Portal de Periódicos da CAPES

Special Report

2022; Lippincott Williams & Wilkins; Volume: 44; Issue: 7 Linguagem: Inglês

10.1097/01.eem.0000852592.66955.58

1552-3624

Gina Shaw,

Homicide, Infanticide, and Child Abuse

Figure: abortion, Roe v. Wade, reproductive health, miscarriageJanneke Parrish, a technology professional and community organizer in Texas, posted a series of tweets on May 9 about what happened when she went to see a doctor after experiencing bleeding and significant pain in her lower back and pelvis, following weeks of nausea. The doctor did an ultrasound that confirmed Ms. Parrish's symptoms were related to a miscarriage: She had unknowingly been pregnant. “The doctor asked me about pregnancy, going into consolation mode. They asked me if I'd been trying to get pregnant, if I'd been pregnant before. I told them I had been pregnant, once before,” Parrish wrote. (https://bit.ly/37YNNbU.) But when she said the previous pregnancy had ended in an abortion when she was 19, the conversation's tone shifted “dramatically.” “Upon hearing that, this doctor in Texas rattled through a list of drugs, asking if I'd taken any of them in the last six weeks. They asked about my activities, what I'd been doing, if I'd intentionally injured myself,” she wrote. “Eventually, it stopped. They were satisfied that I hadn't known I was pregnant and induced an illegal abortion in Texas. I left, though not without the fear that because I'd gone for medical help, I'd now be reported, per Texas law. Because if I'd known I was pregnant, I wouldn't have gone.” This story, especially the last sentence, raises questions for emergency physicians, not just in Texas but throughout the United States: What will happen to women who avoid seeking emergency care for pregnancy-related symptoms because they fear prosecution and to the women who are prosecuted for pregnancy loss? The U.S. Supreme Court was expected at press time to hand down by early summer an already-leaked ruling in the Dobbs v. Jackson Women's Health Organization that, if the leak is accurate, will overturn the court's 1973 decision in Roe v. Wade barring states from making abortion illegal prior to the third trimester of pregnancy and requiring exceptions to any abortion law to protect the life and health of the pregnant patient. The Dobbs case relates to a Mississippi ban on all abortions after 15 weeks' gestation, but the draft of the opinion, written by Justice Samuel Alito, invalidates Roe and would return all decisions about abortion law to the states. That means the states will be free to enact any kind of abortion ban. A review by the Guttmacher Institute, a research and policy organization advancing sexual and reproductive health and rights, projected that 26 states are certain or likely to ban abortion if Roe is overturned. (Oct. 28, 2021; https://bit.ly/3G0fLk4.) Many are likely to be modeled after Texas' Senate Bill 8, enacted in 2021, that bans all abortions after cardiac activity is detectable, which is typically around six weeks' gestation (four weeks after a missed menstrual period) when many do not yet know they are pregnant. No exceptions are made for cases of rape or incest. Several states also have trigger laws in place that ban all or almost all abortions, which could be enforced as soon as Roe is overturned: Arkansas, Idaho, Iowa, Kentucky, Louisiana, Oklahoma, South Dakota, Tennessee, and Wyoming. Other states have pre-Roe abortion bans on the books that were never removed, and could be enforced as soon as the Supreme Court's decision is handed down. More legislation is expected. A bill recently introduced in Louisiana attempted to classify abortion as homicide and charge anyone undergoing an abortion with murder, although it was withdrawn from debate on May 12. Risks for EPs Some cases already hint at what may lie ahead for emergency physicians. Lizelle Hernandez, a 26-year-old who miscarried at a Texas hospital, divulged to her caregivers that she had attempted to self-induce an abortion. She was indicted on a murder charge and arrested by sheriff's deputies on April 7. Little details have been released about what led to the charges, but the indictment stated that on Jan. 7 Ms. Herrera did “intentionally and knowingly cause the death of an individual ... by self-induced abortion.” The charges were dropped after a public outcry and advocacy on her behalf by reproductive rights advocates. And 21-year-old Brittany Poolaw was convicted of manslaughter in Oklahoma last October and sentenced to four years in prison following a 2020 miscarriage, which prosecutors blamed on her use of methamphetamine and marijuana, although she also experienced placental abruption and the fetus had congenital anomalies. She was imprisoned for 18 months after being unable to pay her $20,000 bond, wrote Jennifer Tsai, MD, an emergency physician in New Haven, CT. (Bustle.com. Oct. 26, 2021; https://bit.ly/38EVDaT.) “As an emergency medicine physician, I find her sentencing a disgrace,” she wrote, adding, “I'm also scared. In Oklahoma and 24 other states, health care providers are required to report suspected prenatal drug use to police. This case could set a precedent that convinces patients to withhold necessary information or forgo medical care altogether—because when they see this case, they will hear one major message: Don't trust the doctor.” Dr. Tsai noted that every major professional medical and public health organization “opposes ‘criminal sanctions or civil liability for harmful behavior by the pregnant woman toward her fetus.’” “Statements from organizations like the American Medical Association, the American College of Obstetricians and Gynecologists, and American Academy of Pediatrics call such actions ‘inappropriate,’” she wrote, “because they can obstruct proper medical treatment and communication, and because substance abuse disorders are ‘diseases that require treatment, not incarceration.’” (NAPW. June 1, 2021; https://bit.ly/3Px1cZx; AMA. 2018; https://bit.ly/3wABeMh; American Nurses Association. March 15, 2017; https://bit.ly/3wFHjqC.) A 2013 study by National Advocates for Pregnant Women (NAPW) found that 413 women were arrested or deprived of liberty during the 32-year period between 1973 and 2005 because they were accused of endangering or harming their fetuses. But the organization also determined that 1254 such cases occurred during a shorter 14-year period between 2006 and 2020, a 204 percent increase over the 32-year period, and it called on health care providers and others “to examine the role they play in the arrests and detentions of and forced interventions on pregnant women.” (J Health Polit Policy Law. 2013;38[2]:299; https://bit.ly/3LtXHjz.) Difficult Situations for EPs “Emergency physicians are often the doctors first to make the diagnosis of a pregnancy, a potential miscarriage, or ectopic pregnancy when a patient comes to the hospital,” said Utsha Khatri, MD, an emergency physician in New York City. “Frequently in the ED, a patient who knows they are pregnant will come in with bleeding, worrying that they might be miscarrying,” Dr. Khatri said. “Other times, patients will come to the ED not knowing that they are pregnant at all. There are medical decisions around both situations, regardless of whether the patient is miscarrying or not.” She said the rise of anti-abortion laws is going to put emergency physicians into situations where they have to make difficult case-by-case decisions about whether providing appropriate medical care may get them in legal trouble or even charged with a felony. “This will create a climate in which there will be fear of punishment for the patients, the providers, and the health care institutions, and this will damage the trust between patients and their doctors,” Dr. Khatri said. “Patients should know that their physicians prioritize their health and well-being above all else, and these laws threaten that.” It is also a double-edged sword for physicians where they could be prosecuted or sued no matter what they do, she said. “On one hand, we're talking about the possibility of physicians and health systems providing substandard medical care for pregnant patients out of fear that they are breaking the law,” Dr. Khatri said. “Then if they do that and a patient is harmed, that patient or their family could take legal action for malpractice or gross negligence.” Emergency physicians should be prepared to see an increase in the number of patients who have delayed care for suspected miscarriages, ectopic pregnancies, and other pregnancy-related problems, said Aishat Olatunde, MD, an obstetrician-gynecologist at Einstein Medical Center Philadelphia who provides abortions and works with the advocacy group Physicians for Reproductive Health. “People will be frightened to seek out care for fear of retribution or criminalization, whether that's in the setting of an ectopic pregnancy, a miscarriage, or an abortion,” she said. “That makes it even more paramount to focus on the patient at hand and not investigate them for seeking out the help that they need.” Dr. Khatri noted that emergency physicians are the only doctors available to patients 24 hours a day, seven days a week, regardless of ability to pay. “We are the safety net, often taking care of the most marginalized patients, patients who can't get care elsewhere in the health care system,” she said. “Our priority should be to promote the health and well-being of our patients who have reproductive rights. That's why we entered medicine, and we take an oath to do that, but these laws create an environment of uncertainty around our ability to fulfill that oath.” Trust in Physicians Marginalized populations, who often seek care in the ED, are also more likely to be affected by anti-abortion laws and laws that criminalize pregnancy loss. The 2013 NAPW study found that 71 percent of the 413 arrests and forced interventions of pregnant women from 1973 to 2005 were indigent, 59 percent were women of color, and 52 percent were Black. Black women were also more likely to be charged with serious crimes than white women, with 85 percent of Black women receiving felony charges compared with 71 percent of white women. (NAPW. June 1, 2021; https://bit.ly/3Px1cZx.) “Health care providers in all specialties have a very important role in making sure that our patients feel like they can trust us and that they are safe when getting care, particularly those from marginalized communities who may be less likely to trust the health care system in the first place and are at disproportionately increased risk of being targeted for criminalization,” Dr. Olatunde said. “We shouldn't be participating in policing patients. Law enforcement and politicians don't have any right being in the exam room with our patients, whether physically or metaphorically speaking. Our role is to make sure that our patients trust us and we keep them safe.” The trend toward more restrictive laws governing reproductive health care also places responsibility on the shoulders of emergency department and hospital administration to provide clear leadership, Dr. Khatri said. “It's very important to have a standard protocol that is not dependent on an individual physician's own beliefs and interpretation of the law,” she said. “There is no other medical condition that we treat in which your personal beliefs directly impact the care options you provide, and health systems need to make clear how they interpret the law and the fact that their patients' health are their top priority. They should be willing to protect their physicians in providing that care in the event of legal or law enforcement interference.” Dr. Olatunde urged emergency physicians to speak out against these laws. “We have to raise our voices as medical providers, recognizing that seeking out reproductive health care is not a crime, and no person should be facing criminal charges or jail time for any aspect of their pregnancy or miscarriage or abortion. We are in the business of care and compassion; that should be our goal.” EMN contacted emergency physicians in several states with abortion bans, but all declined to comment or did not respond. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected]. Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work athttp://www.writergina.com/Home.html. Follow her on Twitter@writergina.