If guilt were an Olympic sport, mothers would win every medal. We worry we should have prevented our children’s problems or might have even caused them. Mothers tiptoe through a minefield of complex personal, family, and societal expectations that no one escapes unscathed.
As an OB/GYN resident, I sought extra training to care for mothers experiencing miscarriage and stillbirth. Miscarriage occurs in 1 in 4 pregnancies due to early genetic missteps by chromosomes. However, the most valuable thing I learned was not facts but to ask a very particular question. A question that spotlights the maternal guilt often magnified by miscarriage:
“What do you think you did to cause this?”
When I ask the question, patients suck in a quick breath and won’t meet my eyes. They “know” what they did. I gently encourage them to tell me because it matters. A 30-year-old executive fidgeting in a curtained-off cubicle blurts out she had two margaritas the night she conceived. My best friend whispers through the phone she argued with her husband the night before their baby died. A mother of two toddlers confesses she briefly thought she didn’t want this pregnancy.
The science of reproductive biology is complex. It does not lend itself to simplified equations of cause and effect. Risk factors identify groups of people predisposed to health conditions but cannot accurately predict one patient’s experience.
Not everyone who smokes gets lung cancer. Not all pregnancies develop the same way or are lost the same way (despite what political soundbites and sassy memes imply).
People with many risks sometimes beat the odds. People with none sometimes don’t.
When I was a medical student on my first obstetrics rotation, I cared for a homeless woman, 27 weeks pregnant, and bleeding after using cocaine. We rushed her to an emergency C-section but couldn’t save the baby. Since then, I have cared for many patients with substance use disorders who have delivered healthy children.
One of my patients conceived quickly after getting married at age 36. She was devastated when she miscarried. Three months later, I told her her new pregnancy was healthy, but the lump in her breast was aggressive breast cancer.
Asking pregnant patients to share their greatest fears allows me to gently explain that their thoughts and actions likely made no difference in their miscarriage. Biology plays by its own rules, not our morality. I try to prevent my patients’ guilt from compounding their loss.
As an OB/GYN hospitalist, I see women in the emergency department with heavy bleeding from a miscarriage or severe pain from an ectopic pregnancy. Medical science cannot save these pregnancies. We know how to save a pregnant person.
Mothers can bleed to death from a miscarriage within hours or develop severe infections within days. We are already seeing this play out in Texas after the passage of Senate Bill 8.
Miscarriage and induced abortion look the same on exam and ultrasound. A doctor cannot reliably tell them apart. In our post-Roe world, women will be reluctant to seek care for a miscarriage to avoid being accused of having an illegal abortion.
Based on the new “heartbeat bill” in my state, I am expected to compound my patients’ grief by subjecting them to a legal inquisition. The inaccuracy and cruelty of these questions are inhumane. Criminalizing motherhood doesn’t defend life; it only harms women.
The consequences of making miscarriage management unsafe will land most heavily on the marginalized and vulnerable. Our appalling maternal mortality rate in people of color will increase by miscarrying while Black. Our country and health care system are rigged to assume criminal intent and withhold lifesaving treatment from these mothers.
The bedrock of my professional relationship with my patients is compassion and trust. I need to be a safe harbor where my patients can share their deepest fears, and I can respond with information and understanding.
Motherhood and miscarriage already carry too much guilt. Our current legal quagmire now also makes them more dangerous.
Kim M. Puterbaugh is an obstetrician-gynecologist.
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