SPECIAL FEATURE

Ethical Care for Patients

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with Self-Managed
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Abortion After Roe

A review of the guidelines and laws that can help nurses make clear
decisions about care.

ABSTRACT: The 2022 Supreme Court decision leaving the regulation of abortion to the states is sure to
result in a complex regulatory environment for patients and nurses. In states where abortion is illegal,
patients may self-manage abortions using medications they obtain through the mail or by other means.
Nurses may care for these patients in multiple settings and may wonder about their own legal and ethical
obligations. This article reviews patient privacy as it relates to self-managed abortion, ethical reporting
requirements for nurses, and best practices for treating complications of self-managed abortion using
a harm reduction framework, with a focus on protecting patients’ rights. Recommendations for ethical
patient care are also provided.
Keywords: harm reduction, medication abortion, nursing ethics, reproductive rights, self-managed abor-
tion, social justice

I
n June 2022, the U.S. Supreme Court ruled in
Dobbs v. Jackson Women’s Health Organization
that states may regulate the provision of abortion
services,1 which could mean criminalizing abortion,
including medication abortion. As a result, changing
legal environments may create practice challenges
for nurses caring for patients presenting with mis-
carriage or bleeding during early pregnancy. In
­areas where legal abortion is unavailable, people
may seek abortion pills to end their pregnancies
without clinician involvement, a practice called
self-managed abortion.
Telemedicine and mail-order pharmacies can
provide medically safe and effective medications
(mifepristone and misoprostol) to terminate early
pregnancies safely. Mail-order pharmacies often
provide medications without clinician involvement,
and evidence to date demonstrates both the safety
and efficacy of this option.2 (See A Quick Guide to
Medication Abortion.) Individuals can also obtain
misoprostol by visiting countries, such as Mexico,
where it may be available over the counter.
However, some pregnant people, lacking timely
and legal access to abortion, resort to unsafe meth-
ods.3 As a result, as many as 39,000 women die an-
nually from unsafe abortions, although that number
may be underestimated given the poor statistical
­reporting systems in some countries.3
Individuals who follow World Health Organiza-
tion (WHO) protocols to terminate their pregnancies
at up to 12 weeks’ gestation using mifepristone or
letrozole plus misoprostol, or misoprostol alone, are
unlikely to need hospital care. (See WHO Medica-
tion Abortion Regimens at < 12 Weeks’ Gestation.3, 4)
These regimens are safe and effective; typically, no
additional medical care is needed beyond informa-
tional support.3 Severe complications are extremely
rare.3, 4
Some patients, though, may present to EDs or
ambulatory settings with bleeding, pelvic pain, or
infection. These patients may require or desire clini-
cians to complete the abortion or to manage symp-
toms or complications. What then is the duty of the
nurse when the cause of early pregnancy complica-
tions is either ambiguous or reported to result from
an attempt to end the pregnancy? Does this respon-
sibility change when abortion is criminalized in the
state where the nurse practices?

38 AJN ▼ January 2023 ▼ Vol. 123, No. 1

 By Laura Manns-James, PhD, CNM, WHNP-BC, CNE, FACNM,
Kelly Pfeifer, MD, and Mickey Gillmor-Kahn, MSN, CNM

ABORTION IN THE UNITED STATES Figure 1. You Have a Right to Privacy About Your Pregnancy
Approximately one in four women in the
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United States has an abortion in her life-

time.5 Most Americans who obtain an
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abortion (60%) are in their 20s, and 59%

of women who have had an abortion have
other children.6 Although people of all
ages, races, ethnicities, and incomes have
abortions, most (75%) are disproportion-
ately poor or low income.6 They are also
more likely to be Black, Indigenous, His-
panic, and other people of color4-8 due to a
lack of equitable access to high-quality re-
productive health services, resulting in a
higher burden of unintentional pregnancy.
Structural racism results in longstanding
inequities in maternal morbidity and mor-
tality that make continuing a pregnancy
to term more dangerous, particularly for
Black and Indigenous people.5 A recent
­estimate suggests that a nationwide total
abortion ban in the United States would
result in an increase in the lifetime risk
of death from all pregnancy-related causes
from 1 in 3,300 to 1 in 2,800 for all
women.9 For non-Hispanic Black women,
the risk would increase further, from 1 in
1,300 to 1 in 1,0009—three times that of
the general population.
In 2019, the latest year for which data
are available, the Centers for Disease Con-
trol and Prevention stated that 42.3% of
all reported abortions in the United States
were medication abortions (typically mife-
pristone followed by misoprostol) at nine
weeks’ or less gestation and 1.4% were
medication abortions at more than nine
weeks’ gestation.8 These figures do not in-
clude self-managed medication abortions For a full size, printable version of this poster, go to http://links.lww.com/AJN/A239.
that were not reported to a health system; HHS = Department of Health and Human Services; HIPAA = Health Insurance Portability
further, some jurisdictions do not report and Accountability Act.
medication versus other types of abortion. 8

Medication abortion as a proportion

of all ­abortions has risen steadily over time.10 The
increase ­accelerated in 2021, when the Food and
Drug Administration began allowing telemedicine
prescribing of abortion medications in response
to the coronavirus pandemic. Medication abor-
tions are anticipated to increase in the future,
both despite and because of state-based changes
in the legality of abortion provision.10 Online re-
quests for self-managed abortion medications have bodies have repeatedly called for the decriminaliza-
increased since the Dobbs decision, particularly in
states that severely restrict legal abortion access.11
Laws that criminalize abortion have a long his-
tory of causing harm, particularly to those whose
position within social hierarchies makes them vul-
nerable.12, 13 For this reason, many organizations
have publicly opposed making abortion illegal. In
its information series on sexual and reproductive
health and rights, the UN Office of the High Com-
missioner for Human Rights says, “Human rights
tion of abortion in all circumstances.”14 The Ameri-
can College of Obstetricians and Gynecologists

AJN ▼ January 2023 ▼ Vol. 123, No. 1 39


A Quick Guide to Medication Abortion
Information on cost, and online or mail-order access.
•• Plan C (www.plancpills.org) or For telemedicine, mail order, and
referrals to services, visit Aid Access (https://aidaccess.org).
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•• Costs to patients of the medication abortion regimen of
­mifepristone and misoprostol vary, from about $100 to $500
per dose. Some services may offer a sliding scale.
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•• It usually takes four to eight days to receive the medications ­using
express shipping, although delivery can take as long as three weeks.
•• Mail-order pharmacies typically send one dose (one mifepristone
tab and four misoprostol tabs); extra misoprostol may be needed
at or over nine weeks’ gestation.
(ACOG) opposes the criminalization of self-managed
and clinician-assisted abortion, as do the National
League for Nursing, Nurse Practitioners in Women’s
Health, American College of Nurse-Midwives, and
Association of Women’s Health, Obstetric and Neo-
natal Nurses.15-19 More than 70 other health care or-
ganizations have affirmed safe, legal abortion as an
essential element of reproductive health care.20
ABORTION AND PATIENT PRIVACY
The Health Insurance Portability and Accountabil-
ity Act of 1996 (HIPAA), developed by the U.S.
Department of Health and Human Services (HHS)
Office for Civil Rights, requires respect for the pri-
vacy and confidentiality of people deciding to self-
manage abortion or receive telemedicine services.21
This means that nurses may risk penalties for HIPAA
violations if they report suspected or patient-­
disclosed attempts at abortion to law enforcement,
state agencies charged with the prevention of child
abuse (such as child protective services [CPS]), or
any other individual or entity not designated by the
patient, in the absence of a court order or ­subpoena.
As of November 2022, no state required the
­reporting of people who attempt to end their own
pregnancies.22 However, even before the Dobbs rul-
ing, individuals in several states had been investi-
gated owing to suspicions that they attempted to
terminate their own pregnancies.23 Between 2000
and 2020, at least 61 people were criminally inves-
tigated because of allegations that they either ended
their own pregnancies or helped someone else to
do so.24 Of those 61, 39% were reported to author-
ities by health care providers and another 6% by
social workers. Most (56%) were poor, and people
of color were overrepresented. Prosecutors used
criminal statutes such as concealment of birth, child
abuse and assault, and homicide to charge alleged
offenders, and homicide charges were twice as
likely to be brought against racially minoritized
defendants. Of the 61 cases on record, 87% resulted
in arrest.24
40 AJN ▼ January 2023 ▼ Vol. 123, No. 1
HARMS OF REPORTING AND NURSING ETHICS
Black people and other people of color have his-
torically been disproportionately targeted for the
enforcement of laws governing behavior during
pregnancy, such as drug use.25 This policing, which
often starts with reports to authorities by profes-
sionals, increases distrust in the medical system
and health care providers among communities of
color.26 Moreover, clinician bias can influence re-
porting decisions,27, 28 so laws criminalizing abortion
or risky behaviors during pregnancy will almost
certainly contribute to structural racism, health
disparities, and family disruption29 unless clinicians
keep health information private.
There is no reason for clinicians to use a decision to
terminate a pregnancy as grounds to report ­patients
to CPS, since self-managed abortions do not endan-
ger children in the home. Similarly, minors who use
mifepristone and misoprostol to self-manage an
abortion are not a danger to themselves or others.4
The American Nurses Association (ANA) Code
of Ethics for Nurses with Interpretive Statements30
may help guide ethical decision-making for nurses
who care for patients presenting for abortion-­
related health care, particularly in jurisdictions
where the provision of abortion services is prohib-
ited or restricted. Provisions 1, 3, 4, and 8 are par-
ticularly relevant to nursing practice involving
pregnant patients in these jurisdictions.
Provision 1 speaks to the rights of patients to
self-determination and to be cared for in accor-
dance with their values. Patients have the “right to
determine what will be done with and to their own
person,”30 and a nurse must respect patient deci-
sions even when those decisions may conflict with
the nurse’s own values. The Code of Ethics does not
require support for or agreement with patient deci-
sions but does require nurses to establish a relation-
ship of trust, setting aside biases and prejudice.
Provision 3 establishes the duty of the nurse to
protect and advocate for the rights, health, and
safety of the patient, including the right to privacy
and confidentiality.30 The Code of Ethics explicitly
acknowledges the damage to the nurse–patient re-
lationship that can result from a breach of confi-
dentiality, resulting in loss of patient trust and
jeopardizing patient well-being. However, the duty
to protect confidential information may be limited,
such as when disclosure is legally mandated due to
public safety or health considerations.
Provision 4 establishes that nurses are account-
able for their own conduct, though institutions may
at times share responsibility.30
Provision 8 explicates a duty of the nurse to “ad-
vance health and human rights and reduce dispari-
ties” by collaborating “with others to change unjust
structures and processes that affect both individuals
and communities.”30
 None of these provisions include a duty to partic-
ipate actively in providing abortions or pregnancy
terminations; provision 5.3 allows for the exercise
of conscience by individual nurses.30 In nonemergent
contexts, nurses may decline to participate in care to
which they morally object.30 Provision 5 does not,
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pate in emergent care or to break patient confiden-
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tiality, nor does it supersede patient rights or duties
to the patient.
ETHICAL REPORTING REQUIREMENTS FOR NURSES
Legal and ethical indications for reporting are rare,
and the ANA Code of Ethics and federal law should
inform nursing practice in the following instances.
Reporting suspicion of induced abortion to law
enforcement. Unless state law explicitly requires it,
nurses should not proactively report suspicion of
abortion to law enforcement. Nurses should not re-
lease protected health information (PHI) to law en-
forcement or any other non-treating provider or
agency without a subpoena or court order (in which
case the PHI released must be restricted to the PHI re-
quested). Disclosing PHI outside of these limited cir-
cumstances is a HIPAA violation and puts the
nurse and the hospital at risk for fines and ­penalties.21
The following are real-world examples.21
• A law enforcement official goes to an ED and
requests records of pregnancy outcomes for ED
patients. Unless the request includes a court or-
der or other legally enforceable mandate, the
HIPAA “privacy rule” does not permit the ED
to disclose the records or other PHI. Disclosure
without a legal mandate is considered a breach
of unsecured PHI and requires formally notify-
ing both HHS and the patient.
• A law enforcement official presents an ED with a
court order requiring the release of PHI about a par-
ticular patient. Only the PHI expressly contained
in the court order may be disclosed by the ED.
Reporting intent to terminate a pregnancy.
­According to ACOG, it is inconsistent with profes-
sional standards of ethical conduct to disclose PHI
about an individual’s plans regarding contraception
or pregnancy outcomes to law enforcement or oth-
ers.15 The ANA specifically affirms the right to pri-
vacy for individually identifiable health information,
including oral reporting, in all treatment settings and
venues; use or disclosure of this information is pro-
hibited unless required by law.31
A real-world example: In a state that bans abortion,
a patient informs the nurse that she’s planning to go
out of state to secure an abortion. The nurse believes
it appropriate to report the patient’s plan to the po-
lice, to prevent the abortion. However, the HIPAA
privacy rule forbids this disclosure of PHI because
the HHS doesn’t consider a statement of intent to
terminate a pregnancy a “serious and imminent
threat to the health or safety of a person or the pub-
lic.”21 This act is also contrary to professional ethical
standards, would violate the integrity of the nurse–
patient relationship, and could harm the patient.
Reporting to CPS. Suspicion of abortion should
not be a reason to contact a CPS agency, for these
reasons:
• Historical precedent suggests that such reporting
will disproportionately disrupt racially minori-
tized families and children. For instance, despite
similar rates of substance use, Black women are
more likely to be reported to CPS agencies than
White women,32 and more likely to have parental
rights terminated.33 Indigenous children are most
at risk for legal separation from their parents.33
• There is no evidence that a minor patient or an
adult patient’s children are at any risk solely due to
the patient’s decision to end a pregnancy through
self-managed abortion. To the contrary, many
people ending a pregnancy do so to be better able
to care for the children they have.34 The five-year
Turnaway Study, which followed 813 women
who presented for abortion, found negative effects
on the children of women who were denied an
abortion, including poorer maternal–child bond-
ing, greater economic insecurity, greater exposure
to interpersonal violence, and a nearly fourfold
greater risk of growing up in poverty.35, 36
WHO Medication Abortion Regimens at < 12
Weeks’ Gestation3
Recommended regimens.a
Mifepristone + misoprostol:
•• 200-mg mifepristone administered orally, followed 1–2 days later
by 800-mcg misoprostol administered vaginally, sublingually, or
buccally
•• Minimum recommended time between administration of
mifepristone and misoprostol is 24 hoursb
•• Repeat misoprostol doses if necessary
•• More effective than misoprostol alone
Misoprostol alone:
•• 800-mcg misoprostol administered vaginally, sublingually,
or buccally
•• Repeat misoprostol doses if necessary
•• Less effective than combined regimen
Suggested regimen.c,  d
•• Letrozole 10 mg orally daily for 3 days, then misoprostol 800 mcg
sublingually on day 4
a
Recommended for self-management.
b
High efficacy was achieved when mifepristone and misoprostol were administered ≤ 8 hours
apart in two studies.4
c
Not yet studied for self-management.
d
May be effective up to 14 weeks’ gestation.
AJN ▼ January 2023 ▼ Vol. 123, No. 1 41
 • Women who were able to access abortion in the
Turnaway Study were three times more likely to
be employed, less likely to need public assistance,
and less likely to stay in abusive relationships.35, 36
A real-world example: A patient in a state that
bans abortion claims she is having a miscarriage,
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but the nurse thinks the patient may have caused
the miscarriage by using abortion medications. The
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nurse wants to report this patient to his county CPS
agency because he believes the fetus was harmed
through the mother’s actions. As stated above, re-
gardless of the nurse’s personal beliefs, HIPAA does
not permit release of PHI to government agencies
such as CPS, as pregnancy termination is not con-
sidered a CPS-reportable issue.
EVIDENCE-BASED RECOMMENDATIONS FOR NURSES
Nurses come to work with a wide range of personal,
religious, and spiritual beliefs regarding pregnancy
Figure 2. After Roe v. Wade: What Should Nurses Do?
For a full size, printable version of this poster, go to http://links.lww.com/
AJN/A240. HIPAA = Health Insurance Portability and Accountability Act;
PHI = protected health information.
42 AJN ▼ January 2023 ▼ Vol. 123, No. 1
and contraception. Fortunately, our professional so-
cieties provide clear principles to guide our actions
in this complex and changing environment. The fol-
lowing recommendations for nurses who treat pa-
tients with self-managed medication abortion are
supported by current evidence and guidelines.
Take a harm reduction approach. Nurses treat
many conditions created by illegal or extralegal be-
havior that leads to ED visits, such as use of alcohol
by minors, illegal drug use, or car accidents caused
by excessive speed. None of these are mandated to
report to law enforcement. All require nonjudgmen-
tal, compassionate care to preserve the patient’s
trusting relationship with the nurse.
Manage abnormal bleeding as you would spon-
taneous miscarriage,4 keeping in mind that the emo-
tional support needs of the patient with self-managed
medication abortion may vary significantly. Because
bleeding in early pregnancy can have multiple causes,
keep initial interview questions open ended so the
patient can describe their situation in their own words
and manage information disclosure; seek informa-
tion only to the extent that management decisions
may be affected, and support needs determined.4
Treatment may include uterotonic medications
(such as misoprostol) or procedural interventions
(dilation and aspiration and/or curettage).37 As with
miscarriage, the presence of uterine debris on ultra-
sound only requires medical intervention if the pa-
tient is having severe pain or hemorrhaging.38 If the
symptoms indicate unsafe methods of self-managed
abortion, such as toxic ingestion or self-instrumen-
tation, management proceeds based on the cause of
the symptoms.39 The WHO recommends against the
use of anti-D immunoglobulin—also called rho(D)
or RhoGAM—at less than 12 weeks’ gestation.3
Consider whether to document evidence of self-
managed abortion. Carefully weigh documenting
in the health record the use of mifepristone, letro-
zole, or misoprostol to bring about abortion, or the
presence of any medications found in the vaginal
vault. This information is usually unnecessary for
care; recording it may cause significant harm.4
Documenting evidence of self-managed abortion
may lead to delays in care, stigma, or inappropriate
release of medical information to law enforcement
by other members of the health care team.
Ensure patients are aware of their options when
fetal cardiac motion is present and the pregnant per-
son’s health or life is at risk. These situations may include
ectopic pregnancy, when urgent intervention is the
standard of care, as the risk of expectant manage-
ment (wait and see approach) can be tubal rupture,
hemorrhage, and death; inevitable miscarriage due to
medications or spontaneous abortion, where a dilated
cervix may require intervention to prevent infection
and sepsis; and individualized significant health
problems that can be resolved or ameliorated only
 by terminating the pregnancy (such as obstetrical
sepsis, severe early preeclampsia or HELLP [hemoly-
sis, elevated liver enzymes, low platelets] syndrome).
Ensure patients receive an examination and/or
treatment in hospital emergency settings. Under the
federal Emergency Medical Treatment and Labor
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Act (EMTALA), when a pregnant patient presents
to an ED and requests examination or treatment,
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the hospital must either provide stabilizing treat-
ment or transfer the patient to another capable hos-
pital that can. In guidance released in July 2022 and
updated in October, the Centers for Medicare and
Medicaid Services (CMS) clarified that EMTALA
requirements preempt state laws and mandates that
apply to specific procedures.40 (Active litigation inter-
preting the enforceability of the EMTALA guidance is
ongoing.) Appropriate emergency care must be pro-
vided by physicians and hospital staff regardless of
state abortion bans and restrictions.
Refer patients who need legal advice to resources
such as If/When/How (www.ifwhenhow.org), a legal
helpline for people who need information about their
rights and self-managed abortion or other pregnancy
termination services (see Figure 1).
Be aware of any harmful action or practice that
disproportionately affects racially minoritized and
other vulnerable individuals due to biases in report-
ing and justice system/child welfare system treat-
ment. Endeavor to reduce disparities and promote
social justice. Specifically, maintain patient privacy
and avoid any reporting to law enforcement or CPS
agencies that is not specifically mandated by law
(see Figure 2).
IMPLICATIONS FOR NURSING PRACTICE
Nurses approach caregiving using personal codes of
ethics and moral commitments, and these may sus-
tain us in difficult situations. However, given that
religious and spiritual views on reproductive health
vary dramatically, nurses must turn to the ANA Code
of Ethics for guidance. The Code of Ethics provides
important principles to guide practice and behavior,
and recent federal directives from the HHS have
clarified federal privacy protections, which super-
sede state law.
Most important, in our care of patients, nurses
should do no harm. Reporting patients to law en-
forcement can have devastating and lasting effects,
including disrupting healthy, intact families and pre-
cipitating vulnerable families into poverty and
homelessness. While nurses may not always agree
with patients’ choices, we must uphold their right
to make decisions based on their own values and
keep their health information private whenever we
are legally able to do so.
Laws that criminalize abortion may negatively
affect nurses as well as patients. Nurses risk moral
injury when they wish to practice in accordance with
If You Have Questions About . . .
•• State laws related to reproductive rights:
https://reproductiverights.org/maps/abortion-laws-by-state
•• Filing a complaint related to violation of privacy:
https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf
•• Legal rights related to self-managed abortion or other
pregnancy termination services:
www.reprolegalhelpline.org
•• Evidence-based clinical recommendations on comprehensive
abortion care:
www.ipas.org/clinical-update/english/introduction
•• Federal privacy protections:
www.hhs.gov/about/news/2022/08/26/hhs-takes-action-
strengthen-access-reproductive-health-care-including-abortion-
care.html
their values and those of their patients but are
­legally prohibited from doing so. Moral injury can
occur when nurses are placed in a situation where
it is impossible or nearly impossible to act in a way
that’s consistent with their moral values.41 This is
­especially true when following the law may lead to
patient harm.
Historically, “conscience clauses” have allowed
nurses to opt out of providing nonemergency care
when doing so would cause moral compromise. Nurs-
ing ethicists should urgently address the inevitable
moral dilemmas nurses will face when they practice in
states that criminalize abortion, where participation in
necessary health care is prohibited even when it could
preserve health and lives. People need access to safe,
legal abortion when pregnancy threatens their fu-
tures, health, or lives or when pregnancy termina-
tion can reduce otherwise inevitable suffering. ▼
Laura Manns-James is an associate professor and Mickey Gillmor-
Kahn is course faculty in the Department of Midwifery and Wom-
en’s Health, Frontier Nursing University, Versailles, KY. Kelly Pfeifer
is an abortion provider in Kansas, Arizona, and California, and an
abortion policy advocate and consultant. The authors acknowledge
Gail Spake for editorial assistance, Kiernan Cobb, BSN, RN, for
creating the two featured posters, and Christina Bourne, MD,
MPH, Kiernan Cobb, BSN, RN, Jessica Gelsomino, MSN, RN,
and Dhalbir Khalsa, MA, PA-C, for providing helpful early
­reviews of the manuscript. Contact author: Laura Manns-James,
laura.manns-james@frontier.edu. The authors have disclosed no
potential conflicts of interest, financial or otherwise.
REFERENCES
1. U.S. Supreme Court. Dobbs, State Health Officer of the Mississippi
Department of Health, et al. v. Jackson Women’s Health Orga-
nization et al. 597 U.S. __ (2022); https://www.supremecourt.
gov/opinions/21pdf/19-1392_6j37.pdf.
2. Moseson H, et al. Effectiveness of self-managed medication
abortion with accompaniment support in Argentina and
­Nigeria (SAFE): a prospective, observational cohort study
and non-inferiority analysis with historical controls. Lancet
Glob Health 2022;10(1):e105-e113.
3. World Health Organization. Abortion care guideline. Geneva,
Switzerland; 2022. https://www.who.int/publications-detail-
redirect/9789240039483.
AJN ▼ January 2023 ▼ Vol. 123, No. 1 43

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44
4. Verma N, et al. Society of Family Planning interim clinical rec-
ommendations: self-managed abortion. Denver, CO; 2022 Sep
8. https://www.societyfp.org/wp-content/uploads/2022/06/SFP-
Interim-Recommendation-Self-managed-abortion-09.08.22.pdf.
5. Kozhimannil KB, et al. Abortion access as a racial justice is-
sue. N Engl J Med 2022;387(17):1537-9.
6. Guttmacher Institute. U.S. abortion patients [infographic].
2016. https://www.guttmacher.org/infographic/2016/us-abortion-
patients.
7. Jones RK, Jerman J. Population group abortion rates and
lifetime incidence of abortion: United States, 2008-2014. Am
J Public Health 2017;107(12):1904-9.
8. Kortsmit K, et al. Abortion surveillance—United States, 2019.
MMWR Surveill Summ 2021;70(9):1-29.
9. Stevenson AJ. The pregnancy-related mortality impact of a
total abortion ban in the United States: a research note on
increased deaths due to remaining pregnant. Demography
2021;58(6):2019-28.
10. Skuster P, Moseson H. The growing importance of self-managed
and telemedicine abortion in the United States: medically safe,
but legal risk remains. Am J Public Health 2022;112(8):
1100-3.
11. Aiken ARA, et al. Requests for self-managed medication
abortion provided using online telemedicine in 30 US states
before and after the Dobbs v Jackson Women’s Health Or-
ganization decision. JAMA 2022;328(17):1768-70.
12. National Advocates for Pregnant Women. Confronting preg-
nancy criminalization: a practical guide for healthcare providers,
lawyers, medical examiners, child welfare workers, and policy-
makers. New York, NY; 2022 Jun 22. https://www.national
advocatesforpregnantwomen.org/wp-content/uploads/2022/
06/1.Confronting-Pregnancy-Criminalization_6.22.23-1.pdf.
13. World Health Organization. Abortion care guideline: web an-
nex A: key international human rights standards on abortion.
Geneva, Switzerland; 2022. https://apps.who.int/iris/bitstream/
handle/10665/349317/9789240039506-eng.pdf.
14. United Nations Office of the High Commissioner for Human
Rights. Abortion. Geneva, Switzerland; 2020. Information
series on sexual and reproductive health and rights; https://
www.ohchr.org/sites/default/files/Documents/Issues/Women/
WRGS/SexualHealth/INFO_Abortion_WEB.pdf.
15. American College of Obstetricians and Gynecologists. Oppo-
sition to the criminalization of self-managed abortion. Wash-
ington, DC; 2022 Jul 6. Policy and position statements;
https://www.acog.org/clinical-information/policy-and-position-
statements/position-statements/2022/opposition-to-the-
criminalization-of-self-managed-abortion.
16. National League for Nursing. NLN strongly objects to Su-
preme Court decision to overturn Roe v. Wade, jeopardizing
public health [press release]. 2022 Jun 24. https://www.nln.
org/detail-pages/news/2022/06/24/nln-strongly-objects-to-­
supreme-court-decision-to-overturn-roe-v.-wade-jeopardizing-
public-health.
17. Nurse Practitioners in Women’s Health. The National Asso-
ciation of Nurse Practitioners in Women’s Health (NPWH) re-
productive rights policy summary. Washington, DC; 2022
May. Position statement; https://cdn.ymaws.com/npwh.org/
resource/resmgr/positionstatement/npwh_reproductive_
rights_pol.pdf.
18. American College of Nurse-Midwives. ACNM condemns
SCOTUS decision, Dobbs v. Jackson Women’s Health Organi-
zation; 2022 Jun 24. Statement; https://www.midwife.org/
statement-acnm-condemns-scotus-decision-dobbs-v.-jackson-
women-s-health-organization.
19. Association of Women’s Health, Obstetric and Neonatal Nurses
(AWHONN). AWHONN responds to Supreme Court decision
on Roe v. Wade [press release]. 2022 Jun 24. https://www.
awhonn.org/awhonn-responds-to-supreme-court-decision-on-
roe-v-wade.
20. American College of Obstetricians and Gynecologists. More
than 75 health care organizations release joint statement in
opposition to legislative interference [press release]. 2022 Jul 7.
https://www.acog.org/news/news-releases/2022/07/more-
than-75-health-care-organizations-release-joint-statement-in-
opposition-to-legislative-interference.
AJN ▼ January 2023 ▼ Vol. 123, No. 1
21. U.S. Department of Health and Human Services, Office for
Civil Rights. HIPAA privacy rule and disclosures of informa-
tion relating to reproductive health care. Washington, DC;
2022 Jun 29. https://www.hhs.gov/hipaa/for-professionals/
privacy/guidance/phi-reproductive-health/index.html.
22. Center for Reproductive Rights. After Roe fell: abortion laws
by state. 2022. https://reproductiverights.org/maps/abortion-
laws-by-state.
23. Diaz-Tello F, et al. Roe’s unfinished promise: decriminalizing
abortion once and for all. Berkeley, CA: SIA Legal Team,
Center on Reproductive Rights and Justice, University of
California Berkeley School of Law; 2017 Nov 28. https://
www.ifwhenhow.org/resources/roes-unfinished-promise.
24. Huss L, et al. Self-care, criminalized: August 2022 preliminary
findings. Oakland, CA: If/When/How: Lawyering for Repro-
ductive Justice 2022. https://www.ifwhenhow.org/resources/
self-care-criminalized-preliminary-findings.
25. Goodwin M. Pregnancy and the new Jane Crow. Conn Law
Rev 2021;53(3):542-69.
26. Benkert R, et al. Ubiquitous yet unclear: a systematic review
of medical mistrust. Behav Med 2019;45(2):86-101.
27. Palusci VJ, Botash AS. Race and bias in child maltreatment
diagnosis and reporting. Pediatrics 2021;148(1):e2020049625.
28. Sedlak AJ, et al. Trends in child abuse reporting. In: Krug-
man RD, Korbin JE, editors. Handbook of child maltreat-
ment. Cham, Switzerland: Spinger International; 2022.
p. 3-26. Child maltreatment: contemporary issues in research
and policy.
29. Itzkowitz M, Olson K. Closing the front door of child pro-
tection: rethinking mandated reporting. Child Welfare 2022;
100(2):77-98.
30. American Nurses Association. Code of ethics for nurses with
interpretive statements. Silver Spring, MD; 2015.
31. American Nurses Association. Privacy and confidentiality.
Silver Spring, MD; 2015 Jun. Position statement; https://
www.nursingworld.org/~4ad4a8/globalassets/docs/ana/­
position-statement-privacy-and-confidentiality.pdf.
32. Bridges KM. Race, pregnancy, and the opioid epidemic: White
privilege and the criminalization of opioid use during pregnancy.
Harv Law Rev 2019;133(3):771-851.
33. Wildeman C, et al. The cumulative prevalence of termination
of parental rights for U.S. children, 2000-2016. Child Maltreat
2020;25(1):32-42.
34. Biggs MA, et al. Understanding why women seek abortions
in the US. BMC Womens Health 2013;13:29.
35. Foster DG, et al. Comparison of health, development, mater-
nal bonding, and poverty among children born after denial of
abortion vs after pregnancies subsequent to an abortion. JAMA
Pediatr 2018;172(11):1053-60.
36. Foster DG, et al. Socioeconomic outcomes of women who
receive and women who are denied wanted abortions in the
United States. Am J Public Health 2018;108(3):407-13.
37. Shorter JM, et al. Management of early pregnancy loss, with
a focus on patient centered care. Semin Perinatol 2019;43(2):
84-94.
38. Ipas. Ultrasound findings at follow-up. Chapel Hill, NC;
2021 Feb 7. Clinical updates in reproductive health; https://
www.ipas.org/clinical-update/english/recommendations-­
for-abortion-before-13-weeks-gestation/medical-abortion/­
ultrasound-findings-at-follow-up.
39. Orlowski MH, et al. Management of postabortion complica-
tions for the emergency medicine clinician. Ann Emerg Med
2021;77(2):221-32.
40. Centers for Medicare and Medicaid Services, Center for
Clinical Standards and Quality. Reinforcement of EMTALA
obligations specific to patients who are pregnant or who are
experiencing pregnancy loss. Baltimore, MD: Department of
Health and Human Services; 2022 Oct 3. Ref: QSO-
21-22-Hospitals. https://www.cms.gov/files/document/qso-
21-22-hospital-revised.pdf.
41. Moral Injury Project. What is moral injury. Ithaca, NY:
­Syracuse University; 2014. https://moralinjuryproject.syr.edu/
about-moral-injury.