• Sun. Mar 26th, 2023

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‘It’s not just about abortion’: Overturning Roe could limit miscarriage care

Anti-abortion legislation can have unintended medical consequences that extend beyond women seeking to terminate a pregnancy — particularly in the management of a miscarriage, experts say.

On Monday, a leaked draft Supreme Court opinion published by Politico revealed that the high court intends to overturn Roe v. Wade, the 1973 decision that guarantees abortion access.

Up to one in four pregnancies end in miscarriage, according to some estimates, a loss that can be traumatic and dangerous for women. The risk is even higher after age 40. But the medical care a woman needs when she’s had a miscarriage can mirror how an abortion is performed, experts say. 

“Medically, miscarriage and abortions are treated in very similar way,” said Dr. Stephanie Mischell, a family medicine physician in Texas and fellow with Physicians for Reproductive Health.

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That means that laws that restrict abortion or that outlaw certain medications or procedures used in abortion, also have the potential to limit treatment for miscarriage.

“There is this false assumption that abortions can be regulated and restricted and criminalized without impacting women’s health care more broadly,” said Yvonne Lindgren, an associate professor of law at the University of Missouri-Kansas City, who specializes in reproductive rights.

Inga, 62, of Ann Arbor, Michigan, still feels the trauma of her miscarriage from nearly 30 years ago. (She requested her last name not be used due to the stigma around miscarriage.)  

She was 13 weeks pregnant with her third child. 

Extremely heavy bleeding led to a drop in her blood pressure, and her husband rushed her to the emergency room of a Catholic hospital in the state. 

“I was crashing,” Inga said. “I thought, ‘This could kill me.’” 

At the hospital, doctors confirmed she was having a miscarriage. After staunching the bleeding, an obstetrician wanted to perform a procedure called a dilation and curettage — commonly referred to as a D&C — to remove the tissue from the uterus. Not doing so could lead to sepsis or other serious complications, sometimes within hours. 

But the hospital, which was subject to religious doctrine, wouldn’t allow it due to strict anti-abortion policies. That’s because a D&C is also the procedure used during a surgical abortion. 

Inga went home for three days. During that time, her body attempted to pass the tissue that remained in her uterus. She recalls the pain as constant and unbearable. 

Finally, she got the green light to get the procedure, but only if she would first undergo an ultrasound to make sure there was no heartbeat. 

‘A very challenging environment’

Stories of hospitals denying miscarriage care for religious reasons may foreshadow how women’s reproductive health care could be unintentionally impacted by anti-abortion legislation at the state and federal level, Lindgren said.

“In these cases, doctors were faced with ethics committee investigations,” she said, referring to cases at hospitals that follow religious mandates. “Now we’re taking this to a whole new level with risk of criminalization.” 

A miscarriage is considered to be a pregnancy loss that occurs before 20 weeks of pregnancy, according to the Centers for Disease Control and Prevention. A loss that occurs at 20 weeks or later is referred to as stillbirth. 

The same clinical skills used in surgical abortion procedures are often the same as those needed to clear the uterine lining after a miscarriage to prevent serious complications.

The drugs used during a medical abortion can also be used to manage a miscarriage. These drugs — called mifepristone and misoprostol — can help a woman pass a miscarriage. 

If there is already cardiac activity — which usually occurs around six weeks and is currently used as the cutoff for an abortion in a handful of states — it creates a difficult situation for doctors faced with caring for patients who are miscarrying. 

“It’s going to be a very challenging environment for doctors to work in, treating people who are coming with emergency issues related to miscarriages,” Lindgren said. 

Mischell said this is already happening in states like Texas, which bans abortion after six weeks. 

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“I’ve had patients who were 15, 16, or 17 weeks pregnant when the fetus died and had to carry it around, and I’ve seen patients who had been told they can’t get care for miscarriages, even though these services are completely legal for miscarriage,” Mischell said.

The Texas Hospital Association did not immediately respond to a request for comment.

In some cases, doctors may be fearful of being construed as helping someone have an abortion, according to Mischell. Other times, access to abortion medication or D&C equipment are restricted to OB-GYNs — though many women are treated in emergency rooms by emergency medicine doctors. According to the March of Dimes, almost 40 percent of rural counties and 60 percent of urban counties do not have access to hospital-based obstetric services. 

Although current state-level anti-abortion laws limit certain providers’ ability to treat patients for miscarriage, some states have proposed laws that would outlaw these tools completely. For example, a Missouri bill, House Bill 2810, would make using, prescribing and even ordering abortion-inducing devices or drugs a Class A felony.

“These laws don’t outright address miscarriages,” Lindgren said. But “lawmakers have not thought carefully about how we cannot restrict abortion without restricting aspects of women’s reproductive health in ways that are going to be harmful to women.” 

“It’s not just about abortion,” Mischell said. “If it was, people having miscarriages wouldn’t be affected by the law, but they are.”

Giving control to the patient

There is no way to tell exactly when, after a pregnancy loss, the cramping and bleeding which accompanies the passing of the miscarriage will start, and how long it will last, said Dr. Courtney Schriber, an OB-GYN at Penn Medicine in Philadelphia who specializes in family planning, miscarriage and early pregnancy care.

“Expelling the tissue can take hours, or several weeks or even months,” she said. “Because of that, once they have their diagnosis, many patients do not want to continue walking around with a nonviable pregnancy in their bodies. They are looking to reconcile and move on with their lives and try getting pregnant again if that’s what they’d like.”  

Schriber said that the medications that help women plan for this process — rather than risk it unexpectedly occurring when they’re at work, out to dinner, in the middle of the night — also help them regain a sense of control during an often traumatic time. 

“The planning strategy allows people to take control of the process and allows them to feel they don’t have to just be victimized by the event, just wait for nature to take its course,” she said.

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