In a post-Roe America, patients may not receive miscarriage care


In a post-Roe America, patients may not receive miscarriage care

Texas could be a worrisome harbinger for anyone wondering how miscarriages will be handled in a post-Roe America.

Anna, a woman from Central Texas, was 19 weeks pregnant when her waters broke on her wedding night in December 2021. The baby had no hope of surviving because it was too early in the pregnancy. Anna was not only going to lose her child, but she was also at risk of becoming septic or bleeding out, according to NPR. Her doctors told her they couldn't terminate the pregnancy because of the tight abortion rules that had taken effect in Texas that September, which permitted doctors to terminate a pregnancy only if there was a "danger of death or a real risk of considerable impairment of a key bodily function." Anna had no choice but to fly to Colorado in order to receive treatment. She reserved front-row tickets so she could be near to the bathroom if she went into labour during the journey.

Anna's case is unlikely to be the last if Roe is overturned. Maya Manian, a professor at American University's Washington College of Law who focuses on health care access and reproductive justice and rights, warns, "That's the kind of stuff we're going to see more and more."

When a woman has a miscarriage (the spontaneous loss of a pregnancy before the 20th week), her doctor usually gives her three options: medication to cause the tissue to pass out of the womb; surgery (dilation and curettage, or D&C) to remove the tissue from the uterus; or waiting for signs of danger. While the patient has the option of terminating the pregnancy, the standard of care is to do so via medicine.

Miscarriages can be lethal, in addition to the emotional pain they cause. The wait-and-see strategy is far riskier than the other two, not just in terms of the pregnant woman's future fertility but also in terms of her safety. If the tissue does not pass, it might get infected and cause sepsis, a condition in which the immune system overreacts and attacks the body's tissues. Failure to pass all of the tissue can lead to a life-threatening blood clot problem known as disseminated intravascular coagulation, which becomes more likely the longer you wait to remove the tissue from the uterus.

Thirteen US states have "trigger" legislation that, if Roe is overturned, will make abortion illegal immediately or very quickly. Theoretically, these regulations would allow for the termination of a pregnancy if the pregnant woman's life was in danger, but the doctor would have to evaluate what qualified under that criteria. "My fear is that some states may try to interpret it in a very, very restricted way," says Lisa Harris, an ob-gyn and University of Michigan professor.

Due to the ambiguity of the laws, medical professionals will have to decide whether or not to terminate a pregnancy, knowing that the consequences for calling a case too soon or if it does not perfectly fit the risk criteria could include hefty fines, suspension of their medical licence, and even life in prison. Having a broadly written law can have a chilling effect, Manian argues. This is why politicians don't usually regulate medicine.

How does a doctor calculate the percentage chance that their patient will die in order to justify terminating a pregnancy? Is it necessary for the patient to be in danger of dying within the next hour? Is it necessary for death to be a prerequisite? What if carrying the pregnancy resulted in the patient suffering significant disability rather than death?

If Roe is overturned, the future availability of medications to treat miscarriages could be jeopardised. According to Harris, the medicine option—two pills, misoprostol and mifepristone—is the best and most effective treatment for a miscarriage that hasn't yet gone. Both medicines, however, can be used to induce an abortion. So, will doctors hand these out to their patients? Will pharmacies even have them in stock? "Or will they be too concerned that someone would believe they're doing anything illegal?" Harris wonders. There have already been stories of Texas pharmacies refusing to fill their prescriptions.

Savita Halappanavar, a 31-year-old dentist, died needlessly in Ireland in October 2012 when doctors refused to terminate her pregnancy. The circumstances surrounding her death are about to become a new reality in the United States a decade later. Savita was hospitalised to a Galway hospital for a miscarriage at seventeen weeks into her pregnancy. Her doctors refused to terminate the pregnancy because the foetus still had a detectable heartbeat. They told her, "This is a Catholic country." Her doctors were concerned that they would be accused of breaking the law under Ireland's Eighth Amendment, which affirms the equal right to life of a pregnant woman and her unborn child. A week later, Savita died of septicemia. Valentina Milluzzo, another Italian woman, died in 2016 while having a miscarriage after her doctor declined to intervene on religious grounds. In a post-Roe America, we can probably expect to see more cases like Savita's and Valentina's.

In states where abortion is outlawed, religious organisations readily give a template for how miscarriages should be handled. For example, the Catholic Church has a significant impact on the US healthcare system: A Catholic hospital has one in every six acute-care hospital beds. Four of the ten largest health systems in the United States are owned by Catholics. Many people are unaware that they are at a Catholic hospital: According to a 2018 survey, nearly 40% of female respondents were unaware that their primary hospital had a religious association. Pregnant women of colour are also more likely than white women to give birth in a Catholic hospital, according to research.

The Ethical and Religious Directives, which govern Catholic health care facilities, state that aborting a pregnancy is only permitted if foetal heart tones are absent or the pregnant woman gets ill—basically, the watch-and-wait strategy. This has resulted in patients being denied crucial care at these institutions, as seen in many cases brought forward by the American Civil Liberties Union. And that, in and of itself, is immoral and bad for medicine. But now, I believe, a portion of the United States could follow their lead," says Lori Freedman, a medical sociologist at the University of California, San Francisco, who studies how our social structure and medical culture impact reproductive health care.

Because of the high density of Catholic hospitals in some areas of the country, women may have to travel long distances to receive care at a non-Catholic facility—possibly while experiencing a miscarriage. If Roe is overturned, women from all over the country may be forced to travel for medical treatment. Combine that with the fact that 35% of counties in the United States have been designated as maternity-care deserts, meaning they lack a hospital that is appropriately staffed to offer treatment to pregnant women. "It's quite unconscionable," says Freedman.

Legal wrangling around miscarriage care may dissuade women from seeking help for fear of being accused of inducing an abortion on their own. A miscarriage that occurs spontaneously and a pregnancy that ends because someone used medicine are almost indistinguishable, Harris adds. The concern is that it will become a world where women—particularly low-income women and women of colour—are criminalised when they walk into the emergency room bleeding from a miscarriage, Manian says.

According to Harris, a miscarriage is already fraught with shame. And this will simply add to the silence and stigma around an already terrible experience for so many people. Harris' hospital has started developing clear standards and rules to guarantee that professionals may make judgments based on what is best for the patient rather than fear of breaking the law. However, I'm not sure that all institutions are aware of what is about to happen, she says.

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