A young woman came with her husband to our OB triage after having cramping at home. She was just over 22 weeks pregnant with her first pregnancy – twins – a pregnancy which she and her husband had been incredibly excited about since they were married the year before. Unfortunately, when the physician checked her cervix, they found she was about 4 centimeters dilated with the bag of water bulging, well beyond where she should be at this gestational age. While she was not actively laboring, the likelihood that she would deliver within the next few days was extremely high. This patient and her husband were devastated.

They were devastated when maternal fetal medicine doctors said that she was beyond the point where they could place a stitch to close the cervix, and they were devastated when they talked to the neonatal doctors about what the survival and health of fetuses born at this age may be. They sat in shock as all medical options were discussed with them. They spoke with their parents, their minister, their friends; they cried with each other, and we cried with them.

After 24 hours of heart-wrenching discussions, they informed our care team that they had decided to end the pregnancy. They wept for their babies and what could have been, but had come to the conclusion they felt best for their current and future family after considering all options and potential outcomes. By this point, they had a good understanding of the implications of waiting. Within the next few weeks, terminating the pregnancy would no longer be an option. If the twins were born after 24 weeks, regardless of the severity of their medical comorbidities, they would be resuscitated, intubated, and taken to the NICU. While the patient and her husband respected that some parents may choose this option, it wasn’t the option they chose. The thought of going through labor and having one or both of the twins die after delivery was simply too much to handle. And even if one or both did survive, the possibility of these children having life-long health conditions was more likely than not. Thinking of their future together, including the other children they hoped to have, the couple had come to the decision of what was the best available option for them.

However, when we tried to schedule the patient for a procedure later that day, we were told by their insurance company that the procedure would not be covered. The patient’s husband was in the military, and their insurance would not allow for such a procedure unless the patient’s life was directly at risk. While all medical evidence pointed toward a poor outcome for these twins, the insurance company’s policy was telling the patient she had wait for something worse to happen (the bag of water to break, infection, bleeding, fetal demise, etc.) before we could proceed. I remember how angry the husband was, and how the patient could not stop crying. The husband first said that they would pay out of pocket until learning of the prohibitive cost. He then insisted they had good insurance. He asked me how a company that knew nothing about them and nothing about the hell of making this decision could deny what he and his wife had decided was best for them. No insurance company could know what this was like. He asked me who was going to take care of these twins if they beat the odds and survived after a periviable birth, but not without severe life-long conditions. That was not what they were choosing, and yet it would still be their emotional and financial responsibility. He asked me how an insurance company could not cover a legal procedure that he and his wife had the right to obtain. I had no logical answers to his questions.

The patient then looked me directly in the eyes and asked me to break her bag of water. She knew that if the bag was broken, her risk of infection was higher, and the care team could then make a case that we had to proceed. She pleaded for me to tell her husband how he could break her bag of water. “Just tell us what to do, and leave the room,” she said through heaving sobs. Less than two days ago, they were planning baby showers and discussing middle names. Now, faced with the unimaginable, this woman held her stomach while begging to do something that would put her health at risk. They sat together in a hospital bed, him holding her, knowing what would be best for them but having no way to get it. They were desperate, and I could do nothing. Unlike so many other women in the United States and worldwide, this patient lived somewhere that abortion is legal through 24 weeks gestation. This patient came to a hospital with specialists and with physicians trained to perform abortions through 24 weeks. This patient had insurance and had been receiving regular prenatal care. This patient was able to speak to experts about the implications of continuing and ending her pregnancy, and what it could mean for her health, her fetuses, her family, and her future.

And yet, despite the absence of barriers that stop many women from making informed decisions about obtaining an abortion, this woman could still not access the legal procedure she chose to undergo. Should we have discussed all the options with her? Or should we have only discussed the options that her insurance company considered reasonable enough to cover? It seems so wrong to have cost come into a discussion as personal and emotional as this. It seems so wrong to call an insurance company before you speak to your patient. And yet, I have never felt like I failed a patient more than when I left this room. First, abortion must be safe and legal. And second, women have to be able to access it – geographically, financially, emotionally, and otherwise. Without access to safe and legal abortion, we are doing a disservice to our patients and women’s health overall.