“A patient just came into room five with vaginal bleeding. You should probably see her right away. She looks sick!”
I rushed to the bedside of a 33-year-old female with severe pelvic pain and vaginal bleeding. She looked ill and was staring up at me in anguish. The patient, whom we will call Ms. X, had recently learned that she was pregnant, but she was unable to afford prenatal care and had poor health literacy. She was evaluated in another emergency department (ED) 1 week earlier and was in her first trimester. Ms. X was discharged without obstetric follow-up because she was uninsured.
Then, 2 days later in the bathroom stall of a restaurant, she experienced a sudden gush of blood, followed by the passage of what she suspected was the baby. She cut the visible portion of the umbilical cord with a pair of scissors, but was too afraid to seek medical care. Ms. X’s family found her at home — barely conscious and drenched in blood. Our examination confirmed a septic abortion — a miscarriage in which not all the contents of the pregnancy have passed, triggering life-threatening infection and bleeding. If her family had not brought her to the ED, her condition would have been fatal.
I thought of Ms. X again on January 22, 2024, which would have marked the 51st anniversary of Roe v. Wade. In medicine, the term “abortion” describes any type of miscarriage — whether spontaneous (as in Ms. X’s case) or elective. Abortion care and reproductive health are persistent and polarizing issues in this country. Regardless of where one falls on the political spectrum, we can all acknowledge that many pregnant women in the U.S. do not have access to the care they need and deserve. As Ms. X’s story illustrates, depriving pregnant women of appropriate medical care can have deadly consequences.
As an ED physician, I see the disparities in our healthcare system through my patients’ eyes. Ms. X is one of many women who have visited my ED because they lacked access to prenatal care. Sometimes, they have sought care that could have been obtained in an obstetrician’s office, such as a routine ultrasound. Other times, as in Ms. X’s case, they have presented with serious complications that could have been prevented or treated with early and frequent prenatal care.
National reports list “problems with pregnancy” as one of the top five reasons for women to visit the ED, and estimate that up to 50% of women have visited the ED at least once during their pregnancy. Studies also show that women who use the ED for obstetric care are more likely to identify with racial or ethnic minority groups and to have significant socioeconomic needs. Alarmingly, a lack of prenatal care has been associated with increased maternal and fetal deaths and pregnancy-related complications. Perhaps if EDs were better equipped to address barriers to prenatal care, patients would present less frequently with pregnancy-related complications.
To be sure, there are limitations to the ED’s ability to address barriers to prenatal care. EDs are not ob/gyn clinics. ED physicians are trained to address obstetric emergencies and cannot provide routine prenatal care. The high-acuity, high-volume, and high-stakes setting of the ED does not lend itself to preventative screening or managing chronic conditions. Resource allocation and physician shortages further limit opportunities for prenatal care.
In Georgia, where I currently practice, 82 of the state’s 159 counties do not have ob/gyns, and most ob/gyn clinics are concentrated around Fulton and Dekalb counties. This exacerbates the vulnerability of pregnant patients throughout Georgia — particularly in rural areas.
The American healthcare system is costly, resource-starved, and difficult to navigate. Therefore, many pregnant women seek their prenatal care in the ED and never establish outpatient ob/gyn care.
If early prenatal care could decrease maternal and fetal morbidity and mortality, how do we make this care more accessible?
We need long-term, systemic changes to fix the problem. The election of diverse candidates to governmental positions will hopefully lead to the prioritization of solutions to address disparities in women’s health. Until then, ED physicians must speak up about the nationwide barriers to prenatal care and draw upon our experiences at the bedside to better inform our policy-makers.
We can also work with our ob/gyn colleagues to design solutions to address these disparities, such as telehealth appointments in areas without ob/gyn clinics. We can create shorter-term solutions, such as standardized discharge paperwork with local options for affordable prenatal care. We can also partner with community organizations to streamline existing resources for our pregnant patients.
This work will not be easy or instantaneous, but we must rise to the challenge. As newly-elected Saint-Paul City Councilwoman Rebecca Noecker stated, “Think about the people outside of this room — the people in your neighborhood, at your workplace, your school — the people you interact with every day … Community is what this is all about.”
Pregnant women — particularly those who identify as minorities and those with socioeconomic limitations, are oft-overlooked members of our communities. EDs are extensions of the community. They are places of refuge for such women — women like Ms. X. We, as ED physicians, owe it to her, and others like her, to address the barriers to early and appropriate prenatal care.
Naomi Newton, MD, is an emergency medicine physician and inaugural health policy and advocacy fellow at Emory University.
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