Where the Risks of Pregnancy Meet Abortion Laws and Health Care

As the United States has grappled with the unfolding consequences of the Supreme Court’s decision overruling Roe v. Wade, one question lurks between the lines of court opinions and news stories alike: Why are the risks of pregnancy so rarely discussed anywhere, even though that information is relevant not just to individual decisions but to policies about abortion, pregnancy, and health care for women?

With the wave of abortion bans taking place in states across America, those risks are going to be more in the spotlight — figuring both in women’s decisions about whether to risk getting pregnant if they live in a state that has banned abortions, and the arguments that will happen in state legislature chambers over how much threat to a mother’s health must be present to permit an abortion under untested and rapidly changing state laws.

“We spend an awful lot of time talking about avoiding behaviors because of very small risks that could happen that are associated with the fetus. ‘Don’t eat bean sprouts,’ or ‘don’t eat deli meats,’” Emily Oster, a Brown University economist and author “Expecting Better,” a data-driven book about pregnancy, told me. “And then we sort of never talk to people about the risks of things that are almost definitely going to happen.”

For instance, in a vaginal birth, “Your vagina’s going to tear. It’s going to tear a lot,” she said. “That’s not even risk, it’s just realistic.” Those who give birth via cesarean section, a major abdominal surgery, end up with a large wound requiring a significant recovery period.

And more serious complications, while rare, are not that rare. In any given moms’ group, someone has probably survived hyperemesis gravidarum (which can occur in up to one in 30 pregnancies), an ectopic pregnancy (up to one in 50 pregnancies), or a pregnancy-induced hypertensive disorder (up to one in 10 pregnancies). All of those conditions can be lethal.

In most situations, the standard for risk is informed consent: awareness of the potential for harm, and a chance to accept or refuse it. If riding in a car or taking a plane meant a near-guaranteed abdominal or genital wound and a 10 percent chance of a life-threatening accident, people would expect a warning and an opportunity to consider whether the journey was worth it.

But pregnancy is different.

Jonathan Lord, a practicing gynecologist and the English medical director of MSI Reproductive Choices, an organization that provides family planning and abortion services in countries around the world, said that he suspects people often don’t talk about the dangers of pregnancy for women’s health because they see such conversations as a cause of unnecessary distress. “It’s sort of ingrained in society, really. It’s not so much a medical thing, but people do not talk about the risks and the unpleasant aspects, and I think that’s largely because people want to be kind,” he said.

Oster had a similar hypothesis about serious pregnancy complications. “In general, we’re not interested in confronting the risk of really bad things,” she said. “We would very much like to pretend that they’re zero.”

And yet if you look at the messaging around risks to the fetus during pregnancy, rather than the mother, the plot thickens.

Women are “bombarded” with messaging about the risks they themselves could pose to their fetuses, said Rebecca Blaylock, the research lead of the British Pregnancy Advisory Service, a charity that provides abortion and other reproductive health services. The research team at her organization, along with colleagues from Sheffield University, studied British media messaging around pregnancy. They found that media coverage overwhelmingly framed women as a vector of harm, not a population in need of protection. Fetuses were the sole focus of health outcomes.

Such assumptions even affected prenatal care. “We were seeing women suffering with hyperemesis gravidarum” — an extreme and potentially deadly form of morning sickness that involves near-constant vomiting — “who weren’t receiving appropriate treatment because their health care providers thought the medication posed a risk to their pregnancy, and who really felt they had no option but to terminate an otherwise wanted pregnancy at that point,” Blalock said.

The differing attitudes toward risk “really fit within a larger cultural climate where women are blamed for any and all ills that may or may not befall their children, and a preoccupation with reproducing the next generation of healthy citizens” Blaylock told me.

That study focused on the United Kingdom. But Kate Manne, a professor of philosophy at Cornell University and author of two books on the ways sexism shapes society, said that there is a widespread assumption in the United States and elsewhere that having children is something that women are naturally or even morally destined to do. Accordingly, guiding them toward that — even if that means denying them an opportunity to give informed consent to the risks — is seen by some as in their best interests. (She noted that transgender men and nonbinary people can also get pregnant, but said that the norms and societal assumptions about pregnancy tend to presume pregnant people are women.)

“We don’t tend to think of pregnancy as something that someone might very rationally decide not to do because it’s too much of a risk,” she said. “That kind of thought process is obviated by the sense that it’s natural and moral, and perhaps also holy, for women to do this.”

But such reluctance to acknowledge risks can make the dangers of pregnancy invisible to policymakers as well. One consequence is abortion bans that are written so bluntly that they fail to provide clear paths for doctors to protect women’s lives and health. In Poland, where most abortions are not allowed, vague exceptions that would allow them to go ahead have left doctors confused about potential liability, leading to the death of a pregnant woman last year. And now similar confusion is unfolding in U.S. states whose abortion bans took effect after last week’s Supreme Court decision overturning Roe v. Wade.

Doctors in several U.S. states, for instance, have raised concerns about whether women will be able to get timely care for ectopic pregnancies, a condition in which a fertilized egg implants outside the uterus or in the wrong part of it. Such pregnancies are never viable: It is not possible for a fetus to grow to term unless it implants correctly. But those that implant in scar tissue in the uterus, Dr. Lord said, can continue to develop for several months before eventually rupturing, at which point they are life threatening to the mother, he said.

“You really need to get in there early before it’s grown to that extent,” he said. “It’s an inevitability that the fetus will die, but it will probably kill the mother with it.”

“I do fear that in those states that have got strict laws, that will happen.”