A ‘striking’ trend: After Texas banned abortion, more women nearly bled to death during miscarriage

From ProPublica:

Before states banned abortion, one of the gravest outcomes of early miscarriage could easily be avoided: Doctors could offer a dilation and curettage procedure, which quickly empties the uterus and allows it to close, protecting against a life-threatening hemorrhage.

But because the procedures, known as D&Cs, are also used to end pregnancies, they have gotten tangled up in state legislation that restricts abortion. Reports now abound of doctors hesitating to provide them and women who are bleeding heavily being discharged from emergency rooms without care, only to return in such dire condition that they need blood transfusions to survive. As ProPublica reported last year, one woman died of hemorrhage after 10 hours in a Houston hospital that didn’t perform the procedure.

Now, a new ProPublica data analysis adds empirical weight to the mounting evidence that abortion bans have made the common experience of miscarriage — which occurs in up to 30% of pregnancies — far more dangerous. It is based on hospital discharge data from Texas, the largest state to ban abortion, and captures emergency department visits from 2017 to 2023, the most recent year available.

After Texas made performing abortions a felony in August 2022, ProPublica found, the number of blood transfusions during emergency room visits for first-trimester miscarriage shot up by 54%.

The number of emergency room visits for early miscarriage also rose, by 25%, compared with the three years before the COVID-19 pandemic — a sign that women who didn’t receive D&Cs initially may be returning to hospitals in worse condition, more than a dozen experts told ProPublica.

While that phenomenon can’t be confirmed by the discharge data, which tracks visits rather than individuals, doctors and researchers who reviewed ProPublica’s findings say these spikes, along with the stories patients have shared, paint a troubling picture of the harm that results from unnecessary delays in care.

“This is striking,” said Dr. Elliott Main, a hemorrhage expert and former medical director for the California Maternal Quality Care Collaborative. “The trend is very clear.”

The data mirrors a sharp rise in cases of sepsis — a life-threatening reaction to infection — ProPublica previously identified during second-trimester miscarriage in Texas.

Blood loss is expected during early miscarriage, which usually ends without complication. Some cases, however, can turn deadly very quickly. Main said ProPublica’s analysis suggested to him that “physicians are sitting on nonviable pregnancies longer and longer before they’re doing a D&C — until patients are really bleeding.”

That’s what happened to Sarah De Pablos Velez in Austin last summer. As she was miscarrying and bleeding profusely, she said physicians didn’t explain that she had options for care. Sent home from the emergency room without a D&C two times, she ultimately needed blood transfusions so that she wouldn’t die, according to medical records. “What happened to me was just so wrong,” she told ProPublica. “Doctors need to be providing care to pregnant women — that needs to be a baseline.”

Sarah De Pablos Velez was sent home from an emergency room while bleeding profusely during a miscarriage last year; she ultimately needed blood transfusions to save her life. Ilana Panich-Linsman for ProPublica

After ProPublica exposed preventable deaths following delays in care, the Texas Legislature passed a bill this year to clarify that doctors can provide abortions when a patient is facing a life-threatening emergency, even if it is not imminent.

Doctors and nurses involved in Ngumezi’s care did not respond to multiple requests for comment for ProPublica’s story last fall, and the hospital did not answer questions about her care when asked about it again for this story. A spokesperson from Methodist Hospital said its OB-GYNs follow ACOG’s miscarriage diagnosis guidelines, which recommend considering clinical factors in addition to ultrasounds.

Visit after visit

Even in circumstances in which the abortion ban allows a doctor to intervene — to treat a life-threatening emergency, for example, or to “remove a dead, unborn baby” — there’s plenty of evidence, detailed in lawsuits and federal investigations, that doctors in Texas still aren’t offering procedures.

As soon as Sarah De Pablos Velez, a 30-year-old media director, learned she was pregnant last summer, she began attending regular checkups at St. David’s Women’s Care, in Austin. During her third appointment at about nine weeks, a resident, Dr. Carla Vilardo, and her supervisor, Dr. Cynthia Mingea, reviewed the ultrasound, according to medical records, which indicated her pregnancy wasn’t viable. Instead of being offered treatment for a miscarriage, De Pablos Velez says she was advised to hold out hope and come back for the next checkup.

Five maternal health experts and practicing OB-GYNs who reviewed the records for ProPublica said by that ultrasound visit, doctors would have had enough information to determine that the pregnancy wasn’t viable, even under the most conservative guidelines. If they wanted to be extra sure, they could have done blood work or one more ultrasound during that visit.

Instead, De Pablos Velez was told to come back in two weeks, according to medical records. During a visit when she should have been nearly 11 weeks pregnant, Mingea wrote in her chart she was “not optimistic” about the pregnancy’s viability. Still, De Pablos Velez was advised to return in another week to be sure.

Within a few days, when the cramping got so bad she could barely walk, De Pablos Velez went to the emergency room at St. David’s Medical Center, unaware that a D&C could stop the pain and the bleeding. “I’ve never researched what it looks like for women who have a miscarriage,” she told ProPublica. “I always thought you go to the bathroom and have a little bit of blood.”

Over two visits to the emergency room, doctors told her that she could complete the miscarriage at home, even as she reported filling up three toilet bowls with blood and a nurse remarked that they needed a janitor to clean the floor, De Pablos Velez and her husband recalled. No obstetrician ever came to assess her condition, according to medical records, and while her hospital chart says “all management options have been discussed with the patient and her husband,” De Pablos Velez and her husband both told ProPublica no one offered her a D&C.

She was told to follow up with her OB at her next appointment in three days. Six hours after discharge, though, she was trying to ride out the pain at home when her husband heard her muttering “lightheaded” in the bathroom and ran to her in time to catch her as she collapsed. “She was pale as a ghost, sweating, convulsing,” said her husband, Sergio De Pablos Velez. “There was blood on the toilet, the trash can — like a scene out of a horror movie.”

An ambulance rushed her to the hospital, where doctors realized she no longer had enough blood flowing to her organs. She received two blood transfusions. Without them, several doctors who reviewed her records told ProPublica, she would have soon lost her life.

De Pablos Velez and her husband, Sergio, at home in Austin. Danielle Villasana for ProPublica

Vilardo and the doctors who saw De Pablos Velez in the emergency room did not respond to requests to speak with ProPublica or declined to be interviewed. St. David’s Medical Center, which is owned by HCA, the largest for-profit hospital chain in America, said it could not discuss her case unless she signed privacy waivers. The hospital did not respond to ProPublica’s questions even after she submitted them. The De Pablos Velezes say that a hospital patient liaison told them after the ordeal that the hospital would conduct an internal investigation, educate the emergency department on best practices and share the results. It never shared anything. When ProPublica asked about the status of the investigation, neither the liaison nor the hospital responded.