Dr Bretsky

Yesterday’s leaked Supreme Court majority opinion on overturning Roe v. Wade is, once again, an example of politically appointed officials without public health training making public health decisions

3 May 2022 Blog Post: On Roe v. Wade

Yesterday’s leaked Supreme Court majority opinion on overturning Roe v. Wade is, once again, an example of politically appointed officials without public health training making public health decisions. We saw this in the early days of the COVID-19 pandemic when Riverside County Sheriff Chad Biaco refused to enforce mitigation measures in the County. It is not without some irony that he is listed on the Riverside County website as Sheriff – Coroner (link: https://www.riversidesheriff.org/).

While some will frame it otherwise, a woman’s right to access competent and safe pregnancy termination care is, quite simply, a public health issue. Let me explain why – epidemiologically.

An estimated 25 percent of pregnancies worldwide end in induced abortion. Similarly, in the United States, close to one in four females will have an abortion during their reproductive life. Readers will know that I bristle at percentages, so here are the rates specific to the United States (from CDC data):

  1. The rate of pregnancy termination was 11.3 per 1000 females ages 15 to 44 years, or 189 per 1000 live births. 
  2. The vast majority of pregnancy terminations were performed in the first trimester: 78 percent at ≤9 weeks and 92 percent at ≤13 weeks of gestation. 

The rate of complications associated with pregnancy termination depends on:

  1. Procedure type
  2. Gestational age
  3. Patient characteristics
  4. Clinician experience. 

In general, the risk of a major complication is low. In a retrospective study of California Medicaid data from 54,911 abortion procedures, the overall complication rate was 2.1 percent. The overall death rate from all legal abortions is far less than the maternal mortality rate among live births in the Unites States.  One study reported no maternal deaths in 170,000 consecutive first-trimester suction curettage (D&C) procedures.

Now that we have set the stage – here’s the crucial data.  Maternal mortality in the United States has not improved whatsoever over the past 20 years – this in sharp contrast to the worldwide experience where maternal mortality is falling. US States with restrictions on access to contraception and safe abortion have seen the highest rates in maternal mortality and are the root cause of this stagnation in care (link: https://www.sciencedirect.com/science/article/abs/pii/S0010782421000901). 

Countries with better training of and access to abortion providers have lower maternal mortality rates. A comprehensive study by The Global Health Policy Summit’s Maternal Health Working Group analyzed factors that explained maternal mortality rate decreases of which the most cost-effective interventions were, first, access to contraception, and second, access to safe abortion.

Access to safe abortion care is an essential component of health care. Unfortunately, a large portion of abortions are considered “unsafe,” and these abortions are a major contributor to both maternal morbidity and mortality. The risk of complications and death from unsafe abortion is inversely related to the provider’s training, skill, conditions for performing the procedure, and availability of appropriate equipment. 

At a national level, governments which expanded reproductive health services (like the UK) such as family planning improved women’s health, in the United States, federal and many state governments have done the opposite through restrictive legislation and decreased funding. 

Twenty years ago, the United States and the United Kingdom had the same maternal mortality rate. Currently the United States has a rate about three times that of the United Kingdom

(link: https://dktwomancare.org/article_pdf/VQFbQlSIeXeIhr9NzYnvyDyDFyJKM9LBNI3l5S92.pdf )

As it stands, hundreds of pregnant American women die unnecessarily each year. The Supreme Court can frame their opinion as constitutional law, but in reality, they have strayed far out of their lane. Evidence-based health policies and good reproductive health care from well trained professionals is needed – not a dangerous majority opinion from political appointees.

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  1. It is refreshing to read an analysis that focuses on women’s health.

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