe will have the greatest impact on our most disadvantaged patients.
      Abortion is both common and safe. In the United States, it has been reported that 1 in 4 women will undergo elective abortion by age 45 years.
      • Jones R.K.
      • Jerman J.
      Population group abortion rates and lifetime incidence of abortion: United States, 2008-2014.
      A small survey of women with glomerular disease found similar results, with 25% reporting at least 1 elective termination.
      • Reynolds M.L.
      • Poulton C.J.
      • Blazek L.N.
      • Hogan S.L.
      • Falk R.J.
      • Derebail V.K.
      Contraceptive use and elective terminations in women enrolled in the Glomerular Disease Collaborative Network.
      Neither medical nor surgical abortions are medically contraindicated in kidney disease. Access to legal, medically supervised abortion procedures reduces the immediate morbidity and mortality of unsafe abortion procedures.
      • Cates Jr., W.
      • Rochat R.W.
      Illegal abortions in the United States: 1972-1974.
      ,
      • Haddad L.B.
      • Nour N.M.
      Unsafe abortion: unnecessary maternal mortality.
      Removal of this choice will also negatively impact the physical, mental, and economic health of people with CKD.
      • Paltrow L.M.
      • Harris L.H.
      • Marshall M.F.
      Beyond abortion: the consequences of overturning Roe.
      In a cohort study, those who were turned away from wanted abortions were more likely to report a persistent worsening in self-rated health 5 years later compared to those who received first- or second-trimester abortions.
      • Ralph L.J.
      • Schwarz E.B.
      • Grossman D.
      • Foster D.G.
      Self-reported physical health of women who did and did not terminate pregnancy after seeking abortion services: a cohort study.
      Nearly 10% of those turned away developed a new diagnosis of gestational hypertension within that pregnancy or a subsequent pregnancy within 5 years,
      • Ralph L.J.
      • Schwarz E.B.
      • Grossman D.
      • Foster D.G.
      Self-reported physical health of women who did and did not terminate pregnancy after seeking abortion services: a cohort study.
      an outcome closely linked to long-term cardiovascular health. As procedural abortion access is further restricted, more pregnant people will likely turn to self-managed abortions. As nephrologists, we must equip ourselves with resources so that when a pregnant patient desires an abortion, we can guide them away from life-threatening techniques and connect them to medical management with mifepristone and misoprostol, where available.
      The juxtaposition of the desire for pregnancy and the burden of managing a chronic disease is challenging for people with CKD.
      • Tong A.
      • Jesudason S.
      • Craig J.C.
      • Winkelmayer W.C.
      Perspectives on pregnancy in women with chronic kidney disease: systematic review of qualitative studies.
      The risks of pregnancy are substantial and only the childbearing individual can weigh these risks in the context of their unique physical, socioeconomic, and reproductive needs and goals. We will continue to argue that the choice should always be theirs to make. The decision to terminate or continue a pregnancy is a personal and private health care decision. We should not take lightly the task entrusted to us to confidentially discuss these topics, support our patients’ decisions, and mitigate risks as best we can. We will continue to stand up for reproductive autonomy and justice, and support access to comprehensive abortion services for all patients with kidney disease. As nephrologists, we must unite post-Roe to engage in multidisciplinary care that ensures all patients receive comprehensive, personalized, and unbiased family planning services that includes the entire spectrum of reproductive health care.

      Article Information

      Authors’ Full Names and Academic Degrees

      Andrea L. Oliverio, MD, MSc, and Monica L. Reynolds, MD, MSCR.

      Support

      Dr Oliverio is supported by National Institute of Diabetes and Digestive and Kidney Diseases grant K23 DK123413.

      Financial Disclosure

      The authors declare that they have no relevant financial interests.

      Peer Review

      Received July 5, 2022. Evaluated by 3 external peer reviewers, with direct editorial input from an Associate Editor, a Deputy Editor, and the Editor-in-Chief. Accepted in revised form August 23, 2022.

      References

      1. Abortion Policy in the Absence of Roe. Guttmacher Institute.
        • Kagan E.
        Dissenting opinion. Dobbs v. Jackson Women's Health Organization. No. 19-1392, 24 June 2022, p. 149. Supreme Court of the United States.
        • Holley J.L.
        The hypothalamic-pituitary axis in men and women with chronic kidney disease.
        Adv Chronic Kidney Dis. 2004; 11: 337-341https://doi.org/10.1053/j.ackd.2004.07.004
        • Reynolds M.L.
        • Poulton C.J.
        • Blazek L.N.
        • Hogan S.L.
        • Falk R.J.
        • Derebail V.K.
        Subfertility and early menopause in women with glomerular disease.
        Nephrol Dial Transplant. 2021; 36: 948-950https://doi.org/10.1093/ndt/gfab005
      2. Missouri Revisor of Statutes, Mo. Rev. Stat. § 188.017 (Eff. 24 June 2022).
      3. Michigan Compiled Law, Mich. Comp. Law §750.14 & 750.15 (Eff. 1931).
      4. State Bans on Abortion Throughout Pregnancy.
        • Hladunewich M.A.
        Chronic kidney disease and pregnancy.
        Semin Nephrol. 2017; 37: 337-346https://doi.org/10.1016/j.semnephrol.2017.05.005
      5. ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions.
        Obstet Gynecol. 2019; 133: e128-e150https://doi.org/10.1097/AOG.0000000000003072
        • Shah S.
        • Christianson A.L.
        • Thakar C.V.
        • Kramer S.
        • Meganathan K.
        • Leonard A.C.
        Contraceptive use among women with end-stage kidney disease on dialysis in the United States.
        Kidney Med. 2020; 2: 707-715.e1https://doi.org/10.1016/j.xkme.2020.08.010
        • Shah S.
        • Christianson A.L.
        • Bumb S.
        • Verma P.
        Contraceptive use among women with kidney transplants in the United States.
        J Nephrol. 2022; 35: 629-638https://doi.org/10.1007/s40620-021-01181-0
        • King R.W.
        • Baca M.J.
        • Armenti V.T.
        • Kaplan B.
        Pregnancy outcomes related to mycophenolate exposure in female kidney transplant recipients.
        Am J Transplant. 2017; 17: 151-160https://doi.org/10.1111/ajt.13928
        • Hendren E.M.
        • Reynolds M.L.
        • Mariani L.H.
        • et al.
        Confidence in women's health: a cross border survey of adult nephrologists.
        J Clin Med. 2019; 8: 176https://doi.org/10.3390/jcm8020176
        • Piccoli G.B.
        • Zakharova E.
        • Attini R.
        • et al.
        Pregnancy in chronic kidney disease: need for higher awareness. A pragmatic review focused on what could be improved in the different CKD stages and phases.
        J Clin Med. 2018; 7: 415https://doi.org/10.3390/jcm7110415
        • Hoyert D.
        Maternal mortality rates in the United States, 2020. NCHS Health E-Stats. 2022.
        • Creanga A.A.
        • Syverson C.
        • Seed K.
        • Callaghan W.M.
        Pregnancy-related mortality in the United States, 2011-2013.
        Obstet Gynecol. 2017; 130: 366-373https://doi.org/10.1097/AOG.00000000000002214
        • Oliverio A.L.
        • Admon L.K.
        • Mariani L.H.
        • Winkelman T.N.A.
        • Dalton V.K.
        Health outcomes and health care utilization among obstetric deliveries with concurrent CKD in the United States.
        Am J Kidney Dis. 2020; 75: 148-150https://doi.org/10.1053/j.ajkd.2019.07.007
        • Zhang J.J.
        • Ma X.X.
        • Hao L.
        • Liu L.J.
        • Lv J.C.
        • Zhang H.
        A systematic review and meta-analysis of outcomes of pregnancy in CKD and CKD outcomes in pregnancy.
        Clin J Am Soc Nephrol. 2015; 10: 1964-1978https://doi.org/10.2215/CJN.09250914
        • Brown H.K.
        • Qazilbash A.
        • Rahim N.
        • Dennis C.L.
        • Vigod S.N.
        Chronic medical conditions and peripartum mental illness: a systematic review and meta-analysis.
        Am J Epidemiol. 2018; 187: 2060-2068https://doi.org/10.1093/aje/kwy080
        • Wiles K.
        • Webster P.
        • Seed P.T.
        • et al.
        The impact of chronic kidney disease Stages 3-5 on pregnancy outcomes.
        Nephrol Dial Transplant. 2021; 36: 2008-2017https://doi.org/10.1093/ndt/gfaa247
        • Brown K.
        • Plummer M.
        • Bell A.
        • et al.
        Black women's lived experiences of abortion.
        Qual Health Res. 2022; 32: 1099-1113https://doi.org/10.1177/10497323221097622
        • Sutton A.
        • Lichter D.T.
        • Sassler S.
        Rural-urban disparities in pregnancy intentions, births, and abortions among US adolescent and young women, 1995-2017.
        Am J Public Health. 2019; 109: 1762-1769https://doi.org/10.2105/AJPH.2019.305318
        • Schaaf J.M.
        • Liem S.M.
        • Mol B.W.
        • Abu-Hanna A.
        • Ravelli A.C.
        Ethnic and racial disparities in the risk of preterm birth: a systematic review and meta-analysis.
        Am J Perinatol. 2013; 30: 433-450https://doi.org/10.1055/s-0032-1326988
        • MacDorman M.F.
        • Thoma M.
        • Declcerq E.
        • Howell E.A.
        Racial and ethnic disparities in maternal mortality in the United States using enhanced vital records, 2016-2017.
        Am J Public Health. 2021; 111: 1673-1681https://doi.org/10.2105/AJPH.2021.306375
        • Norris K.C.
        • Williams S.F.
        • Rhee C.M.
        • et al.
        Hemodialysis disparities in African Americans: the deeply integrated concept of race in the social fabric of our society.
        Semin Dial. 2017; 30: 213-223https://doi.org/10.1111/sdi.12589
        • Jones R.K.
        • Jerman J.
        Population group abortion rates and lifetime incidence of abortion: United States, 2008-2014.
        Am J Public Health. 2017; 107: 1904-1909https://doi.org/10.2105/AJPH.2017.304042
        • Reynolds M.L.
        • Poulton C.J.
        • Blazek L.N.
        • Hogan S.L.
        • Falk R.J.
        • Derebail V.K.
        Contraceptive use and elective terminations in women enrolled in the Glomerular Disease Collaborative Network.
        Kidney Int Rep. 2020; 5: 1780-1783https://doi.org/10.1016/j.ekir.2020.07.005
        • Cates Jr., W.
        • Rochat R.W.
        Illegal abortions in the United States: 1972-1974.
        Fam Plann Perspect. 1976; 8: 86-92
        • Haddad L.B.
        • Nour N.M.
        Unsafe abortion: unnecessary maternal mortality.
        Rev Obstet Gynecol. 2009; 2: 122-126
        • Paltrow L.M.
        • Harris L.H.
        • Marshall M.F.
        Beyond abortion: the consequences of overturning Roe.
        Am J Bioeth. 2022; : 1-13https://doi.org/10.1080/15265161.2022.2075965
        • Ralph L.J.
        • Schwarz E.B.
        • Grossman D.
        • Foster D.G.
        Self-reported physical health of women who did and did not terminate pregnancy after seeking abortion services: a cohort study.
        Ann Intern Med. 2019; 171: 238-247https://doi.org/10.7326/M18-1666
        • Tong A.
        • Jesudason S.
        • Craig J.C.
        • Winkelmayer W.C.
        Perspectives on pregnancy in women with chronic kidney disease: systematic review of qualitative studies.
        Nephrol Dial Transplant. 2015; 30: 652-661https://doi.org/10.1093/ndt/gfu378