How access, racial inequity and politics are impacting maternal care
You know all of this. After a 50-year battle between pro-choice and pro-life forces, The United States Supreme Court overturned the majority opinion in 1973’s Roe Vs. Wade decision. With the new decision in Dobbs v. Jackson Women’s Health Organization (2022), the court majority (made up of five men and one woman) rejected the notion that the constitution protects a pregnant person’s right to decide for themselves whether to keep or abort their baby. The decision sent the issue back to the states, where a number of jurisdictions had trigger laws banning abortion which immediately went into effect. And just like that, abortion was illegal for close to half of the states (with still others to follow suit).
The “pro-life” side of the debate had adopted the opinions that a fertilized ova is a fully-fledged human with the right to life, and that killing that living being is illegal and wrong. Whether that opinion is true or not is a matter of furious dispute, but that’s not really of concern to the Supreme Court. Their job is merely to decide whether the right to abortion is protected in the constitution. And very specifically, it was to decide whether the constitutional “right to privacy” extended to the right to choose whether to have a baby or not. The 1973 Roe court said yes, the 2022 Dobbs court said no.
Pro-life is also pro-death
As a slogan, “pro-life,” is very clear, unambiguous and rigid. Life is good, death is bad. But once you step away from the shouting matches and into the hospital rooms, the issues get mighty complicated.
The closer you look, the clearer it becomes that both sides of the argument are pro-life… AND pro-death. If you believe that life starts at conception, it would follow that an abortion terminates the “life” of the fetus. On the other hand, an abortion could also SAVE the life of the pregnant person. Confused? Join the club.
You see, America is abysmal at taking care of pregnant people – it has the highest maternal mortality rate (MMR), the number of deaths per 100,000 births, in the industrialized world. In fact, maternal mortality is the ninth leading cause of death for women between the ages of 20-44.
By forcing people to give birth, especially those with life-threatening pregnancy complications, these new rigid abortion laws are effectively condemning people to death. If someone in anti-abortion states has a medical complication during their pregnancy, whereby aborting the fetus is the wisest treatment, it could instead be a death sentence. These new restrictive laws have no exceptions for medical emergencies (In fact, most have no exceptions at all – victims of rape and incest, for example, are forced to carry to term).
Therefore, if someone is truly pro-life, then abortion can’t be completely off the table because it could save the life of the pregnant person. In fact, it’s 14 times more dangerous to carry a baby to term than it is to have an abortion. There are medical and societal reasons for this.
Why pregnancy is so dangerous in America
People* have been giving birth since the dawn of time. Of course, life expectancy was around 30 years and people died from simple infections.
Data surrounding the maternal mortality ratio has been collected in the United States since the early 1900’s. In 1915, the MMR was 607.9 (again, deaths per 100,000 births). In 2018, the MMR in the United States was 17.4 – a pretty impressive improvement (yay science!). However, in 2020, that number climbed to 23.8. While reasons for this jump are unclear, one conclusion might be that greater restrictions on abortion have led to the recent spike.
The causes of maternal mortality can be broken out into two categories: medical and societal.
Medical reasons people die during pregnancy and birthing
Having a baby is one of the most miraculous things a human being can do, but it’s incredibly hard on the body. As mentioned previously, the current average death per 100,000 births in the United States is 23.8.
At around 12 weeks pregnant, the uterus is about the size of a grapefruit. By full term, the uterus is the size of a watermelon and has pushed all internal organs out of the way. This kind of trauma has inherent dangers.
Here are just a few of the medical issues that can lead to maternal death:
- Severe bleeding/Hemorrhaging
- Infections and sepsis
- Cardiovascular conditions, such as:
- Blockages (sometimes called embolisms) in arteries and veins
- Stroke (also called cerebrovascular accidents)
- Blood pressure disorders of pregnancy, including preeclampsia and eclampsia
- Heart muscle problems (called cardiomyopathy)
- Heart disease
- Problems with anesthesia
- Amniotic fluid embolism
- Non-cardiovascular conditions, such as diabetes and breathing problems
The maternal mortality rate doesn’t just measure deaths during pregnancy and birth, it also includes up to the first year after giving birth where half of pregnancy-related deaths happen. Breaking down the medical causes further:
- During pregnancy: The leading causes of death are hemorrhage and cardiovascular conditions.
- At birth and shortly after: Infection is the leading cause of death
- In the postpartum period (up to 1 year after giving birth): Cardiomyopathy (weakened heart muscle) and suicide are often the leading causes of death. This is a more dangerous time for new parents as they are no longer in the hospital and beyond the traditional six- or eight-week post-pregnancy visit.
Societal factors that lead to the death of a pregnant or new parent are harder to track, but just as important.
- Economic: Medical care is exorbitant, if not unaffordable for most and babies are expensive. Some people do not have access to doctors, which means they don’t get the prenatal care they need and that might catch possible complications such as gestational diabetes, high-blood pressure, fetal abnormalities, etc. Not having vital prenatal care can lead to an increase in risk for pregnant people. Should preeclampsia or gestational diabetes go unchecked, for example the risk to the pregnant person could be fatal.
- Abusive relationships: Abuse comes in many forms – verbal, emotional, physical, rape, and even murder. Somewhere between 3-9% of pregnant people experience abuse during pregnancy. Even more devastating are the results of a recent study which found that homicide during pregnancy or within 42 days of the end of pregnancy was the number one cause of death – by more than double any other cause. Pregnancy can also trigger the abuse, especially if the abuser wants the baby aborted and that option is not available.
- Mental health: Pregnancy can trigger mental health issues when none previously existed or it can exacerbate ones that are there. If someone is taking medication to manage their mental illness, they may need to stop taking that medication for the duration of the pregnancy – for the safety of the fetus. One in seven people suffer from postpartum depression, and in cases of traumatic birth, people may also suffer from post-traumatic stress disorder. Severe mental health issues can lead to suicide and substance abuse. The rate of post delivery suicide has been steadily increasing.
- Substance abuse: Pregnancy can be wonderful in many ways, but it’s also incredibly hard. Giving birth many times more so. Raising a baby is hard. For some people, the way to cope with this is through abusing drugs or alcohol.
Another major societal cause is a general lack of information available about the risks of pregnancy. There is this idea that talking about the bad things that can happen isn’t good for anyone. Yes, every pregnant person knows to avoid raw fish, alcohol, and soft cheese, but they don’t know that they could die from severe bleeding days after giving birth. We spend so much time warning people about the risk they pose to the fetus, but we don’t spend a lot of time talking about the risks the fetus poses to the pregnant person.
Black people more likely to die
While being pregnant while white can be rough, it’s a cake-walk compared to the Black person’s experience.
Pregnancy is the 7th leading cause of death for Black people between the ages of 20-44 versus 9th overall for the overall population of the U.S.. The MMR for Black women is 37.1 vs. 14.7 for white women. Black women are 5-times more likely to die from pregnancy related cardiomyopathy and blood pressure disorders than white women. In addition, Black women are 3.5 more likely to die from complications after giving birth than their white counterparts.
Being an educated Black person will not help you. A recent study has shown that a Black person with a college education is at a 60% greater risk for maternal death than a white person with less than a high school education.
Being a famous Black woman will not necessarily save you either. In 2018, Serena Williams gave birth to her daughter. Less than 24 hours after giving birth, Serena developed major complications that started with a pulmonary embolism, which is a condition in which one or more arteries in the lungs becomes blocked by a blood clot. She did her best to advocate for herself, and as often happens to Black women in similar situations, she was ignored or dismissed. Luckily for Serena, and the tennis world, she persisted and was listened to. Many Black women are not as lucky.
Not surprisingly, where a person of color lives also plays a major role in the MMR. For example, Mississippi has a MMR of 33.2. However if you break that out by race, the MMR for white women is 18.9 and for Black women it’s 51.9. Read that again. The MMR for Black people in Mississippi is 51.9.
What does this mean for a post-Roe United States?
The Supreme Court’s decision in Dobbs was like a bomb going off. The full impact of this decision has yet to be realized, but if the speed with which states are moving to outlaw abortion are any indication, things are going to get worse. Way worse. We are already hearing about people suffering from delayed medical care. It will not be long before people die from this decision.
Current access to abortion
23 states had laws ready to go into effect the moment Roe was overturned. If you look at a map of the US and the states with laws outlying abortion, you will see a strong correlation with states with the highest MMR – with New Jersey being the only outlier.
With access to abortion being restricted, these are just a few of the ways in which pregnant people’s health care is at risk:
An ectopic pregnancy is when a fertilized egg implants outside of the uterus in the fallopian tube. This is a non-viable pregnancy and very dangerous for the pregnant person. Without an abortion, the pregnant person’s life or future reproductive health is at risk. There is no way a child can be born from an ectopic pregnancy, yet restrictive abortion laws in some states would require a person to go untreated. In some cases the laws have scared doctors so much that they’re unwilling to treat an ectopic pregnancy.
There is only one treatment for an ectopic pregnancy: abortion.
Treatment for cancer and rheumatoid arthritis (and others)
Already, stories are starting to pop up of people of child birthing age being denied their regular medications that can also be used as abortifacients.
For people suffering from Rheumatoid Arthritis or RA related diseases, one of the medications on the market that brings relief is Methotrexate. For some, this is the ONLY medication on the market that works for them. Methotrexate, in combination with vaginal misoprostol, is used in the first trimester for a medicated abortion. In states where abortion has been outlawed or under threat, doctors have stopped prescribing and pharmacists have stopped filling this life saving drug.
(Author’s note: my mother suffered from Adult Onset Stills disease – a rare type of inflammatory arthritis. My mother was hospitalized numerous times before they finally diagnosed her. Once they did, her Rheumatologist prescribed Methotrexate for her and her life changed drastically. Her symptoms went away, and she was able to live a full and active life. Had this medication been taken away from her, she would have suffered terribly. It is enraging to me that anti-abortion laws are taking away this medication from the people who need it the most.)
There are other stories popping up of pregnant cancer patients not being able to get the medical care they need because doctors are afraid of treating them. Chemotherapy and radiation can impact a fetus and cause a miscarriage. Doctors in some states fear that they will be prosecuted. For some cancers (eg. cervical), abortion is required before treatment can begin.
The fear in the medical community is real and is leading to diminished medical care for people capable of getting pregnant.
Access to birth control
It’s not just medication that can be used to induce an abortion. A recent report showed that in twenty-six states, people have filed complaints against pharmacists refusing to fill birth control prescriptions because it violates the pharmacist’s personal beliefs.
With Roe overturned, there is a lot of fear that states will start to go after certain forms of birth control – specifically IUDs and plan B emergency contraception. Missouri has already tried to prohibit Missouri’s Medicaid agency from paying for those forms of contraception.
Soon after the draft of the Dobbs decision was leaked, Louisiana voted on a bill that would have banned IUD’s in the state. They have since backed away from that – but may try again. Because of this, and the fear of retroactive penalties, people are being blocked from getting an IUD or the support medications that are needed to make IUD’s less painful.
Recently, a Walgreens pharmacist in Louisiana refused to fill a prescription for Cytotec, a medication that makes the insertion of an IUD less painful but is also the brand name for misoprostol, the second part of a two-drug cocktail used to terminate a pregnancy. Even though the prescribing doctor made it clear that the drug was to be used to reduce pain in the insertion of an IUD, the pharmacist still refused to fill the prescription.
There is also a risk that Griswold v. Connecticut (1965), which used the same right to privacy in the Constitution as Roe to protect access to birth control, will also be overturned by this Supreme Court. The House of Representatives recently passed a bill to protect access to birth control. Of the 213 Republicans in the House, all but 8 voted against this bill.
Miscarriages being prosecuted
Miscarriage is a terrible thing to go through for most people. It can be painful, heartbreaking, scary and involve a lot of blood loss. In some instances the body will only expel some of the fetal tissue, requiring the rest to be removed medically by a procedure called dilation and curettage (D&C) to avoid the risk of infection. When you miscarry, a doctor or a hospital visit is usually in order to make sure that everything is ok.
In states with strict anti-abortion laws, reports are coming out of people too scared to go to the doctors out of fear that they could be suspected of causing the miscarriage and be prosecuted for an illegal abortion.
Currently, 20% of pregnancies in the United States are lost to miscarriage or still-birth. That is a lot of people potentially not seeking medical care out of fear that they will be charged with a crime. Or a lot of innocent people going to jail.
(Author’s Note: I suffered multiple miscarriages – including one in my second trimester. Had I not gone to a doctor I would have bled out or potentially lost my ability to have a child due to severe uterine infection that was discovered a week after my miscarriage.)
There are other ways that the overturning of Roe will have an adverse effect on people in this country. As the economic divide between those with means and those without continues to grow, the foster care system could be overwhelmed by children that parents either are unable to care for or didn’t want in the first place.
You can also expect plenty more pregnant people to die. A recent study at the CU Population Center at the University of Colorado Boulder shows that banning abortion nationwide would lead to a 21% increase in the number of pregnancy-related deaths for all and a 33% increase among Black people.
Finally, as anti-abortion laws remove carveouts for rape and incest, more stories of traumatized people being further traumatized will come out. If a 10-year old rape victim being impregnated by her attacker and then having to travel across state lines to receive an abortion isn’t enough to shock you, nothing will.
The safety of abortion
While the risks of giving birth are numerous, the risks of abortion are limited. Out of the estimated 900,000 abortions each year, 93% take place in the first trimester (before 13 weeks) 6% are performed between 14 and 20 weeks of pregnancy, and 1% were performed at 21 weeks or more of gestation. The number of deaths per 100,000 legal abortion is 0.4 per 100,000. Compare that to the current MMR of 23.8.
The bottom line in the discussion of abortion and the dangers of being pregnant in American is simple: Abortion is health care. Period.
* Note: The use of person and pregnant person is very intentional as women, trans men and non-binary persons are all capable of getting pregnant. Inclusivity on this topic is as important as the topic itself.