The Daily - How Abortion Bans Are Restricting Miscarriage Care

Episode Date: July 20, 2022

Across the United States, Republicans emboldened by the overturning of Roe v. Wade are passing laws intended to stop medical staff from providing an abortion.But those same laws may also be scaring health workers out of providing basic care for miscarriages.Guest: Pam Belluck, a health and science writer for The New York Times.Want more from The Daily? For one big idea on the news each week from our team, subscribe to our newsletter. Background reading: Although post-Roe laws are technically intended to apply only to abortions, some patients have reported hurdles receiving standard surgical procedures or medication for the loss of desired pregnancies.For more information on today’s episode, visit nytimes.com/thedaily. Transcripts of each episode will be made available by the next workday. 

From The New York Times, I'm Michael Barbaro. This is The Daily. Today, across the country, Republicans emboldened by the end of Roe v. Wade are passing laws designed to scare doctors and nurses out of providing an abortion. and nurses out of providing an abortion. But as my colleague Pam Belluck has found, those same laws may also be scaring them out of providing basic care for a miscarriage. It's Wednesday, July 20th.

Pam, tell us the story of this woman that you have been talking to. Hello? Hi, Amanda. Hi, Pam. Hey. Good. How are you?

Amanda is a 35-year-old woman who lives in the Dallas-Fort Worth area. I am married to the most amazing man in the entire world. And she and her husband have been trying for the past couple of years to have children. And last year, in 2021, they were thrilled to discover that she was pregnant. This was in the spring. How far along were you? spring. How far along were you? I was 10 weeks along. And she, you know, had an obstetrician gynecologist. She was going for regular appointments. We went in for our 10-week ultrasound. And at one of those regular appointments in her first trimester of pregnancy,

the doctor did an ultrasound. And they could press an ultrasound and gave them the very disappointing news that there was no heartbeat in the embryo. There was no cardiac activity. He told us the news and my husband just cried. And that basically she had experienced a miscarriage. And I remember asking him, like, did I do something wrong? And he's like, no, no, miscarriages are so common. You know, one in ten known pregnancies end in miscarriage. And when you count situations where people don't even know that they're pregnant yet, it can be as high as one in four pregnancies ending in miscarriage, especially in

the first trimester. So he had told me like, there are options, there is medicine we can give you, and he's like, but really the safest thing for you to do is to get this DNC. I didn't even know what it was before. So her doctor recommends that she have a surgical procedure, which is called a dilation and curatage. It's known as a DNC. It's a very standard procedure to remove the pregnancy tissue from her uterus. And it's important not to leave the tissue in there because that can cause infection and bleeding and various complications. And then he scheduled me for a few days later at a hospital. She goes to the hospital.

My doctor came in and I was very nervous and I was very sad. And he actually like held my hand while he like talked me through the procedure and how long it would take. She has the procedure. Her doctor performs it. She wakes up from the anesthesia. She was able to go home that day. Her doctor had actually sent her home with prescriptions for pain relievers and with Tylenol, and she didn't need any of that.

She wasn't feeling the physical pain. And so I think she just felt like it was kind of the best possible way of dealing with a difficult emotional situation. And she and her husband continued to try to conceive. So I went in at six weeks and I got to see the baby. They measured the baby, said I was like on the right schedule. And some months later, she was thrilled to learn that she was pregnant again. We were optimistic because we could see the baby in the ultrasound. We had the right hormone levels.

So we thought everything was going to be okay. But then sometime during her first trimester, she starts having terrible cramping. My husband, he had gone to work and it started out like, but by the time he got home I was like in such bad pain, I was like nauseous from the pain. And

she's very worried about it and so she goes to the same hospital. She is doubled over in pain from the cramping, and she starts bleeding. Passing, you know, large blood clots. They do an ultrasound,

and they can tell that there's no cardiac activity. And in fact, she has... She's miscarrying again. She's miscarrying again. And I said, okay, well, can I have a DNC? She tells the hospital, you know, I was here eight months earlier. I had a DNC. Can I have one again?

And they said, no, we can't perform the DNC here. She said the hospital told her no. And basically they sent her home. And they said, you know, if you are bleeding excessively, then come back. And my husband was like, oh, she's here because she's bleeding excessively. Like, how do we know what excessively is? she's here because she's bleeding excessively. Like, how do we know what excessively is?

And they said to her, you don't need to come back unless the blood fills a diaper in the space of an hour. And he said, okay, so if she does that, how long do I have to get her from home to the hospital where she's not in danger? And they said about 20 minutes if she's, like, hemorrhaging or bleeding out. He was like, well, I was 30 minutes from the hospital. This is a very different treatment than what she received just a few months earlier.

Yes, this is a very different experience than what occurred just eight months earlier. And it's very, very upsetting for her and her husband. And they are incredibly distraught. So it was so different from my first experience where they were so nice and so comforting to just feel like alone and terrified. So what happens to her once she gets home? She goes home. You know, she's in an adult diaper. She goes and sits on the toilet because she's bleeding. She's just in so much pain.

Her husband fills up the bathtub with warm water. They think that might be a little bit more comforting for her. comforting for her. And we were just, we were scared and we were sad and I was in pain and he didn't know what to do. And it was scaring him because the bathtub, you know, the water is just dark red. Like you're just sitting in a tub. It looks like it's filled with blood.

They're terrified. They're in tears. And he called back up to the ER doctor and was like, look, you guys said you wouldn't give her anything, that Tylenol would be enough, but I'm telling you it's not enough. And her husband calls the hospital, this is in the middle of the night, begs for a prescription for something beyond the Tylenol that she's taken. And they finally, several hours later, when the pharmacy opens, are able to pick up a muscle relaxer.

She takes it. It helps a little bit. But basically, she has a kind of excruciating 48 hours sitting, you know, a lot of that time in the bathtub. And after that, she continues for about a week or so to bleed, sort of like a bad period, and she does pass all the pregnancy tissue. She doesn't end up having to go back to the emergency room with an infection or with hemorrhaging or anything like that. But emotionally, it was a very traumatic

and excruciating experience for her. I thought the first miscarriage was tough because of how sadly it was. But you can see it's the kind of thing that could have been avoided if she had been able to have the DNC that she requested and that she had had for her first miscarriage. And Pam, what is Amanda's understanding, and yours as well, of why this second miscarriage was treated so profoundly differently by the same hospital. Texas rolled out a law that was a very, very strict ban on most abortions after about six weeks of pregnancy. And Amanda feels that the climate of fear and nervousness that this law created caused the hospital to treat her second miscarriage differently than they treated her first miscarriage.

Right. We cover this law on the show. It was at the time the most restrictive abortion law in the country. And beyond saying that you couldn't have an abortion in Texas after six weeks, it had a quality of vigilantism built into it that encouraged people to report someone who assisted in trying to get someone an abortion after that period. And the Supreme Court let the law stand, which turned Texas into a kind of post-Roe v. Wade state even before Roe was struck down.

But Pam, Amanda is not having an abortion. She's having a miscarriage. So help me understand how this law would have anything to do with what Amanda's going through. Well, the law shouldn't actually have anything to do with Amanda's situation. The law is not about miscarriage. The law is about abortion, but those two things can present in the same way when the person shows up at a hospital. Explain that. So if a person is seeking an abortion, one of the things that they can do to facilitate that

abortion is to take pills. That's called medication abortion, and that involves taking two types of pills 24 to 48 hours apart. And that causes cramping and it causes bleeding. And ultimately, over a week or two, the pregnancy tissue passes. Now, when someone is having a miscarriage, they can present with exactly the same symptoms of cramping and bleeding as their body is working to expel the pregnancy tissue. That cramping and bleeding looks exactly the same as if they had taken abortion pills. When it comes to treatment for a miscarriage, if the doctor is looking for a way to help the person expel the pregnancy tissue, they have a couple of options and both of those options look exactly the same as the

treatment that somebody would get if they had requested an abortion for example that surgical procedure that amanda received in her first miscarriage the dnc that's also the same procedure that is used in some cases of abortion so you can imagine that doctors and hospitals in a place like Texas would get very worried that there might be confusion about whether they are actually facilitating an abortion instead of a miscarriage. Interesting. Interesting. So when a woman like Amanda shows up at a hospital in Texas and says she's pregnant and she's cramping and she's bleeding, in the minds of the doctors and the nurses who are supposed to treat her, there's not a simple way to tell the difference between someone who has potentially taken pills to have an abortion and someone who has just naturally miscarried. And as a result, they may ask that person just to go home. Yeah, I mean, those situations are medically identical. And it isn't actually helped by the official medical terminology for miscarriage, which in the medical textbooks is called a spontaneous abortion or a threatened abortion. So, you know,

I think the doctors understand what's happening. The hospital understands what's happening, but their fear is that somebody outside the hospital who doesn't have a medical education and is just trying to prevent anything that even looks like an abortion. I think their concern is that it will be misconstrued or could be misconstrued and that the hospital could be facing a lawsuit. So the thinking here, the fear really, by doctors and nurses is that the same legal repercussions that they would face for carrying out an abortion in Texas under this law could be applied to them for treating a woman

with pretty standard care for having a miscarriage. Yes, I think that's the fear. And I've heard from, you know, several doctors in Texas that they are worried about exactly this kind of situation. exactly this kind of situation. Now, to be very fair to the hospital, we do not know that they were motivated by the law to change their treatment in Amanda's case. They didn't mention the law to her and they declined to discuss the case with me when I asked. And they also declined to say whether the law had prompted them to make any changes. But for Amanda, she believes that this is the reason that she got such starkly different treatment in her two miscarriages. And what it's important to note about Texas is that Texas's law, you know, took effect nine months before Roe was overturned. But since Roe was overturned, we now have something like 20 states that have or will very soon have bans or very, very strict laws that make them very similar to Texas. And so the concern is that doctors and hospitals in many states

will be worried they're going to get in trouble if they follow their best medical judgment when it comes to treating miscarriage. We'll be right back. Pam, I know that the abortion laws that we have been talking about, like the one in Texas, Pam, I know that the abortion laws that we have been talking about, like the one in Texas, don't cover miscarriage. But I'm curious if one of the intended impacts of these laws that are now going into effect in so many different states is to make miscarriage something that doctors fear treating. So, no. So, no. I think that if you asked people who were involved in writing these laws, and I have, they would say no. The laws are not intended to have that effect. And I spoke to the president of Texas Right to Life. He said that it's definitely not the intention of the law or the letter of the law to prevent women from getting treatment for miscarriage or

prevent doctors from giving that treatment. And he said he had heard of cases where this kind of thing is happening, but he blamed that on doctors misunderstanding the law. And he said that medical societies need to do a better job of explaining to doctors what they can and can't do. And he seems to think that, you know, if they do that, if they do a better job of explaining it, that this will sort of sort itself out and these types of unintended consequences won't occur. And Pam, is that a realistic expectation because there's such a climate of fear and worry that somebody is going to misinterpret what they do or the treatment that they're providing. And so it almost doesn't really matter exactly what the letter of the law is. I think it matters more that somebody who doesn't have medical training might misinterpret the care that a doctor is providing

and think it looks like abortion treatment when it is actually miscarriage treatment. So I think there's just enough kind of heightened concern and a lot of misunderstanding among sort of the public and people especially who live in these anti-abortion states that it's got doctors and hospitals very concerned that even when they're doing something that isn't really addressed at all by the law that it might appear to be. by the law that it might appear to be. Right, because these doctors, in order to do this work, have to trust that the system will understand the nuances here. And as you have explained, the nuances are meaningful because the symptoms and the treatments for miscarriages and abortions are very much the same. They're very similar, yes.

So let's talk about what it's going to mean for now millions of women to live in this new world where medical experts are starting to worry that they may end up going to jail for offering what has been very standard care for a miscarriage, what that's going to look like on a larger national scale. So Amanda's story is one version of how this kind of nervousness and fear might play out. But there are a number of other scenarios that are occurring. And one of them is that another way

of treating a miscarriage is with medication. And those pills are exactly the same Another way of treating a miscarriage is with medication. And those pills are exactly the same as the medication that is prescribed for somebody seeking an abortion. So another way in which miscarriage looks just like abortion. Yes. So what has been happening is that women are going to pharmacies to have prescriptions filled for medication for their miscarriage. And they're facing a lot of questioning. A lot of times they're facing delays because the pharmacist feels that they need to go back to the doctor and make sure that this medication is really for a miscarriage and not for an abortion. And so that's

causing a lot of difficulties for patients. And in some cases, you know, when you tell somebody that they have to come back in a couple of days to pick up pills for their miscarriage, you know, some people may not be able to afford to come back. So some patients are just not picking up the medication and then they're staying at home, they're continuing to bleed in the same way that Amanda did and they may come back to the doctor a week or two later with either bleeding problems or having not passed the pregnancy and then having to have surgery or something like that

that they didn't intend to have. Another scenario is something that happens when doctors are actually following the letter of these abortion bans. Sometimes there are situations where there are complications that occur in a pregnancy before the fetus is viable. A common scenario is a pregnant woman's water breaks, and it's 16 weeks, 17 weeks, 18 weeks into a pregnancy and there is no way that she is going to be able to give birth to a baby in that situation.

It's too early. It's way too early. But in some of those cases, there is still a fetal heartbeat at that time. So in a state like Texas and many of these other states, if there is still cardiac activity, if there's still a fetal heartbeat, then doctors are not allowed to intervene

to treat the pregnant person until the heartbeat stops or there is a situation where the health of the pregnant woman is so serious and she's basically in a life-threatening or serious health-threatening situation, and that's when doctors can intervene. And, you know, it can often take a long time to get to that point. So you have a situation where doctors are unable to treat the pregnant person because they're waiting for her to get sicker and sicker and sicker. And there was actually a study just published recently with two major hospitals in Texas. major hospitals in Texas. And they looked at the experience of patients in this circumstance after Texas passed its law that we were talking about. And they found that patients had to wait

an average of nine days until either the heartbeat stopped or they got so sick that doctors could legally intervene under the law. And that more than half of those women ended up with serious infections or serious hemorrhaging. Basically, their health got a lot worse before doctors were able to do anything about it, and there was no way that they were going to have a viable pregnancy. So before these laws, doctors would have intervened much earlier in one way or another, but now

that these laws are in place, they don't intervene because they can't intervene, which in a very real way puts the mother in danger, even though the pregnancy is not viable. Yes, that's right. And it's not as if the supporters of these abortion bans didn't anticipate this kind of scenario. It's actually kind of baked right into these laws. And that's because they have an ethical framework where they are equating the fetus with the pregnant person. And so in their view, if there is still fetal cardiac activity, then they are saying that that is the equivalent to the life of the pregnant woman. And so the doctor can't do anything to extinguish that fetal cardiac activity, even if it means that the pregnant woman's health is going to get worse and worse while they're waiting. Pam, I wonder where this leaves what is really supposed to be a kind of sacred relationship in medicine between patient and doctor,

between those who are pregnant and the doctors that they expect to be advocates for their health. Yeah, so I think, you know, in an ideal world, patients would go to the doctor and they would get the best treatment for their condition. You know, you break your leg and you don't expect the doctor to be grilling you about whether you were jaywalking when you fell and your leg got broken. Right. So this situation sets up a climate where the distrust can get so great that you may have patients who are reluctant to go to the doctor because they're worried that they're going to be questioned, and you may have doctors who are reluctant to follow their best medical instincts because they're worried that somebody's going to think that they're providing an abortion when they're not. And that's the kind of scenario that

hits hardest for people in communities where there has already been distrust of medical institutions and there's already been systemic problems that have led to lack of access. So I think there's a real concern that for some people, healthcare in pregnancy and maybe healthcare in general is going to get worse. Right. Care is going to be worse. Yeah. Care and their willingness to seek care. Pam, I wanted to end on Amanda. It's been a few months since her second miscarriage. Is she still trying to have a baby?

So Amanda actually felt the need to share with me that she and her husband are not going to try and conceive anymore, at least not while they still are living in Texas. We tried for two years, we had two losses, and now we don't feel like it's safe in Texas to continue to try after what we went through. Yeah, I'm so sorry. It affects everybody so much. I'm trying not to cry. It goes so far out. They just don't feel like they can be confident that they'll be able to get the treatment that they're seeking

if she happens to miscarry again. I was forced to go through this trauma and this pain, and now it's not safe for us to try again. There's going to be so many women that don't even want to try to have children anymore. They don't trust the medical system anymore. They don't trust the medical system anymore they don't trust the medical system anymore under these laws well pam thank you very much thank you we'll be right back. Here's what else you need to know today.

Britain made climate history on Tuesday as the heat wave gripping much of Europe pushed temperatures there past 104 degrees Fahrenheit, the highest level ever recorded in the country. As a result, train tracks buckled, electric transformers overheated, and fires broke out across the country, prompting the mayor of London to put the city on emergency footing. We simply can't cope with the number of fires across our city directly attributable to the heat wave we're experiencing.

Scorching temperatures across Europe are expected to fall beginning today, but are likely to return. Researchers told The Times that the frequency of heat waves in Europe are increasing at a faster rate than almost any part of the world. Meanwhile, a different heat wave is blanketing the U.S. On Tuesday, more than 100 million Americans from Texas to Kentucky were under heat advisories or warnings from the National Weather Service. This is more than just your typical summer heat.

These are new records that are being set across the area. In Oklahoma City, temperatures reached 110 degrees. Today's episode was produced by Nina Feldman, Muj Zaydi, Rob Zipko, and Claire Tennesgetter. It was edited by Peach Cowett, contains original music from Marion Lozano and Dan Pell, and was engineered by Chris Wood. Our theme music is by Jim Brunberg and Ben Landsberg of Wonderland.

That's it for The Daily. I'm Michael Bavaro. See you tomorrow.