After months of trying, Angela Costales eagerly watched her at-home pregnancy test turn positive. She and her husband were so excited that they filmed a video at 3 a.m. to document the moment 鈥� but the joy they felt didn鈥檛 last.
Costales鈥� first ultrasound showed placental abnormalities and no fetal heartbeat. She had lost the pregnancy and her first chance at becoming a mom.
It was devastating, she said. What happened after made her feel even worse: The CVS Pharmacy in her San Diego neighborhood, she said, refused to fill the prescription given to her to manage her miscarriage.
The drug Costales needed was misoprostol, a pill commonly used to help with miscarriages that is also used in . Three separate pharmacy employees refused to help her acquire the medication while she stood in the store bleeding and in pain on Dec. 20, according to Costales and her lawyer.
鈥淚 couldn鈥檛 believe what was happening,鈥� Costales said. 鈥淚 really felt like I was in danger and [CVS]鈥� denied my care without my well-being in mind.鈥�
Costales and the nonprofit National Women鈥檚 Law Center assert that the retail pharmacy chain broke federal and state laws when it turned her away. They have issued a formal demand to CVS in the form of a that describes CVS staff members refusing to fill Costales鈥� prescriptions, and the laws violated by such a refusal. The letter includes a list of demands, among them that CVS improve its policies and employee training nationwide to prevent similar occurrences. It asks CVS to post a notice at every pharmacy detailing 鈥減atients鈥� rights to obtain their prescribed medication.鈥�
Costales has not filed a lawsuit against CVS but is not ruling one out, her attorney said.
If it happened to me, it鈥檚 happening to other people,鈥� Costales said.
The company is investigating Costales鈥� claims, CVS Pharmacy spokesperson Amy Thibault said in a written statement.
Thibault said any pharmacist who has personal objections to providing certain medications is required to notify the company in advance so that arrangements can be made to fill the prescription.
鈥淥ur highest priority is ensuring safe and timely access to medications for our patients, and we understand the important role pharmacies serve in support of women鈥檚 health care. We have policies in place to ensure no patient is ever denied access to medication prescribed by a physician based on a pharmacist鈥檚 individual religious or moral beliefs,鈥� Thibault said in an email.
More broadly, reproductive rights advocates say the alleged incident is a jarring reminder of how the national fight over abortion can spill over into , affecting patient care. In the two years since the U.S. Supreme Court eliminated federal abortion protections, California lawmakers have gone to great lengths to expand and , and voters in 2022 to include the right to an abortion. But enforcing the laws on the ground can be difficult, experts say.
Legal scholars, doctors and abortion rights advocates also contend ongoing court battles and laws criminalizing abortion in other states can affect reproductive health access everywhere 鈥� even when abortion is not involved.
鈥淭his prescription was to manage continued miscarriage, and yet employees at CVS, their stigma against anything that looks like abortion or sounds like abortion, interfered with their legal obligation to provide (Costales) with her medication,鈥� said Clara Spera, senior counsel for the National Women鈥檚 Law Center and Costales鈥� attorney.
California law requires pharmacies to dispense legally prescribed medications to patients and make accommodations for both the patient and employee if an individual employee registers a sincerely held objection to providing the medication. Costales鈥� attorney said CVS violated that law 鈥� as well as the state鈥檚 prohibiting discrimination based on sex or pregnancy-related conditions 鈥� when it denied her misoprostol.
CVS and its national competitor Walgreens have faced scrutiny from federal regulators before over similar complaints from patients around the country. Last year, the U.S. Department of Health and Human Services Office of Civil Rights after numerous discrimination complaints of medication denial from women experiencing miscarriages and people with disabilities. The agreement included training pharmacy staff on reproductive health rights and monitoring medication denials to ensure patients receive prescriptions in a timely manner.
Thibault did not answer questions about when the last time employees at Costales鈥� local pharmacy had been trained on reproductive health rights or what specific company policies are in place to ensure patients get medications in a timely manner.
A rare pregnancy complication
Based on Costales鈥� ultrasound and other tests, she said doctors suspected she might have a , a rare complication that can form cancer if untreated. They recommended surgery to find out, she said.
Surgery is the only way to remove the tissue and confirm a molar pregnancy diagnosis, said Dr. Aparna Sridhar, an obstetrician and associate clinical professor at UCLA鈥檚 David Geffen School of Medicine. Sridhar was not involved in Costales鈥� care.
After the procedure, Costales said she felt fine until a week later when she woke up bleeding heavily and in severe pain. At the emergency room, the doctor recommended misoprostol to help her body finish expelling any remaining pregnancy tissue or uterine lining.
鈥淚 wanted to get my medication as soon as I could. And I wanted to get home and administer it so that we could feel at ease and at peace with, you know, the rest of our care plan,鈥� Costales said.
For most , Sridhar said the three management options are surgical intervention, medication and waiting to see if the body successfully empties the uterus by itself. Determining the course of treatment should be a joint decision between the patient and doctor, and all three options have been shown to be safe, Sridhar said.
But at the CVS pharmacy at 4829 Clairemont Drive, the first employee told Costales there was no prescription for her on file, the National Women鈥檚 Law Center letter alleges. The second employee told her 鈥淚 don鈥檛 know if we can fill this,鈥� according to the letter. And after asking to speak with the pharmacist for an explanation, Costales alleges in the letter that the pharmacist said 鈥淚t doesn鈥檛 matter if I have it, I am not comfortable dispensing it to you鈥� and walked away.
The experience was humiliating, Costales said, adding that the shame and anger have lasted for months.
鈥淭he hardest part is I feel like CVS robbed me of my ability to mourn my pregnancy loss,鈥� Costales said.
Abortion challenges continue
The CVS employees did not tell Costales why they objected to providing her with the medication prescribed to her, she said. Nonetheless, California health experts say there is confusion among providers about what the law requires since the U.S. Supreme Court two years ago and ended the constitutional right to abortion.
Last week, the to overturn federal Food and Drug Administration regulations that expanded access to another medication, mifepristone, used both for abortion and miscarriage management. The plaintiffs were doctors opposed to abortion who argued that they could be required to treat someone in the emergency room with a complication related to abortion.
In the ruling, Justice Brett Kavanaugh wrote that federal law guarantees 鈥渂road and comprehensive conscience protections鈥� for doctors who object to abortion and that the plaintiffs had no examples of being forced to treat a patient who had an abortion. The anti-abortion legal group leading the case against the FDA has already pledged to continue its legal battle
Experts say religious and moral objections have been protected for decades.
鈥淭hat鈥檚 the status quo. We have decided that we are going to allow people to opt out of care that they don鈥檛 want to perform,鈥� said Cathren Cohen, a staff attorney with the UCLA Center on Reproductive Health, Law and Policy.
Despite laws that also protect a patient鈥檚 right to get medical care, individuals can struggle to defend or advocate for themselves.
鈥淭his flip-flopping of changing of laws from day-to-day does have a detrimental and chilling effect on care people are getting,鈥� Cohen said.
Even in California the constantly changing landscape causes uncertainty, said Dr. Josie Urbina, an obstetrician at the Zuckerberg San Francisco General Hospital. Doctors like herself have difficulty keeping up with the ripple effects of national decision-making, and patients find it especially hard to know what is available to them and what they have a right to, she said.
鈥淚t still causes confusion, it still causes people to think 鈥楾his may affect me,鈥欌�� Urbina said.
Spera, Costales鈥� lawyer, said that confusion and the loss of federal abortion protections emboldens people who are not involved in an individual鈥檚 health care to say 鈥淚 know what鈥檚 best.鈥� Costales said she wants Californians who identify with her story to know that they have legal protections.
鈥淥ne of the reasons why I live in California is to make sure I will be protected, and I don鈥檛 have to worry about planning for my family,鈥� Costales said. 鈥淗ow many other people are being impacted by this and are getting their rights neglected or just stomped on?鈥�
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