Usually, articles in medical journals are about science; they bring data to their readers, who can use them to provide evidence-based care to their patients.
But sometimes, evidence is an expression of grief or even rage. A recent journal article, “Maternal Morbidity and Fetal Outcomes Among Pregnant Women at 22 Weeks’ Gestation or Less with Complications in 2 Texas Hospitals After Legislation on Abortion,” contains such evidence.
To understand this article, you need to know that any number of complications can threaten a pregnancy, such as rupture of the bag of water around the baby, preterm labor, or heavy bleeding. When those complications arise before 22 weeks of gestation— before the age of viability when a fetus can live outside of a uterus—the standard of medical care is to offer a patient termination of pregnancy as an option. Women who continue pregnancy in these situations take on significant risks to their own health, and because of the early gestation, the chance for a healthy baby is very, very low.
However, in September 2021, Texas adopted two measures, S.B. 4 and S.B. 8, which instituted punitive actions against anyone providing abortion. These laws took effect before the Supreme Court decision ended Roe v. Wade. And all of a sudden, termination of pregnancy became impossible in Texas unless and until there was an “immediate threat to maternal life.”
The journal article, published in the American Journal of Obstetrics and Gynecology, describes the experience of two large Texas hospitals over a period of eight months following that legislation. The authors, who care for patients at those hospitals, describe how their hospitals managed 28 women who presented at less than 22 weeks’ gestation with serious complications following the ban on abortion.
Without the ability to offer abortion to their patients, all 28 women were managed expectantly. This is a medical way of saying that they waited for something terrible to happen. That wait lasted, on average, nine days.
During that nine days of waiting, here is what was achieved for the babies: 27 of the patients had loss of the fetus in utero or the death of the infant shortly after delivery. Of the entire cohort, one baby remained alive, still in the NICU at time of the journal article’s publication, with a long list of complications from extreme prematurity, including bleeding in the brain, brain swelling, damage to intestines, chronic lung disease. and liver dysfunction. If a baby survives these complications, they often result in permanent, lifelong illnesses.
During those nine days of waiting for an immediate threat to maternal life, here is what happened to the women of that cohort: Most of them went into labor, or had a stillbirth, which meant the medical team could then legally intervene and empty the uterus. Fifty-seven percent of those pregnant women had some sort of complication, and for about a third of them, it was serious enough to require intensive-care admission, surgery, or a second admission to the hospital. One of the 28 patients ended up with a hysterectomy, which means she will never carry a pregnancy again. The authors of the article estimate, based on their pre-September practice, that about half of those maternal complications would have been avoided if immediate abortion had been offered as a choice. But of course, post-September in Texas, these women didn’t get a choice.
Recently, 1,500 miles away from those patients in Texas, I took care of a similar patient, who we’ll call M, at my practice in New York City. M was at 20 weeks’ gestation and had three prior term pregnancies. While she was shopping at the grocery store, her water broke. She came into our labor and delivery unit, where we diagnosed her rupture of membranes; the pregnancy now was not protected from infection, and was likely to end in infection or labor within days to weeks.
I spent over an hour with M and her husband, as the high-risk pregnancy expert, discussing all the things that might happen. I brought in our neonatology ICU experts for further counseling. I offered her watchful management of the continuing pregnancy, and I offered her termination of pregnancy. I offered to give her more time to decide. There was no rush, I said; there was no current immediate threat to her maternal life, though that could change quickly.
At the end of that counseling, M was clear: She needed to get home to her three young children. She did not feel that she could take on the high risk of trying to stay pregnant with a baby that would likely not survive. She asked us to start an induction of labor as soon as possible.
We started her labor that evening; by the morning, she was delivered of her pregnancy. She bled very little, and she never got an infection. At her request, she was discharged home a few hours later, with close follow-up, just 24 hours after that outing to the grocery store.
She walked out of my hospital with her family. She was grieving, but healthy.
She has an appointment with me in a few weeks in which we’ll discuss what happened and make a plan so her next pregnancy, should she desire one, can be as healthy as possible.
This is the care that modern medical practice demands we provide: patient-centered and evidence-based. It is care full of options that I am grateful to be able to offer to patients who need them. And it is also care that my colleagues in Texas, or in Arizona or North Dakota or the 10 other states where abortion has been categorically banned, can no longer give. Instead, they are forced to compel women into waiting until an immediate threat to maternal life can be proven, when they can finally offer to act. None of that care feels compatible with the central medical tenet of “do no harm”; the journal article shows exactly how much harm this kind of care causes. “Although limited by sample size,” the authors write, “our findings offer a glimpse into the possible not-so-distant future.”
The people who suffer most because of limitations in good obstetric care in these states are, of course, the patients. The paper was written by doctors who are no longer allowed to provide the care they trained for years to provide. And in that setting, they wrote this paper to document the suffering and danger they see, which they could have offered choices to help prevent. This is a medical publication of data about that compromised medical care. It is a paper full of evidence. It is also a paper full of the rage and grief of being forced to offer substandard medical care to patients who are suffering. It won’t be the last.