If you went to the drug store and the pharmacist wouldn't let you have ibuprofen because he thinks there's a chance your headache is from a hangover and not from reading in dim light, you'd probably be furious. Someone else's value judgments about what they think is happening inside your body determining your medical treatment — or the deciding factor in whether you get treatment at all? Unconscionable. This is not a rhetorical scenario. There are signs that is already happening around pregnancy termination in the wake of the overturning of Roe v. Wade. A country where in numerous places restrictions on voluntary abortion mean you can't get a D&C or a prescription to manage a miscarriage? It's basically the same story.
Opponents of reproductive choice argue that despite the wave of abortion bans going into effect around the country, pregnant people will still be protected in life threatening situations — they will still, as Oklahoma law puts it, be allowed to be treated with interventions to remove a "dead unborn child caused by spontaneous abortion." And yet with doctors and pharmacists spooked by the fear of lawsuits or even criminal penalties, there is good reason to fear that will not necessarily be true for everyone.
"Medical providers who treat pregnancy-related issues in red states exist in a constant state of fear of performing any procedure that can be classified as an abortion—even while the procedures remain legal," wrote Dr. Leah Torres, an OB-GYN in Alabama, in a Slate essay published in May after the draft Supreme Court ruling leaked. Torres described treating patients who were miscarrying and who had been made to wait for standard medical treatment such as a D&C, and one whose physician "was denied the ability to perform the D&C" by the hospital after the patient went into sepsis following an incomplete medication abortion. In Texas, a law restricting the use of "abortion inducing drugs" has led to hesitancy to provide miscarriage care, an NPR report finds. "The challenge is that the treatment for an abortion and the treatment for a miscarriage are exactly the same," Dr. Sarah Prager told NPR.
In the health care world, different terminologies — "abortion" or "D&C," "medication abortion" or "abortion pills" — can essentially describe the same procedures, processes or prescriptions. There are many reasons a pregnant person might need medical intervention to remove the contents of the uterus, from a desired abortion to finding out the fetus isn't viable. And the same pills are prescribed and the same surgical procedures are performed to manage miscarriages and elective abortions.
"It's a medical procedure. It is not a value judgment."
"The word 'abortion' got taken away from medical nomenclature, which is what it is," Dr. Suzanne Gilberg-Lenz, a Beverly Hills OB-GYN and the author of "Menopause Bootcamp," told me in a recent interview. "It's a medical procedure. It is not a value judgment. When patients see insurance coding, for instance, for 'incomplete abortion, missed abortion,' these are miscarriages. That's the medical term: Abortion. Abortion. Because abortion is not about how you feel about it. Kind of like getting your tonsils out is not about your feelings."
One method of managing pregnancy termination is through a surgical procedure called a D&C — dilation and curettage. Dr. Katharine White, an associate professor of OB-GYN at the Boston University School of Medicine and gynecologist specializing in miscarriage care, explained how it works.
"First, the cervix is opened by stretching the natural opening (dilation) with a series of dilators," she said. "Then the provider (usually a doctor) removes the pregnancy tissue using suction, either [with] a hand-operated device or an electric vacuum (curettage). Traditionally, a curettage is performed by scraping the lining of the uterus, but most doctors now use a vacuum to remove pregnancy tissue, and the procedure is called a suction curettage or simply aspiration."
"While the name D&C isn't exactly medically accurate anymore, it's how most people still refer to this surgery," she added.
And, White explained, "technically, the steps are the same" for treating a first-trimester miscarriage and a first-trimester abortion, though "there may be a higher risk of heavy bleeding with the miscarriage procedure."
"It's the same thing," Gilberg-Lenz affirmed.
Another way of medically assisting the end of a pregnancy is through medication, typically with mifepristone and misoprostol.
"We use that medication for a lot of different things," said Gilberg-Lenz. "We could use it to expel the contents in an elective termination of pregnancy. It could be used because you had a postpartum hemorrhage and you come in to see me and you're still bleeding because it turns out you got a little bit of clot in there. Or maybe we think you have some placenta. I use it all the time, most of us do, to prep for any surgery where I'm going to need to go into the cervix. This is just a medication we use because, you know, we're doctors."
On social media, stories are emerging that indicate fears, judgments or assumptions around the procedures and medications associated with pregnancy termination are beginning to affect miscarriage patient care, too. On one such Reddit thread, a poster wrote that a Missouri pharmacist refused to dispense misoprostol prescription for her recent miscarriage. It's a similar story to the 2018 Michigan pharmacist who refused to dispense the same medication to a patient (in that case, specifically because of his religious beliefs). Another Reddit poster asked for help on a miscarriage forum: "I've talked to the doctors about it but they won't give me miso or a d&c."
Someone who understands these processes very well is Laura Fletcher. The founder & CEO of Selah Fertility and author of the upcoming memoir, "The Grace of Grief: Healing and Hope After Miscarriage," Fletcher experienced four miscarriages between the births of her two children.
"Carelessly written laws sweep up so many people who were not intended to be affected by them."
"The first miscarriage didn't require any medical management," she recalled. "I didn't need to take any medications. I didn't need to have any surgery. The next three miscarriages all required medical intervention, whether that was a medical abortion, or a surgical abortion, more commonly known in the fertility world as a D & C."
Fletcher also pointed out the "misconception" that a D & C is not an abortion.
"They are the same procedure," she said. "I had a scenario in which medical abortion via medication failed and I had to be rushed in for a secondary emergency medical abortion."
Without it, she said, "I absolutely would have died."
Fletcher now is passionate about making people understand that without access to abortion, women will die.
"A lot of women will die, women that are already in a very traumatized state," she said. "Women that are having a miscarriage or an ectopic pregnancy, without access to either medical or surgical abortion, or occasionally both, will die."
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When people who aren't doctors — like Supreme Court justices or Catholic bishops — are dictating medical policy, people like Fletcher, who woke up in the middle of one terrible night in a pool of her own blood, are the ones who get hurt.
"People think there's two categories — pregnancies you want and pregnancies you don't," said White. "The reality of people's lives is that it's not that simple. Even very desired pregnancies can run into complications, where an abortion is the best thing for the health of the person who is pregnant, or where it becomes a nonviable pregnancy loss but because there's still the presence of a fetal heartbeat, the doctors hands are tied. That's why carelessly written laws sweep up so many people who were not intended to be affected by them."
"I want people to really understand," she said emphatically, "that it is not 'those women over there having abortions' and the rest of us. They are not separate buckets. You cannot separate out abortion care from the rest of pregnancy care."
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