Patients May Not Receive Miscarriage Care in a Post-Roe America

For those wondering how miscarriages would be managed in a post- Roe America, Texas could be a frightening harbinger. In December 2021, Anna, a woman who lives in Central Texas, was 19 weeks pregnant when her waters broke on her wedding night. It was too early in the pregnancy for the baby to have a chance of survival. But not only was Anna going to lose her child, she was also at high risk of going septic or bleeding out, NPR reported . And because of the strict abortion laws that had taken effect that September in Texas—where ending a pregnancy is only allowed if there is “danger of death or a serious risk of substantial impairment of a major bodily function”—her doctors told her they couldn’t terminate the pregnancy. It meant that Anna was left with no choice but to fly to Colorado to receive care. She booked front-row seats to be close to the bathroom in case she went into labor on the flight. If Roe is overturned, Anna’s case likely won’t be the last. “That’s the kind of thing we’re going to be seeing more and more,” warns Maya Manian, a professor at American University’s Washington College of Law who focuses on health care access and reproductive justice and rights. Typically, when someone has a miscarriage—the spontaneous loss of a pregnancy before the 20th week—they are offered three options by their caregiver: medication to cause the tissue to pass out of the womb; surgery (a procedure referred to as dilation and curettage, or D&C) to remove the tissue from the uterus; or the choice to sit tight and watch for signs of danger. While the patient can decide, the standard of care is to terminate the pregnancy, usually with medication. On top of the emotional turmoil miscarriages bring, they can take a turn for the deadly. The wait-and-see approach is much more treacherous than the other two, not only for the pregnant person’s future fertility but for their safety. If the tissue doesn’t pass, it can become infected and lead to sepsis, where the immune system dangerously overreacts and begins to attack the body’s tissues. Failing to pass the all of the tissue can also result in a life-threatening blood-clot complication called disseminated intravascular coagulation, the risk of which increases the longer you wait to rid the uterus of the tissue. Thirteen US states have “trigger” laws that would immediately or very quickly outlaw abortion if Roe falls. Theoretically, these laws would make an exception for ending a pregnancy in circumstances where the pregnant person’s life is at risk—but what qualifies under that definition is up to the doctor to decide. “My fear is that there’ll be some states that want to interpret that in a very, very narrow way,” says Lisa Harris, an ob-gyn and professor at the University of Michigan. The vagueness of the laws mean that medical professionals will have to decide whether to terminate a pregnancy—knowing that penalties for calling a case too soon or it not perfectly fitting the risk criteria could range from hefty fines to suspension of their medical license to life in prison. “When you have a broadly worded law, it can have a chilling effect,” says Manian. “This is why we generally don’t have politicians regulate medicine.” How does a doctor determine the percentage risk of their patient dying to justify ending a pregnancy? Does the patient have to be at risk of dying within the next hour? And does dying have to be the qualifier? What if carrying the pregnancy didn’t meant the patient would die, but they would have severe disabilities as a result? The future availability of the drugs needed to treat a miscarriage could also be in peril if Roe falls. The medication option—two drugs, misoprostol and mifepristone—is the best and most effective treatment for a miscarriage where the pregnancy hasn’t passed yet, says Harris. But both drugs are also used to induce an abortion. So will doctors give them to patients? Will pharmacies even stock them? “Or will they be too worried that someone will think that they’re doing something illegal?” says Harris. There are already reports of pharmacies in Texas refusing to fill prescriptions for them. Back in October 2012, Savita Halappanavar, a 31-year-old dentist, died unnecessarily in Ireland because doctors refused to terminate her pregnancy. A decade later, the circumstances that led to her death are poised to become a new reality in the US. Seventeen weeks into her pregnancy, Savita was admitted to a hospital in Galway while experiencing a miscarriage. But as the fetus still had a detectable heartbeat, her doctors refused her a termination. “This is a Catholic country,” they told her . Under the Eighth Amendment of the Constitution of Ireland—which recognizes the equal right to life of a pregnant person and their unborn child—her doctors feared they could be accused of breaking the law. Savita died of septicemia a week later. Another woman, Valentina Milluzzo, died in Italy in 2016 while having a miscarriage after her doctor refused to intervene on religious grounds. We can likely expect to see more cases like Savita’s and Valentina’s in a post- Roe America. Religious institutions readily provide a template for how miscarriages could be treated in states where abortion is illegal. The Catholic Church, for example, has a sizable influence on the US health care system: One in six acute-care hospital beds are in a Catholic hospital. Out of the 10 largest health systems in the US, four of them are Catholic-owned. Often people don’t even know when they’re in a Catholic hospital: A 2018 survey found that almost 40 percent of its female respondents were not aware their primary hospital had a religious affiliation. Research has also shown that pregnant women of color are more likely than their white counterparts to give birth at a Catholic hospital. Catholic health care facilities are governed by the Ethical and Religious Directives , a set of rules that dictate that aborting a pregnancy only becomes permissible if fetal heart tones are not present or the pregnant person becomes ill—essentially, the watch-and-wait method. This has meant, as multiple cases brought forward by the American Civil Liberties Union have shown, that people are denied critical care they need at these institutions. “And that right there is really unethical and deeply problematic for medicine. But now what we’re seeing is, I think, part of the United States could follow their example,” says Lori Freedman, a medical sociologist at the University of California, San Francisco, who investigates the ways reproductive health care is shaped by our social structure and medical culture. In certain parts of the country, the sheer density of Catholic hospitals means women might have to travel significant distances to receive care at a non-Catholic facility—potentially while suffering a miscarriage. If Roe is overturned, women from a far larger portion of the country may similarly be forced to travel for care. Combine that with the fact that 35 percent of counties in the US are identified as maternity-care deserts—counties with no hospital adequately staffed to provide care for pregnant people. “It’s really unconscionable,” Freedman says. The legal red tape surrounding miscarriage care could also deter women from seeking treatment, for fear of being accused of self-inducing an abortion. “A miscarriage that happens naturally on its own and a pregnancy the ends because someone took medication—they’re pretty indistinguishable,” says Harris. “The fear,” says Manian, “is that it’s going to become a world in which women—especially low-income women and women of color—are criminalized when they come into the emergency room, bleeding from a miscarriage.” A miscarriage is already often shrouded in shame, Harris says. “And this is only going to add a layer of silence and stigma to an experience that is already so difficult for so many people.” Harris’ hospital has begun mapping out clear guidelines and policies to ensure clinicians can make decisions on the basis of what’s best for the patient—not out of fear of breaking the law. “But I’m not sure that all institutions realize what is coming,” she says.