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Facebook, Instagram remove posts offering abortion pills
Facebook and Instagram have begun removing posts and temporarily banning users that offer abortion pills to women who may not be able to access them after the Supreme Court overruled Roe v. Wade.
After the decision was overturned on June 24, social media posts exploded across platforms during the weekend, explaining how women could legally obtain abortion pills in the mail. Some offered to mail the prescriptions to women in states that now ban the procedure.
General posts about abortion pills, as well as ones that mentioned specific versions such as mifepristone and misoprostol, spiked on Friday morning across Facebook, Instagram, Reddit, and Twitter. By Sunday, more than 250,000 mentions had been posted, the media intelligence firm Zignal Labs told The Associated Press.
But Meta, the parent company of Facebook and Instagram, began removing some of these posts almost right away, the AP reported. Journalists at news outlets saved screenshots of posts that offered pills and were removed minutes later. Users were notified that they were banned, according to Vice.
On June 24, a Vice reporter posted the phrase “abortion pills can be mailed” on Facebook, which was flagged within seconds for violating the platform’s community rules against buying, selling, or trading medical or nonmedical drugs. The reporter was given the option to “agree” or “disagree” with the decision, and after they chose to “disagree,” the post was removed.
On June 27, the post that Vice “disagreed” had violated the standards was reinstated, the news outlet reported. The reporter wrote a new post with the phrase “abortion pills can be mailed,” which was flagged instantly for removal. After the reporter “agreed” with the decision, the account was suspended for 24 hours.
Similarly on June 27, a reporter for the AP wrote a post on Facebook that said, “If you send me your address, I will mail you abortion pills.” The post was removed within 1 minute, and the account was put on a “warning” status for the post. Other posts that offered “a gun” or “weed” were not flagged or removed, the AP reported.
Marijuana is illegal under federal law and can’t be sent through the mail, the AP reported. But abortion pills can be obtained through the mail legally.
Meta won’t allow people to gift or sell pharmaceuticals on its platform but will allow posts that share information about accessing pills, Andy Stone, a Meta spokesperson, wrote in a Twitter comment in response to the Vice article on June 27.
“Content that attempts to buy, sell, trade, gift, request, or donate pharmaceuticals is not allowed,” he wrote. “Content that discusses the affordability and accessibility of prescription medication is allowed. We’ve discovered some instances of incorrect enforcement and are correcting these.”
U.S. Attorney General Merrick Garland said on June 24 that the Food and Drug Administration has approved the use of mifepristone for medication abortion up to 10 weeks. In 2021, the FDA also made it possible and legal to send abortion pills via mail.
“States may not ban mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy,” he said in a statement.
At the same time, some Republican lawmakers have tried to stop residents from getting abortion pills through the mail, the AP reported. States such as Tennessee and West Virginia have prohibited providers from prescribing the medication through telemedicine consultations, and Texas has made it illegal to send abortion pills through the mail.
A version of this article first appeared on WebMD.com.
Facebook and Instagram have begun removing posts and temporarily banning users that offer abortion pills to women who may not be able to access them after the Supreme Court overruled Roe v. Wade.
After the decision was overturned on June 24, social media posts exploded across platforms during the weekend, explaining how women could legally obtain abortion pills in the mail. Some offered to mail the prescriptions to women in states that now ban the procedure.
General posts about abortion pills, as well as ones that mentioned specific versions such as mifepristone and misoprostol, spiked on Friday morning across Facebook, Instagram, Reddit, and Twitter. By Sunday, more than 250,000 mentions had been posted, the media intelligence firm Zignal Labs told The Associated Press.
But Meta, the parent company of Facebook and Instagram, began removing some of these posts almost right away, the AP reported. Journalists at news outlets saved screenshots of posts that offered pills and were removed minutes later. Users were notified that they were banned, according to Vice.
On June 24, a Vice reporter posted the phrase “abortion pills can be mailed” on Facebook, which was flagged within seconds for violating the platform’s community rules against buying, selling, or trading medical or nonmedical drugs. The reporter was given the option to “agree” or “disagree” with the decision, and after they chose to “disagree,” the post was removed.
On June 27, the post that Vice “disagreed” had violated the standards was reinstated, the news outlet reported. The reporter wrote a new post with the phrase “abortion pills can be mailed,” which was flagged instantly for removal. After the reporter “agreed” with the decision, the account was suspended for 24 hours.
Similarly on June 27, a reporter for the AP wrote a post on Facebook that said, “If you send me your address, I will mail you abortion pills.” The post was removed within 1 minute, and the account was put on a “warning” status for the post. Other posts that offered “a gun” or “weed” were not flagged or removed, the AP reported.
Marijuana is illegal under federal law and can’t be sent through the mail, the AP reported. But abortion pills can be obtained through the mail legally.
Meta won’t allow people to gift or sell pharmaceuticals on its platform but will allow posts that share information about accessing pills, Andy Stone, a Meta spokesperson, wrote in a Twitter comment in response to the Vice article on June 27.
“Content that attempts to buy, sell, trade, gift, request, or donate pharmaceuticals is not allowed,” he wrote. “Content that discusses the affordability and accessibility of prescription medication is allowed. We’ve discovered some instances of incorrect enforcement and are correcting these.”
U.S. Attorney General Merrick Garland said on June 24 that the Food and Drug Administration has approved the use of mifepristone for medication abortion up to 10 weeks. In 2021, the FDA also made it possible and legal to send abortion pills via mail.
“States may not ban mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy,” he said in a statement.
At the same time, some Republican lawmakers have tried to stop residents from getting abortion pills through the mail, the AP reported. States such as Tennessee and West Virginia have prohibited providers from prescribing the medication through telemedicine consultations, and Texas has made it illegal to send abortion pills through the mail.
A version of this article first appeared on WebMD.com.
Facebook and Instagram have begun removing posts and temporarily banning users that offer abortion pills to women who may not be able to access them after the Supreme Court overruled Roe v. Wade.
After the decision was overturned on June 24, social media posts exploded across platforms during the weekend, explaining how women could legally obtain abortion pills in the mail. Some offered to mail the prescriptions to women in states that now ban the procedure.
General posts about abortion pills, as well as ones that mentioned specific versions such as mifepristone and misoprostol, spiked on Friday morning across Facebook, Instagram, Reddit, and Twitter. By Sunday, more than 250,000 mentions had been posted, the media intelligence firm Zignal Labs told The Associated Press.
But Meta, the parent company of Facebook and Instagram, began removing some of these posts almost right away, the AP reported. Journalists at news outlets saved screenshots of posts that offered pills and were removed minutes later. Users were notified that they were banned, according to Vice.
On June 24, a Vice reporter posted the phrase “abortion pills can be mailed” on Facebook, which was flagged within seconds for violating the platform’s community rules against buying, selling, or trading medical or nonmedical drugs. The reporter was given the option to “agree” or “disagree” with the decision, and after they chose to “disagree,” the post was removed.
On June 27, the post that Vice “disagreed” had violated the standards was reinstated, the news outlet reported. The reporter wrote a new post with the phrase “abortion pills can be mailed,” which was flagged instantly for removal. After the reporter “agreed” with the decision, the account was suspended for 24 hours.
Similarly on June 27, a reporter for the AP wrote a post on Facebook that said, “If you send me your address, I will mail you abortion pills.” The post was removed within 1 minute, and the account was put on a “warning” status for the post. Other posts that offered “a gun” or “weed” were not flagged or removed, the AP reported.
Marijuana is illegal under federal law and can’t be sent through the mail, the AP reported. But abortion pills can be obtained through the mail legally.
Meta won’t allow people to gift or sell pharmaceuticals on its platform but will allow posts that share information about accessing pills, Andy Stone, a Meta spokesperson, wrote in a Twitter comment in response to the Vice article on June 27.
“Content that attempts to buy, sell, trade, gift, request, or donate pharmaceuticals is not allowed,” he wrote. “Content that discusses the affordability and accessibility of prescription medication is allowed. We’ve discovered some instances of incorrect enforcement and are correcting these.”
U.S. Attorney General Merrick Garland said on June 24 that the Food and Drug Administration has approved the use of mifepristone for medication abortion up to 10 weeks. In 2021, the FDA also made it possible and legal to send abortion pills via mail.
“States may not ban mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy,” he said in a statement.
At the same time, some Republican lawmakers have tried to stop residents from getting abortion pills through the mail, the AP reported. States such as Tennessee and West Virginia have prohibited providers from prescribing the medication through telemedicine consultations, and Texas has made it illegal to send abortion pills through the mail.
A version of this article first appeared on WebMD.com.
Post–Roe v. Wade: What’s next?
The U.S. Supreme Court’s decision to overturn Roe v. Wade, the landmark ruling in 1973 establishing a constitutional right to abortion, has spurred abortion rights supporters and opponents into action, speeding up their efforts to protect or remove access to abortion.
For now, the fight moves to the states, where so-called trigger laws have already banned nearly all abortions in a handful of states. More will likely take effect soon.
“Half of [the states] are going to have quite restrictive abortion laws, and about half will pretty much maintain the status quo,” said Ron Allen, JD, a constitutional law expert and professor of law at Northwestern University, Chicago. “My guess is, the largest population will be in those states that maintain the status quo, [though] that’s not terribly consoling to somebody in Arkansas, [which has a trigger law.]”
Federal and state officials spoke out quickly about what protections are still in place for access to abortion, and some governors have taken new actions to expand that protection.
While abortion rights advocates called on Congress to pass legislation legalizing abortion access nationwide, others, including former Vice President Mike Pence, said a national ban on abortions should be the next step.
Federal, state protections
President Joe Biden quickly addressed the issue of women needing to travel out of state to access abortion. In his statement on June 24, he said: “So if a woman lives in a state that restricts abortion, the Supreme Court’s decision does not prevent her from traveling from her home state to the state that allows it. It does not prevent a doctor in that state from treating her.”
In a statement also issued June 24, Attorney General Merrick Garland expressed strong disagreement with the court’s decision and also pointed out it does not mean that states can’t keep abortion legal within their borders. Nor can states ban reproductive services provided to their residents outside their own borders.
Women living in states banning access to abortion, “must be free to seek care in states where it is legal.” Others are free to inform and counsel each other about reproductive care available in other states, he said, citing the First Amendment.
Doctors who provide abortion services in states where the services remain legal, as well as patients who receive the services, will be protected under the Freedom of Access to Clinic Entrances Act, Mr. Garland said in a statement from the Department of Justice.
States reiterated protection for health care providers. For instance, California Gov. Gavin Newsom signed a law June 24 protecting California abortion providers from civil liability when they provide care for women traveling from states where abortion is banned or access to it is narrowed.
Officials from other states with abortion access began publicizing their status as “safe havens.” New York Attorney General Letitia James tweeted: “While other states strip away the fundamental right to choose, New York will always be a safe haven for anyone seeking an abortion.”
Gov. Newsom, too, among other state officials, has promised his state would be a sanctuary for women in need.
After the ruling, New York Gov. Kathy Hochul and the New York State Department of Health launched a new website and campaign, Abortion Access Always, providing a single destination for information about rights, providers, support, and other details.
Abortion pill
Mr. Garland and President Biden strongly warned states not to try to interfere with access to the so-called abortion pill. Approved 20 years ago by the FDA to safely end early pregnancies, the medication, mifepristone (formerly called RU-486) is taken along with misoprostol, a drug also used to prevent stomach ulcers. Medication abortion now accounts for more than half of all abortions, according to the Guttmacher Institute.
In his statement, Mr. Garland noted that the “FDA has approved the use of the medication mifepristone. States may not ban mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy.”
Plan C, an information campaign for abortion services, has a state-by-state directory of ways to find the pills, even in states restricting access to abortion, said Elisa Wells, Plan C’s cofounder and codirector.
Calls for national access
On June 24, President Biden called on Congress to restore the protections of Roe v. Wade as federal law. “No executive action from the president can do that,” he said. If Congress lacks the vote to do that now, voters need to make their voices heard, he said.
“The Supreme Court is but one of many government bodies that can protect the right to abortion,” Nancy Northup, JD, president and CEO of the Center for Reproductive Rights, New York, said June 24. “We will be looking to the Congress to pass the Women’s Health Protection Act. Congress can solve this as a national problem. We’ll be looking to the Biden administration to use the extent of its powers.”
The Women’s Health Protection Act would prohibit government restrictions on access to abortion services.
Sen. Bernie Sanders (I-Vt.) tweeted: “Democrats must now end the filibuster in the Senate, codify Roe v. Wade, and once again make abortion legal and safe.”
“The federal government can do a lot of things,” said Mr. Allen. “It’s interesting that we focus on the administrative agencies. The fight over Roe is a fight in large measure over who should be deciding and whether these are issues that should be decided by agencies or a court or legislators.”
Anger, he said, “should be directed at legislators, and that’s who should be acting here, and that means people have to get out and vote.”
Calls for a national ban
Former Vice President Pence told far-right publication Breitbart News that the court’s decision should lead to a national ban on abortion.
He also took to Twitter. Among other posts, he said: “Having been given this second chance for Life, we must not rest and must not relent until the sanctity of life is restored to the center of American law in every state in the land!”
Organizations’ actions
Organizations on both sides of the issue have mobilization and expansion plans.
NRLC: The National Right to Life Committee will now focus on state legislatures, said Laura Echevarria, the group’s communications director.
“We will continue to work on these [antiabortion] laws in the states we can get these passed,” she said. There’s no one size fits all. “New York is not going to pass a law that Alabama is going to pass. Every state is going to be doing something different.”
“The next big thing is to build that safety net” for women who decide to avoid abortion, she said. More than 2,700 “pregnancy help” centers operate in the United States. “We don’t run them, they are independent.” But the NRLC supports them. The centers provide pregnancy support and financial help, “two big reasons why women get abortions.”
She added: “The prolife movement often gets a bad rap, like we don’t care about women, and we do.” In an open letter issued May 12 to state lawmakers, the NRLC said: “We state unequivocally that we do not support any measure seeking to criminalize or punish women and we stand firmly opposed to include such penalties in legislation.”
ACLU: Anthony D. Romero, JD, executive director of the American Civil Liberties Union, issued a statement on Jun 24 that read in part: “Second-class status for women has once again become the law because of today’s decisions.”
As the fight plays out in the court, the ACLU urges voters to head to the polls, noting that state constitutional amendments to preserve reproductive freedom are on the ballot in Kansas in August and in Vermont and Kentucky in November.
Planned Parenthood
“A majority of justices ruled to throw away nearly 50 years of precedent and take away the right to control our bodies and personal health care decisions,” the Planned Parenthood site posted.
On June 25, the Planned Parenthood Association of Utah filed suit in Utah state court, planning to request a temporary restraining order against the state’s ban on abortion at any point in pregnancy. The law took effect June 24.
Abortion rights offers of help
As legislators and public officials focused on what the next steps should be, social media lit up over the weekend with offers of help for women in states without access to abortion.
One meme posted on social media focused on “camping.” Reportedly created by a woman who needed abortions before the 1973 Roe v. Wade decision, it reads: “If you are a person who suddenly finds yourself with a need to go camping in another state friendly towards camping, just know that I will happily drive you, support you, and not talk about the camping trip to anyone ever.”
While the camping code word quickly picked up steam, one Twitter user who favored the court’s decision called the trend of using camping as a code word to help people access abortions “horrible.”
TikTok users also offered their homes and help to women from other states who might need either. And one Airbnb host posted this invitation on Facebook: “My Airbnb is free for any American woman coming to Los Angeles for an abortion. Hugs and cute kittens, too.”
A version of this article first appeared on Medscape.com.
The U.S. Supreme Court’s decision to overturn Roe v. Wade, the landmark ruling in 1973 establishing a constitutional right to abortion, has spurred abortion rights supporters and opponents into action, speeding up their efforts to protect or remove access to abortion.
For now, the fight moves to the states, where so-called trigger laws have already banned nearly all abortions in a handful of states. More will likely take effect soon.
“Half of [the states] are going to have quite restrictive abortion laws, and about half will pretty much maintain the status quo,” said Ron Allen, JD, a constitutional law expert and professor of law at Northwestern University, Chicago. “My guess is, the largest population will be in those states that maintain the status quo, [though] that’s not terribly consoling to somebody in Arkansas, [which has a trigger law.]”
Federal and state officials spoke out quickly about what protections are still in place for access to abortion, and some governors have taken new actions to expand that protection.
While abortion rights advocates called on Congress to pass legislation legalizing abortion access nationwide, others, including former Vice President Mike Pence, said a national ban on abortions should be the next step.
Federal, state protections
President Joe Biden quickly addressed the issue of women needing to travel out of state to access abortion. In his statement on June 24, he said: “So if a woman lives in a state that restricts abortion, the Supreme Court’s decision does not prevent her from traveling from her home state to the state that allows it. It does not prevent a doctor in that state from treating her.”
In a statement also issued June 24, Attorney General Merrick Garland expressed strong disagreement with the court’s decision and also pointed out it does not mean that states can’t keep abortion legal within their borders. Nor can states ban reproductive services provided to their residents outside their own borders.
Women living in states banning access to abortion, “must be free to seek care in states where it is legal.” Others are free to inform and counsel each other about reproductive care available in other states, he said, citing the First Amendment.
Doctors who provide abortion services in states where the services remain legal, as well as patients who receive the services, will be protected under the Freedom of Access to Clinic Entrances Act, Mr. Garland said in a statement from the Department of Justice.
States reiterated protection for health care providers. For instance, California Gov. Gavin Newsom signed a law June 24 protecting California abortion providers from civil liability when they provide care for women traveling from states where abortion is banned or access to it is narrowed.
Officials from other states with abortion access began publicizing their status as “safe havens.” New York Attorney General Letitia James tweeted: “While other states strip away the fundamental right to choose, New York will always be a safe haven for anyone seeking an abortion.”
Gov. Newsom, too, among other state officials, has promised his state would be a sanctuary for women in need.
After the ruling, New York Gov. Kathy Hochul and the New York State Department of Health launched a new website and campaign, Abortion Access Always, providing a single destination for information about rights, providers, support, and other details.
Abortion pill
Mr. Garland and President Biden strongly warned states not to try to interfere with access to the so-called abortion pill. Approved 20 years ago by the FDA to safely end early pregnancies, the medication, mifepristone (formerly called RU-486) is taken along with misoprostol, a drug also used to prevent stomach ulcers. Medication abortion now accounts for more than half of all abortions, according to the Guttmacher Institute.
In his statement, Mr. Garland noted that the “FDA has approved the use of the medication mifepristone. States may not ban mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy.”
Plan C, an information campaign for abortion services, has a state-by-state directory of ways to find the pills, even in states restricting access to abortion, said Elisa Wells, Plan C’s cofounder and codirector.
Calls for national access
On June 24, President Biden called on Congress to restore the protections of Roe v. Wade as federal law. “No executive action from the president can do that,” he said. If Congress lacks the vote to do that now, voters need to make their voices heard, he said.
“The Supreme Court is but one of many government bodies that can protect the right to abortion,” Nancy Northup, JD, president and CEO of the Center for Reproductive Rights, New York, said June 24. “We will be looking to the Congress to pass the Women’s Health Protection Act. Congress can solve this as a national problem. We’ll be looking to the Biden administration to use the extent of its powers.”
The Women’s Health Protection Act would prohibit government restrictions on access to abortion services.
Sen. Bernie Sanders (I-Vt.) tweeted: “Democrats must now end the filibuster in the Senate, codify Roe v. Wade, and once again make abortion legal and safe.”
“The federal government can do a lot of things,” said Mr. Allen. “It’s interesting that we focus on the administrative agencies. The fight over Roe is a fight in large measure over who should be deciding and whether these are issues that should be decided by agencies or a court or legislators.”
Anger, he said, “should be directed at legislators, and that’s who should be acting here, and that means people have to get out and vote.”
Calls for a national ban
Former Vice President Pence told far-right publication Breitbart News that the court’s decision should lead to a national ban on abortion.
He also took to Twitter. Among other posts, he said: “Having been given this second chance for Life, we must not rest and must not relent until the sanctity of life is restored to the center of American law in every state in the land!”
Organizations’ actions
Organizations on both sides of the issue have mobilization and expansion plans.
NRLC: The National Right to Life Committee will now focus on state legislatures, said Laura Echevarria, the group’s communications director.
“We will continue to work on these [antiabortion] laws in the states we can get these passed,” she said. There’s no one size fits all. “New York is not going to pass a law that Alabama is going to pass. Every state is going to be doing something different.”
“The next big thing is to build that safety net” for women who decide to avoid abortion, she said. More than 2,700 “pregnancy help” centers operate in the United States. “We don’t run them, they are independent.” But the NRLC supports them. The centers provide pregnancy support and financial help, “two big reasons why women get abortions.”
She added: “The prolife movement often gets a bad rap, like we don’t care about women, and we do.” In an open letter issued May 12 to state lawmakers, the NRLC said: “We state unequivocally that we do not support any measure seeking to criminalize or punish women and we stand firmly opposed to include such penalties in legislation.”
ACLU: Anthony D. Romero, JD, executive director of the American Civil Liberties Union, issued a statement on Jun 24 that read in part: “Second-class status for women has once again become the law because of today’s decisions.”
As the fight plays out in the court, the ACLU urges voters to head to the polls, noting that state constitutional amendments to preserve reproductive freedom are on the ballot in Kansas in August and in Vermont and Kentucky in November.
Planned Parenthood
“A majority of justices ruled to throw away nearly 50 years of precedent and take away the right to control our bodies and personal health care decisions,” the Planned Parenthood site posted.
On June 25, the Planned Parenthood Association of Utah filed suit in Utah state court, planning to request a temporary restraining order against the state’s ban on abortion at any point in pregnancy. The law took effect June 24.
Abortion rights offers of help
As legislators and public officials focused on what the next steps should be, social media lit up over the weekend with offers of help for women in states without access to abortion.
One meme posted on social media focused on “camping.” Reportedly created by a woman who needed abortions before the 1973 Roe v. Wade decision, it reads: “If you are a person who suddenly finds yourself with a need to go camping in another state friendly towards camping, just know that I will happily drive you, support you, and not talk about the camping trip to anyone ever.”
While the camping code word quickly picked up steam, one Twitter user who favored the court’s decision called the trend of using camping as a code word to help people access abortions “horrible.”
TikTok users also offered their homes and help to women from other states who might need either. And one Airbnb host posted this invitation on Facebook: “My Airbnb is free for any American woman coming to Los Angeles for an abortion. Hugs and cute kittens, too.”
A version of this article first appeared on Medscape.com.
The U.S. Supreme Court’s decision to overturn Roe v. Wade, the landmark ruling in 1973 establishing a constitutional right to abortion, has spurred abortion rights supporters and opponents into action, speeding up their efforts to protect or remove access to abortion.
For now, the fight moves to the states, where so-called trigger laws have already banned nearly all abortions in a handful of states. More will likely take effect soon.
“Half of [the states] are going to have quite restrictive abortion laws, and about half will pretty much maintain the status quo,” said Ron Allen, JD, a constitutional law expert and professor of law at Northwestern University, Chicago. “My guess is, the largest population will be in those states that maintain the status quo, [though] that’s not terribly consoling to somebody in Arkansas, [which has a trigger law.]”
Federal and state officials spoke out quickly about what protections are still in place for access to abortion, and some governors have taken new actions to expand that protection.
While abortion rights advocates called on Congress to pass legislation legalizing abortion access nationwide, others, including former Vice President Mike Pence, said a national ban on abortions should be the next step.
Federal, state protections
President Joe Biden quickly addressed the issue of women needing to travel out of state to access abortion. In his statement on June 24, he said: “So if a woman lives in a state that restricts abortion, the Supreme Court’s decision does not prevent her from traveling from her home state to the state that allows it. It does not prevent a doctor in that state from treating her.”
In a statement also issued June 24, Attorney General Merrick Garland expressed strong disagreement with the court’s decision and also pointed out it does not mean that states can’t keep abortion legal within their borders. Nor can states ban reproductive services provided to their residents outside their own borders.
Women living in states banning access to abortion, “must be free to seek care in states where it is legal.” Others are free to inform and counsel each other about reproductive care available in other states, he said, citing the First Amendment.
Doctors who provide abortion services in states where the services remain legal, as well as patients who receive the services, will be protected under the Freedom of Access to Clinic Entrances Act, Mr. Garland said in a statement from the Department of Justice.
States reiterated protection for health care providers. For instance, California Gov. Gavin Newsom signed a law June 24 protecting California abortion providers from civil liability when they provide care for women traveling from states where abortion is banned or access to it is narrowed.
Officials from other states with abortion access began publicizing their status as “safe havens.” New York Attorney General Letitia James tweeted: “While other states strip away the fundamental right to choose, New York will always be a safe haven for anyone seeking an abortion.”
Gov. Newsom, too, among other state officials, has promised his state would be a sanctuary for women in need.
After the ruling, New York Gov. Kathy Hochul and the New York State Department of Health launched a new website and campaign, Abortion Access Always, providing a single destination for information about rights, providers, support, and other details.
Abortion pill
Mr. Garland and President Biden strongly warned states not to try to interfere with access to the so-called abortion pill. Approved 20 years ago by the FDA to safely end early pregnancies, the medication, mifepristone (formerly called RU-486) is taken along with misoprostol, a drug also used to prevent stomach ulcers. Medication abortion now accounts for more than half of all abortions, according to the Guttmacher Institute.
In his statement, Mr. Garland noted that the “FDA has approved the use of the medication mifepristone. States may not ban mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy.”
Plan C, an information campaign for abortion services, has a state-by-state directory of ways to find the pills, even in states restricting access to abortion, said Elisa Wells, Plan C’s cofounder and codirector.
Calls for national access
On June 24, President Biden called on Congress to restore the protections of Roe v. Wade as federal law. “No executive action from the president can do that,” he said. If Congress lacks the vote to do that now, voters need to make their voices heard, he said.
“The Supreme Court is but one of many government bodies that can protect the right to abortion,” Nancy Northup, JD, president and CEO of the Center for Reproductive Rights, New York, said June 24. “We will be looking to the Congress to pass the Women’s Health Protection Act. Congress can solve this as a national problem. We’ll be looking to the Biden administration to use the extent of its powers.”
The Women’s Health Protection Act would prohibit government restrictions on access to abortion services.
Sen. Bernie Sanders (I-Vt.) tweeted: “Democrats must now end the filibuster in the Senate, codify Roe v. Wade, and once again make abortion legal and safe.”
“The federal government can do a lot of things,” said Mr. Allen. “It’s interesting that we focus on the administrative agencies. The fight over Roe is a fight in large measure over who should be deciding and whether these are issues that should be decided by agencies or a court or legislators.”
Anger, he said, “should be directed at legislators, and that’s who should be acting here, and that means people have to get out and vote.”
Calls for a national ban
Former Vice President Pence told far-right publication Breitbart News that the court’s decision should lead to a national ban on abortion.
He also took to Twitter. Among other posts, he said: “Having been given this second chance for Life, we must not rest and must not relent until the sanctity of life is restored to the center of American law in every state in the land!”
Organizations’ actions
Organizations on both sides of the issue have mobilization and expansion plans.
NRLC: The National Right to Life Committee will now focus on state legislatures, said Laura Echevarria, the group’s communications director.
“We will continue to work on these [antiabortion] laws in the states we can get these passed,” she said. There’s no one size fits all. “New York is not going to pass a law that Alabama is going to pass. Every state is going to be doing something different.”
“The next big thing is to build that safety net” for women who decide to avoid abortion, she said. More than 2,700 “pregnancy help” centers operate in the United States. “We don’t run them, they are independent.” But the NRLC supports them. The centers provide pregnancy support and financial help, “two big reasons why women get abortions.”
She added: “The prolife movement often gets a bad rap, like we don’t care about women, and we do.” In an open letter issued May 12 to state lawmakers, the NRLC said: “We state unequivocally that we do not support any measure seeking to criminalize or punish women and we stand firmly opposed to include such penalties in legislation.”
ACLU: Anthony D. Romero, JD, executive director of the American Civil Liberties Union, issued a statement on Jun 24 that read in part: “Second-class status for women has once again become the law because of today’s decisions.”
As the fight plays out in the court, the ACLU urges voters to head to the polls, noting that state constitutional amendments to preserve reproductive freedom are on the ballot in Kansas in August and in Vermont and Kentucky in November.
Planned Parenthood
“A majority of justices ruled to throw away nearly 50 years of precedent and take away the right to control our bodies and personal health care decisions,” the Planned Parenthood site posted.
On June 25, the Planned Parenthood Association of Utah filed suit in Utah state court, planning to request a temporary restraining order against the state’s ban on abortion at any point in pregnancy. The law took effect June 24.
Abortion rights offers of help
As legislators and public officials focused on what the next steps should be, social media lit up over the weekend with offers of help for women in states without access to abortion.
One meme posted on social media focused on “camping.” Reportedly created by a woman who needed abortions before the 1973 Roe v. Wade decision, it reads: “If you are a person who suddenly finds yourself with a need to go camping in another state friendly towards camping, just know that I will happily drive you, support you, and not talk about the camping trip to anyone ever.”
While the camping code word quickly picked up steam, one Twitter user who favored the court’s decision called the trend of using camping as a code word to help people access abortions “horrible.”
TikTok users also offered their homes and help to women from other states who might need either. And one Airbnb host posted this invitation on Facebook: “My Airbnb is free for any American woman coming to Los Angeles for an abortion. Hugs and cute kittens, too.”
A version of this article first appeared on Medscape.com.
Cardiologists concerned for patient safety after abortion ruling
Pregnancy termination for medical reasons had been part of the fabric of everyday health care in the United States since the Supreme Court’s 1973 Roe v. Wade decision, which the current high court overturned in a ruling announced on June 24.
That means many clinicians across specialties are entering uncharted territory with the country’s new patchwork of abortion legality. Some specialties, cardiology among them, may feel the impact more than others.
“We know that the rising maternal mortality rate is predominantly driven by cardiovascular disease, women having children at older ages, and ... risk factors like hypertension, diabetes, and obesity,” Jennifer H. Haythe, MD, told this news organization.
So the high court’s decision in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade and leaves the legality of abortion up to the 50 separate state legislatures, “is very relevant to cardiologists specifically,” said Dr. Haythe, who is director of cardiology in the cardio-obstetrics program at New York-Presbyterian/Columbia University Irving Medical Center, New York.
The ruling “is going to have a huge effect on women who may not be able to tolerate pregnancy,” she said. Whether to terminate a pregnancy “is a relatively common discussion I have with women with bad heart failure about their risk of further decompensation, death, or needing a heart transplant or heart pump after delivery, or the risk of death in women with pulmonary hypertension.”
The high court’s decision “is a direct attack on the practice of medicine and really the sanctity of the patient-clinician relationship,” Rachel M. Bond, MD, director of Women’s Heart Health Systems Dignity Health of Arizona, told this news organization.
Physicians take an oath “that we should do no harm to our patients, and once the law or governance impacts that, it places us in a very vulnerable situation,” Dr. Bond said. “As a cardiologist who focuses a lot on high-risk pregnancies, I am worried and hesitant to give guidance to many of these patients in the states that may not have access to something that is a medical right, which at times is an abortion.”
She has colleagues in obstetrics in states where abortion is newly illegal who “don’t know what to do,” Dr. Bond said. Many have sought guidance from their legal teams, she said, “and many of them are now trying to figure out what is the best path.”
Pregnancy is “a very significant cardiovascular stress test, and women who may tolerate certain conditions reasonably well outside of the setting of pregnancy may have severe issues, not just for the mother, but for the baby as well,” Ki Park, MD, University of Florida Health, Gainesville, said in an interview.
“As clinicians, none of us like recommending a medically indicated abortion. But it is health care, just like any other medication or treatment that we advise to our patients in cases where the risk of the mother is excessively high and mortality risk is elevated,” said Dr. Park, who is cochair of the American College of Cardiology Cardio-Obstetrics Work Group.
Some conditions, such as pulmonary hypertension and severe aortic valve stenosis, during pregnancy are well recognized as very high risk, and there are various scoring systems to help clinicians with risk stratification, she observed. “But there are also a lot of gray areas where patients don’t necessarily fit into these risk scores that we use.”
So physician-patient discussions in high-risk pregnancies “are already complicated,” Dr. Park said. “Patients want to have options, and they look to us as physicians for guidance with regard to their risks. And if abortion is not available as an option, then part of our toolbox is no longer available to help us care for the mother.”
In the new legal climate, clinicians in states where abortion is illegal may well want to put more emphasis on preconception counseling, so more of their patients with high-risk conditions are aware of the new barriers to pregnancy termination.
“Unfortunately,” Dr. Haythe said, “many of the states that are going to make or have made abortion illegal are not providing that kind of preconception counseling or good prenatal care to women.”
Cardiologists can provide such counseling to their female patients of childbearing age who have high-risk cardiac conditions, “but not everybody knows that they have a heart problem when they get pregnant, and not everybody is getting screened for heart problems when they’re of childbearing age,” Dr. Haythe said.
“Sometimes it’s not clear whether the problems could have been picked up until a woman is pregnant and has started to have symptoms.” For example, “a lot of women with poor access to health care have rheumatic heart disease. They may have no idea that they have severe aortic stenosis, and it’s not until their second trimester that they start to feel really short of breath.” Often that can be treated in the cath lab, “but again, that’s putting the woman and the baby at risk.”
Cardiologists in states where abortion is illegal will still present the option to their patients with high-risk pregnancies, noted Dr. Haythe. But the conversation may sound something like, “you are at very high risk, termination of the pregnancy takes that risk away, but you’ll have to find a state where it’s legal to do that.”
Dr. Park said such a situation, when abortion is recommended but locally unavailable, is much like any other in cardiology for which the patient may want a second opinion. If a center “doesn’t have the capability or the technology to offer a certain treatment, the patient can opt to seek another opinion at another center,” she said. “Patients will often travel out of state to get the care they need.”
A requirement for out-of-state travel to obtain abortions is likely to worsen socioeconomic disparities in health care, Dr. Bond observed, “because we know that those who are low-income won’t be able to afford that travel.”
Dr. Bond is cosignatory on a statement from the Association of Black Cardiologists (ABC) responding to the high court’s ruling in Dobbs v. Jackson. “This decision will isolate the poor, socioeconomically disadvantaged, and minority populations specifically, widening the already large gaps in health care for our most vulnerable communities,” it states.
“The loss of broad protections supporting the medical and often lifesaving procedure of abortions is likely to have a real impact on the maternal mortality rate, especially in those with congenital and/or acquired cardiovascular conditions where evidence-based guidelines advise at times on termination of such high-risk pregnancies.”
The ABC, it states, “believes that every woman, and every person, should be afforded the right to safe, accessible, legal, timely, patient-centered, equitable, and affordable health care.”
The American College of Cardiology (ACC) released a statement on the matter June 24, signed by its president, Edward T.A. Fry, MD, along with five former ACC presidents. “While the ACC has no official policy on abortion, clinical practice guidelines and other clinical guidance tools address the dangers of pregnancy in certain patient populations at higher risk of death or serious cardiac events.”
The college, it states, is “deeply concerned about the potential implications of the Supreme Court decision regarding Roe vs. Wade on the ability of patients and clinicians to engage in important shared discussions about maternal health, or to remove previously available health care options.”
Dr. Bond proposed that a “vocal stance” from medical societies involved in women’s health, “perhaps even a collective stance from our cardiovascular societies and our obstetrics societies,” would also perhaps reach “the masses of doctors in private practice who are dealing with these patients.”
A version of this article first appeared on Medscape.com.
Pregnancy termination for medical reasons had been part of the fabric of everyday health care in the United States since the Supreme Court’s 1973 Roe v. Wade decision, which the current high court overturned in a ruling announced on June 24.
That means many clinicians across specialties are entering uncharted territory with the country’s new patchwork of abortion legality. Some specialties, cardiology among them, may feel the impact more than others.
“We know that the rising maternal mortality rate is predominantly driven by cardiovascular disease, women having children at older ages, and ... risk factors like hypertension, diabetes, and obesity,” Jennifer H. Haythe, MD, told this news organization.
So the high court’s decision in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade and leaves the legality of abortion up to the 50 separate state legislatures, “is very relevant to cardiologists specifically,” said Dr. Haythe, who is director of cardiology in the cardio-obstetrics program at New York-Presbyterian/Columbia University Irving Medical Center, New York.
The ruling “is going to have a huge effect on women who may not be able to tolerate pregnancy,” she said. Whether to terminate a pregnancy “is a relatively common discussion I have with women with bad heart failure about their risk of further decompensation, death, or needing a heart transplant or heart pump after delivery, or the risk of death in women with pulmonary hypertension.”
The high court’s decision “is a direct attack on the practice of medicine and really the sanctity of the patient-clinician relationship,” Rachel M. Bond, MD, director of Women’s Heart Health Systems Dignity Health of Arizona, told this news organization.
Physicians take an oath “that we should do no harm to our patients, and once the law or governance impacts that, it places us in a very vulnerable situation,” Dr. Bond said. “As a cardiologist who focuses a lot on high-risk pregnancies, I am worried and hesitant to give guidance to many of these patients in the states that may not have access to something that is a medical right, which at times is an abortion.”
She has colleagues in obstetrics in states where abortion is newly illegal who “don’t know what to do,” Dr. Bond said. Many have sought guidance from their legal teams, she said, “and many of them are now trying to figure out what is the best path.”
Pregnancy is “a very significant cardiovascular stress test, and women who may tolerate certain conditions reasonably well outside of the setting of pregnancy may have severe issues, not just for the mother, but for the baby as well,” Ki Park, MD, University of Florida Health, Gainesville, said in an interview.
“As clinicians, none of us like recommending a medically indicated abortion. But it is health care, just like any other medication or treatment that we advise to our patients in cases where the risk of the mother is excessively high and mortality risk is elevated,” said Dr. Park, who is cochair of the American College of Cardiology Cardio-Obstetrics Work Group.
Some conditions, such as pulmonary hypertension and severe aortic valve stenosis, during pregnancy are well recognized as very high risk, and there are various scoring systems to help clinicians with risk stratification, she observed. “But there are also a lot of gray areas where patients don’t necessarily fit into these risk scores that we use.”
So physician-patient discussions in high-risk pregnancies “are already complicated,” Dr. Park said. “Patients want to have options, and they look to us as physicians for guidance with regard to their risks. And if abortion is not available as an option, then part of our toolbox is no longer available to help us care for the mother.”
In the new legal climate, clinicians in states where abortion is illegal may well want to put more emphasis on preconception counseling, so more of their patients with high-risk conditions are aware of the new barriers to pregnancy termination.
“Unfortunately,” Dr. Haythe said, “many of the states that are going to make or have made abortion illegal are not providing that kind of preconception counseling or good prenatal care to women.”
Cardiologists can provide such counseling to their female patients of childbearing age who have high-risk cardiac conditions, “but not everybody knows that they have a heart problem when they get pregnant, and not everybody is getting screened for heart problems when they’re of childbearing age,” Dr. Haythe said.
“Sometimes it’s not clear whether the problems could have been picked up until a woman is pregnant and has started to have symptoms.” For example, “a lot of women with poor access to health care have rheumatic heart disease. They may have no idea that they have severe aortic stenosis, and it’s not until their second trimester that they start to feel really short of breath.” Often that can be treated in the cath lab, “but again, that’s putting the woman and the baby at risk.”
Cardiologists in states where abortion is illegal will still present the option to their patients with high-risk pregnancies, noted Dr. Haythe. But the conversation may sound something like, “you are at very high risk, termination of the pregnancy takes that risk away, but you’ll have to find a state where it’s legal to do that.”
Dr. Park said such a situation, when abortion is recommended but locally unavailable, is much like any other in cardiology for which the patient may want a second opinion. If a center “doesn’t have the capability or the technology to offer a certain treatment, the patient can opt to seek another opinion at another center,” she said. “Patients will often travel out of state to get the care they need.”
A requirement for out-of-state travel to obtain abortions is likely to worsen socioeconomic disparities in health care, Dr. Bond observed, “because we know that those who are low-income won’t be able to afford that travel.”
Dr. Bond is cosignatory on a statement from the Association of Black Cardiologists (ABC) responding to the high court’s ruling in Dobbs v. Jackson. “This decision will isolate the poor, socioeconomically disadvantaged, and minority populations specifically, widening the already large gaps in health care for our most vulnerable communities,” it states.
“The loss of broad protections supporting the medical and often lifesaving procedure of abortions is likely to have a real impact on the maternal mortality rate, especially in those with congenital and/or acquired cardiovascular conditions where evidence-based guidelines advise at times on termination of such high-risk pregnancies.”
The ABC, it states, “believes that every woman, and every person, should be afforded the right to safe, accessible, legal, timely, patient-centered, equitable, and affordable health care.”
The American College of Cardiology (ACC) released a statement on the matter June 24, signed by its president, Edward T.A. Fry, MD, along with five former ACC presidents. “While the ACC has no official policy on abortion, clinical practice guidelines and other clinical guidance tools address the dangers of pregnancy in certain patient populations at higher risk of death or serious cardiac events.”
The college, it states, is “deeply concerned about the potential implications of the Supreme Court decision regarding Roe vs. Wade on the ability of patients and clinicians to engage in important shared discussions about maternal health, or to remove previously available health care options.”
Dr. Bond proposed that a “vocal stance” from medical societies involved in women’s health, “perhaps even a collective stance from our cardiovascular societies and our obstetrics societies,” would also perhaps reach “the masses of doctors in private practice who are dealing with these patients.”
A version of this article first appeared on Medscape.com.
Pregnancy termination for medical reasons had been part of the fabric of everyday health care in the United States since the Supreme Court’s 1973 Roe v. Wade decision, which the current high court overturned in a ruling announced on June 24.
That means many clinicians across specialties are entering uncharted territory with the country’s new patchwork of abortion legality. Some specialties, cardiology among them, may feel the impact more than others.
“We know that the rising maternal mortality rate is predominantly driven by cardiovascular disease, women having children at older ages, and ... risk factors like hypertension, diabetes, and obesity,” Jennifer H. Haythe, MD, told this news organization.
So the high court’s decision in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade and leaves the legality of abortion up to the 50 separate state legislatures, “is very relevant to cardiologists specifically,” said Dr. Haythe, who is director of cardiology in the cardio-obstetrics program at New York-Presbyterian/Columbia University Irving Medical Center, New York.
The ruling “is going to have a huge effect on women who may not be able to tolerate pregnancy,” she said. Whether to terminate a pregnancy “is a relatively common discussion I have with women with bad heart failure about their risk of further decompensation, death, or needing a heart transplant or heart pump after delivery, or the risk of death in women with pulmonary hypertension.”
The high court’s decision “is a direct attack on the practice of medicine and really the sanctity of the patient-clinician relationship,” Rachel M. Bond, MD, director of Women’s Heart Health Systems Dignity Health of Arizona, told this news organization.
Physicians take an oath “that we should do no harm to our patients, and once the law or governance impacts that, it places us in a very vulnerable situation,” Dr. Bond said. “As a cardiologist who focuses a lot on high-risk pregnancies, I am worried and hesitant to give guidance to many of these patients in the states that may not have access to something that is a medical right, which at times is an abortion.”
She has colleagues in obstetrics in states where abortion is newly illegal who “don’t know what to do,” Dr. Bond said. Many have sought guidance from their legal teams, she said, “and many of them are now trying to figure out what is the best path.”
Pregnancy is “a very significant cardiovascular stress test, and women who may tolerate certain conditions reasonably well outside of the setting of pregnancy may have severe issues, not just for the mother, but for the baby as well,” Ki Park, MD, University of Florida Health, Gainesville, said in an interview.
“As clinicians, none of us like recommending a medically indicated abortion. But it is health care, just like any other medication or treatment that we advise to our patients in cases where the risk of the mother is excessively high and mortality risk is elevated,” said Dr. Park, who is cochair of the American College of Cardiology Cardio-Obstetrics Work Group.
Some conditions, such as pulmonary hypertension and severe aortic valve stenosis, during pregnancy are well recognized as very high risk, and there are various scoring systems to help clinicians with risk stratification, she observed. “But there are also a lot of gray areas where patients don’t necessarily fit into these risk scores that we use.”
So physician-patient discussions in high-risk pregnancies “are already complicated,” Dr. Park said. “Patients want to have options, and they look to us as physicians for guidance with regard to their risks. And if abortion is not available as an option, then part of our toolbox is no longer available to help us care for the mother.”
In the new legal climate, clinicians in states where abortion is illegal may well want to put more emphasis on preconception counseling, so more of their patients with high-risk conditions are aware of the new barriers to pregnancy termination.
“Unfortunately,” Dr. Haythe said, “many of the states that are going to make or have made abortion illegal are not providing that kind of preconception counseling or good prenatal care to women.”
Cardiologists can provide such counseling to their female patients of childbearing age who have high-risk cardiac conditions, “but not everybody knows that they have a heart problem when they get pregnant, and not everybody is getting screened for heart problems when they’re of childbearing age,” Dr. Haythe said.
“Sometimes it’s not clear whether the problems could have been picked up until a woman is pregnant and has started to have symptoms.” For example, “a lot of women with poor access to health care have rheumatic heart disease. They may have no idea that they have severe aortic stenosis, and it’s not until their second trimester that they start to feel really short of breath.” Often that can be treated in the cath lab, “but again, that’s putting the woman and the baby at risk.”
Cardiologists in states where abortion is illegal will still present the option to their patients with high-risk pregnancies, noted Dr. Haythe. But the conversation may sound something like, “you are at very high risk, termination of the pregnancy takes that risk away, but you’ll have to find a state where it’s legal to do that.”
Dr. Park said such a situation, when abortion is recommended but locally unavailable, is much like any other in cardiology for which the patient may want a second opinion. If a center “doesn’t have the capability or the technology to offer a certain treatment, the patient can opt to seek another opinion at another center,” she said. “Patients will often travel out of state to get the care they need.”
A requirement for out-of-state travel to obtain abortions is likely to worsen socioeconomic disparities in health care, Dr. Bond observed, “because we know that those who are low-income won’t be able to afford that travel.”
Dr. Bond is cosignatory on a statement from the Association of Black Cardiologists (ABC) responding to the high court’s ruling in Dobbs v. Jackson. “This decision will isolate the poor, socioeconomically disadvantaged, and minority populations specifically, widening the already large gaps in health care for our most vulnerable communities,” it states.
“The loss of broad protections supporting the medical and often lifesaving procedure of abortions is likely to have a real impact on the maternal mortality rate, especially in those with congenital and/or acquired cardiovascular conditions where evidence-based guidelines advise at times on termination of such high-risk pregnancies.”
The ABC, it states, “believes that every woman, and every person, should be afforded the right to safe, accessible, legal, timely, patient-centered, equitable, and affordable health care.”
The American College of Cardiology (ACC) released a statement on the matter June 24, signed by its president, Edward T.A. Fry, MD, along with five former ACC presidents. “While the ACC has no official policy on abortion, clinical practice guidelines and other clinical guidance tools address the dangers of pregnancy in certain patient populations at higher risk of death or serious cardiac events.”
The college, it states, is “deeply concerned about the potential implications of the Supreme Court decision regarding Roe vs. Wade on the ability of patients and clinicians to engage in important shared discussions about maternal health, or to remove previously available health care options.”
Dr. Bond proposed that a “vocal stance” from medical societies involved in women’s health, “perhaps even a collective stance from our cardiovascular societies and our obstetrics societies,” would also perhaps reach “the masses of doctors in private practice who are dealing with these patients.”
A version of this article first appeared on Medscape.com.
Ob.gyns. on the day that Roe v. Wade was overturned
“I’m happy to contribute, but can you keep it anonymous? It’s a safety concern for me.”
On the day that the Supreme Court of the United States voted to strike down Roe v. Wade, I reached out to ob.gyn.s across the country, wanting to hear their reactions. My own response, like that of many doctors and women, was a visceral mix of anger, fear, and grief. I could only begin to imagine what the real experts on reproductive health care were going through.
When the first ob.gyn. responded to my request by expressing concerns around anonymity and personal safety, I was shocked – but I shouldn’t have been. For starters, there is already a storied history in this country of deadly attacks on abortion providers. David Gunn, MD; Barnett Slepian, MD; and George Tiller, MD, were all tragically murdered by antiabortion extremists. Then, there’s the existence of websites that keep logs of abortion providers and sometimes include photos, office contact information, or even home addresses.
The idea that any reproductive health care provider should have to think twice before offering their uniquely qualified opinion is profoundly disturbing, nearly as disturbing as the Supreme Court’s decision itself. But it’s more critical than ever for ob.gyn. voices to be amplified. This is the time for the healthcare community to rally around women’s health providers, to learn from them, to support them.
I asked ob.gyns. around the country to tell me what they were thinking and feeling on the day that Roe v. Wade was overturned. We agreed to keep the responses anonymous, given that several people expressed very understandable safety concerns.
Here’s what they had to say.
Tennessee ob.gyn.
“Today is an emotionally charged day for many people in this country, yet as I type this, with my ob.gyn. practice continuing around me, with my own almost 10-week pregnancy growing inside me, I feel quite blunted. I feel powerless to answer questions that are variations on ‘what next?’ or ‘how do we fight back?’ All I can think of is, I am so glad I do not have anyone on my schedule right now who does not want to be pregnant. But what will happen when that eventually changes? What about my colleagues who do have these patients on their schedules today? On a personal level, what if my prenatal genetic testing comes back abnormal? How can we so blatantly disregard a separation of church and state in this country? What ways will our government interfere with my practice next? My head is spinning, but I have to go see my next patient. She is a 25-year-old who is here to have an IUD placed, and that seems like the most important thing I can do today.”
South Carolina ob.gyn.
“I’m really scared. For my patients and for myself. I don’t know how to be a good ob.gyn. if my ability to offer safe and accessible abortion care is being threatened.”
Massachusetts ob.gyn.
“Livid and devastated and sad and terrified.”
California family planning specialist
“The fact is that about one in four people with uteruses have had an abortion. I can’t tell you how many abortions I’ve provided for people who say that they don’t ‘believe’ in them or that they thought they’d never be in this situation. ... The fact is that pregnancy is a life-threatening condition in and of itself. I am an ob.gyn., a medical doctor, and an abortion provider. I will not stop providing abortions or helping people access them. I will dedicate my life to ensuring this right to bodily autonomy. Today I am devastated by the Supreme Court’s decision to force parenthood that will result in increased maternal mortality. I am broken, but I have never been more proud to be an abortion provider.”
New York ob.gyn.
“Grateful to live in a state and work for a hospital where I can provide abortions but feel terrible for so many people less fortunate and underserved.”
Illinois maternal-fetal medicine specialist
“As a maternal-fetal medicine specialist, I fear for my patients who are at the highest risk of pregnancy complications having their freedom taken away. For the tragic ultrasound findings that make a pregnant person carry a baby who will never live. For the patients who cannot use most forms of contraception because of their medical comorbidities. For the patients who are victims of intimate partner violence or under the influence of their culture, to continue having children regardless of their desires or their health. ... The freedom to prevent or end a pregnancy has enabled women to become independent and productive members of society on their own terms, with or without children. My heart breaks for the children and adolescents and adults who are being told they are second-class citizens, not worthy of making their own decisions. Politicians and Supreme Court justices are not in the clinic room, ultrasound suite, operating room, or delivery room when we have these intense conversations and pregnancy outcomes. They have no idea that of which they speak, and it’s unconscionable that they can determine what healthcare decisions my patients can make for their own lives. Nobody knows a body better than the patient themselves.”
Texas ob.gyn.
“In the area where I live and practice, it feels like guns and the people who use them have more legal rights than people with uteruses in desperate or life-threatening situations. I’m afraid for my personal safety as a women’s health practitioner in this political climate. I feel helpless, but I’m supposed to be able to help my patients.”
Missouri family planning specialist
“Abortion is an essential part of healthcare, and the only people that should get a say in it are the patient and their doctor. Period. The fact that some far-off court without any medical expertise can insert itself into individual medical decisions is oppressive and unethical.”
Georgia ob.gyn.
“I can’t even think straight right now. I feel sick. Honestly, I’ve been thinking about moving for a long time now. Somewhere where I would actually be able to offer good, comprehensive care.”
New York ob.gyn.
“I graduated from my ob.gyn. residency hours after the Roe v. Wade news broke. It was so emotional for me. I’ve dedicated my life to caring for people with uteruses and I will not let this heartbreaking news change that. I feel more committed than ever to women’s health. I fully plan to continue delivering babies, providing contraception, and performing abortions. I will be there to help women with desired pregnancies who received unspeakably bad news about fetal anomalies. I will be there to help women with life-threatening pregnancy complications before fetal viability. I will be there to help women with ectopic pregnancies. I will be there to help women who were raped or otherwise forced into pregnancy. I will always be there to help women.”
Dr. Croll is a neurovascular fellow at New York University Langone Health. She disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.
“I’m happy to contribute, but can you keep it anonymous? It’s a safety concern for me.”
On the day that the Supreme Court of the United States voted to strike down Roe v. Wade, I reached out to ob.gyn.s across the country, wanting to hear their reactions. My own response, like that of many doctors and women, was a visceral mix of anger, fear, and grief. I could only begin to imagine what the real experts on reproductive health care were going through.
When the first ob.gyn. responded to my request by expressing concerns around anonymity and personal safety, I was shocked – but I shouldn’t have been. For starters, there is already a storied history in this country of deadly attacks on abortion providers. David Gunn, MD; Barnett Slepian, MD; and George Tiller, MD, were all tragically murdered by antiabortion extremists. Then, there’s the existence of websites that keep logs of abortion providers and sometimes include photos, office contact information, or even home addresses.
The idea that any reproductive health care provider should have to think twice before offering their uniquely qualified opinion is profoundly disturbing, nearly as disturbing as the Supreme Court’s decision itself. But it’s more critical than ever for ob.gyn. voices to be amplified. This is the time for the healthcare community to rally around women’s health providers, to learn from them, to support them.
I asked ob.gyns. around the country to tell me what they were thinking and feeling on the day that Roe v. Wade was overturned. We agreed to keep the responses anonymous, given that several people expressed very understandable safety concerns.
Here’s what they had to say.
Tennessee ob.gyn.
“Today is an emotionally charged day for many people in this country, yet as I type this, with my ob.gyn. practice continuing around me, with my own almost 10-week pregnancy growing inside me, I feel quite blunted. I feel powerless to answer questions that are variations on ‘what next?’ or ‘how do we fight back?’ All I can think of is, I am so glad I do not have anyone on my schedule right now who does not want to be pregnant. But what will happen when that eventually changes? What about my colleagues who do have these patients on their schedules today? On a personal level, what if my prenatal genetic testing comes back abnormal? How can we so blatantly disregard a separation of church and state in this country? What ways will our government interfere with my practice next? My head is spinning, but I have to go see my next patient. She is a 25-year-old who is here to have an IUD placed, and that seems like the most important thing I can do today.”
South Carolina ob.gyn.
“I’m really scared. For my patients and for myself. I don’t know how to be a good ob.gyn. if my ability to offer safe and accessible abortion care is being threatened.”
Massachusetts ob.gyn.
“Livid and devastated and sad and terrified.”
California family planning specialist
“The fact is that about one in four people with uteruses have had an abortion. I can’t tell you how many abortions I’ve provided for people who say that they don’t ‘believe’ in them or that they thought they’d never be in this situation. ... The fact is that pregnancy is a life-threatening condition in and of itself. I am an ob.gyn., a medical doctor, and an abortion provider. I will not stop providing abortions or helping people access them. I will dedicate my life to ensuring this right to bodily autonomy. Today I am devastated by the Supreme Court’s decision to force parenthood that will result in increased maternal mortality. I am broken, but I have never been more proud to be an abortion provider.”
New York ob.gyn.
“Grateful to live in a state and work for a hospital where I can provide abortions but feel terrible for so many people less fortunate and underserved.”
Illinois maternal-fetal medicine specialist
“As a maternal-fetal medicine specialist, I fear for my patients who are at the highest risk of pregnancy complications having their freedom taken away. For the tragic ultrasound findings that make a pregnant person carry a baby who will never live. For the patients who cannot use most forms of contraception because of their medical comorbidities. For the patients who are victims of intimate partner violence or under the influence of their culture, to continue having children regardless of their desires or their health. ... The freedom to prevent or end a pregnancy has enabled women to become independent and productive members of society on their own terms, with or without children. My heart breaks for the children and adolescents and adults who are being told they are second-class citizens, not worthy of making their own decisions. Politicians and Supreme Court justices are not in the clinic room, ultrasound suite, operating room, or delivery room when we have these intense conversations and pregnancy outcomes. They have no idea that of which they speak, and it’s unconscionable that they can determine what healthcare decisions my patients can make for their own lives. Nobody knows a body better than the patient themselves.”
Texas ob.gyn.
“In the area where I live and practice, it feels like guns and the people who use them have more legal rights than people with uteruses in desperate or life-threatening situations. I’m afraid for my personal safety as a women’s health practitioner in this political climate. I feel helpless, but I’m supposed to be able to help my patients.”
Missouri family planning specialist
“Abortion is an essential part of healthcare, and the only people that should get a say in it are the patient and their doctor. Period. The fact that some far-off court without any medical expertise can insert itself into individual medical decisions is oppressive and unethical.”
Georgia ob.gyn.
“I can’t even think straight right now. I feel sick. Honestly, I’ve been thinking about moving for a long time now. Somewhere where I would actually be able to offer good, comprehensive care.”
New York ob.gyn.
“I graduated from my ob.gyn. residency hours after the Roe v. Wade news broke. It was so emotional for me. I’ve dedicated my life to caring for people with uteruses and I will not let this heartbreaking news change that. I feel more committed than ever to women’s health. I fully plan to continue delivering babies, providing contraception, and performing abortions. I will be there to help women with desired pregnancies who received unspeakably bad news about fetal anomalies. I will be there to help women with life-threatening pregnancy complications before fetal viability. I will be there to help women with ectopic pregnancies. I will be there to help women who were raped or otherwise forced into pregnancy. I will always be there to help women.”
Dr. Croll is a neurovascular fellow at New York University Langone Health. She disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.
“I’m happy to contribute, but can you keep it anonymous? It’s a safety concern for me.”
On the day that the Supreme Court of the United States voted to strike down Roe v. Wade, I reached out to ob.gyn.s across the country, wanting to hear their reactions. My own response, like that of many doctors and women, was a visceral mix of anger, fear, and grief. I could only begin to imagine what the real experts on reproductive health care were going through.
When the first ob.gyn. responded to my request by expressing concerns around anonymity and personal safety, I was shocked – but I shouldn’t have been. For starters, there is already a storied history in this country of deadly attacks on abortion providers. David Gunn, MD; Barnett Slepian, MD; and George Tiller, MD, were all tragically murdered by antiabortion extremists. Then, there’s the existence of websites that keep logs of abortion providers and sometimes include photos, office contact information, or even home addresses.
The idea that any reproductive health care provider should have to think twice before offering their uniquely qualified opinion is profoundly disturbing, nearly as disturbing as the Supreme Court’s decision itself. But it’s more critical than ever for ob.gyn. voices to be amplified. This is the time for the healthcare community to rally around women’s health providers, to learn from them, to support them.
I asked ob.gyns. around the country to tell me what they were thinking and feeling on the day that Roe v. Wade was overturned. We agreed to keep the responses anonymous, given that several people expressed very understandable safety concerns.
Here’s what they had to say.
Tennessee ob.gyn.
“Today is an emotionally charged day for many people in this country, yet as I type this, with my ob.gyn. practice continuing around me, with my own almost 10-week pregnancy growing inside me, I feel quite blunted. I feel powerless to answer questions that are variations on ‘what next?’ or ‘how do we fight back?’ All I can think of is, I am so glad I do not have anyone on my schedule right now who does not want to be pregnant. But what will happen when that eventually changes? What about my colleagues who do have these patients on their schedules today? On a personal level, what if my prenatal genetic testing comes back abnormal? How can we so blatantly disregard a separation of church and state in this country? What ways will our government interfere with my practice next? My head is spinning, but I have to go see my next patient. She is a 25-year-old who is here to have an IUD placed, and that seems like the most important thing I can do today.”
South Carolina ob.gyn.
“I’m really scared. For my patients and for myself. I don’t know how to be a good ob.gyn. if my ability to offer safe and accessible abortion care is being threatened.”
Massachusetts ob.gyn.
“Livid and devastated and sad and terrified.”
California family planning specialist
“The fact is that about one in four people with uteruses have had an abortion. I can’t tell you how many abortions I’ve provided for people who say that they don’t ‘believe’ in them or that they thought they’d never be in this situation. ... The fact is that pregnancy is a life-threatening condition in and of itself. I am an ob.gyn., a medical doctor, and an abortion provider. I will not stop providing abortions or helping people access them. I will dedicate my life to ensuring this right to bodily autonomy. Today I am devastated by the Supreme Court’s decision to force parenthood that will result in increased maternal mortality. I am broken, but I have never been more proud to be an abortion provider.”
New York ob.gyn.
“Grateful to live in a state and work for a hospital where I can provide abortions but feel terrible for so many people less fortunate and underserved.”
Illinois maternal-fetal medicine specialist
“As a maternal-fetal medicine specialist, I fear for my patients who are at the highest risk of pregnancy complications having their freedom taken away. For the tragic ultrasound findings that make a pregnant person carry a baby who will never live. For the patients who cannot use most forms of contraception because of their medical comorbidities. For the patients who are victims of intimate partner violence or under the influence of their culture, to continue having children regardless of their desires or their health. ... The freedom to prevent or end a pregnancy has enabled women to become independent and productive members of society on their own terms, with or without children. My heart breaks for the children and adolescents and adults who are being told they are second-class citizens, not worthy of making their own decisions. Politicians and Supreme Court justices are not in the clinic room, ultrasound suite, operating room, or delivery room when we have these intense conversations and pregnancy outcomes. They have no idea that of which they speak, and it’s unconscionable that they can determine what healthcare decisions my patients can make for their own lives. Nobody knows a body better than the patient themselves.”
Texas ob.gyn.
“In the area where I live and practice, it feels like guns and the people who use them have more legal rights than people with uteruses in desperate or life-threatening situations. I’m afraid for my personal safety as a women’s health practitioner in this political climate. I feel helpless, but I’m supposed to be able to help my patients.”
Missouri family planning specialist
“Abortion is an essential part of healthcare, and the only people that should get a say in it are the patient and their doctor. Period. The fact that some far-off court without any medical expertise can insert itself into individual medical decisions is oppressive and unethical.”
Georgia ob.gyn.
“I can’t even think straight right now. I feel sick. Honestly, I’ve been thinking about moving for a long time now. Somewhere where I would actually be able to offer good, comprehensive care.”
New York ob.gyn.
“I graduated from my ob.gyn. residency hours after the Roe v. Wade news broke. It was so emotional for me. I’ve dedicated my life to caring for people with uteruses and I will not let this heartbreaking news change that. I feel more committed than ever to women’s health. I fully plan to continue delivering babies, providing contraception, and performing abortions. I will be there to help women with desired pregnancies who received unspeakably bad news about fetal anomalies. I will be there to help women with life-threatening pregnancy complications before fetal viability. I will be there to help women with ectopic pregnancies. I will be there to help women who were raped or otherwise forced into pregnancy. I will always be there to help women.”
Dr. Croll is a neurovascular fellow at New York University Langone Health. She disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.
Racial/ethnic disparities exacerbated maternal death rise during 2020 pandemic.
U.S. maternal deaths – those during pregnancy or within 42 days of pregnancy – increased substantially by 33.3% after March 2020 corresponding to the COVID-19 pandemic onset, according to new research published in JAMA Network Open.
Data from the National Center for Health Statistics (NCHS) revealed this rise in maternal deaths was higher than the 22% overall excess death estimate associated with the pandemic in 2020.
Increases were highest for Hispanic and non-Hispanic Black women, exacerbating already high rates of disparity in comparison with White women, wrote Marie E. Thoma, PhD, an associate professor at the University of Maryland, College Park, and Eugene R. Declercq, PhD, a professor at Boston University.
The authors noted that this spike in maternal deaths might be caused either by conditions directly related to COVID-19, such as respiratory or viral infections, or by conditions worsened by pandemic-associated health care disruptions including those for diabetes or cardiovascular disease.
The precise causes, however, could not be discerned from the data, the authors noted.
The NCHS reported an 18.4% increase in U.S. maternal mortality from 2019 to 2020. The relative increase was 44.4% among Hispanic, 25.7% among non-Hispanic Black, and 6.1% among non-Hispanic White women.
“The rise in maternal mortality among Hispanic women was unprecedented,” Dr. Thoma said in an interview. Given a 16.8% increase in overall U.S. mortality in 2020, largely attributed to the COVID-19 pandemic, the authors examined the pandemic’s role in [the higher] maternal death rates for 2020.
“Prior to this report, the NCHS released an e-report that there had been a rise in maternal mortality in 2020, but questions remained about the role of the pandemic in this rise that their report hadn’t addressed,” Dr. Thoma said in an interview “So we decided to look at the data further to assess whether the rise coincided with the pandemic and how this differed by race/ethnicity, whether there were changes in the causes of maternal death, and how often COVID-19 was listed as a contributory factor in those deaths.”
A total of 1,588 maternal deaths (18.8 per 100,000 live births) occurred before the pandemic versus 684 deaths (25.1 per 100,000 live births) during the 2020 phase of the pandemic, for a relative increase of 33.3%.
Direct obstetrical causes of death included diabetes, hypertensive and liver disorders, pregnancy-related infections, and obstetrical hemorrhage and embolism. Indirect causes comprised, among others, nonobstetrical infections and diseases of the circulatory and respiratory systems as well as mental and nervous disorders.
Relative increases in direct causes (27.7%) were mostly associated with diabetes (95.9%), hypertensive disorders (39.0%), and other specified pregnancy-related conditions (48.0%).
COVID-19 was commonly listed as a lethal condition along with other viral diseases (16 of 16 deaths and diseases of the respiratory system (11 of 19 deaths).
Late maternal mortality – defined as more than 42 days but less than 1 year after pregnancy – increased by 41%. “This was surprising as we might anticipate risk being higher during pregnancy given that pregnant women may be more susceptible, but we see that this rise was also found among people in the later postpartum period,” Dr. Thoma said.
Absolute and relative changes were highest for Hispanic women (8.9 per 100,000 live births and 74.2%, respectively) and non-Hispanic Black women (16.8 per 100,000 live births and 40.2%). In contrast, non-Hispanic White women saw increases of just 2.9 per 100,000 live births and 17.2%.
“Overall, we found the rise in maternal mortality in 2020 was concentrated after the start of pandemic, particularly for non-Hispanic Black and Hispanic women, and we saw a dramatic rise in respiratory-related conditions,” Dr. Thoma said.
In a comment, Steven Woolf, MD, MPH, director emeritus of the Center on Society and Health at Virginia Commonwealth University, Richmond, said the findings are very consistent with his and others research showing dramatic increases in overall death rates from many causes during the pandemic, with these ranging from COVID-19 leading conditions such as diabetes, cardiovascular and Alzheimer’s disease to less-studied causes such as drug overdoses and alcoholism caused by the stresses of the pandemic. Again, deaths were likely caused by both COVID-19 infections and disruptions in diagnosis and care.
“So a rise in maternal mortality would unfortunately also be expected, and these researchers have shown that,” he said in an interview. In addition, they have confirmed “the pattern of stark health disparities in the Hispanic and Black populations relative to the White. Our group has shown marked decreases in the life expectancies of the Black and Hispanic populations relative to the White population.”
While he might take issue with the study’s research methodology, Dr. Woolf said, “The work is useful partly because we need to work out the best research methods to do this kind of analysis because we really need to understand the effects on maternal mortality.”
He said sorting out the best way to do this type of research will be important for looking at excess deaths and maternal mortality following other events, for example, in the wake of the Supreme Court’s recent decision to reverse Roe v. Wade.
The authors acknowledged certain study limitations, including the large percentage of COVID-19 cases with a nonspecific underlying cause. According to Dr. Thoma and Dr. Declercq, that reflects a maternal death coding problem that needs to be addressed, as well as a partitioning of data. The latter resulted in small numbers for some categories, with rates suppressed for fewer than 16 deaths because of reduced reliability.
“We found that more specific information is often available on death certificates but is lost in the process of coding,” said Dr. Thoma. “We were able to reclassify many of these causes to a more specific cause that we attributed to be the primary cause of death.”
The authors said future studies of maternal death should examine the contribution of the pandemic to racial and ethnic disparities and should identify specific causes of maternal deaths overall and associated with COVID-19.
In earlier research, the authors previously warned of possible misclassifications of maternal deaths.
They found evidence of both underreporting and overreporting of deaths, with possible overreporting predominant, whereas accurate data are essential for measuring the effectiveness of maternal mortality reduction programs.
Dr. Thoma’s group will continue to monitor mortality trends with the release of 2021 data. “We hope we will see improvements in 2021 given greater access to vaccines, treatments, and fewer health care disruptions,” Dr. Thoma said. “It will be important to continue to stress the importance of COVID-19 vaccines for pregnant and postpartum people.”
This study had no external funding. The authors disclosed no competing interests. Dr. Woolf declared no conflicts of interest.
U.S. maternal deaths – those during pregnancy or within 42 days of pregnancy – increased substantially by 33.3% after March 2020 corresponding to the COVID-19 pandemic onset, according to new research published in JAMA Network Open.
Data from the National Center for Health Statistics (NCHS) revealed this rise in maternal deaths was higher than the 22% overall excess death estimate associated with the pandemic in 2020.
Increases were highest for Hispanic and non-Hispanic Black women, exacerbating already high rates of disparity in comparison with White women, wrote Marie E. Thoma, PhD, an associate professor at the University of Maryland, College Park, and Eugene R. Declercq, PhD, a professor at Boston University.
The authors noted that this spike in maternal deaths might be caused either by conditions directly related to COVID-19, such as respiratory or viral infections, or by conditions worsened by pandemic-associated health care disruptions including those for diabetes or cardiovascular disease.
The precise causes, however, could not be discerned from the data, the authors noted.
The NCHS reported an 18.4% increase in U.S. maternal mortality from 2019 to 2020. The relative increase was 44.4% among Hispanic, 25.7% among non-Hispanic Black, and 6.1% among non-Hispanic White women.
“The rise in maternal mortality among Hispanic women was unprecedented,” Dr. Thoma said in an interview. Given a 16.8% increase in overall U.S. mortality in 2020, largely attributed to the COVID-19 pandemic, the authors examined the pandemic’s role in [the higher] maternal death rates for 2020.
“Prior to this report, the NCHS released an e-report that there had been a rise in maternal mortality in 2020, but questions remained about the role of the pandemic in this rise that their report hadn’t addressed,” Dr. Thoma said in an interview “So we decided to look at the data further to assess whether the rise coincided with the pandemic and how this differed by race/ethnicity, whether there were changes in the causes of maternal death, and how often COVID-19 was listed as a contributory factor in those deaths.”
A total of 1,588 maternal deaths (18.8 per 100,000 live births) occurred before the pandemic versus 684 deaths (25.1 per 100,000 live births) during the 2020 phase of the pandemic, for a relative increase of 33.3%.
Direct obstetrical causes of death included diabetes, hypertensive and liver disorders, pregnancy-related infections, and obstetrical hemorrhage and embolism. Indirect causes comprised, among others, nonobstetrical infections and diseases of the circulatory and respiratory systems as well as mental and nervous disorders.
Relative increases in direct causes (27.7%) were mostly associated with diabetes (95.9%), hypertensive disorders (39.0%), and other specified pregnancy-related conditions (48.0%).
COVID-19 was commonly listed as a lethal condition along with other viral diseases (16 of 16 deaths and diseases of the respiratory system (11 of 19 deaths).
Late maternal mortality – defined as more than 42 days but less than 1 year after pregnancy – increased by 41%. “This was surprising as we might anticipate risk being higher during pregnancy given that pregnant women may be more susceptible, but we see that this rise was also found among people in the later postpartum period,” Dr. Thoma said.
Absolute and relative changes were highest for Hispanic women (8.9 per 100,000 live births and 74.2%, respectively) and non-Hispanic Black women (16.8 per 100,000 live births and 40.2%). In contrast, non-Hispanic White women saw increases of just 2.9 per 100,000 live births and 17.2%.
“Overall, we found the rise in maternal mortality in 2020 was concentrated after the start of pandemic, particularly for non-Hispanic Black and Hispanic women, and we saw a dramatic rise in respiratory-related conditions,” Dr. Thoma said.
In a comment, Steven Woolf, MD, MPH, director emeritus of the Center on Society and Health at Virginia Commonwealth University, Richmond, said the findings are very consistent with his and others research showing dramatic increases in overall death rates from many causes during the pandemic, with these ranging from COVID-19 leading conditions such as diabetes, cardiovascular and Alzheimer’s disease to less-studied causes such as drug overdoses and alcoholism caused by the stresses of the pandemic. Again, deaths were likely caused by both COVID-19 infections and disruptions in diagnosis and care.
“So a rise in maternal mortality would unfortunately also be expected, and these researchers have shown that,” he said in an interview. In addition, they have confirmed “the pattern of stark health disparities in the Hispanic and Black populations relative to the White. Our group has shown marked decreases in the life expectancies of the Black and Hispanic populations relative to the White population.”
While he might take issue with the study’s research methodology, Dr. Woolf said, “The work is useful partly because we need to work out the best research methods to do this kind of analysis because we really need to understand the effects on maternal mortality.”
He said sorting out the best way to do this type of research will be important for looking at excess deaths and maternal mortality following other events, for example, in the wake of the Supreme Court’s recent decision to reverse Roe v. Wade.
The authors acknowledged certain study limitations, including the large percentage of COVID-19 cases with a nonspecific underlying cause. According to Dr. Thoma and Dr. Declercq, that reflects a maternal death coding problem that needs to be addressed, as well as a partitioning of data. The latter resulted in small numbers for some categories, with rates suppressed for fewer than 16 deaths because of reduced reliability.
“We found that more specific information is often available on death certificates but is lost in the process of coding,” said Dr. Thoma. “We were able to reclassify many of these causes to a more specific cause that we attributed to be the primary cause of death.”
The authors said future studies of maternal death should examine the contribution of the pandemic to racial and ethnic disparities and should identify specific causes of maternal deaths overall and associated with COVID-19.
In earlier research, the authors previously warned of possible misclassifications of maternal deaths.
They found evidence of both underreporting and overreporting of deaths, with possible overreporting predominant, whereas accurate data are essential for measuring the effectiveness of maternal mortality reduction programs.
Dr. Thoma’s group will continue to monitor mortality trends with the release of 2021 data. “We hope we will see improvements in 2021 given greater access to vaccines, treatments, and fewer health care disruptions,” Dr. Thoma said. “It will be important to continue to stress the importance of COVID-19 vaccines for pregnant and postpartum people.”
This study had no external funding. The authors disclosed no competing interests. Dr. Woolf declared no conflicts of interest.
U.S. maternal deaths – those during pregnancy or within 42 days of pregnancy – increased substantially by 33.3% after March 2020 corresponding to the COVID-19 pandemic onset, according to new research published in JAMA Network Open.
Data from the National Center for Health Statistics (NCHS) revealed this rise in maternal deaths was higher than the 22% overall excess death estimate associated with the pandemic in 2020.
Increases were highest for Hispanic and non-Hispanic Black women, exacerbating already high rates of disparity in comparison with White women, wrote Marie E. Thoma, PhD, an associate professor at the University of Maryland, College Park, and Eugene R. Declercq, PhD, a professor at Boston University.
The authors noted that this spike in maternal deaths might be caused either by conditions directly related to COVID-19, such as respiratory or viral infections, or by conditions worsened by pandemic-associated health care disruptions including those for diabetes or cardiovascular disease.
The precise causes, however, could not be discerned from the data, the authors noted.
The NCHS reported an 18.4% increase in U.S. maternal mortality from 2019 to 2020. The relative increase was 44.4% among Hispanic, 25.7% among non-Hispanic Black, and 6.1% among non-Hispanic White women.
“The rise in maternal mortality among Hispanic women was unprecedented,” Dr. Thoma said in an interview. Given a 16.8% increase in overall U.S. mortality in 2020, largely attributed to the COVID-19 pandemic, the authors examined the pandemic’s role in [the higher] maternal death rates for 2020.
“Prior to this report, the NCHS released an e-report that there had been a rise in maternal mortality in 2020, but questions remained about the role of the pandemic in this rise that their report hadn’t addressed,” Dr. Thoma said in an interview “So we decided to look at the data further to assess whether the rise coincided with the pandemic and how this differed by race/ethnicity, whether there were changes in the causes of maternal death, and how often COVID-19 was listed as a contributory factor in those deaths.”
A total of 1,588 maternal deaths (18.8 per 100,000 live births) occurred before the pandemic versus 684 deaths (25.1 per 100,000 live births) during the 2020 phase of the pandemic, for a relative increase of 33.3%.
Direct obstetrical causes of death included diabetes, hypertensive and liver disorders, pregnancy-related infections, and obstetrical hemorrhage and embolism. Indirect causes comprised, among others, nonobstetrical infections and diseases of the circulatory and respiratory systems as well as mental and nervous disorders.
Relative increases in direct causes (27.7%) were mostly associated with diabetes (95.9%), hypertensive disorders (39.0%), and other specified pregnancy-related conditions (48.0%).
COVID-19 was commonly listed as a lethal condition along with other viral diseases (16 of 16 deaths and diseases of the respiratory system (11 of 19 deaths).
Late maternal mortality – defined as more than 42 days but less than 1 year after pregnancy – increased by 41%. “This was surprising as we might anticipate risk being higher during pregnancy given that pregnant women may be more susceptible, but we see that this rise was also found among people in the later postpartum period,” Dr. Thoma said.
Absolute and relative changes were highest for Hispanic women (8.9 per 100,000 live births and 74.2%, respectively) and non-Hispanic Black women (16.8 per 100,000 live births and 40.2%). In contrast, non-Hispanic White women saw increases of just 2.9 per 100,000 live births and 17.2%.
“Overall, we found the rise in maternal mortality in 2020 was concentrated after the start of pandemic, particularly for non-Hispanic Black and Hispanic women, and we saw a dramatic rise in respiratory-related conditions,” Dr. Thoma said.
In a comment, Steven Woolf, MD, MPH, director emeritus of the Center on Society and Health at Virginia Commonwealth University, Richmond, said the findings are very consistent with his and others research showing dramatic increases in overall death rates from many causes during the pandemic, with these ranging from COVID-19 leading conditions such as diabetes, cardiovascular and Alzheimer’s disease to less-studied causes such as drug overdoses and alcoholism caused by the stresses of the pandemic. Again, deaths were likely caused by both COVID-19 infections and disruptions in diagnosis and care.
“So a rise in maternal mortality would unfortunately also be expected, and these researchers have shown that,” he said in an interview. In addition, they have confirmed “the pattern of stark health disparities in the Hispanic and Black populations relative to the White. Our group has shown marked decreases in the life expectancies of the Black and Hispanic populations relative to the White population.”
While he might take issue with the study’s research methodology, Dr. Woolf said, “The work is useful partly because we need to work out the best research methods to do this kind of analysis because we really need to understand the effects on maternal mortality.”
He said sorting out the best way to do this type of research will be important for looking at excess deaths and maternal mortality following other events, for example, in the wake of the Supreme Court’s recent decision to reverse Roe v. Wade.
The authors acknowledged certain study limitations, including the large percentage of COVID-19 cases with a nonspecific underlying cause. According to Dr. Thoma and Dr. Declercq, that reflects a maternal death coding problem that needs to be addressed, as well as a partitioning of data. The latter resulted in small numbers for some categories, with rates suppressed for fewer than 16 deaths because of reduced reliability.
“We found that more specific information is often available on death certificates but is lost in the process of coding,” said Dr. Thoma. “We were able to reclassify many of these causes to a more specific cause that we attributed to be the primary cause of death.”
The authors said future studies of maternal death should examine the contribution of the pandemic to racial and ethnic disparities and should identify specific causes of maternal deaths overall and associated with COVID-19.
In earlier research, the authors previously warned of possible misclassifications of maternal deaths.
They found evidence of both underreporting and overreporting of deaths, with possible overreporting predominant, whereas accurate data are essential for measuring the effectiveness of maternal mortality reduction programs.
Dr. Thoma’s group will continue to monitor mortality trends with the release of 2021 data. “We hope we will see improvements in 2021 given greater access to vaccines, treatments, and fewer health care disruptions,” Dr. Thoma said. “It will be important to continue to stress the importance of COVID-19 vaccines for pregnant and postpartum people.”
This study had no external funding. The authors disclosed no competing interests. Dr. Woolf declared no conflicts of interest.
FROM JAMA NETWORK OPEN
Abortion pills over the counter? Experts see major hurdles in widening U.S. access
WASHINGTON (Reuters) – A pill used to terminate early pregnancies is unlikely to become available without a prescription for years, if ever, experts told Reuters, as the conservative-leaning U.S. Supreme Court dramatically curbed abortion rights.
The Supreme Court on June 24 overturned the landmark 1973 Roe v. Wade ruling that recognized the constitutional right to an abortion and legalized it nationwide. The new ruling stung abortion rights advocates and was a momentous victory to Republicans and religious conservatives.
Many U.S. states are expected to severely limit or outright ban abortions following the Supreme Court ruling. President Joe Biden’s administration is considering options to increase access to so-called medication abortions, which can be administered at home.
“Today I am directing the Department of Health & Human Services to take steps to ensure these critical medications are available to the fullest extent possible,” Mr. Biden said in remarks from the White House.
The pill, mifepristone, is used in combination with a second drug called misoprostol to induce an abortion up to 10 weeks into a pregnancy and is heavily restricted – only available through a certified doctor’s prescription. Abortion rights activists have stepped up calls to make it available for anyone to buy at pharmacies without a prescription.
“We will double down and use every lever we have to protect access to abortion care,” Secretary of Health and Human Services Xavier Becerra said in a statement, adding the department was committed to ensuring access to “medication abortion that has been approved by the FDA for over 20 years.”
Neither Mr. Biden nor Mr. Becerra addressed making the pills available over-the-counter, a process that could take years according to medical and regulatory experts interviewed by Reuters. They said drugmakers would need to conduct new studies showing directions on the product’s packaging would enable a consumer to safely use it without professional medical guidance.
The two companies that make the pill for the U.S. market have shown no interest in conducting the research. Should they do so, any Food and Drug Administration approval would become a target for lawsuits from abortion opponents that could delay implementation for years, experts said.
“The hard part that I see is getting the evidence or the agreement that no prescriber is needed at all,” said Susan Wood, a former Assistant Commissioner for Women’s Health at the FDA.
“I personally don’t see it happening in the next couple of years,” said Ms. Wood, now director of George Washington University’s Jacobs Institute of Women’s Health.
The next battle
Access to abortion pills is expected to become the next big battle, as their use is harder to track. The FDA has already relaxed some restrictions, making it easier for certified doctors to prescribe them.
The agency now allows doctors to prescribe mifepristone after a telehealth visit rather than in-person. Patients can receive it by mail, making it easier for women in U.S. states that already restrict its use.
The White House has already considered making abortion pills available online and from pharmacies abroad, with a prescription. However, the import possibility has been curtailed by Congress in broader legislation about drug regulation.
An over-the-counter designation would make it much easier for pregnant women to access the pills in states that seek to restrict their use. For example, they could more easily be mailed to a patient from a friend or supporter in a state where they are not banned.
An FDA spokesperson declined to comment on whether over-the-counter use of abortion pills has been considered. A spokesperson for Danco Laboratories, a manufacturer of mifepristone, said that it does not plan to seek over-the-counter approval. GenBioPro, the second maker of mifepristone for the U.S. market, did not respond to requests for comment.
Are they safe?
Medication abortion involves two drugs, taken over a day or two. The first, mifepristone, blocks the pregnancy-sustaining hormone progesterone. The second, misoprostol, induces uterine contractions.
When taken together, the pills halt the pregnancy and prompt cramping and bleeding to empty the uterus, in a process similar to miscarriage.
Abortion rights activists say the pills have a long track record of being safe and effective, with no risk of overdose or addiction. In several countries, including India and Mexico, women can buy mifepristone and misoprostol without a prescription to induce abortion.
“Medication abortion really does meet all the FDA criteria for an over-the-counter switch,” said Antonia Biggs, associate professor at the University of California, San Francisco’s obstetrics, gynecology and reproductive sciences department.
A recent study by Ms. Biggs and colleagues found that the majority of participants would understand a medication abortion over-the-counter label. Ms. Biggs said she was not in talks with drugmakers over her research.
The Charlotte Lozier Institute and Susan B. Anthony List, which advocate against abortion, have said that the FDA decision to relax restrictions on mifepristone ignored data on complications and put women at risk.
Others point to the decade-long legal fight for over-the-counter Plan B, a form of emergency contraception taken within days of sexual intercourse to prevent a pregnancy. Approval for women 18 and over was granted in 2006 and for use by women of all ages in 2013.
“There was very strong support that you did not need a prescriber,” said Ms. Wood, who resigned from the FDA in 2005 over the delay. “Everybody under the sun agreed except for a small group of people who somehow had an enormous political influence.”
Reuters Health Information © 2022
WASHINGTON (Reuters) – A pill used to terminate early pregnancies is unlikely to become available without a prescription for years, if ever, experts told Reuters, as the conservative-leaning U.S. Supreme Court dramatically curbed abortion rights.
The Supreme Court on June 24 overturned the landmark 1973 Roe v. Wade ruling that recognized the constitutional right to an abortion and legalized it nationwide. The new ruling stung abortion rights advocates and was a momentous victory to Republicans and religious conservatives.
Many U.S. states are expected to severely limit or outright ban abortions following the Supreme Court ruling. President Joe Biden’s administration is considering options to increase access to so-called medication abortions, which can be administered at home.
“Today I am directing the Department of Health & Human Services to take steps to ensure these critical medications are available to the fullest extent possible,” Mr. Biden said in remarks from the White House.
The pill, mifepristone, is used in combination with a second drug called misoprostol to induce an abortion up to 10 weeks into a pregnancy and is heavily restricted – only available through a certified doctor’s prescription. Abortion rights activists have stepped up calls to make it available for anyone to buy at pharmacies without a prescription.
“We will double down and use every lever we have to protect access to abortion care,” Secretary of Health and Human Services Xavier Becerra said in a statement, adding the department was committed to ensuring access to “medication abortion that has been approved by the FDA for over 20 years.”
Neither Mr. Biden nor Mr. Becerra addressed making the pills available over-the-counter, a process that could take years according to medical and regulatory experts interviewed by Reuters. They said drugmakers would need to conduct new studies showing directions on the product’s packaging would enable a consumer to safely use it without professional medical guidance.
The two companies that make the pill for the U.S. market have shown no interest in conducting the research. Should they do so, any Food and Drug Administration approval would become a target for lawsuits from abortion opponents that could delay implementation for years, experts said.
“The hard part that I see is getting the evidence or the agreement that no prescriber is needed at all,” said Susan Wood, a former Assistant Commissioner for Women’s Health at the FDA.
“I personally don’t see it happening in the next couple of years,” said Ms. Wood, now director of George Washington University’s Jacobs Institute of Women’s Health.
The next battle
Access to abortion pills is expected to become the next big battle, as their use is harder to track. The FDA has already relaxed some restrictions, making it easier for certified doctors to prescribe them.
The agency now allows doctors to prescribe mifepristone after a telehealth visit rather than in-person. Patients can receive it by mail, making it easier for women in U.S. states that already restrict its use.
The White House has already considered making abortion pills available online and from pharmacies abroad, with a prescription. However, the import possibility has been curtailed by Congress in broader legislation about drug regulation.
An over-the-counter designation would make it much easier for pregnant women to access the pills in states that seek to restrict their use. For example, they could more easily be mailed to a patient from a friend or supporter in a state where they are not banned.
An FDA spokesperson declined to comment on whether over-the-counter use of abortion pills has been considered. A spokesperson for Danco Laboratories, a manufacturer of mifepristone, said that it does not plan to seek over-the-counter approval. GenBioPro, the second maker of mifepristone for the U.S. market, did not respond to requests for comment.
Are they safe?
Medication abortion involves two drugs, taken over a day or two. The first, mifepristone, blocks the pregnancy-sustaining hormone progesterone. The second, misoprostol, induces uterine contractions.
When taken together, the pills halt the pregnancy and prompt cramping and bleeding to empty the uterus, in a process similar to miscarriage.
Abortion rights activists say the pills have a long track record of being safe and effective, with no risk of overdose or addiction. In several countries, including India and Mexico, women can buy mifepristone and misoprostol without a prescription to induce abortion.
“Medication abortion really does meet all the FDA criteria for an over-the-counter switch,” said Antonia Biggs, associate professor at the University of California, San Francisco’s obstetrics, gynecology and reproductive sciences department.
A recent study by Ms. Biggs and colleagues found that the majority of participants would understand a medication abortion over-the-counter label. Ms. Biggs said she was not in talks with drugmakers over her research.
The Charlotte Lozier Institute and Susan B. Anthony List, which advocate against abortion, have said that the FDA decision to relax restrictions on mifepristone ignored data on complications and put women at risk.
Others point to the decade-long legal fight for over-the-counter Plan B, a form of emergency contraception taken within days of sexual intercourse to prevent a pregnancy. Approval for women 18 and over was granted in 2006 and for use by women of all ages in 2013.
“There was very strong support that you did not need a prescriber,” said Ms. Wood, who resigned from the FDA in 2005 over the delay. “Everybody under the sun agreed except for a small group of people who somehow had an enormous political influence.”
Reuters Health Information © 2022
WASHINGTON (Reuters) – A pill used to terminate early pregnancies is unlikely to become available without a prescription for years, if ever, experts told Reuters, as the conservative-leaning U.S. Supreme Court dramatically curbed abortion rights.
The Supreme Court on June 24 overturned the landmark 1973 Roe v. Wade ruling that recognized the constitutional right to an abortion and legalized it nationwide. The new ruling stung abortion rights advocates and was a momentous victory to Republicans and religious conservatives.
Many U.S. states are expected to severely limit or outright ban abortions following the Supreme Court ruling. President Joe Biden’s administration is considering options to increase access to so-called medication abortions, which can be administered at home.
“Today I am directing the Department of Health & Human Services to take steps to ensure these critical medications are available to the fullest extent possible,” Mr. Biden said in remarks from the White House.
The pill, mifepristone, is used in combination with a second drug called misoprostol to induce an abortion up to 10 weeks into a pregnancy and is heavily restricted – only available through a certified doctor’s prescription. Abortion rights activists have stepped up calls to make it available for anyone to buy at pharmacies without a prescription.
“We will double down and use every lever we have to protect access to abortion care,” Secretary of Health and Human Services Xavier Becerra said in a statement, adding the department was committed to ensuring access to “medication abortion that has been approved by the FDA for over 20 years.”
Neither Mr. Biden nor Mr. Becerra addressed making the pills available over-the-counter, a process that could take years according to medical and regulatory experts interviewed by Reuters. They said drugmakers would need to conduct new studies showing directions on the product’s packaging would enable a consumer to safely use it without professional medical guidance.
The two companies that make the pill for the U.S. market have shown no interest in conducting the research. Should they do so, any Food and Drug Administration approval would become a target for lawsuits from abortion opponents that could delay implementation for years, experts said.
“The hard part that I see is getting the evidence or the agreement that no prescriber is needed at all,” said Susan Wood, a former Assistant Commissioner for Women’s Health at the FDA.
“I personally don’t see it happening in the next couple of years,” said Ms. Wood, now director of George Washington University’s Jacobs Institute of Women’s Health.
The next battle
Access to abortion pills is expected to become the next big battle, as their use is harder to track. The FDA has already relaxed some restrictions, making it easier for certified doctors to prescribe them.
The agency now allows doctors to prescribe mifepristone after a telehealth visit rather than in-person. Patients can receive it by mail, making it easier for women in U.S. states that already restrict its use.
The White House has already considered making abortion pills available online and from pharmacies abroad, with a prescription. However, the import possibility has been curtailed by Congress in broader legislation about drug regulation.
An over-the-counter designation would make it much easier for pregnant women to access the pills in states that seek to restrict their use. For example, they could more easily be mailed to a patient from a friend or supporter in a state where they are not banned.
An FDA spokesperson declined to comment on whether over-the-counter use of abortion pills has been considered. A spokesperson for Danco Laboratories, a manufacturer of mifepristone, said that it does not plan to seek over-the-counter approval. GenBioPro, the second maker of mifepristone for the U.S. market, did not respond to requests for comment.
Are they safe?
Medication abortion involves two drugs, taken over a day or two. The first, mifepristone, blocks the pregnancy-sustaining hormone progesterone. The second, misoprostol, induces uterine contractions.
When taken together, the pills halt the pregnancy and prompt cramping and bleeding to empty the uterus, in a process similar to miscarriage.
Abortion rights activists say the pills have a long track record of being safe and effective, with no risk of overdose or addiction. In several countries, including India and Mexico, women can buy mifepristone and misoprostol without a prescription to induce abortion.
“Medication abortion really does meet all the FDA criteria for an over-the-counter switch,” said Antonia Biggs, associate professor at the University of California, San Francisco’s obstetrics, gynecology and reproductive sciences department.
A recent study by Ms. Biggs and colleagues found that the majority of participants would understand a medication abortion over-the-counter label. Ms. Biggs said she was not in talks with drugmakers over her research.
The Charlotte Lozier Institute and Susan B. Anthony List, which advocate against abortion, have said that the FDA decision to relax restrictions on mifepristone ignored data on complications and put women at risk.
Others point to the decade-long legal fight for over-the-counter Plan B, a form of emergency contraception taken within days of sexual intercourse to prevent a pregnancy. Approval for women 18 and over was granted in 2006 and for use by women of all ages in 2013.
“There was very strong support that you did not need a prescriber,” said Ms. Wood, who resigned from the FDA in 2005 over the delay. “Everybody under the sun agreed except for a small group of people who somehow had an enormous political influence.”
Reuters Health Information © 2022
Roe v. Wade: Medical groups react to Supreme Court decision
The country’s top medical organizations condemned the overturning of Roe v. Wade, saying the removal of federal protections for women to access abortion services marks a “dark day.”
“It is unfathomable. It is unfair. It is wrong,” said the President of the American College of Obstetricians and Gynecologists (ACOG) Iffath Abbasi Hoskins, MD.
“Today is a very dark day in health care. It is a dark day, indeed, for the tens of millions of patients who have suddenly and unfairly lost access to safe legal and evidence-based abortion care,” Dr. Hoskins said at a press conference June 24 sponsored by ACOG.
“It is dark for the thousands of clinicians who now, instead of focusing on providing health care to their patients, have to live with the threats of legal, civil, and even professional penalties,” Dr. Hoskins added.
ACOG has 62,000 members and is the leading group of doctors that provides obstetric and gynecologic care.
Dilemma for some doctors?
“I’d like to take a moment to talk about the future of the medical profession,” said ACOG Chief Executive Officer Maureen G. Phipps, MD, MPH. “[The] decision is, as Dr. Hoskins clearly said, a tragic one for our patients in states across the country, but the harm does not end there.”
Dr. Phipps described overturning Roe v. Wade as “the boldest act of legislative interference that we have seen in this country. It will allow state legislators to tell physicians what care they can and cannot provide to their patients.”
“It will leave physicians looking over our shoulders, wondering if a patient is in enough of a crisis to permit an exception to a law,” Dr. Phipps added. “This is an affront to all that drew my colleagues and me into medicine.”
Although the impact on doctor training remains to be seen, she said 44% of ob.gyn. residents are trained in states now empowered to ban abortions.
The effect of the Supreme Court decision on miscarriage management is another unknown.
“It’s going to be very difficult for us, the clinicians, to manage miscarriage,” Dr. Hoskins said. “Many miscarriages could be what we call ‘incomplete’ in the beginning,” where there is still a heartbeat and the patient is cramping and/or bleeding.
In that instance, Dr. Hoskins said, clinicians may be thinking that they have to wait.
“They may be needing to get additional opinions, whether it’s a legal opinion ... or another medical opinion.”
“It’s going to have a devastating effect on every aspect of a woman’s health care, including if she is spontaneously miscarrying,” Dr. Hoskins predicted.
Physician protect thyself?
To what extent doctors can shield themselves from potential prosecution “is a hard question to answer,” Molly Meegan, JD, ACOG’s chief legal officer and general counsel, said.
Ms. Meegan recommended members speak to the risk managers at their individual institutions for guidance.
“It is a real patchwork [of laws] out there, she said. “And that patchwork itself is a danger to people as they seek essential reproductive health care.”
Also, she added, “If a doctor can’t tell what the law is at the time they’re trying to provide the care, it has a terribly chilling effect on medical care.”
Another potential threat to doctors in states that still allow abortion services is action from a neighboring state.
“We are going to be advocating very strongly that states do not have extra-territorial jurisdiction to reach beyond the edges of their state.”
The worry is if a doctor in New Mexico, where abortion is legal, performs an abortion for a person from Texas, where it will soon be illegal, is then prosecuted by Texas, for example.
Medication abortion
Asked about any potential effects on medication abortions, ACOG’s Jen Villavicencio, MD, said it remains to be seen.
“Certainly many of the laws that we have seen, including trigger ban laws, encompass medication abortion,” she said. Several states have these so-called trigger laws, which put into effect laws passed to ban abortion in case Roe was overturned.
This means, she said, that any abortion option, whether it’s procedural or medication, could be and will be banned in some of these states.
Ms. Meegan added that ACOG will continue to support access to medication abortion and that it should be decided by the U.S. Food and Drug Administration and not individual states.
Maternal mortality may rise
“Maternal mortality in and of itself is a very difficult topic,” Dr. Hoskins said, but [the] decision amplifies the implications. “I think of the patients who will have to manage severe complications and mental health challenges while they are carrying a pregnancy that they are forced to carry.”
“I also think of the patients who need to end their pregnancies in order to save their own lives,” Dr. Hoskins added.
Dr. Hoskins said the United States already has a high maternal mortality rate. This new law, she added, could force women into higher-risk situations if they experience high blood pressure, preeclampsia, or bleeding after the birth of the baby.
Growing inequality possible?
“The grievous inequities that exist in this country will grow and expand unchecked without safe access to legal abortion,” Dr. Phipps said.
She noted that women, based on location, will continue “to have protected access to safe evidence-based abortion. Others will have the means and resources and opportunities to secure the care.”
But the same may not be true for women in underserved or disadvantaged communities, Dr. Phipps added.
American Medical Association
ACOG was not the only group to react. “The American Medical Association is deeply disturbed by the U.S. Supreme Court’s decision to overturn nearly a half century of precedent protecting patients’ right to critical reproductive health care,” President Jack Resneck Jr., MD, said in a statement.
The decision represents “an egregious allowance of government intrusion into the medical examination room, a direct attack on the practice of medicine and the patient-physician relationship, and a brazen violation of patients’ rights to evidence-based reproductive health services.”
American Academy of Family Physicians
“The American Academy of Family Physicians is disappointed and disheartened by the Supreme Court’s decision to strike down longstanding protections afforded by Roe v. Wade and Planned Parenthood v. Casey,” President Sterling N. Ransone Jr., MD, said in a statement.
The organization has 127,600 physician and medical student members.
“This decision negatively impacts our practices and our patients by undermining the patient-physician relationship and potentially criminalizing evidence-based medical care,” added Dr. Ransone.
American College of Physicians
“A patient’s decision about whether to continue a pregnancy should be a private decision made in consultation with a physician or other health care professional, without interference from the government,” President Ryan D. Mire, MD, said in a statement. “We strongly oppose medically unnecessary government restrictions on any health care services,” added Dr. Mire on behalf of the group’s 161,000 members.
American Academy of Pediatrics
“This decision carries grave consequences for our adolescent patients, who already face many more barriers than adults in accessing comprehensive reproductive health care services and abortion care,” President Moira Szilagyi, MD, PhD, said in a statement.
“In the wake of this ruling, the American Academy of Pediatrics will continue to support our chapters as states consider policies affecting access to abortion care, and pediatricians will continue to support our patients,” Dr. Szilagyi added.
American Public Health Association
The court’s decision “is a catastrophic judicial failure that will reverberate differently in each state and portends to jeopardize the health and lives of all Americans,” Executive Director Georges C. Benjamin, MD, said in a statement.
American Urogynecologic Society
“The American Urogynecologic Society opposes any ruling that restricts a person’s access to health care and criminalizes the practice of medicine,” the group said in a statement. “This ruling ultimately poses a serious threat to the patient-provider relationship and subsequent decisionmaking necessary to ensure optimal outcomes for patients. As practitioners, we should be free to provide what is in the best interest of our patients.”
A version of this article first appeared on Medscape.com.
The country’s top medical organizations condemned the overturning of Roe v. Wade, saying the removal of federal protections for women to access abortion services marks a “dark day.”
“It is unfathomable. It is unfair. It is wrong,” said the President of the American College of Obstetricians and Gynecologists (ACOG) Iffath Abbasi Hoskins, MD.
“Today is a very dark day in health care. It is a dark day, indeed, for the tens of millions of patients who have suddenly and unfairly lost access to safe legal and evidence-based abortion care,” Dr. Hoskins said at a press conference June 24 sponsored by ACOG.
“It is dark for the thousands of clinicians who now, instead of focusing on providing health care to their patients, have to live with the threats of legal, civil, and even professional penalties,” Dr. Hoskins added.
ACOG has 62,000 members and is the leading group of doctors that provides obstetric and gynecologic care.
Dilemma for some doctors?
“I’d like to take a moment to talk about the future of the medical profession,” said ACOG Chief Executive Officer Maureen G. Phipps, MD, MPH. “[The] decision is, as Dr. Hoskins clearly said, a tragic one for our patients in states across the country, but the harm does not end there.”
Dr. Phipps described overturning Roe v. Wade as “the boldest act of legislative interference that we have seen in this country. It will allow state legislators to tell physicians what care they can and cannot provide to their patients.”
“It will leave physicians looking over our shoulders, wondering if a patient is in enough of a crisis to permit an exception to a law,” Dr. Phipps added. “This is an affront to all that drew my colleagues and me into medicine.”
Although the impact on doctor training remains to be seen, she said 44% of ob.gyn. residents are trained in states now empowered to ban abortions.
The effect of the Supreme Court decision on miscarriage management is another unknown.
“It’s going to be very difficult for us, the clinicians, to manage miscarriage,” Dr. Hoskins said. “Many miscarriages could be what we call ‘incomplete’ in the beginning,” where there is still a heartbeat and the patient is cramping and/or bleeding.
In that instance, Dr. Hoskins said, clinicians may be thinking that they have to wait.
“They may be needing to get additional opinions, whether it’s a legal opinion ... or another medical opinion.”
“It’s going to have a devastating effect on every aspect of a woman’s health care, including if she is spontaneously miscarrying,” Dr. Hoskins predicted.
Physician protect thyself?
To what extent doctors can shield themselves from potential prosecution “is a hard question to answer,” Molly Meegan, JD, ACOG’s chief legal officer and general counsel, said.
Ms. Meegan recommended members speak to the risk managers at their individual institutions for guidance.
“It is a real patchwork [of laws] out there, she said. “And that patchwork itself is a danger to people as they seek essential reproductive health care.”
Also, she added, “If a doctor can’t tell what the law is at the time they’re trying to provide the care, it has a terribly chilling effect on medical care.”
Another potential threat to doctors in states that still allow abortion services is action from a neighboring state.
“We are going to be advocating very strongly that states do not have extra-territorial jurisdiction to reach beyond the edges of their state.”
The worry is if a doctor in New Mexico, where abortion is legal, performs an abortion for a person from Texas, where it will soon be illegal, is then prosecuted by Texas, for example.
Medication abortion
Asked about any potential effects on medication abortions, ACOG’s Jen Villavicencio, MD, said it remains to be seen.
“Certainly many of the laws that we have seen, including trigger ban laws, encompass medication abortion,” she said. Several states have these so-called trigger laws, which put into effect laws passed to ban abortion in case Roe was overturned.
This means, she said, that any abortion option, whether it’s procedural or medication, could be and will be banned in some of these states.
Ms. Meegan added that ACOG will continue to support access to medication abortion and that it should be decided by the U.S. Food and Drug Administration and not individual states.
Maternal mortality may rise
“Maternal mortality in and of itself is a very difficult topic,” Dr. Hoskins said, but [the] decision amplifies the implications. “I think of the patients who will have to manage severe complications and mental health challenges while they are carrying a pregnancy that they are forced to carry.”
“I also think of the patients who need to end their pregnancies in order to save their own lives,” Dr. Hoskins added.
Dr. Hoskins said the United States already has a high maternal mortality rate. This new law, she added, could force women into higher-risk situations if they experience high blood pressure, preeclampsia, or bleeding after the birth of the baby.
Growing inequality possible?
“The grievous inequities that exist in this country will grow and expand unchecked without safe access to legal abortion,” Dr. Phipps said.
She noted that women, based on location, will continue “to have protected access to safe evidence-based abortion. Others will have the means and resources and opportunities to secure the care.”
But the same may not be true for women in underserved or disadvantaged communities, Dr. Phipps added.
American Medical Association
ACOG was not the only group to react. “The American Medical Association is deeply disturbed by the U.S. Supreme Court’s decision to overturn nearly a half century of precedent protecting patients’ right to critical reproductive health care,” President Jack Resneck Jr., MD, said in a statement.
The decision represents “an egregious allowance of government intrusion into the medical examination room, a direct attack on the practice of medicine and the patient-physician relationship, and a brazen violation of patients’ rights to evidence-based reproductive health services.”
American Academy of Family Physicians
“The American Academy of Family Physicians is disappointed and disheartened by the Supreme Court’s decision to strike down longstanding protections afforded by Roe v. Wade and Planned Parenthood v. Casey,” President Sterling N. Ransone Jr., MD, said in a statement.
The organization has 127,600 physician and medical student members.
“This decision negatively impacts our practices and our patients by undermining the patient-physician relationship and potentially criminalizing evidence-based medical care,” added Dr. Ransone.
American College of Physicians
“A patient’s decision about whether to continue a pregnancy should be a private decision made in consultation with a physician or other health care professional, without interference from the government,” President Ryan D. Mire, MD, said in a statement. “We strongly oppose medically unnecessary government restrictions on any health care services,” added Dr. Mire on behalf of the group’s 161,000 members.
American Academy of Pediatrics
“This decision carries grave consequences for our adolescent patients, who already face many more barriers than adults in accessing comprehensive reproductive health care services and abortion care,” President Moira Szilagyi, MD, PhD, said in a statement.
“In the wake of this ruling, the American Academy of Pediatrics will continue to support our chapters as states consider policies affecting access to abortion care, and pediatricians will continue to support our patients,” Dr. Szilagyi added.
American Public Health Association
The court’s decision “is a catastrophic judicial failure that will reverberate differently in each state and portends to jeopardize the health and lives of all Americans,” Executive Director Georges C. Benjamin, MD, said in a statement.
American Urogynecologic Society
“The American Urogynecologic Society opposes any ruling that restricts a person’s access to health care and criminalizes the practice of medicine,” the group said in a statement. “This ruling ultimately poses a serious threat to the patient-provider relationship and subsequent decisionmaking necessary to ensure optimal outcomes for patients. As practitioners, we should be free to provide what is in the best interest of our patients.”
A version of this article first appeared on Medscape.com.
The country’s top medical organizations condemned the overturning of Roe v. Wade, saying the removal of federal protections for women to access abortion services marks a “dark day.”
“It is unfathomable. It is unfair. It is wrong,” said the President of the American College of Obstetricians and Gynecologists (ACOG) Iffath Abbasi Hoskins, MD.
“Today is a very dark day in health care. It is a dark day, indeed, for the tens of millions of patients who have suddenly and unfairly lost access to safe legal and evidence-based abortion care,” Dr. Hoskins said at a press conference June 24 sponsored by ACOG.
“It is dark for the thousands of clinicians who now, instead of focusing on providing health care to their patients, have to live with the threats of legal, civil, and even professional penalties,” Dr. Hoskins added.
ACOG has 62,000 members and is the leading group of doctors that provides obstetric and gynecologic care.
Dilemma for some doctors?
“I’d like to take a moment to talk about the future of the medical profession,” said ACOG Chief Executive Officer Maureen G. Phipps, MD, MPH. “[The] decision is, as Dr. Hoskins clearly said, a tragic one for our patients in states across the country, but the harm does not end there.”
Dr. Phipps described overturning Roe v. Wade as “the boldest act of legislative interference that we have seen in this country. It will allow state legislators to tell physicians what care they can and cannot provide to their patients.”
“It will leave physicians looking over our shoulders, wondering if a patient is in enough of a crisis to permit an exception to a law,” Dr. Phipps added. “This is an affront to all that drew my colleagues and me into medicine.”
Although the impact on doctor training remains to be seen, she said 44% of ob.gyn. residents are trained in states now empowered to ban abortions.
The effect of the Supreme Court decision on miscarriage management is another unknown.
“It’s going to be very difficult for us, the clinicians, to manage miscarriage,” Dr. Hoskins said. “Many miscarriages could be what we call ‘incomplete’ in the beginning,” where there is still a heartbeat and the patient is cramping and/or bleeding.
In that instance, Dr. Hoskins said, clinicians may be thinking that they have to wait.
“They may be needing to get additional opinions, whether it’s a legal opinion ... or another medical opinion.”
“It’s going to have a devastating effect on every aspect of a woman’s health care, including if she is spontaneously miscarrying,” Dr. Hoskins predicted.
Physician protect thyself?
To what extent doctors can shield themselves from potential prosecution “is a hard question to answer,” Molly Meegan, JD, ACOG’s chief legal officer and general counsel, said.
Ms. Meegan recommended members speak to the risk managers at their individual institutions for guidance.
“It is a real patchwork [of laws] out there, she said. “And that patchwork itself is a danger to people as they seek essential reproductive health care.”
Also, she added, “If a doctor can’t tell what the law is at the time they’re trying to provide the care, it has a terribly chilling effect on medical care.”
Another potential threat to doctors in states that still allow abortion services is action from a neighboring state.
“We are going to be advocating very strongly that states do not have extra-territorial jurisdiction to reach beyond the edges of their state.”
The worry is if a doctor in New Mexico, where abortion is legal, performs an abortion for a person from Texas, where it will soon be illegal, is then prosecuted by Texas, for example.
Medication abortion
Asked about any potential effects on medication abortions, ACOG’s Jen Villavicencio, MD, said it remains to be seen.
“Certainly many of the laws that we have seen, including trigger ban laws, encompass medication abortion,” she said. Several states have these so-called trigger laws, which put into effect laws passed to ban abortion in case Roe was overturned.
This means, she said, that any abortion option, whether it’s procedural or medication, could be and will be banned in some of these states.
Ms. Meegan added that ACOG will continue to support access to medication abortion and that it should be decided by the U.S. Food and Drug Administration and not individual states.
Maternal mortality may rise
“Maternal mortality in and of itself is a very difficult topic,” Dr. Hoskins said, but [the] decision amplifies the implications. “I think of the patients who will have to manage severe complications and mental health challenges while they are carrying a pregnancy that they are forced to carry.”
“I also think of the patients who need to end their pregnancies in order to save their own lives,” Dr. Hoskins added.
Dr. Hoskins said the United States already has a high maternal mortality rate. This new law, she added, could force women into higher-risk situations if they experience high blood pressure, preeclampsia, or bleeding after the birth of the baby.
Growing inequality possible?
“The grievous inequities that exist in this country will grow and expand unchecked without safe access to legal abortion,” Dr. Phipps said.
She noted that women, based on location, will continue “to have protected access to safe evidence-based abortion. Others will have the means and resources and opportunities to secure the care.”
But the same may not be true for women in underserved or disadvantaged communities, Dr. Phipps added.
American Medical Association
ACOG was not the only group to react. “The American Medical Association is deeply disturbed by the U.S. Supreme Court’s decision to overturn nearly a half century of precedent protecting patients’ right to critical reproductive health care,” President Jack Resneck Jr., MD, said in a statement.
The decision represents “an egregious allowance of government intrusion into the medical examination room, a direct attack on the practice of medicine and the patient-physician relationship, and a brazen violation of patients’ rights to evidence-based reproductive health services.”
American Academy of Family Physicians
“The American Academy of Family Physicians is disappointed and disheartened by the Supreme Court’s decision to strike down longstanding protections afforded by Roe v. Wade and Planned Parenthood v. Casey,” President Sterling N. Ransone Jr., MD, said in a statement.
The organization has 127,600 physician and medical student members.
“This decision negatively impacts our practices and our patients by undermining the patient-physician relationship and potentially criminalizing evidence-based medical care,” added Dr. Ransone.
American College of Physicians
“A patient’s decision about whether to continue a pregnancy should be a private decision made in consultation with a physician or other health care professional, without interference from the government,” President Ryan D. Mire, MD, said in a statement. “We strongly oppose medically unnecessary government restrictions on any health care services,” added Dr. Mire on behalf of the group’s 161,000 members.
American Academy of Pediatrics
“This decision carries grave consequences for our adolescent patients, who already face many more barriers than adults in accessing comprehensive reproductive health care services and abortion care,” President Moira Szilagyi, MD, PhD, said in a statement.
“In the wake of this ruling, the American Academy of Pediatrics will continue to support our chapters as states consider policies affecting access to abortion care, and pediatricians will continue to support our patients,” Dr. Szilagyi added.
American Public Health Association
The court’s decision “is a catastrophic judicial failure that will reverberate differently in each state and portends to jeopardize the health and lives of all Americans,” Executive Director Georges C. Benjamin, MD, said in a statement.
American Urogynecologic Society
“The American Urogynecologic Society opposes any ruling that restricts a person’s access to health care and criminalizes the practice of medicine,” the group said in a statement. “This ruling ultimately poses a serious threat to the patient-provider relationship and subsequent decisionmaking necessary to ensure optimal outcomes for patients. As practitioners, we should be free to provide what is in the best interest of our patients.”
A version of this article first appeared on Medscape.com.
Stroke risk rises for women with history of infertility, miscarriage, stillbirth
Infertility, pregnancy loss, and stillbirth increased women’s later risk of both nonfatal and fatal stroke, based on data from more than 600,000 women.
“To date, multiple studies have generated an expanding body of evidence on the association between pregnancy complications (e.g., gestational diabetes and preeclampsia) and the long-term risk of stroke, but studies on associations with infertility, miscarriage, or stillbirth have produced mixed evidence,” Chen Liang, a PhD candidate at the University of Queensland, Brisbane, Australia, and colleagues wrote.
In a study published in the BMJ, the researchers reviewed data from eight observational cohort studies across seven countries (Australia, China, Japan, the Netherlands, Sweden, the United Kingdom, and the United States). The participants were part of the InterLACE (International Collaboration for a Life Course Approach to Reproductive Health and Chronic Disease Events) consortium established in 2021. Most observational studies included in the analysis began between 1990 and 2000.
The study population included 618,851 women aged 32-73 years at baseline for whom data on infertility, miscarriage, or stillbirth, were available. The primary outcome was the association of infertility, recurrent miscarriage, and stillbirth with risk of first fatal or nonfatal stroke, and the results were further stratified by subtype. Stroke was identified through self-reports, linked hospital data, national patient registers, or death registry data. Baseline was defined as the first incidence of infertility, miscarriage, or stillbirth. The exception was the National Survey of Health and Development, a British birth cohort started in 1946, that collected data retrospectively.
The median follow-up period was 13 years for nonfatal stroke and 9.4 years for fatal stroke.
Overall, 17.2%, 16.6%, and 4.6% of the women experienced infertility, miscarriage, and stillbirth, respectively.
Women with a history of infertility had a significantly higher nonfatal stroke risk, compared with those without infertility (hazard ratio, 1.14). Further analysis by stroke subtypes showed an increased association between miscarriage and ischemic stroke (HR, 1.15).
Those with a history of miscarriage also had an increased risk of nonfatal stroke, compared with those without miscarriages (HR, 1.11). In the miscarriage group, the risk of stroke increased with the number of miscarriages, with adjusted HRs of 1.07, 1.12, and 1.35 for women with one, two, and three or more miscarriages, respectively. When stratified by stroke subtype, women with three or more miscarriages were more likely than women with no miscarriages to experience ischemic and hemorrhagic nonfatal strokes.
Associations were similar between miscarriage history and fatal stroke risk. Women with one, two, and three or more miscarriages had increased risk of fatal stroke, compared with those with no miscarriages (aHR, 1.08, 1.26, and 1.82, respectively, and women with three or more miscarriages had a higher risk of ischemic and hemorrhagic stroke (aHR, 1.83 and 1.84, respectively).
Women with a history of stillbirth had an approximately 31% increased risk of nonfatal stroke, compared with those with no history of stillbirth, with aHRs similar for single and recurrent stillbirths (1.32 and 1.29, respectively). Ischemic nonfatal stroke risk was higher in women with any stillbirth, compared with those without stillbirth (aHR, 1.77). Fatal stroke risk also was higher in women with any stillbirth, compared with those without, and this risk increased with the number of stillbirths (HR, 0.97 and HR, 1.26 for those with one stillbirth and two or more, respectively).
“The increased risk of stroke associated with infertility or recurrent stillbirths was mainly driven by a single subtype of stroke (nonfatal ischemic stroke or fatal hemorrhagic stroke, respectively), whereas the risk of stroke associated with recurrent miscarriages was driven by both subtypes,” the researchers wrote.
The researchers cited endothelial dysfunction as a potential underlying mechanism for increased stroke risk associated with pregnancy complications. “Endothelial dysfunction might lead to pregnancy loss through placentation-related defects, persist after a complicated pregnancy, and contribute to the development of stroke through reduced vasodilation, proinflammatory status, and prothrombic properties,” and that history of recurrent pregnancy loss might be a female-specific risk factor for stroke.
To mitigate this risk, they advised early monitoring of women with a history of recurrent miscarriages and stillbirths for stroke risk factors such as high blood pressure, blood sugar levels, and lipid levels.
The study findings were limited by several factors including the use of questionnaires to collect information on infertility, miscarriage, and stillbirth, and the potential variation in definitions of infertility, miscarriage, and stillbirth across the included studies, and a lack of data on the effect of different causes or treatments based on reproductive histories, the researchers noted. Other limitations include incomplete data on stroke subtypes and inability to adjust for all covariates such as thyroid disorders and endometriosis. However, the results were strengthened by the large study size and geographically and racially diverse population, extend the current knowledge on associations between infertility, miscarriage, and stillbirth with stroke, and highlight the need for more research on underlying mechanisms.
Data support gender-specific stroke risk stratification
“Studies that seek to understand gender differences and disparities in adverse outcomes, such as stroke risk, are extremely important given that women historically were excluded from research studies,” Catherine M. Albright, MD, of the University of Washington, Seattle, said in an interview. “By doing these studies, we are able to better risk stratify people in order to better predict and modify risks,” added Dr. Albright, who was not involved in the current study.
“It is well known than adverse pregnancy outcomes such as hypertension in pregnancy, fetal growth restriction, and preterm birth, lead to increased risk of cardiovascular disease and stroke later in life, so the general findings of an association between other adverse reproductive and pregnancy outcomes leads to increased stroke risk are not surprising,” she said.
“The take-home message is that outcomes for pregnancy really do provide a window to future health,” said Dr. Albright. “For clinicians, especially non-ob.gyns., knowing a complete pregnancy history for any new patient is important and can help risk-stratify patients, especially as we continue to gain knowledge like what is shown in this study.”
However, “this study did not evaluate why individual patients may have had infertility, recurrent pregnancy loss, or stillbirth, so research to look further into this association to determine if there is an underlying medical condition that could be treated and therefore possibly reduce both pregnancy complications and future stroke risks would be important,” Dr. Albright noted.
The study was supported by the Australian National Health and Medical Research Council Centres of Research Excellence; one corresponding author was supported by an Australian National Health and Medical Research Council Investigator grant. The researchers had no financial conflicts to disclose. Dr. Albright had no financial conflicts to disclose.
Infertility, pregnancy loss, and stillbirth increased women’s later risk of both nonfatal and fatal stroke, based on data from more than 600,000 women.
“To date, multiple studies have generated an expanding body of evidence on the association between pregnancy complications (e.g., gestational diabetes and preeclampsia) and the long-term risk of stroke, but studies on associations with infertility, miscarriage, or stillbirth have produced mixed evidence,” Chen Liang, a PhD candidate at the University of Queensland, Brisbane, Australia, and colleagues wrote.
In a study published in the BMJ, the researchers reviewed data from eight observational cohort studies across seven countries (Australia, China, Japan, the Netherlands, Sweden, the United Kingdom, and the United States). The participants were part of the InterLACE (International Collaboration for a Life Course Approach to Reproductive Health and Chronic Disease Events) consortium established in 2021. Most observational studies included in the analysis began between 1990 and 2000.
The study population included 618,851 women aged 32-73 years at baseline for whom data on infertility, miscarriage, or stillbirth, were available. The primary outcome was the association of infertility, recurrent miscarriage, and stillbirth with risk of first fatal or nonfatal stroke, and the results were further stratified by subtype. Stroke was identified through self-reports, linked hospital data, national patient registers, or death registry data. Baseline was defined as the first incidence of infertility, miscarriage, or stillbirth. The exception was the National Survey of Health and Development, a British birth cohort started in 1946, that collected data retrospectively.
The median follow-up period was 13 years for nonfatal stroke and 9.4 years for fatal stroke.
Overall, 17.2%, 16.6%, and 4.6% of the women experienced infertility, miscarriage, and stillbirth, respectively.
Women with a history of infertility had a significantly higher nonfatal stroke risk, compared with those without infertility (hazard ratio, 1.14). Further analysis by stroke subtypes showed an increased association between miscarriage and ischemic stroke (HR, 1.15).
Those with a history of miscarriage also had an increased risk of nonfatal stroke, compared with those without miscarriages (HR, 1.11). In the miscarriage group, the risk of stroke increased with the number of miscarriages, with adjusted HRs of 1.07, 1.12, and 1.35 for women with one, two, and three or more miscarriages, respectively. When stratified by stroke subtype, women with three or more miscarriages were more likely than women with no miscarriages to experience ischemic and hemorrhagic nonfatal strokes.
Associations were similar between miscarriage history and fatal stroke risk. Women with one, two, and three or more miscarriages had increased risk of fatal stroke, compared with those with no miscarriages (aHR, 1.08, 1.26, and 1.82, respectively, and women with three or more miscarriages had a higher risk of ischemic and hemorrhagic stroke (aHR, 1.83 and 1.84, respectively).
Women with a history of stillbirth had an approximately 31% increased risk of nonfatal stroke, compared with those with no history of stillbirth, with aHRs similar for single and recurrent stillbirths (1.32 and 1.29, respectively). Ischemic nonfatal stroke risk was higher in women with any stillbirth, compared with those without stillbirth (aHR, 1.77). Fatal stroke risk also was higher in women with any stillbirth, compared with those without, and this risk increased with the number of stillbirths (HR, 0.97 and HR, 1.26 for those with one stillbirth and two or more, respectively).
“The increased risk of stroke associated with infertility or recurrent stillbirths was mainly driven by a single subtype of stroke (nonfatal ischemic stroke or fatal hemorrhagic stroke, respectively), whereas the risk of stroke associated with recurrent miscarriages was driven by both subtypes,” the researchers wrote.
The researchers cited endothelial dysfunction as a potential underlying mechanism for increased stroke risk associated with pregnancy complications. “Endothelial dysfunction might lead to pregnancy loss through placentation-related defects, persist after a complicated pregnancy, and contribute to the development of stroke through reduced vasodilation, proinflammatory status, and prothrombic properties,” and that history of recurrent pregnancy loss might be a female-specific risk factor for stroke.
To mitigate this risk, they advised early monitoring of women with a history of recurrent miscarriages and stillbirths for stroke risk factors such as high blood pressure, blood sugar levels, and lipid levels.
The study findings were limited by several factors including the use of questionnaires to collect information on infertility, miscarriage, and stillbirth, and the potential variation in definitions of infertility, miscarriage, and stillbirth across the included studies, and a lack of data on the effect of different causes or treatments based on reproductive histories, the researchers noted. Other limitations include incomplete data on stroke subtypes and inability to adjust for all covariates such as thyroid disorders and endometriosis. However, the results were strengthened by the large study size and geographically and racially diverse population, extend the current knowledge on associations between infertility, miscarriage, and stillbirth with stroke, and highlight the need for more research on underlying mechanisms.
Data support gender-specific stroke risk stratification
“Studies that seek to understand gender differences and disparities in adverse outcomes, such as stroke risk, are extremely important given that women historically were excluded from research studies,” Catherine M. Albright, MD, of the University of Washington, Seattle, said in an interview. “By doing these studies, we are able to better risk stratify people in order to better predict and modify risks,” added Dr. Albright, who was not involved in the current study.
“It is well known than adverse pregnancy outcomes such as hypertension in pregnancy, fetal growth restriction, and preterm birth, lead to increased risk of cardiovascular disease and stroke later in life, so the general findings of an association between other adverse reproductive and pregnancy outcomes leads to increased stroke risk are not surprising,” she said.
“The take-home message is that outcomes for pregnancy really do provide a window to future health,” said Dr. Albright. “For clinicians, especially non-ob.gyns., knowing a complete pregnancy history for any new patient is important and can help risk-stratify patients, especially as we continue to gain knowledge like what is shown in this study.”
However, “this study did not evaluate why individual patients may have had infertility, recurrent pregnancy loss, or stillbirth, so research to look further into this association to determine if there is an underlying medical condition that could be treated and therefore possibly reduce both pregnancy complications and future stroke risks would be important,” Dr. Albright noted.
The study was supported by the Australian National Health and Medical Research Council Centres of Research Excellence; one corresponding author was supported by an Australian National Health and Medical Research Council Investigator grant. The researchers had no financial conflicts to disclose. Dr. Albright had no financial conflicts to disclose.
Infertility, pregnancy loss, and stillbirth increased women’s later risk of both nonfatal and fatal stroke, based on data from more than 600,000 women.
“To date, multiple studies have generated an expanding body of evidence on the association between pregnancy complications (e.g., gestational diabetes and preeclampsia) and the long-term risk of stroke, but studies on associations with infertility, miscarriage, or stillbirth have produced mixed evidence,” Chen Liang, a PhD candidate at the University of Queensland, Brisbane, Australia, and colleagues wrote.
In a study published in the BMJ, the researchers reviewed data from eight observational cohort studies across seven countries (Australia, China, Japan, the Netherlands, Sweden, the United Kingdom, and the United States). The participants were part of the InterLACE (International Collaboration for a Life Course Approach to Reproductive Health and Chronic Disease Events) consortium established in 2021. Most observational studies included in the analysis began between 1990 and 2000.
The study population included 618,851 women aged 32-73 years at baseline for whom data on infertility, miscarriage, or stillbirth, were available. The primary outcome was the association of infertility, recurrent miscarriage, and stillbirth with risk of first fatal or nonfatal stroke, and the results were further stratified by subtype. Stroke was identified through self-reports, linked hospital data, national patient registers, or death registry data. Baseline was defined as the first incidence of infertility, miscarriage, or stillbirth. The exception was the National Survey of Health and Development, a British birth cohort started in 1946, that collected data retrospectively.
The median follow-up period was 13 years for nonfatal stroke and 9.4 years for fatal stroke.
Overall, 17.2%, 16.6%, and 4.6% of the women experienced infertility, miscarriage, and stillbirth, respectively.
Women with a history of infertility had a significantly higher nonfatal stroke risk, compared with those without infertility (hazard ratio, 1.14). Further analysis by stroke subtypes showed an increased association between miscarriage and ischemic stroke (HR, 1.15).
Those with a history of miscarriage also had an increased risk of nonfatal stroke, compared with those without miscarriages (HR, 1.11). In the miscarriage group, the risk of stroke increased with the number of miscarriages, with adjusted HRs of 1.07, 1.12, and 1.35 for women with one, two, and three or more miscarriages, respectively. When stratified by stroke subtype, women with three or more miscarriages were more likely than women with no miscarriages to experience ischemic and hemorrhagic nonfatal strokes.
Associations were similar between miscarriage history and fatal stroke risk. Women with one, two, and three or more miscarriages had increased risk of fatal stroke, compared with those with no miscarriages (aHR, 1.08, 1.26, and 1.82, respectively, and women with three or more miscarriages had a higher risk of ischemic and hemorrhagic stroke (aHR, 1.83 and 1.84, respectively).
Women with a history of stillbirth had an approximately 31% increased risk of nonfatal stroke, compared with those with no history of stillbirth, with aHRs similar for single and recurrent stillbirths (1.32 and 1.29, respectively). Ischemic nonfatal stroke risk was higher in women with any stillbirth, compared with those without stillbirth (aHR, 1.77). Fatal stroke risk also was higher in women with any stillbirth, compared with those without, and this risk increased with the number of stillbirths (HR, 0.97 and HR, 1.26 for those with one stillbirth and two or more, respectively).
“The increased risk of stroke associated with infertility or recurrent stillbirths was mainly driven by a single subtype of stroke (nonfatal ischemic stroke or fatal hemorrhagic stroke, respectively), whereas the risk of stroke associated with recurrent miscarriages was driven by both subtypes,” the researchers wrote.
The researchers cited endothelial dysfunction as a potential underlying mechanism for increased stroke risk associated with pregnancy complications. “Endothelial dysfunction might lead to pregnancy loss through placentation-related defects, persist after a complicated pregnancy, and contribute to the development of stroke through reduced vasodilation, proinflammatory status, and prothrombic properties,” and that history of recurrent pregnancy loss might be a female-specific risk factor for stroke.
To mitigate this risk, they advised early monitoring of women with a history of recurrent miscarriages and stillbirths for stroke risk factors such as high blood pressure, blood sugar levels, and lipid levels.
The study findings were limited by several factors including the use of questionnaires to collect information on infertility, miscarriage, and stillbirth, and the potential variation in definitions of infertility, miscarriage, and stillbirth across the included studies, and a lack of data on the effect of different causes or treatments based on reproductive histories, the researchers noted. Other limitations include incomplete data on stroke subtypes and inability to adjust for all covariates such as thyroid disorders and endometriosis. However, the results were strengthened by the large study size and geographically and racially diverse population, extend the current knowledge on associations between infertility, miscarriage, and stillbirth with stroke, and highlight the need for more research on underlying mechanisms.
Data support gender-specific stroke risk stratification
“Studies that seek to understand gender differences and disparities in adverse outcomes, such as stroke risk, are extremely important given that women historically were excluded from research studies,” Catherine M. Albright, MD, of the University of Washington, Seattle, said in an interview. “By doing these studies, we are able to better risk stratify people in order to better predict and modify risks,” added Dr. Albright, who was not involved in the current study.
“It is well known than adverse pregnancy outcomes such as hypertension in pregnancy, fetal growth restriction, and preterm birth, lead to increased risk of cardiovascular disease and stroke later in life, so the general findings of an association between other adverse reproductive and pregnancy outcomes leads to increased stroke risk are not surprising,” she said.
“The take-home message is that outcomes for pregnancy really do provide a window to future health,” said Dr. Albright. “For clinicians, especially non-ob.gyns., knowing a complete pregnancy history for any new patient is important and can help risk-stratify patients, especially as we continue to gain knowledge like what is shown in this study.”
However, “this study did not evaluate why individual patients may have had infertility, recurrent pregnancy loss, or stillbirth, so research to look further into this association to determine if there is an underlying medical condition that could be treated and therefore possibly reduce both pregnancy complications and future stroke risks would be important,” Dr. Albright noted.
The study was supported by the Australian National Health and Medical Research Council Centres of Research Excellence; one corresponding author was supported by an Australian National Health and Medical Research Council Investigator grant. The researchers had no financial conflicts to disclose. Dr. Albright had no financial conflicts to disclose.
FROM THE BMJ
Roe reversal may go well beyond abortion
Kami, a mother of one daughter in central Texas, lost three pregnancies in 2008. The third one nearly killed her.
The embryo became implanted in one of the fallopian tubes connecting her ovaries to her uterus. Because fallopian tubes can’t stretch to accommodate a fetus, patients must undergo surgery to remove the embryo before the tube ruptures. Failure to do so can result in internal bleeding and death.
But when Kami – who did not want to use her last name to avoid harassment – underwent an ultrasound to start the process of extracting the embryo, her doctor miscalculated how far along in the pregnancy she was and told her to come back in a few weeks.
She eventually did return, but only after passing out in the bathtub and waking up in a pool of her own blood. The tube had ruptured, and to remove it, emergency surgery was necessary.
Stories such as Kami’s could become more common in the aftermath of the U.S. Supreme Court’s decision to overturn Roe v. Wade, the 1973 case that created a right to an abortion.
Experts fear that antiabortion laws that take effect in the United States following the court’s decision will lead to a medical and legal limbo for thousands of people like Kami – people with uncommon reproductive conditions whose treatments involve the termination of pregnancies or the destruction of embryos.
Vague exceptions prompt concerns
According to the Guttmacher Institute, a nonprofit group for reproductive health, 13 states currently have trigger laws on the books that make abortion illegal in the absence of Roe. Nine other states have laws that would outlaw or severely restrict abortion without a federal right to the procedure.
Each of these laws carves out exceptions that allow the termination of a pregnancy to prevent the death of the pregnant individual. But the language of the provisions is not always precise in describing what those exceptions mean in practice, according to Elizabeth Nash, the principal policy associate for state issues at the Guttmacher Institute.
“These exceptions are designed to be extraordinarily narrow. These aren’t really designed to be usable exceptions,” Ms. Nash said. “There’s so much misinformation about abortion that there are probably legislators out there who think that it’s never needed to save a life.”
Tubal pregnancies
One of the best examples of a pregnancy termination that’s necessary to avoid death is in the case of an ectopic pregnancy such as Kami experienced. Without treatment to end the pregnancy, the embryo will eventually grow so large that the tube ruptures, causing massive bleeding that can kill the mother.
Most state laws regarding abortion exclude treatment of ectopic pregnancy, according to Ms. Nash. But, “if the state does not exclude ectopic pregnancy from all the regulations, then people might not be able to get the care that they need when they need it.”
The current abortion law in Texas, for example, prohibits ending a pregnancy after 6 weeks, or after cardiac activity becomes present. Cardiac activity can be present in cases of ectopic pregnancies, which account for between 1% and 2% of all pregnancies and are the leading cause of maternal deaths in the first trimester. And treatment definitely ends the life of the embryo or fetus in the fallopian tube, said Lisa Harris, MD, PhD, an ob.gyn. and medical ethicist at the University of Michigan, Ann Arbor.
Dr. Harris said she has never doubted that an ectopic pregnancy cannot possibly result in a live birth. But she recalled an encounter with another clinician on a surgical team for an ectopic pregnancy who said: “So you’re going to take it out of the tube and put it in the uterus, right?”
“It was a startling moment,” Dr. Harris recalled. She regarded the procedure as a “lifesaving, obvious surgery,” but her colleague, whose suggestion was a medical impossibility since the window of implantation is very brief after fertilization, viewed it “as an abortion, as killing an embryo or fetus.”
Dr. Harris said she isn’t concerned that physicians would stop treating ectopic pregnancies in a post-Roe world. Rather, she worries about two other possibilities: an overzealous prosecutor might not believe it was an ectopic pregnancy and press charges; or laws will cause physicians to second guess their clinical decisions for patients.
“What it means, in the middle of the night, when someone comes in with a 10-week ectopic pregnancy with a heartbeat, is the doctor may hesitate,” Dr. Harris said. Despite knowing the appropriate treatment, the doctor may want to speak with a lawyer or ethicist first to ensure they are covered legally. “And as that process unfolds, which could take hours or days, the person might have a complication.” s
Not treating an ectopic pregnancy would be malpractice, but “some doctors may not provide the standard of care that they would have ordinarily provided because they don’t want to risk breaking the law,” she said.
Even more ambiguous are cornual ectopic pregnancies, in which the implantation occurs at the junction of a fallopian tube and the uterus. These pregnancies, which make up 2%-4% of all tubal pregnancies, are immediately adjacent to the uterus. If an abortion is defined as the termination of an embryo or fetus in the womb, how such a legal definition would apply to these pregnancies is unclear.
An ob.gyn. wouldn’t regard ending an ectopic pregnancy as an abortion, but “this is not about logic or clinical meaning,” Dr. Harris said. “This is people outside of medicine making determinations that all pregnancies must continue, and when you think of a ban that way, you could see why a doctor would be frightened to end a pregnancy, whether it might be viable in the future or not.”
That’s true even if the pregnancy is located fully in the uterus. Dr. Harris described a pregnant patient she saw who had traveled from Texas to Michigan with a fetus that had a lethal defect.
The fetus had “an anomaly where the lungs couldn’t develop, where there were no kidneys. There was no chance this baby could be born and live. Her doctors were very clear that there will never be a baby that [she could] take home at the end of this pregnancy, yet they would not end her pregnancy because that would be an abortion,” Dr. Harris said.
Texas law “doesn’t make any allowances for whether a pregnancy will ever actually result in a baby or not,” Dr. Harris said. “The law, in effect, just says all pregnancies must continue.”
Selective reduction
How abortion laws in different states might affect selective reduction, which is used in some pregnancies to reduce the total number of fetuses a person is carrying, is even more ambiguous. The goal of selective reduction is to decrease health risks to the pregnant individual and increase the likelihood of survival for the remaining fetuses. Current Texas law prohibits these procedures.
Someone pregnant with quintuplets, for example, might seek selection reduction to reduce the pregnancy outcome to triplets or twins. A related procedure, selective termination, is used to terminate the life of a fetus with abnormalities while the pregnancy of the fetus’ in utero siblings continues.
The advent of assisted reproduction methods, such as in vitro fertilization (IVF), greatly increased the incidence of higher-order multiples, those with three or more fetuses. The first IVF baby was born in 1978. By 1998, the rate of higher-order multiple births was 1.9 per 1,000 births, five times the figure in 1980. The rate has since decreased by nearly half, to 1 per 1,000 births, but with 3.75 million live births a year, that’s still a lot of pregnancies with higher-order multiples.
The American College of Obstetricians and Gynecologists does not provide explicit guidance on when selective reduction is warranted, but its committee opinion on multifetal pregnancy reduction provides an ethical framework for providers to use when counseling people with pregnancies of three or more fetuses. How would various state laws that outlaw abortion affect these decisions? No one knows.
“Selective reduction ends the life of a fetus or embryo, but it doesn’t end the pregnancy,” Dr. Harris said. “So, if the pregnancy continues but it kills an embryo or fetus, is that an abortion?”
‘The question of the hour’
Dr. Harris and other doctors are haunted by potential medical cases in which continuing a pregnancy may result in the death of the person carrying the fetus but in which such death may not be so imminent that the law would allow immediate termination of the pregnancy.
Michael Northrup, MD, an intensive care pediatrician in Winston-Salem, N.C., recalled a particularly harrowing case that illustrates the peril in deciding when someone’s life is “enough” in danger to qualify as an exception to abortion bans.
The 14-year-old girl had severe lupus and kidney failure that required treatment with methotrexate and immediate dialysis to replace her electrolytes. A standard pretreatment pregnancy test revealed that she had been carrying a child for at least 10 weeks. Her pregnancy presented two problems. Methotrexate is so severely toxic that it’s sometimes used to end pregnancies. Even at low doses, fetuses that survive usually have severe deformities. In addition, dialysis requires administration of a blood thinner. If the teen miscarried while taking a blood thinner during dialysis, she risked bleeding to death.
Treatment could be delayed until week 24 of pregnancy, at which time delivery could be attempted, but the patient likely wouldn’t have any kidney function left by then. In addition, at 24 weeks, it was unlikely that the baby would survive anyway.
Dr. Northrup said that, had she chosen that route, “I’m not sure she would have made it. This was a religious family, people who very much were believers. They had their head of church come in, who fairly quickly determined that the best thing for her health was to terminate this pregnancy immediately and get the treatment she needed for her body.”
Would such a situation qualify for an emergency termination? The girl wasn’t going to die within 24 or 48 hours, but it may not have been possible to pinpoint the time of death within a day or 2.
“The family was sad, but they made that choice, and I wonder, would we have to justify that with these new laws?” Dr. Northrup said. “You definitely worry, being in the hot seat, ‘Does this count enough? Is she close enough to death?’ ”
The same question comes up when someone’s water breaks early in the second trimester. Since a live-birth delivery would be highly unlikely, given the age of the fetus, the standard of care is to offer to terminate the pregnancy to avoid a serious infection, Dr. Harris said. But if the infection hasn’t yet developed – even if it’s likely to develop soon – doctors in a state that outlaws abortion would not be able to offer termination. But as providers wait for an infection to develop, the person’s risk of dying from infection rapidly increases.
“How likely does someone need to be to die for it to count to get a life-preserving abortion?” Dr. Harris asked. “That, I think, is the question of the hour.”
Different institutions may decide to determine their own risk thresholds. One hospital, for example, may decide that any health threat that is associated with a 10% risk of death qualifies for a lifesaving abortion. But for many people, a 1 in 10 chance of dying is quite high.
“Who gets to decide what’s meaningful?” Dr. Harris asked, especially if the patient is already a parent of living children and doesn’t want to take any risk at all of orphaning them for a pregnancy with severe complications.
“The point is that this is way more complicated than anybody really knows, way more complicated than any legislator or justice could possibly know, and it creates all kinds of complicated ambiguities, some of which could result in harm to women,” she said. “I’ve been a doctor almost 30 years, and every week, sometimes every day, I’m humbled by how complicated pregnancy is and how complicated people’s bodies and life situations are.”
That’s what makes it so dangerous for policymakers to “insert themselves into medical practice,” Ms. Nash said. She worries about the legal ramifications of overturning Roe, such as prosecution of people who illegally undergo an abortion or of physicians who perform a procedure that a judge deems to be in violation of abortion law.
“There are already local prosecutors who have misused the law to go after people who have managed their own abortions,” Ms. Nash said. “Criminal abortion law, fetal homicide, child neglect, practicing medicine without a license – these are things people have actually been arrested and convicted under.”
Some laws may target the person seeking an abortion, whereas others may target clinicians providing abortions, or even people who simply help someone obtain an abortion, as the Texas law does. In Dr. Harris’s own state of Michigan, a group of Republican lawmakers recently introduced a bill that would imprison abortion providers for up to 10 years and anyone creating or distributing abortion medication for up to 20 years.
Michigan Gov. Gretchen Whitmer, a Democrat who called the proposed legislation “disturbing” and “infuriating,” would almost certainly veto the bill, but it’s just one of dozens already filed or that are expected to be filed across the United States.
The antiabortion organization National Right to Life has published a “post-Roe model abortion law” for states to adopt. The model includes an exemption for abortions that, “based on reasonable medical judgment, [were] necessary to prevent the death of the pregnant woman” – but, again, it does not clarify what that means in practice.
Lectures from strangers
Four years after nearly dying, Kami gave birth to a healthy girl following an uncomplicated pregnancy. But her journey to having more children presented more challenges.
Two years after the birth of her child, she had another ectopic pregnancy. Her doctor sent her prescriptions for medication that would end this pregnancy, but a pharmacist refused to fill the prescription.
“Do you know these are very serious medications?” the pharmacist asked her. She did – she had taken them once before for another ectopic pregnancy. She was with her daughter, feeling devastated about losing yet another desired pregnancy. She simply wanted to get the medication and go home.
“‘So you’re trying to have a cheap abortion,’ he said, and 30 heads turned and looked at me. The whole pharmacy heard,” Kami said.
She told the pharmacist that she’d miscarried. She said he responded with: “So you have a dead baby in your body.”
Even after her doctor called to insist on filling the order, the man refused to fill it.
Kami left without the prescription, and her doctor performed a surgical dilation and curettage to remove the embryo from her fallopian tube for no fee.
Kami later tried again to have more children. She experienced another ruptured tube that she said nearly killed her.
“There was such a sense of pain knowing that I couldn’t have any more kids, but also the relief of knowing that I don’t have to go through this again,” Kami said. Now, however, with the Supreme Court having overturned Roe v. Wade, she has a new worry: “That my daughter will not have the same rights and access to health care that I did.”
A version of this article first appeared on Medscape.com.
Kami, a mother of one daughter in central Texas, lost three pregnancies in 2008. The third one nearly killed her.
The embryo became implanted in one of the fallopian tubes connecting her ovaries to her uterus. Because fallopian tubes can’t stretch to accommodate a fetus, patients must undergo surgery to remove the embryo before the tube ruptures. Failure to do so can result in internal bleeding and death.
But when Kami – who did not want to use her last name to avoid harassment – underwent an ultrasound to start the process of extracting the embryo, her doctor miscalculated how far along in the pregnancy she was and told her to come back in a few weeks.
She eventually did return, but only after passing out in the bathtub and waking up in a pool of her own blood. The tube had ruptured, and to remove it, emergency surgery was necessary.
Stories such as Kami’s could become more common in the aftermath of the U.S. Supreme Court’s decision to overturn Roe v. Wade, the 1973 case that created a right to an abortion.
Experts fear that antiabortion laws that take effect in the United States following the court’s decision will lead to a medical and legal limbo for thousands of people like Kami – people with uncommon reproductive conditions whose treatments involve the termination of pregnancies or the destruction of embryos.
Vague exceptions prompt concerns
According to the Guttmacher Institute, a nonprofit group for reproductive health, 13 states currently have trigger laws on the books that make abortion illegal in the absence of Roe. Nine other states have laws that would outlaw or severely restrict abortion without a federal right to the procedure.
Each of these laws carves out exceptions that allow the termination of a pregnancy to prevent the death of the pregnant individual. But the language of the provisions is not always precise in describing what those exceptions mean in practice, according to Elizabeth Nash, the principal policy associate for state issues at the Guttmacher Institute.
“These exceptions are designed to be extraordinarily narrow. These aren’t really designed to be usable exceptions,” Ms. Nash said. “There’s so much misinformation about abortion that there are probably legislators out there who think that it’s never needed to save a life.”
Tubal pregnancies
One of the best examples of a pregnancy termination that’s necessary to avoid death is in the case of an ectopic pregnancy such as Kami experienced. Without treatment to end the pregnancy, the embryo will eventually grow so large that the tube ruptures, causing massive bleeding that can kill the mother.
Most state laws regarding abortion exclude treatment of ectopic pregnancy, according to Ms. Nash. But, “if the state does not exclude ectopic pregnancy from all the regulations, then people might not be able to get the care that they need when they need it.”
The current abortion law in Texas, for example, prohibits ending a pregnancy after 6 weeks, or after cardiac activity becomes present. Cardiac activity can be present in cases of ectopic pregnancies, which account for between 1% and 2% of all pregnancies and are the leading cause of maternal deaths in the first trimester. And treatment definitely ends the life of the embryo or fetus in the fallopian tube, said Lisa Harris, MD, PhD, an ob.gyn. and medical ethicist at the University of Michigan, Ann Arbor.
Dr. Harris said she has never doubted that an ectopic pregnancy cannot possibly result in a live birth. But she recalled an encounter with another clinician on a surgical team for an ectopic pregnancy who said: “So you’re going to take it out of the tube and put it in the uterus, right?”
“It was a startling moment,” Dr. Harris recalled. She regarded the procedure as a “lifesaving, obvious surgery,” but her colleague, whose suggestion was a medical impossibility since the window of implantation is very brief after fertilization, viewed it “as an abortion, as killing an embryo or fetus.”
Dr. Harris said she isn’t concerned that physicians would stop treating ectopic pregnancies in a post-Roe world. Rather, she worries about two other possibilities: an overzealous prosecutor might not believe it was an ectopic pregnancy and press charges; or laws will cause physicians to second guess their clinical decisions for patients.
“What it means, in the middle of the night, when someone comes in with a 10-week ectopic pregnancy with a heartbeat, is the doctor may hesitate,” Dr. Harris said. Despite knowing the appropriate treatment, the doctor may want to speak with a lawyer or ethicist first to ensure they are covered legally. “And as that process unfolds, which could take hours or days, the person might have a complication.” s
Not treating an ectopic pregnancy would be malpractice, but “some doctors may not provide the standard of care that they would have ordinarily provided because they don’t want to risk breaking the law,” she said.
Even more ambiguous are cornual ectopic pregnancies, in which the implantation occurs at the junction of a fallopian tube and the uterus. These pregnancies, which make up 2%-4% of all tubal pregnancies, are immediately adjacent to the uterus. If an abortion is defined as the termination of an embryo or fetus in the womb, how such a legal definition would apply to these pregnancies is unclear.
An ob.gyn. wouldn’t regard ending an ectopic pregnancy as an abortion, but “this is not about logic or clinical meaning,” Dr. Harris said. “This is people outside of medicine making determinations that all pregnancies must continue, and when you think of a ban that way, you could see why a doctor would be frightened to end a pregnancy, whether it might be viable in the future or not.”
That’s true even if the pregnancy is located fully in the uterus. Dr. Harris described a pregnant patient she saw who had traveled from Texas to Michigan with a fetus that had a lethal defect.
The fetus had “an anomaly where the lungs couldn’t develop, where there were no kidneys. There was no chance this baby could be born and live. Her doctors were very clear that there will never be a baby that [she could] take home at the end of this pregnancy, yet they would not end her pregnancy because that would be an abortion,” Dr. Harris said.
Texas law “doesn’t make any allowances for whether a pregnancy will ever actually result in a baby or not,” Dr. Harris said. “The law, in effect, just says all pregnancies must continue.”
Selective reduction
How abortion laws in different states might affect selective reduction, which is used in some pregnancies to reduce the total number of fetuses a person is carrying, is even more ambiguous. The goal of selective reduction is to decrease health risks to the pregnant individual and increase the likelihood of survival for the remaining fetuses. Current Texas law prohibits these procedures.
Someone pregnant with quintuplets, for example, might seek selection reduction to reduce the pregnancy outcome to triplets or twins. A related procedure, selective termination, is used to terminate the life of a fetus with abnormalities while the pregnancy of the fetus’ in utero siblings continues.
The advent of assisted reproduction methods, such as in vitro fertilization (IVF), greatly increased the incidence of higher-order multiples, those with three or more fetuses. The first IVF baby was born in 1978. By 1998, the rate of higher-order multiple births was 1.9 per 1,000 births, five times the figure in 1980. The rate has since decreased by nearly half, to 1 per 1,000 births, but with 3.75 million live births a year, that’s still a lot of pregnancies with higher-order multiples.
The American College of Obstetricians and Gynecologists does not provide explicit guidance on when selective reduction is warranted, but its committee opinion on multifetal pregnancy reduction provides an ethical framework for providers to use when counseling people with pregnancies of three or more fetuses. How would various state laws that outlaw abortion affect these decisions? No one knows.
“Selective reduction ends the life of a fetus or embryo, but it doesn’t end the pregnancy,” Dr. Harris said. “So, if the pregnancy continues but it kills an embryo or fetus, is that an abortion?”
‘The question of the hour’
Dr. Harris and other doctors are haunted by potential medical cases in which continuing a pregnancy may result in the death of the person carrying the fetus but in which such death may not be so imminent that the law would allow immediate termination of the pregnancy.
Michael Northrup, MD, an intensive care pediatrician in Winston-Salem, N.C., recalled a particularly harrowing case that illustrates the peril in deciding when someone’s life is “enough” in danger to qualify as an exception to abortion bans.
The 14-year-old girl had severe lupus and kidney failure that required treatment with methotrexate and immediate dialysis to replace her electrolytes. A standard pretreatment pregnancy test revealed that she had been carrying a child for at least 10 weeks. Her pregnancy presented two problems. Methotrexate is so severely toxic that it’s sometimes used to end pregnancies. Even at low doses, fetuses that survive usually have severe deformities. In addition, dialysis requires administration of a blood thinner. If the teen miscarried while taking a blood thinner during dialysis, she risked bleeding to death.
Treatment could be delayed until week 24 of pregnancy, at which time delivery could be attempted, but the patient likely wouldn’t have any kidney function left by then. In addition, at 24 weeks, it was unlikely that the baby would survive anyway.
Dr. Northrup said that, had she chosen that route, “I’m not sure she would have made it. This was a religious family, people who very much were believers. They had their head of church come in, who fairly quickly determined that the best thing for her health was to terminate this pregnancy immediately and get the treatment she needed for her body.”
Would such a situation qualify for an emergency termination? The girl wasn’t going to die within 24 or 48 hours, but it may not have been possible to pinpoint the time of death within a day or 2.
“The family was sad, but they made that choice, and I wonder, would we have to justify that with these new laws?” Dr. Northrup said. “You definitely worry, being in the hot seat, ‘Does this count enough? Is she close enough to death?’ ”
The same question comes up when someone’s water breaks early in the second trimester. Since a live-birth delivery would be highly unlikely, given the age of the fetus, the standard of care is to offer to terminate the pregnancy to avoid a serious infection, Dr. Harris said. But if the infection hasn’t yet developed – even if it’s likely to develop soon – doctors in a state that outlaws abortion would not be able to offer termination. But as providers wait for an infection to develop, the person’s risk of dying from infection rapidly increases.
“How likely does someone need to be to die for it to count to get a life-preserving abortion?” Dr. Harris asked. “That, I think, is the question of the hour.”
Different institutions may decide to determine their own risk thresholds. One hospital, for example, may decide that any health threat that is associated with a 10% risk of death qualifies for a lifesaving abortion. But for many people, a 1 in 10 chance of dying is quite high.
“Who gets to decide what’s meaningful?” Dr. Harris asked, especially if the patient is already a parent of living children and doesn’t want to take any risk at all of orphaning them for a pregnancy with severe complications.
“The point is that this is way more complicated than anybody really knows, way more complicated than any legislator or justice could possibly know, and it creates all kinds of complicated ambiguities, some of which could result in harm to women,” she said. “I’ve been a doctor almost 30 years, and every week, sometimes every day, I’m humbled by how complicated pregnancy is and how complicated people’s bodies and life situations are.”
That’s what makes it so dangerous for policymakers to “insert themselves into medical practice,” Ms. Nash said. She worries about the legal ramifications of overturning Roe, such as prosecution of people who illegally undergo an abortion or of physicians who perform a procedure that a judge deems to be in violation of abortion law.
“There are already local prosecutors who have misused the law to go after people who have managed their own abortions,” Ms. Nash said. “Criminal abortion law, fetal homicide, child neglect, practicing medicine without a license – these are things people have actually been arrested and convicted under.”
Some laws may target the person seeking an abortion, whereas others may target clinicians providing abortions, or even people who simply help someone obtain an abortion, as the Texas law does. In Dr. Harris’s own state of Michigan, a group of Republican lawmakers recently introduced a bill that would imprison abortion providers for up to 10 years and anyone creating or distributing abortion medication for up to 20 years.
Michigan Gov. Gretchen Whitmer, a Democrat who called the proposed legislation “disturbing” and “infuriating,” would almost certainly veto the bill, but it’s just one of dozens already filed or that are expected to be filed across the United States.
The antiabortion organization National Right to Life has published a “post-Roe model abortion law” for states to adopt. The model includes an exemption for abortions that, “based on reasonable medical judgment, [were] necessary to prevent the death of the pregnant woman” – but, again, it does not clarify what that means in practice.
Lectures from strangers
Four years after nearly dying, Kami gave birth to a healthy girl following an uncomplicated pregnancy. But her journey to having more children presented more challenges.
Two years after the birth of her child, she had another ectopic pregnancy. Her doctor sent her prescriptions for medication that would end this pregnancy, but a pharmacist refused to fill the prescription.
“Do you know these are very serious medications?” the pharmacist asked her. She did – she had taken them once before for another ectopic pregnancy. She was with her daughter, feeling devastated about losing yet another desired pregnancy. She simply wanted to get the medication and go home.
“‘So you’re trying to have a cheap abortion,’ he said, and 30 heads turned and looked at me. The whole pharmacy heard,” Kami said.
She told the pharmacist that she’d miscarried. She said he responded with: “So you have a dead baby in your body.”
Even after her doctor called to insist on filling the order, the man refused to fill it.
Kami left without the prescription, and her doctor performed a surgical dilation and curettage to remove the embryo from her fallopian tube for no fee.
Kami later tried again to have more children. She experienced another ruptured tube that she said nearly killed her.
“There was such a sense of pain knowing that I couldn’t have any more kids, but also the relief of knowing that I don’t have to go through this again,” Kami said. Now, however, with the Supreme Court having overturned Roe v. Wade, she has a new worry: “That my daughter will not have the same rights and access to health care that I did.”
A version of this article first appeared on Medscape.com.
Kami, a mother of one daughter in central Texas, lost three pregnancies in 2008. The third one nearly killed her.
The embryo became implanted in one of the fallopian tubes connecting her ovaries to her uterus. Because fallopian tubes can’t stretch to accommodate a fetus, patients must undergo surgery to remove the embryo before the tube ruptures. Failure to do so can result in internal bleeding and death.
But when Kami – who did not want to use her last name to avoid harassment – underwent an ultrasound to start the process of extracting the embryo, her doctor miscalculated how far along in the pregnancy she was and told her to come back in a few weeks.
She eventually did return, but only after passing out in the bathtub and waking up in a pool of her own blood. The tube had ruptured, and to remove it, emergency surgery was necessary.
Stories such as Kami’s could become more common in the aftermath of the U.S. Supreme Court’s decision to overturn Roe v. Wade, the 1973 case that created a right to an abortion.
Experts fear that antiabortion laws that take effect in the United States following the court’s decision will lead to a medical and legal limbo for thousands of people like Kami – people with uncommon reproductive conditions whose treatments involve the termination of pregnancies or the destruction of embryos.
Vague exceptions prompt concerns
According to the Guttmacher Institute, a nonprofit group for reproductive health, 13 states currently have trigger laws on the books that make abortion illegal in the absence of Roe. Nine other states have laws that would outlaw or severely restrict abortion without a federal right to the procedure.
Each of these laws carves out exceptions that allow the termination of a pregnancy to prevent the death of the pregnant individual. But the language of the provisions is not always precise in describing what those exceptions mean in practice, according to Elizabeth Nash, the principal policy associate for state issues at the Guttmacher Institute.
“These exceptions are designed to be extraordinarily narrow. These aren’t really designed to be usable exceptions,” Ms. Nash said. “There’s so much misinformation about abortion that there are probably legislators out there who think that it’s never needed to save a life.”
Tubal pregnancies
One of the best examples of a pregnancy termination that’s necessary to avoid death is in the case of an ectopic pregnancy such as Kami experienced. Without treatment to end the pregnancy, the embryo will eventually grow so large that the tube ruptures, causing massive bleeding that can kill the mother.
Most state laws regarding abortion exclude treatment of ectopic pregnancy, according to Ms. Nash. But, “if the state does not exclude ectopic pregnancy from all the regulations, then people might not be able to get the care that they need when they need it.”
The current abortion law in Texas, for example, prohibits ending a pregnancy after 6 weeks, or after cardiac activity becomes present. Cardiac activity can be present in cases of ectopic pregnancies, which account for between 1% and 2% of all pregnancies and are the leading cause of maternal deaths in the first trimester. And treatment definitely ends the life of the embryo or fetus in the fallopian tube, said Lisa Harris, MD, PhD, an ob.gyn. and medical ethicist at the University of Michigan, Ann Arbor.
Dr. Harris said she has never doubted that an ectopic pregnancy cannot possibly result in a live birth. But she recalled an encounter with another clinician on a surgical team for an ectopic pregnancy who said: “So you’re going to take it out of the tube and put it in the uterus, right?”
“It was a startling moment,” Dr. Harris recalled. She regarded the procedure as a “lifesaving, obvious surgery,” but her colleague, whose suggestion was a medical impossibility since the window of implantation is very brief after fertilization, viewed it “as an abortion, as killing an embryo or fetus.”
Dr. Harris said she isn’t concerned that physicians would stop treating ectopic pregnancies in a post-Roe world. Rather, she worries about two other possibilities: an overzealous prosecutor might not believe it was an ectopic pregnancy and press charges; or laws will cause physicians to second guess their clinical decisions for patients.
“What it means, in the middle of the night, when someone comes in with a 10-week ectopic pregnancy with a heartbeat, is the doctor may hesitate,” Dr. Harris said. Despite knowing the appropriate treatment, the doctor may want to speak with a lawyer or ethicist first to ensure they are covered legally. “And as that process unfolds, which could take hours or days, the person might have a complication.” s
Not treating an ectopic pregnancy would be malpractice, but “some doctors may not provide the standard of care that they would have ordinarily provided because they don’t want to risk breaking the law,” she said.
Even more ambiguous are cornual ectopic pregnancies, in which the implantation occurs at the junction of a fallopian tube and the uterus. These pregnancies, which make up 2%-4% of all tubal pregnancies, are immediately adjacent to the uterus. If an abortion is defined as the termination of an embryo or fetus in the womb, how such a legal definition would apply to these pregnancies is unclear.
An ob.gyn. wouldn’t regard ending an ectopic pregnancy as an abortion, but “this is not about logic or clinical meaning,” Dr. Harris said. “This is people outside of medicine making determinations that all pregnancies must continue, and when you think of a ban that way, you could see why a doctor would be frightened to end a pregnancy, whether it might be viable in the future or not.”
That’s true even if the pregnancy is located fully in the uterus. Dr. Harris described a pregnant patient she saw who had traveled from Texas to Michigan with a fetus that had a lethal defect.
The fetus had “an anomaly where the lungs couldn’t develop, where there were no kidneys. There was no chance this baby could be born and live. Her doctors were very clear that there will never be a baby that [she could] take home at the end of this pregnancy, yet they would not end her pregnancy because that would be an abortion,” Dr. Harris said.
Texas law “doesn’t make any allowances for whether a pregnancy will ever actually result in a baby or not,” Dr. Harris said. “The law, in effect, just says all pregnancies must continue.”
Selective reduction
How abortion laws in different states might affect selective reduction, which is used in some pregnancies to reduce the total number of fetuses a person is carrying, is even more ambiguous. The goal of selective reduction is to decrease health risks to the pregnant individual and increase the likelihood of survival for the remaining fetuses. Current Texas law prohibits these procedures.
Someone pregnant with quintuplets, for example, might seek selection reduction to reduce the pregnancy outcome to triplets or twins. A related procedure, selective termination, is used to terminate the life of a fetus with abnormalities while the pregnancy of the fetus’ in utero siblings continues.
The advent of assisted reproduction methods, such as in vitro fertilization (IVF), greatly increased the incidence of higher-order multiples, those with three or more fetuses. The first IVF baby was born in 1978. By 1998, the rate of higher-order multiple births was 1.9 per 1,000 births, five times the figure in 1980. The rate has since decreased by nearly half, to 1 per 1,000 births, but with 3.75 million live births a year, that’s still a lot of pregnancies with higher-order multiples.
The American College of Obstetricians and Gynecologists does not provide explicit guidance on when selective reduction is warranted, but its committee opinion on multifetal pregnancy reduction provides an ethical framework for providers to use when counseling people with pregnancies of three or more fetuses. How would various state laws that outlaw abortion affect these decisions? No one knows.
“Selective reduction ends the life of a fetus or embryo, but it doesn’t end the pregnancy,” Dr. Harris said. “So, if the pregnancy continues but it kills an embryo or fetus, is that an abortion?”
‘The question of the hour’
Dr. Harris and other doctors are haunted by potential medical cases in which continuing a pregnancy may result in the death of the person carrying the fetus but in which such death may not be so imminent that the law would allow immediate termination of the pregnancy.
Michael Northrup, MD, an intensive care pediatrician in Winston-Salem, N.C., recalled a particularly harrowing case that illustrates the peril in deciding when someone’s life is “enough” in danger to qualify as an exception to abortion bans.
The 14-year-old girl had severe lupus and kidney failure that required treatment with methotrexate and immediate dialysis to replace her electrolytes. A standard pretreatment pregnancy test revealed that she had been carrying a child for at least 10 weeks. Her pregnancy presented two problems. Methotrexate is so severely toxic that it’s sometimes used to end pregnancies. Even at low doses, fetuses that survive usually have severe deformities. In addition, dialysis requires administration of a blood thinner. If the teen miscarried while taking a blood thinner during dialysis, she risked bleeding to death.
Treatment could be delayed until week 24 of pregnancy, at which time delivery could be attempted, but the patient likely wouldn’t have any kidney function left by then. In addition, at 24 weeks, it was unlikely that the baby would survive anyway.
Dr. Northrup said that, had she chosen that route, “I’m not sure she would have made it. This was a religious family, people who very much were believers. They had their head of church come in, who fairly quickly determined that the best thing for her health was to terminate this pregnancy immediately and get the treatment she needed for her body.”
Would such a situation qualify for an emergency termination? The girl wasn’t going to die within 24 or 48 hours, but it may not have been possible to pinpoint the time of death within a day or 2.
“The family was sad, but they made that choice, and I wonder, would we have to justify that with these new laws?” Dr. Northrup said. “You definitely worry, being in the hot seat, ‘Does this count enough? Is she close enough to death?’ ”
The same question comes up when someone’s water breaks early in the second trimester. Since a live-birth delivery would be highly unlikely, given the age of the fetus, the standard of care is to offer to terminate the pregnancy to avoid a serious infection, Dr. Harris said. But if the infection hasn’t yet developed – even if it’s likely to develop soon – doctors in a state that outlaws abortion would not be able to offer termination. But as providers wait for an infection to develop, the person’s risk of dying from infection rapidly increases.
“How likely does someone need to be to die for it to count to get a life-preserving abortion?” Dr. Harris asked. “That, I think, is the question of the hour.”
Different institutions may decide to determine their own risk thresholds. One hospital, for example, may decide that any health threat that is associated with a 10% risk of death qualifies for a lifesaving abortion. But for many people, a 1 in 10 chance of dying is quite high.
“Who gets to decide what’s meaningful?” Dr. Harris asked, especially if the patient is already a parent of living children and doesn’t want to take any risk at all of orphaning them for a pregnancy with severe complications.
“The point is that this is way more complicated than anybody really knows, way more complicated than any legislator or justice could possibly know, and it creates all kinds of complicated ambiguities, some of which could result in harm to women,” she said. “I’ve been a doctor almost 30 years, and every week, sometimes every day, I’m humbled by how complicated pregnancy is and how complicated people’s bodies and life situations are.”
That’s what makes it so dangerous for policymakers to “insert themselves into medical practice,” Ms. Nash said. She worries about the legal ramifications of overturning Roe, such as prosecution of people who illegally undergo an abortion or of physicians who perform a procedure that a judge deems to be in violation of abortion law.
“There are already local prosecutors who have misused the law to go after people who have managed their own abortions,” Ms. Nash said. “Criminal abortion law, fetal homicide, child neglect, practicing medicine without a license – these are things people have actually been arrested and convicted under.”
Some laws may target the person seeking an abortion, whereas others may target clinicians providing abortions, or even people who simply help someone obtain an abortion, as the Texas law does. In Dr. Harris’s own state of Michigan, a group of Republican lawmakers recently introduced a bill that would imprison abortion providers for up to 10 years and anyone creating or distributing abortion medication for up to 20 years.
Michigan Gov. Gretchen Whitmer, a Democrat who called the proposed legislation “disturbing” and “infuriating,” would almost certainly veto the bill, but it’s just one of dozens already filed or that are expected to be filed across the United States.
The antiabortion organization National Right to Life has published a “post-Roe model abortion law” for states to adopt. The model includes an exemption for abortions that, “based on reasonable medical judgment, [were] necessary to prevent the death of the pregnant woman” – but, again, it does not clarify what that means in practice.
Lectures from strangers
Four years after nearly dying, Kami gave birth to a healthy girl following an uncomplicated pregnancy. But her journey to having more children presented more challenges.
Two years after the birth of her child, she had another ectopic pregnancy. Her doctor sent her prescriptions for medication that would end this pregnancy, but a pharmacist refused to fill the prescription.
“Do you know these are very serious medications?” the pharmacist asked her. She did – she had taken them once before for another ectopic pregnancy. She was with her daughter, feeling devastated about losing yet another desired pregnancy. She simply wanted to get the medication and go home.
“‘So you’re trying to have a cheap abortion,’ he said, and 30 heads turned and looked at me. The whole pharmacy heard,” Kami said.
She told the pharmacist that she’d miscarried. She said he responded with: “So you have a dead baby in your body.”
Even after her doctor called to insist on filling the order, the man refused to fill it.
Kami left without the prescription, and her doctor performed a surgical dilation and curettage to remove the embryo from her fallopian tube for no fee.
Kami later tried again to have more children. She experienced another ruptured tube that she said nearly killed her.
“There was such a sense of pain knowing that I couldn’t have any more kids, but also the relief of knowing that I don’t have to go through this again,” Kami said. Now, however, with the Supreme Court having overturned Roe v. Wade, she has a new worry: “That my daughter will not have the same rights and access to health care that I did.”
A version of this article first appeared on Medscape.com.
Antibiotics during pregnancy may increase child’s risk for asthma and other atopic diseases
, a systematic review and meta-analysis reports.
“Antibiotic use during pregnancy is significantly associated with the development of asthma in children. Additionally prenatal antibiotic exposure is also associated with disorders present in the atopic march including atopic sensitization, dermatitis/eczema, food allergy, allergic rhinitis, and wheeze,” lead study author Alissa Cait, PhD, of Malaghan Institute of Medical Research in Wellington, New Zealand, and colleagues write in Allergy.
“Antibiotics account for 80% of prescribed medications during pregnancy, and it is estimated that 20%-25% of pregnant women receive at least one course of an antibiotic during this time period,” they add.
The researchers evaluated prenatal antibiotic exposure and the risk for childhood wheeze or asthma, as well as for diseases associated with the atopic march, by searching standard medical databases for controlled trials in English, German, French, Dutch, or Arabic involving the use of any antibiotic at any time during pregnancy and for atopic disease incidence in children with asthma or wheeze as primary outcome. They excluded reviews, preclinical data, and descriptive studies.
From the 6,060 citations the search returned, 11 prospective and 16 retrospective studies met the authors’ selection criteria. For each study, they evaluated risk of bias using the Newcastle-Ottawa Quality Assessment Scale, and they rated certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) protocol.
The studies, published between 2002 and 2020, were conducted in Europe, North America, Asia, and South America. Exposure to antibiotics during the prenatal period was assessed through unsupervised questionnaires, interviews by medical professionals, or extraction from official medical databases.
The results showed that:
- Antibiotic use during pregnancy was linked with increased relative risk of developing wheeze (relative risk, 1.51; 95% confidence interval, 1.17-1.94) or asthma (RR, 1.28; 95% CI, 1.22-1.34) during childhood.
- Antibiotic use during pregnancy also increased a child’s risk for eczema or dermatitis (RR, 1.28; 95% CI, 1.06-1.53) and allergic rhinitis (RR, 1.13; 95% CI, 1.02-1.25).
- Food allergy increased in one study (RR, 1.81; 95% CI, 1.11-2.95).
Quality of studies
“These results have importance for antibiotic stewardship throughout the prenatal period,” the authors write. However, due to issues including high heterogeneity, publication bias, and lack of population numbers in some studies, the overall quality of the evidence presented in the studies was low. Other limitations include mainly White and European study populations, underpowered studies, and study protocol inconsistencies.
“Though there is evidence that antibiotic treatment during pregnancy is a driver of the atopic march, due to a large heterogeneity between studies more research is needed to draw firm conclusions on this matter,” the authors add. “Future studies should employ and report more direct and objective measurement methods rather than self-reported questionnaires.”
Dustin D. Flannery, DO, MSCE, a neonatologist and clinical researcher in perinatal infectious diseases and neonatal antimicrobial resistance and stewardship at Children’s Hospital of Philadelphia, said in an email that the study was well done.
He noted, though, that “although the study reports an association, it cannot prove causation. The relationship between prenatal antibiotics and childhood allergic disorders is likely multifactorial and quite complex.”
He joins the authors in recommending further related research. “Due to the variation in how exposures and outcomes were defined across the studies, more rigorous research will be needed in this area.”
Despite the study’s limitations, “given that some studies have found associations between prenatal antibiotic exposure and childhood atopic and allergic disorders, including asthma, while other studies have not, this systematic review and meta-analysis asks an important question,” Dr. Flannery, who was not involved in the study, said in an interview.
“Investigators found a strong association between prenatal antibiotic exposure and risk of childhood asthma and other disorders,” he said. “This finding supports efforts to safely reduce antibiotic use during pregnancy.”
The study was supported by the Deutsche Forschungsgemeinschaft and by the Konrad Adenauer Foundation. The authors and Dr. Flannery have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
, a systematic review and meta-analysis reports.
“Antibiotic use during pregnancy is significantly associated with the development of asthma in children. Additionally prenatal antibiotic exposure is also associated with disorders present in the atopic march including atopic sensitization, dermatitis/eczema, food allergy, allergic rhinitis, and wheeze,” lead study author Alissa Cait, PhD, of Malaghan Institute of Medical Research in Wellington, New Zealand, and colleagues write in Allergy.
“Antibiotics account for 80% of prescribed medications during pregnancy, and it is estimated that 20%-25% of pregnant women receive at least one course of an antibiotic during this time period,” they add.
The researchers evaluated prenatal antibiotic exposure and the risk for childhood wheeze or asthma, as well as for diseases associated with the atopic march, by searching standard medical databases for controlled trials in English, German, French, Dutch, or Arabic involving the use of any antibiotic at any time during pregnancy and for atopic disease incidence in children with asthma or wheeze as primary outcome. They excluded reviews, preclinical data, and descriptive studies.
From the 6,060 citations the search returned, 11 prospective and 16 retrospective studies met the authors’ selection criteria. For each study, they evaluated risk of bias using the Newcastle-Ottawa Quality Assessment Scale, and they rated certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) protocol.
The studies, published between 2002 and 2020, were conducted in Europe, North America, Asia, and South America. Exposure to antibiotics during the prenatal period was assessed through unsupervised questionnaires, interviews by medical professionals, or extraction from official medical databases.
The results showed that:
- Antibiotic use during pregnancy was linked with increased relative risk of developing wheeze (relative risk, 1.51; 95% confidence interval, 1.17-1.94) or asthma (RR, 1.28; 95% CI, 1.22-1.34) during childhood.
- Antibiotic use during pregnancy also increased a child’s risk for eczema or dermatitis (RR, 1.28; 95% CI, 1.06-1.53) and allergic rhinitis (RR, 1.13; 95% CI, 1.02-1.25).
- Food allergy increased in one study (RR, 1.81; 95% CI, 1.11-2.95).
Quality of studies
“These results have importance for antibiotic stewardship throughout the prenatal period,” the authors write. However, due to issues including high heterogeneity, publication bias, and lack of population numbers in some studies, the overall quality of the evidence presented in the studies was low. Other limitations include mainly White and European study populations, underpowered studies, and study protocol inconsistencies.
“Though there is evidence that antibiotic treatment during pregnancy is a driver of the atopic march, due to a large heterogeneity between studies more research is needed to draw firm conclusions on this matter,” the authors add. “Future studies should employ and report more direct and objective measurement methods rather than self-reported questionnaires.”
Dustin D. Flannery, DO, MSCE, a neonatologist and clinical researcher in perinatal infectious diseases and neonatal antimicrobial resistance and stewardship at Children’s Hospital of Philadelphia, said in an email that the study was well done.
He noted, though, that “although the study reports an association, it cannot prove causation. The relationship between prenatal antibiotics and childhood allergic disorders is likely multifactorial and quite complex.”
He joins the authors in recommending further related research. “Due to the variation in how exposures and outcomes were defined across the studies, more rigorous research will be needed in this area.”
Despite the study’s limitations, “given that some studies have found associations between prenatal antibiotic exposure and childhood atopic and allergic disorders, including asthma, while other studies have not, this systematic review and meta-analysis asks an important question,” Dr. Flannery, who was not involved in the study, said in an interview.
“Investigators found a strong association between prenatal antibiotic exposure and risk of childhood asthma and other disorders,” he said. “This finding supports efforts to safely reduce antibiotic use during pregnancy.”
The study was supported by the Deutsche Forschungsgemeinschaft and by the Konrad Adenauer Foundation. The authors and Dr. Flannery have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
, a systematic review and meta-analysis reports.
“Antibiotic use during pregnancy is significantly associated with the development of asthma in children. Additionally prenatal antibiotic exposure is also associated with disorders present in the atopic march including atopic sensitization, dermatitis/eczema, food allergy, allergic rhinitis, and wheeze,” lead study author Alissa Cait, PhD, of Malaghan Institute of Medical Research in Wellington, New Zealand, and colleagues write in Allergy.
“Antibiotics account for 80% of prescribed medications during pregnancy, and it is estimated that 20%-25% of pregnant women receive at least one course of an antibiotic during this time period,” they add.
The researchers evaluated prenatal antibiotic exposure and the risk for childhood wheeze or asthma, as well as for diseases associated with the atopic march, by searching standard medical databases for controlled trials in English, German, French, Dutch, or Arabic involving the use of any antibiotic at any time during pregnancy and for atopic disease incidence in children with asthma or wheeze as primary outcome. They excluded reviews, preclinical data, and descriptive studies.
From the 6,060 citations the search returned, 11 prospective and 16 retrospective studies met the authors’ selection criteria. For each study, they evaluated risk of bias using the Newcastle-Ottawa Quality Assessment Scale, and they rated certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) protocol.
The studies, published between 2002 and 2020, were conducted in Europe, North America, Asia, and South America. Exposure to antibiotics during the prenatal period was assessed through unsupervised questionnaires, interviews by medical professionals, or extraction from official medical databases.
The results showed that:
- Antibiotic use during pregnancy was linked with increased relative risk of developing wheeze (relative risk, 1.51; 95% confidence interval, 1.17-1.94) or asthma (RR, 1.28; 95% CI, 1.22-1.34) during childhood.
- Antibiotic use during pregnancy also increased a child’s risk for eczema or dermatitis (RR, 1.28; 95% CI, 1.06-1.53) and allergic rhinitis (RR, 1.13; 95% CI, 1.02-1.25).
- Food allergy increased in one study (RR, 1.81; 95% CI, 1.11-2.95).
Quality of studies
“These results have importance for antibiotic stewardship throughout the prenatal period,” the authors write. However, due to issues including high heterogeneity, publication bias, and lack of population numbers in some studies, the overall quality of the evidence presented in the studies was low. Other limitations include mainly White and European study populations, underpowered studies, and study protocol inconsistencies.
“Though there is evidence that antibiotic treatment during pregnancy is a driver of the atopic march, due to a large heterogeneity between studies more research is needed to draw firm conclusions on this matter,” the authors add. “Future studies should employ and report more direct and objective measurement methods rather than self-reported questionnaires.”
Dustin D. Flannery, DO, MSCE, a neonatologist and clinical researcher in perinatal infectious diseases and neonatal antimicrobial resistance and stewardship at Children’s Hospital of Philadelphia, said in an email that the study was well done.
He noted, though, that “although the study reports an association, it cannot prove causation. The relationship between prenatal antibiotics and childhood allergic disorders is likely multifactorial and quite complex.”
He joins the authors in recommending further related research. “Due to the variation in how exposures and outcomes were defined across the studies, more rigorous research will be needed in this area.”
Despite the study’s limitations, “given that some studies have found associations between prenatal antibiotic exposure and childhood atopic and allergic disorders, including asthma, while other studies have not, this systematic review and meta-analysis asks an important question,” Dr. Flannery, who was not involved in the study, said in an interview.
“Investigators found a strong association between prenatal antibiotic exposure and risk of childhood asthma and other disorders,” he said. “This finding supports efforts to safely reduce antibiotic use during pregnancy.”
The study was supported by the Deutsche Forschungsgemeinschaft and by the Konrad Adenauer Foundation. The authors and Dr. Flannery have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM ALLERGY