This is the second episode of a three-part series examining recent legislation restricting abortion in Iowa and its potential impact on public health.

Lauren’s guest is Dr. Stephanie Radke, OBGYN at University of Iowa Healthcare, who talks about Iowa’s “Fetal Heartbeat” bill from a public health, medical, and healthcare perspective, including potential disproportional impact on underserved populations who can face barriers to accessing services.

Lauren Lavin:

Hello everybody, and welcome back to From the Front Row. As you know, we’re doing a three-part series on the Iowa Heartbeat bill, and this week is part two in that three-part series. This week we were talking to Dr. Radke, a board certified OBGYN at the University of Iowa, and she’s going to share what the impact of this bill is from a public health perspective. As we begin this episode, we’d like to provide a content warning for abortion-related topics.

Front Row was produced and edited by the students of the University of Iowa College of Public Health. The views and opinions expressed in this podcast are solely those of the guests and contributors. They do not necessarily reflect the views or opinions of the University of Iowa or the College of Public Health. Information shared in this podcast is intended for educational, general information, and-

My name is Lauren Lavin, and if you’re new here, welcome. We’re a student-run podcast that talks about major issues in public health and how they are relevant to anyone, both in and outside the field of public health.

Hello, Dr. Radke. Thank you so much for being on the show today. I would love to start off if you could introduce yourself to our listeners and to give us an overview of what you do and why you’re here.

Stephanie Radke:

Sure. Yeah. Thanks so much for having me. I am Stephanie Radke. I am an OBGYN in practice at the University of Iowa here in Iowa City, speaking to you with my own opinions, not representing the university. I practice primarily obstetrics at this point in my career because I do a fair bit of public health work in the realm of quality improvement.

So I run a program called the Iowa Maternal Quality Care Collaborative that helps support all the hospitals in Iowa that have open labor and delivery units in ensuring that they’re practicing to the current standard of evidence-based medicine, thinking about specific practices that are shown to reduce maternal morbidity and mortality.

Lauren Lavin:

Well, you’re a great expert to have on this topic. Today, we’ll be talking about the Iowa Heartbeat bill that was passed and then injuncted all in … It’s kind of a mess, but it happened in July. And so, I was wondering if you could start us off by explaining the Iowa Heartbeat bill from your perspective.

Stephanie Radke:

Sure. Yeah. So this is a bill that is intended to restrict termination of pregnancy beyond the point where, I’ll air quote say, a fetal “heartbeat” is able to be detected with some exceptions of when it might be appropriate beyond that. I say quote unquote “heartbeat” because physiologically we know that based on embryology, there isn’t a heart at that stage of development the way that I think people think about it.

The heart is a four-chambered structure that pumps blood around the body, and at this stage of development, what will eventually become the heart is a tube and it’s having somewhat random electrical movements, and it is not pumping blood around because there are not red blood cells in the embryo at that point. But when we can see activity at that area is when the law says that we wouldn’t be able to have a pregnancy terminated electively. And typically that’s about when somebody would be about six weeks along in their pregnancy.

So for someone who’s intending to become pregnant or aware of the possibility that they could have become pregnant, this is right around the time that you may have a positive home pregnancy test, but to be honest, probably within days of being able to detect a pregnancy on a home pregnancy test. And somebody who’s maybe not planning to become pregnant or not aware of the possibility or who has irregular periods to some extent, it is very possible that you would not yet have noticed that you were pregnant at the time that you would then be passing the point where a pregnancy termination would be an option for that person.

Lauren Lavin:

That is good information. I know that people have talked about the medical maybe inaccuracies of the bill and that heartbeat portion being one of them. Were there any other things in there that from a medical standpoint you were concerned about?

Stephanie Radke:

I mean, I think that it really can tug at people’s heartstrings to talk about. I think many people think about the essence of life being a beating heart. And so to me, it felt a little bit manipulative to suggest that there’s a fully formed tiny human at that stage, and so that felt a little medically inaccurate.

I think the other challenge with that being the criteria rather than an actual gestational age is that it also depends on how you perform the ultrasound and characteristics of somebody’s body habitus. If you’re doing an abdominal ultrasound on somebody with a larger body, you probably would need to be a little further along before you would be able to definitively see some cardiac activity. And so that makes it inconsistent how this would be applied, which again, doesn’t feel appropriate.

I think some of the other things are the medical emergencies exception is an endangerment to the mother or pregnant person’s life or fetal abnormalities that are incompatible with life, and that’s not very well-defined. Nothing in medicine is purely black and white, and so there are many fetal anomalies, for example, where we know there is a much higher rate of deaths, but it’s really hard to say, like is there a 100% chance that a baby born with this condition would die versus a 100% chance that someone would live? We sort of live in the gray.

And that’s where I think it’s really important for people to be able to make informed choices, and that language certainly muddies the water there about what is appropriate to still offer somebody a pregnancy termination for a really significant abnormality.

Lauren Lavin:

Yeah-

Stephanie Radke:

A lot to wrestle with.

Lauren Lavin:

Right. As a clinical practitioner, what impact does this bill have on your clinical practice or maybe clinical practice at large in the State of Iowa?

Stephanie Radke:

I mean, I think that many people are paying attention to this, and so this isn’t the first go-around of legislation that has sought to limit people’s choices and availability of family planning services. And so we have seen more fear amongst some women in that they’re coming in and requesting longer acting contraceptive devices such as IUDs, people seeking sterilization due to stated fears that if they were to accidentally become pregnant, that they wouldn’t have the ability to end a pregnancy that was unplanned and unwanted. And so, it feels to me like there’s some fear in some members of the community of women of reproductive age.

I think that it certainly poses challenges for people who have limited access to healthcare and may not have the ability to obtain contraception. We know that there’s a significant portion of the population of women of reproductive age who are not insured, people who either are not eligible for Medicaid due to their legal status in the United States, or their income is just above a Medicaid cutoff, but they don’t make enough money to actually have an employer-provided plan or to be able to afford purchasing health insurance.

And I think that gap of people is really underserved in many ways, but this sort of limitation, I think poses further challenges to people who are generally already financially strained in being able to access healthcare and be able to access pregnancy prevention services if they’re not desiring to be pregnant.

So we don’t really see people who don’t have health insurance entering the healthcare system all that much, but we know that they are there and then we see them enter the healthcare system with unplanned or poorly timed pregnancies, and they haven’t been receiving care and they didn’t have the opportunity to prevent the pregnancy that they now will be carrying because they don’t have the option to terminate.

Lauren Lavin:

Right. I think this is tangentially relevant, but one of my favorite stats that I think people don’t realize is that 50% of the births in America are covered under Medicaid. And so reproductive health and maternal and child health is, I don’t know, it’s a government issue [inaudible]-

Stephanie Radke:

Yeah.

Lauren Lavin:

… Medicaid coverage.

Stephanie Radke:

Yeah, and in Iowa it’s about 40% are primary Medicaid, and then an additional portion that I don’t know the number of, people have Medicaid as a secondary. People may not know that Iowa actually has really generous Medicaid eligibility for what’s called pregnancy Medicaid, meaning that when you are pregnant, you are eligible for Medicaid under a different set of criteria than a non-pregnant adult.

And so the income eligibility for Medicaid in Iowa when you’re pregnant is really high. And so that means that we basically don’t have that gap that I had mentioned previously where what we instead see is there’s often an overlap where there are people who are employed but at maybe the lower end of the income spectrum, actually have dual coverage in pregnancy, meaning that they have an employer plan or some other plan, and then they also have Medicaid.

And that’s really helpful because a lot of times the commercial insurance plans have higher deductibles, and so the Medicaid can kick in and help cover that. So Iowa does a really great job of ensuring that people who are pregnant can receive healthcare while they are pregnant. But I think you’re exactly right, it is a state government issue. It’s not something that it only lives in the realm of private insurance.

Lauren Lavin:

Right. You kind of touched on this, but maybe we can dive a little bit further. Do you see any equity issues or how does this bill disproportionately impact vulnerable, marginalized communities within Iowa?

Stephanie Radke:

I mean, I kind of started to go there a little bit before, but I think that people who do not have access to health insurance or access to healthcare outside of pregnancy are really disadvantaged because there are very limited opportunities for them to access family planning services to prevent pregnancy.

Certainly people can purchase barrier methods of contraception such as condoms over the counter, but it is really challenging and expensive to access more reliable forms of contraception, such as hormonal contraceptive methods or what are called long-acting reversible contraceptives, which is a category that would include things like intrauterine devices or IUDs and contraceptive implants.

And so I think that really if the goal of the legislation is to encourage pregnancies to be carried to term and be planned and wanted, then I think we need to recognize that there are many people who are not desiring to become pregnant and if we don’t grant them access to health insurance, then it becomes extremely financially prohibitive to obtain some of these methods.

There are certainly a few places where people can obtain family planning services at a reduced out-of-pocket cost, but largely historically in Iowa, that was through clinics like Planned Parenthood, which have been closing because other legislation prevented them from accessing other types of federal funding to provide family planning services.

And so it feels as though people who are lower income are really out of options or have very limited options with regard to being able to control their reproductive potential. And we know that that group of individuals tends to be people who are more likely to have a lower degree of education, more likely to be a racial or ethnic minority, more likely to not have English as their first language.

And so people who may already have other barriers to accessing healthcare and services, as well as if you are very low income and there’s only a handful of clinics where you potentially could obtain a very low cost contraceptive services, it may be geographically very far away from you. And so then there’s travel barriers and childcare barriers. So kind of the layers of challenges that people may face in obtaining services to prevent a pregnancy may be insurmountable for a lot of people, and that’s really disheartening.

Lauren Lavin:

Especially in Iowa. I do a little bit of research with rural communities and just accessing healthcare is difficult, let alone some of these preventative services if that is what they need.

Stephanie Radke:

Absolutely.

Lauren Lavin:

With that, when we talk about minority or marginalized communities, I think a buzzy topic has been maternal morbidity and mortality within that community. And so, do you have any insight on how this restriction might impact those measures for these people?

Stephanie Radke:

Yeah. I mean, I think that that’s a really important question that we should be asking. I think sometimes people just fixate on, “Oh, well, people will carry their pregnancies to term and they’ll have a healthy pregnancy outcome and more babies will be born.” And that may be the ideology that is driving the desire by some to pass this sort of legislation.

But just like I said before, we live in the space of gray. In medicine, it’s really complicated. I mean, there are people who have medical conditions that make pregnancy very unsafe for them because of the way that the body changes, particularly the circulatory system in pregnancy that people who have any sort of underlying heart disease or heart condition. Pregnancy can be extremely unsafe for people who have a high propensity to form blood clots. Pregnancy can be extremely unsafe for people who have cancer.

And you might think, “Oh, that’s so rare. That doesn’t affect anybody.” But it really actually does. And that is, it’s not an unusual thing for us to see at the university, people who have these really complicated medical problems and they’re pregnant, and it’s very complex for our high-risk pregnancy specialists to manage their pregnancy.

But that being said, even more, quote unquote, “normal” people, especially when you think about severe maternal morbidity, which is, generally, it’s a catchall term for different conditions that can arise generally around the time of childbirth that are potentially life-threatening, meaning that somebody is requiring quite a bit of extra medical care and if untreated, there’s a reasonable chance that somebody could even die from that condition.

That’s often studied because the drivers of severe maternal morbidity are very similar to the drivers of maternal mortality and there’s more severe maternal morbidity events. And so it’s a little bit easier to study when we’re thinking about how to prevent maternal deaths.

But we know that people who enter pregnancy with underlying health conditions, even more common things like high blood pressure, diabetes, being overweight or having obesity affecting their pregnancy, asthma, people who smoke, people who are a bit older at the time that they’re carrying a pregnancy, all of those are risk factors for experiencing severe maternal morbidity.

And we know that people who don’t have access to health insurance are less likely to be in a good state of health. We know that if you aren’t able to access health insurance, you probably have barriers to accessing other factors that influence your health, such as healthy foods, the ability to exercise and maintain a healthy weight. People may be more likely to have negative health behaviors such as smoke.

So when you start to think about who is at most risk for an unplanned pregnancy, it’s going to be somebody who doesn’t have health insurance. Who is at most risk then of entering pregnancy in a poor state of health? It’s going to be somebody who hasn’t been receiving healthcare services.

And if people aren’t able to exercise any degree of control over whether or not they continue that pregnancy, I do think we’re going to see more people having high-risk pregnancies, and that is going to lead to more complications and potentially more maternal deaths, just simply doing the numbers of complications that arise related to high blood pressure conditions in pregnancy, related to complications of childbirth, et cetera.

So there’s that bucket of more people who might generally be less healthy and therefore have less healthy pregnancy outcomes. The other bucket is really specific morbidity and mortality that may come from the inability to terminate a pregnancy.

And again, as you mentioned at the beginning, the law is currently not in effect, but I think were the law to go into effect, we are learning a bit about what that could mean with examples coming out of Texas, which has a very similar, very restrictive ban on abortion services where situations where …

And again, the language in Texas is a little bit different than the language here, so I don’t want to completely conflate them, but this medical emergency that endanger someone’s life or fetal abnormalities that are incompatible with life is a little bit of a subjective definition.

And so we think about scenarios that are rare, but very serious for the person who’s pregnant. And if there is any uncertainty on the part of the clinical team about whether it’s appropriate for them to act in a way that would terminate the pregnancy, we would expect that there’s probably going to be delay in treatment and perhaps withholding of appropriate life-saving treatment in rare situations.

So conditions that we see, honestly not infrequently, are people whose water bag breaks well before the baby is of a gestational age to be viable. We have a phenomenal neonatal intensive care unit here at the University of Iowa, arguably considered one of the best in the world for resuscitating premature babies, but there’s still a floor below which the baby is simply not developed enough to be resuscitated.

And so we see this that people come in and their water bag has broken and they’re like 18 weeks or 20 weeks along, so a couple weeks from where you get to the point where our NICU has reasonable chance of survival and people maybe make a choice to continue the pregnancy, or if there was a restriction, they would not be given the choice to continue the pregnancy, and they’re at enormously high risk for infection.

So an infection setting in inside the uterus because the water bag is broken. Usually the cervix is a little bit open at that point. And people can very, very rapidly develop an infection that spreads throughout their body called septic shock, and that can even cause someone to die.

There’s a very publicized case out of the country of Ireland where somebody had that exact situation and because their fetus still had cardiac activity, the pregnancy was not terminated, and ultimately the woman died. And that case actually resulted in that country changing their laws because they recognized that was really an unacceptable outcome.

So I think there is a lot of fear amongst healthcare providers about what to do in that situation because we know that that’s the clinical course that that case could follow. But if she doesn’t have an infection right now, then is it really an endangerment to her life? And so that’s where the gray zone comes in. It’s like, we don’t have a crystal ball that’s going to tell us is she going to get infected or is she not.

And that then limits our ability to say, “Well, can we offer this person a pregnancy termination because of that possibility?” I don’t know. Or what if somebody is bleeding heavily because the placenta has started to prematurely separate from the wall of the uterus? How much bleeding before we would say it’s endangering the person’s life? Does she need to bleed so much she needs a blood transfusion? Does she need to have four blood transfusions? I mean, where is the line there?

And while I certainly appreciate that we don’t want the legislature really getting overly specific in dictating how we practice medicine, I think that the ambiguity in that is going to lead to clinicians hesitating, and that is going to lead to more morbidity and potentially a risk of maternal mortality or maternal death in these complex situations.

So I think probably some examples that maybe people hadn’t thought about, but these are real conditions that come up and these are the types of situations where we may see somebody actually dying because they weren’t able to terminate a pregnancy. And even if that’s only one person, I think we would all agree that that’s one person too many.

Lauren Lavin:

Yeah, I had never heard it explained in those two buckets. So I think that that was a really great way for our listeners, for people to understand how it impacts it in different ways. While this bill does focus on abortion access, do you think there’ll be any impact on access to family planning services as a whole in Iowa?

Stephanie Radke:

I think that’s a really interesting question. I sort of mentioned before that the current limited access to family planning services for certain populations makes this bill more problematic for them. I think it does speak to maybe a value of our legislature that they would prefer that people become pregnant and carry pregnancies to term.

And so I think that there is also a fear, and I don’t know how grounded in reality it is or not, that there may then also be considerations to limit access to certain forms of contraception. And I don’t know, I don’t know that we know that, but it feels like anything is possible in a way that is scary.

And certainly I think that people should be informed and paying attention to the types of bills that people are talking about, because again, if you’re really wanting to just talk about supporting somebody in carrying a pregnancy to term, then we should also be talking about helping people to plan and time their pregnancies appropriately so that their pregnancy is desired and this question of termination is not something routinely coming up.

I mean, the majority of pregnancies, the vast majority of pregnancies that are terminated are because they are unplanned or poorly timed. And so I think if we actually increased our access to family planning services, that would be a more respectful way to decrease utilization of abortion services if that’s the goal.

Lauren Lavin:

This is a little bit of a side note, but how do you feel about the FDA approval of over-the-counter birth control? Do you think that ties in? Is that, do you think in response to lack of access to abortion now in America?

Stephanie Radke:

Sure. Yeah. I mean, I think that this is how we need to start thinking, right? I mean, I think medicine should be available over the counter that the FDA approves or deems appropriate for that, something that minimal screening by a pharmacist could determine eligibility for use. And I would say for many young people of reproductive age who are healthy, a simple screener can determine whether or not they would be eligible to use oral contraceptives. And so I think that may be helpful.

I think it also depends on the details. How much does it cost? Are people going to pay $200 a month for a pack of birth control pills? I mean, what are we going to make it cost? Are we going to make it cost $5? So I think in order for it to truly be a part of a solution, it needs to be affordable, it needs to be accessible, it needs to come without any fear of judgment or stigma on behalf of the personnel at the pharmacy. And so I think it’ll all be in how that’s executed.

Lauren Lavin:

Yeah, I’m interested to see how that plays out in the coming months. We’re going to end on a little bit more of a positive note. If we’re going to have more pregnancy in Iowa as a result of this bill, what policy should we be looking at to optimize and make healthy moms and babies going forward?

Stephanie Radke:

Yeah, and this is where, I don’t know if any members of the legislator are tuning in, but I think again, if the value behind limiting people’s access to terminate a pregnancy is because we want people to carry pregnancies to term and give birth in our state, then I think we really need to think about what do people need to do so in a healthy way?

So starting before pregnancy, people need to have access to healthcare. As I mentioned, we have people entering pregnancy who are in a poorer state of health and have not been able to manage chronic conditions or even be diagnosed with conditions that they may have. And so it would be great if people had access to healthcare prior to becoming pregnant.

We do a great job, as I mentioned in our state, in ensuring people can access healthcare while they’re pregnant. But we are now in the minority of states that have failed to extend Medicaid beyond 60 days postpartum. And so if we want people to carry pregnancies to term, we need to think about how 60 days postpartum people are not back to normal. Their health is not back to normal. They are not just ready to return to work in all situations.

Pregnancy physiology can take up to 12 weeks or three months to get back to a normal pre-pregnancy state. And so that means that conditions such as high blood pressure that have arisen related to pregnancy may not be resolved. People may still need medication, and so they certainly need to maintain access to healthcare.

Mental health is a huge challenge for the perinatal population in our state. And I think everybody knows we do not have enough mental healthcare providers, and if people are no longer able to access healthcare 60 days postpartum, we know that most significant postpartum depression doesn’t even arise until after that point. So we are leaving new mothers without access to vital healthcare services in ways that are dangerous.

I mean, we see morbidity and even mortality related to mental health is not a zero event in our state. And nationally, we know that deaths related to mental health conditions from pregnancies, so we’re talking about deaths from overdose and suicide, primarily happen later in the first postpartum year.

So I think if it is really important that we have all of these pregnancies carried to term, then we need to plan to continue to take care of these mothers after they give birth. And we need to make sure that we have all of the things that they need to raise their children in healthy communities, such as strong education, access to healthy foods, safe communities, all of these things that we think about a lot in public health. And that would really be a very pro-family approach to supporting maternal and child health in our state.

Lauren Lavin:

Well, thank you so much for joining us and giving us insight on the public health side of it and how this bill can impact our state. I appreciate your expertise in adding into the nuance of this conversation. And with that, I will say goodbye.

Stephanie Radke:

All right. Thanks so much for having me.

Lauren Lavin:

That’s it for our episode this week. Big thank you to Dr. Radke for joining us today. This episode was hosted and written by Lauren Lavin and edited and produced by Lauren Lavin.

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