Opinion
Reproductive Rights in Neurology—
VIEWPOINT
The Supreme Court's Impact on All of Us
Sara C. LaHue, MD The overturning of Roe v Wade through the US Su-
Department of preme Court’s official ruling in Dobbs v Jackson Wo-
Neurology, School of men’s Health Organization is already having an undeni-
Medicine, University of
able ripple effect on health care delivery across the
California, San
Francisco; and UCSF nation. How this may change clinical practice for both
Weill Institute for adult and child neurologists and management of neu-
Neurosciences, rologic diseases appears initially less relevant. Neurolo-
Department of
Neurology,
gists rarely prescribe contraception or menopausal hor-
University of California, mone therapy and do not participate in fertility treatment
San Francisco. procedures or terminations of pregnancy. Except for con-
traception, these topics are seldom included in training
Dawn Gano, MD, MAS and neurologic practice, and only 2 fellowship pro-
Department of
Neurology, School of grams specialize in sex- and gender-informed neurol-
Medicine, University of ogy nationally. However, bans on abortion will immedi-
California, San ately affect the delivery of current standard neurologic
Francisco; and
care for many patients, specifically standards that de-
Department of
Pediatrics, School of pend on planning or preventing pregnancies using indi-
Medicine, vidual choice.
University of California, Limits on reproductive health affect a wide diver-
San Francisco.
sity of populations and could magnify racial, ethnic, and
social inequities that can negatively affect health out-
Riley Bove, MD, MSc
Department of comes for people with neurological conditions.1 Elimi-
Neurology, School of nation of abortion as a constitutional right will restrict
Medicine, University of its availability to as many as 58% of women of repro-
California, San
Francisco; and UCSF ductive age in the US.2 Further, termination of preg-
Weill Institute for nancy is not exclusively a women’s rights issue—those
Neurosciences, who do not identify as women, such as transgender men
Department of
and nonbinary people, may also seek abortion. Abor-
Neurology,
University of California, tion rates are higher in non-Hispanic Black women and
San Francisco. Hispanic women compared with non-Hispanic White
women, according to 2019 data published by the US Cen-
ters for Disease Control and Prevention.3 Abortion rates
are also starkly higher in women whose incomes are be-
low the federal poverty line relative to those 200%
above the federal poverty line.4 Further, longitudinal
studies suggest that being denied a wanted abortion is
associated with higher odds of poverty5 and lower odds
of employment5 long term, as well as increased odds of
headache and perception of “fair or poor health.”6 There-
fore, restrictions on reproductive rights may differen-
tially affect the health of women according to their race,
ethnicity, or income levels and could further entrench
women in a cycle of poverty.
Many neurologic diseases disproportionately
affect women during their reproductive years. This is
relevant for common conditions such as migraine and
Corresponding for conditions such as epilepsy and multiple sclerosis
Author: Sara C. LaHue,
MD, UCSF Department
that have had substantial improvements in disease
of Neurology, control and quality of life associated with modern
505 Parnassus Ave, therapies. Known teratogenic medications (including
PO Box 0114,
valproic acid or teriflunomide) may be required to
San Francisco, CA
94143 (sara.lahue@ achieve optimal control of neurologic diseases that
ucsf.edu). may be life threatening (such as status epilepticus) or
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result in accumulation of irreversible disability (such as
multiple sclerosis). However, concerns about medica-
tion teratogenicity for those who are anticipating preg-
nancy or are pregnant may extend beyond medica-
tions with clearly established teratogenicity and
include medications that lack evidence supporting
their safety profiles. For instance, 1 review of 172 medi-
cations approved by the US Food and Drug Adminis-
tration from 2000 to 2010 found “undetermined”
human teratogenic risk profiles for 98% of these
medications.7 In a climate of increased limitations on
reproductive rights, whereby pregnancies cannot be
reliably timed or prevented, neurologists might possi-
bly restrict use of the effective medications that are
standard care for other patient groups because of
potential concerns about causing fetal harm. This
could increase risk of morbidity, mortality, and irrevers-
ible disability accumulation for women with neurologic
diseases.
However, unintended pregnancies occur, even
among participants in clinical trials with protocols
that strictly encourage or require use of effective
contraception,8 and these pregnancies will continue to
occur regardless of legislative constraints on reproduc-
tive health services. Teratogenic drugs are only pre-
scribed when it is possible for women to plan pregnan-
cies and prevent fetal exposure. However, controlling
the timing of teratogenic medication use may not be fea-
sible in the short-term treatment of certain disorders,
such as medically refractory status epilepticus, infec-
tious and autoimmune encephalitis, or vasculitis. Fur-
ther, some neurologic conditions, such as eclampsia, may
occur before fetal viability, increasing the risk of mor-
bidity and mortality for the mother if the pregnancy
cannot be terminated. There are also neurological dis-
eases, such as having a central nervous system neo-
plasm, that are not immediately life threatening, but
where a delay in treatment due to pregnancy could put
both the health and life of the mother at risk. Some bills,
such as Oklahoma Senate Bill 6129 signed into law in
May 2022, restrict legal abortion only “to save the life
of a pregnant woman in a medical emergency.” Ten-
sions in clinical decision-making that exist when the
health of the mother is in opposition to the health of the
fetus will only intensify with additional constraints on
reproductive rights.10
Restricting personal decisions on childbearing will
also change aspects of fetal neurologic care and coun-
seling by child neurologists and maternal-fetal medi-
cine specialists. The anatomic ultrasound at approxi-
mately 20 weeks’ gestation is common in obstetrical
practice, with the goal of evaluating the growth and
health of the fetus, placental position, and amniotic
(Reprinted) JAMA Neurology Published online July 13, 2022 E1
 Opinion Viewpoint

fluid volume. In worst-case scenarios, fetal neurologic conditions
that are not survivable or that could result in poor quality of life
due to profound disability are identified with prenatal ultrasound,
fetal brain magnetic resonance imaging, and/or genetic testing.
The decision to carry or terminate a pregnancy with severe fetal
anomalies (such as anencephaly) or genetic syndromes (such as
trisomy 13 or 18) is highly complex and personal regardless of
which decision each woman makes. If pregnancy termination is
banned, then women may be forced against their wishes to deliver
a newborn that may require prolonged intensive care and end-of-
life care. The loss of bodily autonomy for pregnant women in such
a scenario conscripts the dyad of mother and child to potential
physical and psychological morbidity. Women and their partners
will not have the right to self-determination, as well as the ability
to make reasonable and informed decisions for the health and wel-
fare of their child and family. Helping patients address these issues
also may have psychological consequences for clinicians who pro-
vide care for these patients.
Neurologists should consider how legislating private health
decisions between patients and clinicians might alter the land-
scape of neurologic practice across the patient’s life span. Equity in
care depends on the unrestricted liberty to make personal deci-
sions affecting bodily autonomy. This includes optimization of fer-
tility windows, personal determination of pregnancy timing to limit
disease progression or exacerbation, and pregnancy termination if
necessary for the health of the mother, the fetus, or both. Now that
Roe v Wade is overturned, abortion will be banned or severely re-
stricted in as many as 28 states, compromising the care available to
approximately 40 million women.2 Availability of reproductive health
is integral to equitable delivery of neurologic care. The Supreme
Court's decision will undoubtedly now have an impact on all of us in
the field of neurology.

ARTICLE INFORMATION
Published Online: July 13, 2022.
doi:10.1001/jamaneurol.2022.2347
Conflict of Interest Disclosures: Dr LaHue receives
funding from the National Institute on Aging
(R03AG074035), Larry L. Hillblom Foundation
(A137420), UCSF Claude D. Pepper Older
Americans Independence Center funded by the
National Institute on Aging (P30 AG044281), and
the Bakar Aging Research Institute. She also
receives royalties from Oxford University Press.
Dr Gano is funded by the Cerebral Palsy Alliance
Research Foundation (PG14418) and the UCSF
California Preterm Birth Initiative funded by Marc
and Lynne Benioff, as well as personal fees from
medico-legal consulting. Dr Bove has received
research support from the National Institutes of
Health, National Science Foundation, Department
of Defense, National Multiple Sclerosis Society,
Biogen, Novartis, and Roche Genentech. She has
received consulting or advisory board fees from
Alexion, Biogen, EMD Serono, Genzyme Sanofi,
Janssen, Novartis, Roche Genentech, and TG
Therapeutics. No other disclosures were reported.
Additional Contributions: Dr LaHue would like to
acknowledge Zoe Silverman, MA, Kevin J. LaHue,
Esq, Rita C. Crooms, MD, MPH, Hannah L. Kirsch,
MD, Juliet Morgan, MD, and Andy Matuschak, BS,
for ad hoc discussions helping to refine this work.
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