Treatment for miscarriages under Dobbs v. Jackson

After having no issues with her pregnancy before her third trimester, Marny Smith and her husband were excited to meet their son Heath in a matter of weeks.1 One evening, before falling asleep, her son wasn’t kicking like usual at that time of day. When the next morning came around, and there was still no movement, Smith knew her baby was gone. She and her husband called her physician, and they were told to go to the hospital immediately.

Smith had to endure the pain and wounds of childbirth, along with the pain of having a stillborn child. In the U.S., there are 21,000 stillbirths2 every year, and approximately 15-20%3 of all pregnancies will result in a miscarriage or stillbirth. If a pregnancy is determined to be a miscarriage,4 the treatment is the exact same as one for an abortion.

After the ruling of Dobbs v. Jackson Women’s Health Organization, physicians in many states are left wondering how to treat miscarriages. An abortion pill can be used earlier on in a pregnancy, but when the pregnancy has gone into its third trimester, dilation and curettage surgery is often necessary.4

Pharmacists have admitted reluctance to fill prescriptions for abortion medications in the case of miscarriages out of fear of being prosecuted,5 and that’s still only if the physician has even prescribed it. Not only are pharmacists and physicians at risk of prosecution for treatment for miscarriages; so are the mothers.

Even before Roe v. Wade was overturned, women who had miscarriages were prosecuted for engaging in risky behavior during pregnancy. One woman in California sat in jail for 15 months while facing murder charges because she took hard drugs during her pregnancy, following years of addiction. Legal analysts warn that women will be prosecuted even in cases of miscarriages and stillbirths.6 And in cases where treatment is received, clinicians are at legal risk, too.

Not only does the legality of treatment for miscarriages and stillbirths leave women and providers in a gray area, but postpartum mental health services for women have also not improved. Medicaid covers 4 in 10 births, but only eight states have explicit programs to provide maternal mental healthcare.7 Maternal mental health is often overlooked, but it is especially important for women who have suffered through a miscarriage or stillbirth to have access to assistance following the loss of a pregnancy.

Most women and physicians report believing that mental health services after losing a pregnancy are important, but most women don’t have access to them. Inability to receive counseling after such a traumatic event often results in women being too afraid to become pregnant again.8 Nearly 20% of women who had a miscarriage became symptomatic of anxiety and depression, and for most of these women, these symptoms lasted for years.8

Women should not lose clinical support when they become pregnant. Because more women are likely to face more arduous miscarriages than before in states with restrictive abortion treatment access, finding ways to assist these women better is essential. Women should not be blamed for miscarriages and prosecuted for it, and physicians should be able to perform routine clinical care for those instances.

Edited by: Elissa Gorman

Graphic Designed by: Alejandra Gonzalez-Acosta

References

1. Smith, M. (2022, January). After a death, bringing stillbirth prevention to the US. Health Affairs. Retrieved April 12, 2023, from https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.00745

2. Centers for Disease Control and Prevention. (2022, September 29). What is stillbirth? Centers for Disease Control and Prevention. Retrieved April 12, 2023, from https://www.cdc.gov/ncbddd/stillbirth/facts.html#:~:text=Stillbirth%20affects%20about%201%20in,stillborn%20in%20the%20United%20States.

3. Pregnancy loss - New York. Pregnancy Justice. (2022, December 22). Retrieved April 12, 2023, from https://www.pregnancyjusticeus.org/issues/pregnancy-loss/#:~:text=No%20matter%20what%20a%20pregnant,in%20a%20miscarriage%20or%20stillbirth.

4. Pradhan, R., & Knight, V. (2022, June 28). Five things to know now that the Supreme Court has overturned Roe v. Wade. KFF Health News. Retrieved April 12, 2023, from https://kffhealthnews.org/news/article/five-things-to-know-now-that-the-supreme-court-has-overturned-roe-v-wade/

5. Reingold, R. B., Gostin, L. O., & Bratcher Goodwin, M. (2022, November). Legal Risks and Ethical Dilemmas for Clinicians in the Aftermath of Dobbs. Jama Network. Retrieved April 12, 2023, from https://jamanetwork.com/journals/jama/fullarticle/2797863

6. Baldwin III, R. (2022, July 3). Losing a pregnancy could land you in jail in post-Roe America. NPR. Retrieved April 12, 2023, from https://www.npr.org/2022/07/03/1109015302/abortion-prosecuting-pregnancy-loss

7. Usha Ranji, I. G. (2022, May 19). Medicaid coverage of pregnancy-related services: Findings from a 2021 State Survey - Report. KFF. Retrieved April 12, 2023, from https://www.kff.org/report-section/medicaid-coverage-of-pregnancy-related-services-findings-from-a-2021-state-survey-report/

8. Nynas, J., Narang, P., Kolikonda, M. K., & Lippmann, S. (2015, January 29). Depression and anxiety following early pregnancy loss: Recommendations for Primary Care Providers. The primary care companion for CNS disorders. Retrieved April 12, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4468887/

Mitochondria and Maternal Health

If you ask anyone what they know about biology, at least one of the things they say is probably going to be: “the mitochondria is the powerhouse of the cell.” But what does that actually mean? And what happens if the powerhouse shuts down?

The mitochondria is a type of organelle, a word which refers to things contained within human cells, and it produces the energy (in the form of ATP, Adenosine Triphosphate) needed for the body to function. The mitochondria is special because it has its own DNA separate from the DNA in the nucleus of the cell that makes up most of our genetics. This DNA is crucial for the function of the mitochondria and this the function of the body.

If mutations occur within the DNA of the mitochondria they can cause mitochondrial diseases that have drastic impacts on health causing things like blindness, cardiovascular issues, or neurological issues like seizures. These diseases are not only inheritable, but almost unavoidable because mitochondrial DNA is only passed down on the maternal side. Paternal mitochondrial DNA (mtDNA) is degraded in embryos leaving only the mother’s mtDNA for the child, thus if she has a mutation, her children will likely have it too.

Mitochondrial issues can not only impact fetal vitality but also maternal health throughout her pregnancy. Mitochondria regulate the metabolism and energy in the human body, a process complicated by supporting a fetus. Thus, it’s important for the organelle to work properly. Women with mitochondrial disorders tend to have increased risk of, among other things, gestational diabetes, hypertension, difficulty breathing, tachycardia, muscle weakness, anemia, and preterm delivery.

Concerning maternal health, there is not yet a way to eliminate these genetic diseases, instead support mechanisms are used to aid mother’s feeling the effects. Things such as vitamin supplements or nutrition help. In terms of the fetus, the options are more controversial.

There is the option for use of a donor egg, which would be free from inheritable mitochondrial disease, but this does not allow the mother to be genetically related to her child. In recent years, research has been done about mitochondrial replacement techniques (MRTs), which in essence remove the mitochondria from a mother’s egg, replace it with donor mtDNA, and allow the mother to be the main source of maternal genes for her baby. But of course, it isn’t that simple.

There are two main types of MRTs: Maternal Spindle Transfer (MST) and Pro-Nuclear Transfer (PNT). MST involves removing the nucleus of the donor egg and replacing it with the nucleus of the maternal egg, before fertilizing it with the sperm of the father. PNT instead has the father’s sperm fertilize both the donor and maternal egg, before switching the nucleus of one to the other. The use of MRTs in general is highly debated, as well as whether one technique is more or less permissible than another.

Supporters of the techniques argue that it is a great way to help the mother feel like her child is her own, because it still has genes that are shared by her. There are arguments suggesting that the use of an MRT has an element of selectiveness similar to the idea of genetically engineering a child, because parents are choosing an mtDNA donor. However, counter arguments suggest that particularly with the use of PNT, because the fertilization event has already occurred, the same child will be born regardless of if the mtDNA replacement occurs or not, thus the method is ethically permissible.

It is of course also important to consider that the use of an MRT could be considered destruction of an embryo, which also has complicated ethics. Some argue that the creation of a donor embryo simply to be destroyed makes the process unethical.

Then the child must be considered. This is a new technique and children born with the use of an MRT may be subject to routine doctor check ins throughout their lives they were unable to consent to. Further still, because mtDNA is passed on to children, MRTs could be considered altering the germline, or heritable, genes of the child, which can be dangerous if the effects of the change are not understood.

As this debate continues, so does research. The UK was one of the first countries to allow both MST and PNT for women whose cases have been approved with licensed clinicians, but there remain a vast majority of countries, the United States among them, that restrict the use of these techniques. Discussion should continue about the ethical considerations of MRTs so that we can work towards finding a way to aid mothers who suffer from mitochondrial diseases.

It’s crucial that options for treatment continue to be researched so a technique, whether it be MRTs or not, can become an option for mothers who need it. The option to have a child free of mutated mtDNA who was still genetically their own is a very important thing for a mother.

As genetic technology improves and new methods come about, it will be important to continue to evaluate and ensure that the research remains ethical and high quality. It may also be important to be aware of the socioeconomic disparity the popularization of these techniques may pose should they be expensive. In short, there remain many unanswered questions about these MRTs and about potential solutions to mitochondrial disease inheritance as well, but they can never be answered if we don't ask.

Edited by: Anne Sacks

Graphic Designed by: Shanzeh Sheikh

References

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5102202/

2. https://www.annualreviews.org/doi/10.1146/annurev-genom-111119-101815

3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4620703/

4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7401276/

5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4989604/

6. https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.15667

7. https://mitochondrialdiseasenews.com/2018/08/10/women-with-mitochondrial-disease-dysfunction-more-prone-to-pregnancy-complications/

8. https://www.cambridge.org/core/journals/journal-of-law-medicine-and-ethics/article/mitochondrial-replacement-therapy-in-whose-interests/A12167E4DB71BF52CBFA344ECDED4F79

9. https://www.chop.edu/conditions-diseases/mitochondrial-disease

What You Need to Know About Roe v. Wade

In 1970, Jane Roe filed a lawsuit against Henry Wade, the district attorney of Dallas County, Texas, to challenge a Texas law that banned abortion unless it was a life saving measure used by doctors. This case eventually made its way to the Supreme Court. On January 22, 1973, the Supreme Court passed a landmark decision in the case known as Roe v. Wade. Justice Harry Blackmun delivered the opinion for the 7-2 majority vote, and it was decided that a woman's right to an abortion was protected under the 14th amendment, and that states could only pass laws to regulated abortions received during the second and third trimester of pregnancy.

Under President Donald Trump, senators worked hard to ensure that various republican and notably anti-abortion people were appointed to judicial vacancies. Between 2016 and 2020, three new Supreme Court justices were appointed, who were known to be hostile to reproductive rights. Before Roe v. Wade was overturned, it had been leaked that the Supreme Court had intentions to do so. On Friday, June 24, 2022, the United States Supreme Court overturned Roe v. Wade in a case called Dobbs v. Jackson Women’s Health Organization, which was filed to contest a law that banned abortion after 15 weeks of pregnancy in Mississippi. Thirteen states in the USA had trigger ban abortion laws in place that would take effect almost immediately if Roe was ever overturned, which included fining and/or charging (with a felony) people seeking an abortion in the state the ban was passed.

Prior to Roe. v Wade being overturned, there were still barriers to abortion access in the United States, such as socioeconomic status, health insurance, and income. Now that states have begun passing laws banning abortions, the procedure has become even more out of reach for some women. Some people can travel to a different state to get an abortion. However, this isn't an option for everyone, as states such as Iowa, have begun criminalizing people who help minors leave the state to get this procedure.

The overturning of Roe v. Wade has taken the choice away from many women who want to have abortions, jeopardizing Reproductive Health and Justice in the United States. Having an unwanted child can have negative effects, as explained by research from the turnaway study, a study investigating how unwanted pregnancy can affect women’s lives physically, mentally, and socioeconomically. After following about 1000 self identified women who either received or were denied an abortion, it was found that women who were denied an abortion experienced economic hardship and insecurity that lasted for years and were also more likely to stay in contact with a violent partner. Today one in three women live in states where abortion is not accessible.

Edited by: Deven Gupta

Graphic Designed by: Olivia Fu

References

1. https://www.oyez.org/cases/1971/70-18

2. https://www.plannedparenthoodaction.org/issues/federal-courts

3. https://www.plannedparenthoodaction.org/issues/abortion/roe-v-wade#scotus

4. https://www.american.edu/cas/news/roe-v-wade-overturned-what-it-means-whats-next.cfm

5. https://www.plannedparenthoodaction.org/issues/abortion/roe-v-wade#scotus