Overturning Roe v. Wade : Medical and Legal Impacts on Blood Transfusion in the Obstetric Population

The 1973 landmark U.S. Supreme Court decision in Roe v. Wade recognized that an individual's right to privacy extends to control over pregnancy, standardized how states could regulate abortion, and protected abortion under constitutional rights of privacy. ¹ In the 1992 case of Planned Parenthood v. Casey, the Court reaffirmed an individual's right to choose abortion, although it altered specific nuances of its prior decision by creating a standard regulation based on fetal viability instead of pregnancy trimester. ¹ Subsequently, Roe v. Wade guided U.S. abortion policy for almost 50 years until June 24, 2022 when the Supreme Court overturned the decision in Dobbs v. Jackson Women's Health, arguing that the U.S. Constitution does not guarantee a right to abortion, returning the ability to define abortion rights and determine restrictions to states.

The impacts of this decision will influence multiple facets of patients' health care, ^{2 –6} with significant concern that already increasing U.S. pregnancy-related mortality will grow at a faster rate, ⁷ as access to safe and legal abortion is safer than childbirth. ⁸ One potentially overlooked effect that Roe v. Wade may have on maternal morbidity and mortality is an increased incidence of obstetrical hemorrhage. Obstetrical hemorrhage is among the most common complications of childbirth, and although decreased since the 1980s, postpartum hemorrhage (PPH) remains one of the most significant contributors to maternal mortality, being directly responsible for ∼11% of pregnancy-related deaths in the United States. ^7,9,10 The observed decrease in PPH-associated mortality correlates with increased rates of blood transfusion and peripartum hysterectomy. ¹⁰

Furthermore, bleeding and acquired coagulopathies may occur in obstetric patients, particularly those with placental abruption, intra-amniotic infection, or ectopic pregnancy. ⁷ Hemorrhage also occurs more frequently in patients who present for pregnancy termination in later trimesters, ^11,12 and this population typically includes individuals who have limited access due to logistical challenges or are located in areas with a lack of abortion services. ¹² As these patients may require blood transfusion, the number of these individuals may increase, ^{13 –15} and morbidity from blood transfusion is higher in pregnant patients compared with nonpregnant patients. ^{16 –18} Thus, if delays in management and care of pregnant patients occur, or patients present later for termination, these patients may then require blood transfusion and experience higher morbidity.

Another concern that could theoretically arise from an increase in the number of individuals requiring transfusion is the overall impact on the already strained U.S. blood supply. The addition of patients with obstetric hemorrhage, a condition often requiring large volumes of blood components for resuscitation, ^13,14 to the population already requiring blood transfusion carries the potential to deplete local hospital and even regional blood inventories. ¹⁹ This complication of massive obstetric hemorrhage places not only the obstetric patient but also other individuals dependent on an adequate blood inventory at significant risk; therefore, one must consider the ethical principles of beneficence and justice.

This requires a delicate balancing act between a physician's obligation to the individual patient and a responsibility for ensuring adequate resources are available and the best is done for the most number of individuals. Thus, this newly created hemorrhagic risk within the obstetric population redistributes the ethical balance of beneficence and as a result places multiple patient populations at higher risk of morbidity and mortality due to blood supply challenges.

Additional concerns regarding delayed or complete lack of care for pregnant patients relates to the concept of fetal-maternal hemorrhage, or the mixing of fetal and maternal blood in the maternal circulation. This can result in, among other conditions, maternal alloimmunization, or the development of maternal antibodies to antigens expressed on fetal red blood cells for which the mother lacks. ²⁰ The most significant of these antibodies occurs when a pregnant patient becomes alloimmunized to the RhD antigen. Under normal circumstances, the development of this antibody can be prevented with timely administration of Rh immune globulin.

However, in cases where pregnant patients seek abortions or other prenatal care from nonlicensed individuals or at facilities without a full complement of obstetric care, access to this critical medication may be limited. This could result in an increased number of individuals with anti-D alloantibodies, posing a significant risk to future pregnancies, as this antibody is one of the most common potentiators of severe hemolytic disease of the fetus and newborn. ²¹ In addition, alloimmunization results in greater difficulty in obtaining compatible blood for the individual's lifetime.

Finally, one ethical and legal issue that has yet to be considered is what, if any, impact the Supreme Court's decision will have on members of the medical community regarding their duty to provide care for pregnant patients seeking abortion. Will health care providers now be more emboldened to absolve themselves from performing medical or surgical abortions, or providing support for these procedures such as blood product provision? This describes conscientious objection—a health care provider's right to refuse to offer medical treatment based on moral, ethical, or religious grounds. ²²

Building on previous decisions for conscientious objection, will members of the transfusion medicine and blood bank community now seek a legal precedent to abstain from providing blood products to pregnant patients seeking surgical abortions? This concern is highlighted by an amicus curiae brief comprising >4000 health care providers, including medical technologists, submitted to the U.S. Supreme Court in support of the right to conscientious objection for practices that involve contraception and abortion. ²³ Although much of the impact of overturning Roe v. Wade remains unknown, this decision may set in motion legal precedents for denial of blood product support for obstetric patients, thereby risking the lives of these individuals.

We acknowledge that potential transfusion-related morbidity and mortality, immunologic sequelae, and the blood inventory represent only a few of the complex issues faced by providers and patients; however, the unintended consequences that this decision will have on patient care in the context of blood transfusion must not be overlooked. The medical community must collaborate and participate in thoughtful discussions regarding the health ramifications of our contemporary political climate to mitigate the challenges now faced by individuals who stand to be harmed by unjust legal decisions.