Be Prepared for Dobbs Decision Impact on Maternal Mortality

The World Health Organization has tracked maternal mortality rates across the globe since establishing the improvement of maternal health as one of its top priorities. Through its data, we know that maternal mortality rates in the U.S. have steadily increased over the past three decades, even though most of these maternal deaths are preventable. The recent Dobbs decision could raise U.S. maternal mortality rates by prohibiting some of the treatment options that involve pregnancy termination. In cases where providers or patients may have previously chosen a treatment option that may no longer be available to them, the ability to adapt may be critical.

Dobbs v. Jackson Women’s Health Organization, decided by the U.S. Supreme Court on June 24, 2022, overturned both Roe v. Wade (1973), and Planned Parenthood v. Casey (1992). In Roe v. Wade, the court ruled that the U.S. Constitution conferred the right to an abortion. In Planned Parenthood v. Casey, the Supreme Court prohibited undue burdens on those seeking an abortion, such as waiting periods, spousal notice, and parental consent for minors. In Dobbs v. Jackson, the court ruled that the Constitution does not confer the right to an abortion, returning the power to regulate abortion to the states.

As of August 26, 2022, the New York Times reported that abortion was fully banned in 12 states, with another two states banning abortion after six weeks of pregnancy and three with bans at 15, 18, or 20 weeks. Additional states may soon join the list.

Dobbs decision and medically indicated abortions

For the purpose of this discussion, we set aside abortions that do not involve medical complications. Elective, non-medically-indicated abortions continue to spur disagreement and debate. However, healthcare providers must consider cases under their care that require medical interventions. These cases could cause difficulties for both patients and providers as they navigate new legal realities brought by the Dobbs decision.

In cases of medically necessary abortions where a mother’s life may be at risk, the Dobbs decision may create obstacles to treatment in what may already be very challenging circumstances. In 2019, the American College of Obstetricians and Gynecologists (ACOG) issued a joint statement with Physicians for Reproductive Health, stating, “There are situations where pregnancy termination in the form of an abortion is the only medical intervention that can preserve a patient’s health or save their life. As physicians, we are focused on protecting the health and lives of the patients for whom we provide care. Without question, abortion can be medically necessary.”

Providers can and will continue to recommend treatments that were not impacted by Dobbs for these types of scenarios. For example, if a mother’s life is at risk, labor can still be induced to interrupt a pregnancy.

Pregnancy complications putting a mother’s life at risk

Scenarios involving complications of pregnancy, such as when the mother’s water breaks prematurely and an infection occurs, can be life threatening. If the rupture occurs before 20 weeks, medical professionals have typically recommended abortion because of a high risk that infection could spread quickly from the uterus to the mother’s bloodstream, resulting in sepsis and possible death. Serious complications can also occur during the early stages of a miscarriage or ectopic (tubal) pregnancy.

Another serious, though less common condition is placental abruption, when the placenta begins to separate from the uterus. In a small number of cases, excessive bleeding could lead to hemorrhagic shock and death. In these cases, urgent termination of the pregnancy is necessary to save the mother’s life.

Preeclampsia (high blood pressure during pregnancy) also poses a serious threat. If severe, it can result in organ damage to the mother. Rates of preeclampsia have risen 25% in the U.S. in recent years, increasing the frequency of occurrence and becoming a leading cause of maternal illness and death.

Providers have options for effectively managing these conditions in post-Dobbs states now banning abortion, but they may vary from previous protocols, require changes in staff and patient education, or involve choices and tradeoffs that may differ from previous treatment options.

Preexisting health status affects pregnancy complications

Patients’ health status can also be at risk based on their health status before becoming pregnant. Preexisting conditions such as renal or cardiac disease can “severely compromise health or even cause death,” according to ACOG. Patients with these conditions may have highly elevated health risks if they attempt to carry their pregnancies to term.

In addition, some health conditions, such as cancer, may require treatments that cannot be safely administered during pregnancy. However, postponing treatments could jeopardize the patient’s prognosis. Chemotherapy drugs, radiation, and hormone therapies can pose serious risks to a fetus, including birth defects. Oncologists may typically recommend termination of a pregnancy before administering certain cancer treatments. Many cancers can be managed without pregnancy termination, but new limitations might require a difference in how you communicate options to patients. More patients may need to consider the risks and ramifications of continuing a pregnancy with cancer.

The list of medical conditions in which pregnancy is contraindicated because of the likelihood of maternal death is small — for example, cases of severe pulmonary hypertension may make pregnancy an extremely high risk to the mother — and termination of a pregnancy does not eliminate all of the risks inherent in preexisting health conditions. Providers in affected locations may be called on to counsel and treat more at-risk patients continuing with pregnancies, and they must be ready to provide the resources to do so.

Social determinants may compound Dobbs’ impact

For some mothers, a preexisting health status could have more to do with social determinants of health than biological or genetic factors. Social determinants can include economic instability, food insecurity, a lack of education or support, or unsafe living conditions, which can pose serious risks both during pregnancy and after delivery.

Researchers have studied the effects of social determinants on maternal health long before Dobbs, and some have attributed the poor U.S. maternal mortality rate largely to these factors, which may include a higher prevalence of existing disease or delays in receiving care. Analyses of the data, combined with projections of the ramifications post-Dobbs, indicate that certain demographics will likely experience a worsening maternal mortality rate that will be compounded by the narrowing treatment options.

A 2021 study by a University of Colorado researcher projected a potential 4-13% annual rise in pregnancy-related deaths among non-Hispanic white patients compared to a 12-33% annual rise in pregnancy-related deaths among non-Hispanic Black patients and 6-18% annual rise among Hispanic patients. These maternal mortality projections add to concerns over existing disparities among the different racial and ethnic groups in the U.S. that stem from health inequities and discrimination.

Dobbs decision implications for existing U.S. maternal care problems

Jhpiego, a nonprofit that works globally to improve maternal mortality, reported a 40% worldwide decline in maternal mortality since 1990. These gains have come through efforts to provide affordable high-quality care in over 150 countries. Yet maternal mortality rates in the U.S. have worsened. Why is this?

The leading causes of death in the U.S. directly related to obstetrics are hemorrhage, hypertensive diseases of pregnancy, and sepsis. Indirect obstetric deaths caused by diseases such as anemia and HIV are also rising. In many cases, the causes of death are manageable health conditions for which patients did not receive the care they needed.

U.S. maternal mortality data includes disproportionate numbers of low-income, Black, Hispanic, and other nonmajority-identifying patients in geographic areas where access to quality healthcare is less than ideal.

Looking ahead to scenarios where some patients will have access to medically necessary abortions, but others will not due to their geographic locations and inability to travel to another state for care, it is clear that patients with fewer resources will continue to be disadvantaged. Networks of healthcare professionals will have the challenge of ensuring that these inequities do not lead to an increase in patient deaths.

Actions that can make a difference in maternal mortality

Finding immediate solutions to these challenges is not easy. Healthcare organizations must operate within the laws of their states. Adapting to new limits on previous evidence-based practices will present procedural challenges. Healthcare providers must deliver the highest quality of care within their legal ability do so, but alternative protocols and courses of action may need to be developed quickly to ensure patient safety.

In addition, community organizations, termed “safety net providers,” can help support patients who need assistance. The Commonwealth Fund reported that organizations are already gearing up to request additional federal funding for supplemental coverage for Medicaid patients to help alleviate the impact of the Dobbs decision on low-income patients, people of color, and other underserved populations to help them get the care they need.

In a rapidly changing legal environment, your care teams must stay current on legislative changes and how best to respond and adapt. They must also have the knowledge and confidence to combat misinformation about safe and legal treatment options they can use.

In the longer term, education is critical. Healthcare providers must keep their teams up to date with changes in practice, and they must also help educate their communities. The work ahead will involve documenting policies, protocols, and procedures allowed under new legalities and ensuring that team members are trained to provide care with empathy, follow evidence-based practices, and provide balanced patient information.