Reproductive Health Care in Detroit Part Two
Reproductive Health Care in Detroit
In an ongoing conversation about reproductive health care, I will be giving some facts and figures about abortion in this blog post. Abortion is a flashpoint in our society; as always, I will be taking a measured, evidenced-based approach to this issue as I am a family medicine physician, and I rely on evidence to make clinical decisions.
The conversation here is adult/mature; the content here may be triggering for some readers. The descriptions of abortion here are not typically discussed in polite society. If you have concerns, read no further.
This week, I discussed much of the following information in the Daily Detroit podcast with Jer Staes. If you’d rather listen to this information, you can do so here:
You can listen to the podcast episode, here.
Abortion Rate in the United States
In 2020, the Census Bureau estimated that women made up about 50.7 percent of the population — some 167 million people. In the United States in 2020, the population of women ages 15-44 was 64,543,832.
In 2019, 629,898 legal induced abortions were reported to CDC from 49 reporting areas.
The majority of abortions in 2019 took place early in gestation:
92.7% of abortions were performed at ≤13 weeks’ gestation;
6.2% of abortions were performed at 14–20 weeks’ gestation
fewer than 1.0% of abortions were performed at ≥21 weeks’ gestation.
Early medical abortion is defined as the administration of medications(s) to induce an abortion at ≤9 completed weeks’ gestation, consistent with the current Food and Drug Administration labeling for mifepristone (implemented in 2016).
In 2019, 42.3% of all abortions were early medical abortions.
I think that knowing how many abortions take place per year is important. In short, there are 629,898 abortions for 64,543,832 women of childbearing age (15 to 44 years of age). That means that less than 1% of American women have an abortion each year (629,898 abortions / 64,543,832 women = 0.975% of women have an abortion every year.
And it’s important to know when these abortions take place during pregnancy. 92.7% of abortions take place at 13 weeks or less, or when the baby is the size of a lemon.
When is a Fetus Viable Outside of the Womb?
Doctors now consider 22 weeks the earliest gestational age when a baby is "viable," or able to survive outside the womb. But this is still extremely premature, and a baby born at this age will need a great deal of medical attention. Even if s/he survives, the risk of permanent disability is very high.
What are Common Scenarios When Abortion May Be Needed to Preserve the Health of the Mother or the Developing Fetus?
Ectopic pregnancy
Many people have heard of an ectopic pregnancy. An ectopic pregnancy is a pregnancy in which the fetus develops outside the uterus, typically in a fallopian tube. An ectopic pregnancy always ends in pregnancy loss. About 1 to 2% of all pregnancies in the United States are ectopic pregnancies.
The image on the left shows an embryo that is implanted correctly within the uterus. The right hand image demonstrates the various locations of an ectopic pregnancy. An ectopic pregnancy in the fallopian tube is called a tubal pregnancy, and can result in severe pain and damage to the fallopian tube.
Attribution: By BruceBlaus - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=44897672
An early ectopic pregnancy without unstable bleeding is most often treated with a medication called methotrexate, which stops cell growth and dissolves existing cells. The medication is given by injection.
Salpingostomy and salpingectomy are two laparoscopic surgeries used to treat some ectopic pregnancies. In these procedure, a small incision is made in the abdomen, near or in the navel. Next, your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the tubal area.
In a salpingostomy, the ectopic pregnancy is removed and the tube left to heal on its own. In a salpingectomy, the ectopic pregnancy and the tube are both removed.
Which procedure you have depends on the amount of bleeding and damage and whether the tube has ruptured. Also a factor is whether your other fallopian tube is normal or shows signs of prior damage.
In the context of an abortion ban, doctors may hesitate to intervene on behalf of a woman with an ectopic pregnancy. The doctor may have to contact the legal department at the hospital to ensure that they are not running afoul of the new rules and regulations. This hesitation and the time it takes to clear the legal department will likely result in more ruptured ectopic pregnancies, which will lead to damage to women’s reproductive organs, a decreased chance of healthy pregnancy in the future for these affected women, and potentially death for the mother in cases of sepsis or infected internal organs.
This is a real world consequence of this abortion ban, and this has already happened. Here’s a story from a nurse/health care worker on Instagram who relates how an ectopic pregnancy was not treated in a timely manner, and resulted in a rupture and then 600 mL of blood in the abdomen of the expectant mother, which came close to causing death for the mother.
A story posted on Instagram about a ruptured ectopic pregnancy and the real consequences for an expectant mother.
Here’s a similar story from Kaiser Health News about the importance of prompt care for ectopic pregnancy.
Incomplete Miscarriage
Miscarriage occurs in 8–15% of clinically recognized pregnancies and in ~30% of all pregnancies. Increasing maternal age is associated with an increasing risk of miscarriage. Many women may have a miscarriage and not even know it - they may experience a miscarriage as a heavy period a few weeks after their normal period. Other women may have a pregnancy, have a positive pregnancy test, and then miscarry a few weeks later.
These early miscarriages are often sad and painful, but don’t often require medical intervention as the mother’s lining of the uterus can slough off and expel the embryo/fetus/early pregnancy without retaining any tissue.
However, some pregnancies will experience a spontaneous abortion at 16 weeks or 18 weeks or 20 weeks, and the fetus/baby will be much larger. For whatever reason (usually a severe genetic problem) the baby will die in utero. This is not uncommon. The problem here is that some parts of conception (or body parts of the baby/fetus) can be retained, or some body parts can stay inside the uterus. If these products of conception are not removed, the uterus can be come infected and the mother could become septic and potentially die.
An incomplete abortion is the partial loss of the products of conception within the first 20 weeks. Incomplete abortion usually presents with moderate to severe vaginal bleeding, which may be associated with lower abdominal and/or pelvic pain. It is important to diagnose this early to make sure the patient expels all products of conception.
The overall incidence of spontaneous abortion is 10% to 15%. It is divided into early, <12 weeks, and late, >13 weeks.The causes of abortion are usually unknown but most commonly are attributed to fetal chromosomal abnormalities and the rest due to modifiable etiologies and risk factors. Treatment of incomplete abortion includes expectant, medical, and/or surgical treatment.Complications are rare but can be serious such as sepsis from the retained product, hemorrhagic shock, and uterine rupture. The prognosis for these patients is generally good with a proper workup, close obstetric follow-up, and patient education. [Source]
In patients with conception fragments at the cervical os, a clinician can remove the fragments with forceps to help initiate the process of hemostasis, facilitate uterine contractions, and decrease vagal stimulation. This will prevent cervical shock. In plain English, sometimes body parts of the fetus/baby get stuck in the mom’s uterus/cervix and they need to be removed by the OB/GYN with forceps. This is a heart-wrenching scenario, but again, doctors need to act fast to remove these retained products of conception, otherwise the mom can get a severe infection and die.
Patients with an incomplete abortion and retained products of conception commonly have one or more of the following signs: uterine bleeding, pelvic pain, fever and uterine tenderness. Patients with hemorrhagic shock have obvious blood loss and those with septic abortion have signs of sepsis.
Here’s a story that was circulating on social media over the weekend. A patient had a 16 week gestation fetus/baby in her uterus. Her water broke early, and the baby started to come out of the woman’s uterus, then cervix, then vagina, resulting with the fetus/baby’s foot resting outside of the vagina. In a case like this, the baby will die - it cannot be replaced into the uterus. However, this doctor is practicing in a state that has banned abortion. Because the baby’s heart is still beating, they have to wait until the baby dies before the retained products of conception/fetus/baby can be removed. This is harrowing.
In some cases, an early pregnancy at 8 or 10 or 12 weeks of gestation can die in the womb, but remain in the womb without clearing in a timely manner. This can lead to physical and emotional pain for the mom, and has a risk for infection/sepsis and death in the mother as well. In these cases, doctors can go in and remove the embryo/fetus with a vacuum suction or a dilation and curettage procedure, where the baby is scraped out of the uterus by the doctor.
To make this real, here’s a heartfelt story from NFL player Nick Sundberg about their family’s experience with needing an abortion (dilation and curettage) after his wife miscarried on two separate occasions.
In Vitro Fertilization (IVF)
Depending on the language and interpretation, a state law could curtail access to fertility treatments, and in some cases, make the practice of freezing or discarding unused embryos in In Vitro Fertilization illegal.
The language could affect fertility procedures in two ways.
The first impact could be on selective reduction, or multifetal reduction, the practice of reducing the number of fetuses in one pregnancy.
This procedure is not as common today but may occur if a woman undergoes hormone therapy, which could increase the number of eggs and result in triplets or quadruplets. In these cases, there is a chance the woman or embryos could be at greater risk of an unsuccessful pregnancy, which is why a fertility clinic may decide to reduce one or more of these fetuses. This could meet the definition of abortion in some states.
The more common practice, IVF, which results in half a million deliveries annually, is when eggs are extracted, fertilized and the embryos are formed in a petri dish outside of the body. The embryos are then genetically tested, and only the healthy ones are implanted, reducing the chances of selective reduction because they don’t have to implant as many at once. The unused embryos are either frozen and stored for later use, discarded during or after the process or donated for scientific research.
In some strict interpretations of the abortion ban, freezing or discarding embryos or donating embryos for scientific research could be criminalized.
Babies Without Developed Organs
Anencephaly is a severe congenital condition in which a large part of the skull is absent along with the cerebral hemispheres of the brain. Some women become pregnant and the baby develops without a brain.
Anencephaly is a rare type of neural tube defect that affects about 1 in 4,600 babies. There is no way to treat anencephaly. Babies born with this condition will die before or shortly after birth.
Spina bifida is a congenital defect of the spine in which part of the spinal cord and its meninges are exposed through a gap in the backbone. It often causes paralysis of the lower limbs, and sometimes mental handicap.
Cancer
Chemotherapeutic agents and radiation for cancer treatment can cause birth defects. Studies show there is a risk of birth defects when a woman becomes pregnant while getting or after receiving some types of chemotherapy, radiation therapy, and hormone therapy. In some cases, the risk can last for a long time, making getting pregnant a concern even years after treatment ends.
Rape or incest
Just 1% of women obtain an abortion because they became pregnant through rape, and less than 0.5% do so because of incest.
Does Banning Abortion reduce Abortion Rates?
According to data from the World Health Organization (WHO), the legality of abortion across the world actually has little to no effect on abortion rates throughout the world.
Legal or not, abortions can, will, and do take place.
The legality of abortion, however, does affect how safe those abortions are. Women who do not have access to a legal abortion frequently turn to illegal or "homemade" abortion options, which are typically much riskier, more dangerous, and less effective than legal options conducted by professional doctors in a clinical setting would be. (source)
Is abortion legal in Michigan right now?
Yes. Abortion is still legal in Michigan as long as the injunction is in place.
This is the latest email that I received from LARA or the Licensing and Regulatory Affairs of the State of Michigan:
On Friday, the U.S. Supreme Court overturned a woman’s constitutional right to abortion services. Under this decision, laws and court rulings in each state guide how health professionals provide abortions and abortion-related services. In Michigan, there is an injunction in place, based on a court order prior to Friday’s U.S. Supreme Court decision, that protects women seeking abortion services and the health care professionals assisting them. That order states, “Defendant [the Attorney General] and anyone acting under defendant’s control and supervision, see MCL 14.30, are hereby enjoined during the pendency of this action from enforcing MCL 750.14.” The order also provided that the Attorney General give immediate notice of the preliminary injunction to all state and local officials acting under her supervision. It is LARA’s position that abortion remains legal in Michigan because of the current injunction that prohibits enforcement of the 1931 law.
We understand that you may have some concerns about how continuing to provide medical and surgical services to women seeking abortion may impact your professional license. The Department of Licensing and Regulatory Affairs will not take any action against any health professionals for providing legal abortion services while the current injunction remains in place.
Thank you for your commitment to providing services to women in need and to all Michigan citizens. We will continue to update you as new information becomes available.
Bureau of Professional Licensing, Michigan Department of Licensing and Regulatory Affairs
Where can I Receive an abortion in Michigan right now?
To be clear, we do not perform abortions at our clinic. We do provide counseling, contraceptive care, pap smears, mammograms, women’s health care, and referrals for abortion when needed.
You can likely seek care from your OB/GYN at most major hospital systems or you can seek care from Planned Parenthood. If you are struggling to find options, please reach out to our office so that we can guide you through this difficult process.
How can we reduce abortion rates in michigan?
Abortion should be a last resort for women and for families. It is a difficult decision that can have long-lasting familial, physiological, and emotional effects. There are ways to reduce abortion rates if we want to and that looks like:
Access to free contraceptives
comprehensive sex education
universal health care
paid family leave
welfare funding
secure housing for all
closing the wage gap
funding education
According to the Colorado Department of Public Health and Environment:
The Colorado Family Planning Initiative drove a 50 percent reduction in teen births and abortions, avoided nearly $70 million in public assistance costs and empowered thousands of young women to make their own choices on when or whether to start a family.
A private donor’s investment in the state health department’s family planning program allowed us to train health care providers, support family planning clinics and remove the financial barriers to women choosing the safest, most effective form of contraception.
This initiative empowered thousands of Colorado women to choose when and whether to start a family.
Thanks in large part to the Colorado Family Planning Initiative:
Teen birth rate was nearly cut in half.
Teen abortion rate was nearly cut in half.
Births to women without a high school education fell 38 percent.
Second and higher order births to teens were cut by 57 percent.
Birth rate among young women ages 20-24 was cut by 20 percent.
Average age of first birth increased by 1.2 years among all women.
Rapid repeat births declined by 12 percent among all women.
Costs avoided: $66.1-$69.6 million.
In short, the above example from Colorado is an effective public health policy for reducing abortion. Banning abortion at a Federal level with little thought or care given to the nuances of pregnancy, ectopic pregnancy, miscarriages, etc… is an ineffective way to reduce abortion that will result in harm to the women of our country, their families, and our communities.
Thanks for reading,
-Dr. Paul Thomas with Plum Health DPC in Detroit, Michigan