Nonprofit, independent journalism. Supported by readers.

UCare generously supports MinnPost’s Second Opinion coverage; learn why.

Failed Virginia bill on miscarriages reveals ignorance about women’s health

A Q&A with Dr. Carrie Terrell, an ob-gyn and chief of staff at the University of Minnesota Medical Center, on miscarriages.

virginia capitol
The bill was unanimously voted down by the Virginia State Senate after women’s health advocates made it clear that the bill would place an enormous emotional burden on women.

As I’ve written here before, the medical ignorance of some politicians — particularly in regard to women’s reproductive health — is a continual source of astonishment.

Another one of these incidences hit the news this week. While searching through the legislative history of Virginia state Sen. Mark Obenshain, now running on the Republican ticket for his state’s attorney general position, reporters found that he had authored a bill in 2009 that would have required all women in Virginia to report miscarriages to police or risk legal penalties, including as much as a year in jail.

Specifically, the bill required that within 24 hours of “a fetal death” that occurs without “medical attendance,” the mother or someone acting on her behalf must report that death, the location of the fetal remains and the name of the mother to local police. Furthermore, the “remains” could not be disposed of without police authorization.

The bill was unanimously rejected by the Virginia State Senate, thank goodness — apparently after women’s health advocates made it clear that the bill would place an enormous emotional burden on women.

Article continues after advertisement

Obenshain’s office issued a statement Tuesday which said that the senator never intended to target every woman who miscarries, but only women like the 20-year-old Virginia college student who in 2008 delivered a stillborn baby in her dormitory’s bathroom and then placed the body in a dumpster. She received, under current Virginia law, a 30-day suspended jail sentence and a year of probation. Press reports say she also underwent considerable counseling.

That apparently that wasn’t enough of a punishment for Obenshain. So he drafted his failed bill. What struck me, however, was how that bill’s language reflected such a underlying lack of knowledge about miscarriages — how common they are, how they occur, and how intrusive and emotionally burdensome it would be to ask women to report them to police.

To get the medical facts about miscarriages, I spoke Tuesday with Dr. Carrie Terrell, an ob-gyn and chief of staff at the University of Minnesota Medical Center. A condensed version of that interview follows.

MinnPost: What is a miscarriage?

Carrie Terrell
Carrie Terrell

Carrie Terrell: A miscarriage is spontaneous abortion. It’s generally defined as the expulsion of an embryo or fetus weighing 500 grams [about one pound] or less. We usually use the word fetus for gestations that are greater than 10 weeks and embryo for gestations less than or equal to 10 weeks.

So, in general, a miscarriage is a loss of any pregnancy prior to viability — [when] the fetus could potentially be resuscitated in a hospital setting with the proper equipment. That’s generally considered 24 weeks.

MP: What is the difference between a miscarriage and a stillborn birth?

CT: A stillborn is not a medical term, so it’s not something that we have a definition for. But generally it means a fetus that is born dead past that term of viability.

MP: What are the key causes of miscarriage?

Article continues after advertisement

CT: For the vast majority, their cause is spontaneous and unknown. Only in rare cases can we identify the cause. It can be a maternal factor, a paternal factor, a genetic factor, an exposure factor, or an anatomy problem. A maternal factor might be some set of antibodies [the mother has], or some kind of blood [clotting or bleeding] disorder that causes abortion. A paternal factor could be a genetic component. The chromosome inherited from the sperm could be somehow mutated.

MP: Miscarriages are very common, aren’t they?

CT: Absolutely. The rates that we quote vary, but we generally say that anywhere from 8 to 20 percent of pregnancies — those that have been documented in some way — result in miscarriage.

MP: Do women always know they’ve had a miscarriage?

CT: Women don’t always know. Today, for good or for ill, women often know they’re pregnant quite early. A lot of home pregnancy tests can show that you’re pregnant four to six weeks from the last period, which is how we date pregnancies. So a woman will often get a positive pregnancy test [and then bleed and miscarry] before we can even identify anything on an ultrasound, before anything can be clinically documented.

That’s one thing that happens. The other thing is that sometimes the fetus or the embryo dies, but the body doesn’t necessarily recognize that it is no longer pregnant because there’s still gestational pregnancy tissue in the uterus, the hormones are still at a very high level, and the body hasn’t recognized that the hormone levels are starting to decline. The women still feels pregnant. They still have a positive pregnancy test. They come in for verification and their ultrasound reveals that either the embryo has stopped growing at some point or is no longer viable. Yet they haven’t had any cramping or bleeding. We’re not doing ultrasounds on everyone all the time, so that could have gone on for several more weeks before the body realized, oh, those hormone levels are dropping so it’s time to start cramping and bleeding.

MP: So in previous generations, before early pregnancy testing and ultrasound technology, women would have been less likely to even know they had experienced a miscarriage.

CT:  Yes. It would have been considered a late menses usually.

MP: It’s very common therefore for women to miscarry without a doctor or other health professional present.

Article continues after advertisement

CT:  Absolutely. Frankly, even if they’re under medical care, even if I diagnose a miscarriage because I’ve done an ultrasound on someone and deemed the embryo is not viable or not growing and the pregnancy is not progressing, the woman most times will opt for natural intervention. She’ll just opt to wait and see what happens. She doesn’t necessarily want to have the surgery or medication. She’ll just go about her business, and at some point she’ll cramp and bleed.

I haven’t read [Obenshain’s 2009 bill], but if they’re saying [that all women need to be under medical care for] the passage of the embryo, well that’s not going to happen. Even the ones that we’re managing, even the ones that we administer medication to help the woman pass the tissue, we’re not there when it happens. So, I think we’re talking voluminous increases in monitoring or surveillance or police calls. I can’t even fathom it.

MP: Most of the time we’re talking about something that just looks like heavy bleeding, correct?

CT:  Right. Generally, there’s nothing identifiable. There’s nothing a woman would be able to see with her eyes or separate from the blood or the blood clot in the toilet or on the pad. These early ones are nearly microscopic. There is no fetal growth. There are no parts. It’s just an embryonic sac.

MP: What happens if there is a fetus?

CT: Now we’re talking anything past 10 weeks or above. We technically call that a fetus. There may be something potentially identifiable, but you may or may not be able to find it. As before, if a woman is diagnosed with a miscarriage and she chooses not to have the surgery, she may pass that at home on her own. As the fetus gets larger, passing it at home can be really quite painful and there can be a significant amount of bleeding, so we will encourage women to opt for an intervention, which is most commonly a D&C that is done in the [doctor’s] office or in the hospital.

But women get to make that choice in our society.

MP: In the case that apparently instigated the proposed Virginia legislation, a stillbirth occurred and the woman disposed of the remains in a dumpster. Those cases are extremely rare, correct?

CT:  Right. Number one, those pregnancies are generally under some kind of medical care. And with stillborns, we’re talking 23 or 24 weeks and beyond. That’s a large pregnancy. We would generally not recommend that women try to do that at home on their own. Pain and bleeding would be the big concern. We’ve certainly had rare cases where women have used doulas or midwives to birth a stillborn at home, and that can be fine.

Article continues after advertisement

In rare cases, maybe the woman doesn’t know she’s pregnant or she knows she’s pregnant, but she doesn’t realize that anything’s wrong. She may have some stomach pain, but she doesn’t think it’s labor because it’s so early. Those cases can sometimes progress rapidly, and a woman may deliver at home. In my experience, 99 percent of the time they call an ambulance. They don’t want it to happen. They’re trying to stop it or figure out what to do about it. It’s a horrible thing to go through.

We have certainly all heard of the cases you’re describing. But they are not the norm.

MP: So what is your opinion of requiring all women to report all miscarriages to the police?

CT:  It sounds absurd. From a societal point of view, who’s going to pay for that? Is that going to be a medical expense or a taxpayer expense? Because, again, if we’re saying that up to 20 percent of pregnancies end in miscarriage, that’s an awful lot of phone calls. Because a majority of those aren’t happening in a hospital or a clinic, they are happening at home, even when we’re well aware of them.

MP: It’s also usually a difficult time for women.

CT:  Yes, it’s an emotional time for women. It’s also a completely normal and natural event. It would be sort of like having to report every time you had intercourse or your period. It’s a normal part of a woman’ reproductive life.