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Americans' High Rate of Pregnancy-Related Sickness and Death

Americans lack access to reproductive, maternal, and postpartum healthcare.

Key points

  • The US maternal mortality ratio is higher than in other wealthy countries and is rising.
  • In the US, certain procedures and medications used in gynecological and obstetric practice are prohibited by law.
  • Prohibition of medical procedures means doctors are not trained to do them skillfully.

Six years ago, I somehow emerged mostly unscathed from a complicated pregnancy that threatened my health. I am deeply fearful as I consider what I would have done now, as more and more aspects of healthcare are restricted.

My story began when I presented myself at my gynecologist’s office to rid myself of a “blighted ovum.” My blight was a fertilized egg, which had implanted itself into the uterine wall but would never develop into a fetus. The egg could have been of poor quality, or the sperm that fertilized it, chromosomally deficient. The gestational sac that should contain an embryo instead was empty, devoid of any developing life. Blighted ova must be removed from the uterus via spontaneous or procured miscarriage; otherwise, they can cause hormonal and uterine problems for the people they inhabit. As with many miscarriages, the patient may feel sad, angry, or confused that a wanted pregnancy will not come to fruition.1 Or, as I did, the patient might not feel pregnant at all and may regard a blighted ovum as simply a medical problem to resolve.

Because I am fortunate to live in an area of the United States that has many doctors and currently few legal restrictions on gynecological practice, my doctor was prepared and able to treat my condition. Depending on the size of the ovum, various procedures could be used to expel it if it refused to be rousted on its own through a spontaneous miscarriage. A dilation and curettage (D&C) was prescribed as my remedy.

Without adequate gynecological care, every year worldwide, approximately 295,000 women die because of infections, hemorrhage, or hypertension related to pregnancy (including miscarriage, abortion, and postpartum conditions).2 Most of these deaths are preventable if a woman has timely access to a skilled medical provider with the right tools and medicines. But in rich countries like the US, poorly managed miscarriages, lack of treatment for ectopic pregnancies and other gynecological disorders, and inadequate post-abortion care are the most important causes of pregnancy-related death.3

In fact, America is a dangerous place for those with uteruses. Pregnancy-related death in the US has increased steadily over the past thirty years, with 17.4 women dying for every 100,000 who had a live birth in 2018.4 The maternal mortality ratio of the United States is the highest of the 14 most developed countries in the world, and it is rising while maternal deaths decrease elsewhere.5

A reason—perhaps the reason—for the high rate of pregnancy-related sickness and death for Americans is our lack of access to reproductive, maternal, and postpartum healthcare. In the US, certain procedures and medications used in gynecological and obstetric practice are prohibited by law. These prohibitions place medical standards of care, those medications and services provided by the prudent physician, beyond the physical access of 72.7 million American women of reproductive age.6,7

D&C

Consider the D&C my gynecologist prescribed me. A D&C is a standard gynecological procedure used to remove any tissue that is in the uterus but shouldn’t be: polyps, tumors, and whatever remains after a miscarriage, including a blighted ovum. D&Cs are exceedingly common and so necessary for uterine healthcare that they happen in a doctor’s office and take only five minutes. But the procedure is invasive and requires a skilled practitioner because they require sharp implements, and a poorly done D&C could perforate the uterus.8 A D&C done in a gynecologist’s office usually involves a paracervical block—this is a procedure that uses lidocaine injected adjacent to the cervix to numb pain receptors in the area. Some doctors sedate their patients using general anesthesia given intravenously. This lessens the patient’s pain and anxiety over the procedure but requires special staff to administer, adding to the cost and length of the D&C.

D&E

My doctor could have scheduled me for a different procedure, a dilation and evacuation, the D&E, which is another way gynecologists remove tissue from uteruses when a less invasive surgical procedure is advised.9 D&Es are illegal in certain circumstances in three states, and eight other states have attempted to outlaw them.10 Where D&Es are proscribed, doctors must perform D&Cs instead, even if these are not the ideal procedure for the patient.

Prohibition of medical procedures also means doctors are not trained to do them skillfully. Many OB-GYN residency training programs do not show doctors how to perform D&E procedures safely. Beyond the termination of pregnancy, there are always situations where a D&E is the better procedure. For a patient with a pre-viable pregnancy who is hemorrhaging from an accident or trauma or from placenta previa, a doctor prohibited from doing a D&E would have to make a very large cut in the uterus to stop the bleeding. The patient would then be required to deliver by cesarean section in the future, presaging potential complications. A D&E done through the cervix only would be a safer procedure if a trained provider correctly used the right equipment.

D&X

D&X is a more complex surgery for patients who are miscarrying, seek an autopsy of fetal remains, or reduce potential trauma to the uterus from the introduction of sharp instruments during an abortion. It is exceedingly rare that a doctor would abort a pregnancy using a D&X; however, twenty-one states outlaw dilation and extraction (D&X) for pregnancy terminations.11 Because of prohibitions on when D&X might be used, many medical students are not trained to perform D&X.12 As a result, a cadre of doctors are leaving U.S. medical schools without the necessary skills or knowledge to resolve miscarriages.

Repercussions of Lack of Care

When I discovered I was a bearer of uterine blight and needed help, I was at the mercy of whoever could treat me with whatever tools available, regardless of whether the implements and procedures used were state of the art or just whatever was permitted. This situation was disappointing but not soul-crushing; I was then too naïve to know that I could or should demand better. Because conception and pregnancy are so intensely personal, neither did I consider the public health ramifications of my situation. Any larger lessons I could have learned from needing to seek a quasi-pregnancy termination were utterly lost on me—at least, at first. I would get my D&C and would try again to conceive.

I now realize how lucky I was, and I wonder about the quality of care accessible to Americans.

References

[1] See Cleveland Clinic, “Blighted Ovum,” October 22, 2021, https://my.clevelandclinic.org/health/diseases/21924-blighted-ovum.

[2] See WHO, “Maternal Mortality,” Fact Sheets, September 19, 2019, https://www.who.int/news-room/fact-sheets/detail/maternal-mortality.

[3] See Nicholas J. Kassebaum et al., “Global, Regional, and National Levels of Maternal Mortality, 1990–2015: A systematic Analysis for the Global Burden of Disease Study 2015,” Lancet 388 (October 2016): 1775–1812, Findings section, https://www.sciencedirect.com/science/article/pii/S0140673616314702.

[4] The racial disparity of these data is staggering. Black women die at many times the rate of white women, with the maternal mortality rate for non-Hispanic Black women at 37.3 compared to 14.9 for non-Hispanic whites. [ See Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, “Key Findings,” November 9, 2020, https://www.cdc.gov/nchs/maternal-mortality/index.htm.

[5] See Nina Martin and Renee Montagne, “U.S. Has the Worst Rate of Maternal Deaths in the Developed World,” National Public Radio (NPR) and ProPublica Special Series, Lost Mothers: Maternal Mortality in the U.S., May 12, 2017, https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-mate….

[6] See William C. Shiel Jr., “Medical Definition of the Standard of Care,” MedicineNet, December 21, 2018, https://www.medicinenet.com/script/main/art.asp?articlekey=33263.

[7] See Guttmacher Institute, Contraceptive Use in the United States by Demographics (May 2021), https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states (citing 2018 population estimate).

[8] According to my gynecologist, most doctors try to avoid sharp (metal) curettage with pregnancy D&C. Instead, physicians often use a plastic curette that is attached to a suction device.

[9] See Lindey Lanquist, “A New Arkansas Abortion Law Basically Bans Second Trimester Abortions,” Self, February 3, 2017, https://www.self.com/story/arkansas-trap-law.

[10] See Guttmacher Institute, “Bans on Specific Abortion Methods Used after the First Trimester,” June 1, 2021, https://www.guttmacher.org/state-policy/explore/bans-specific-abortion-….

[11] Ibid.

[12] See Mara Gordon, “The Scarcity of Abortion Training in America’s Medical Schools,” Atlantic, June 9, 2015, https://www.theatlantic.com/health/archive/2015/06/learning-abortion-in….

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