ACLU should sue the doctors as well as bishops over denied medically indicated abortion

Screen shot 2013-12-04 at 7.14.43 AMA pregnant woman in Michigan ruptured her membranes weeks before viability. She is not offered a termination (standard of care in the scenario) and suffers an infectious complication. This case from Michigan has eerie similarities to the Savita tragedy in Ireland. The only difference being Ms. Means did not die and Savita Halappanavar did.

This case happened at Mercy Health Partners,, a Catholic hospital in Muskegon, Mich. What makes it even worse is that Ms. Means is one of four women to suffer the same negligent care with ruptured membranes before viability at Mercy Health Partners who were denied adequate care. The cases were apparently discovered by a federally funded infant and fetal mortality project.

The ACLU, in an heretofore untested legal strategy, is suing the Catholic bishops. An interesting take, one that will undoubtedly wind its way to the higher courts. I hope the Supreme Court Justices weighing in on contraceptive coverage case under the ACA are watching this case unfold in Michigan, because the two cases are just a hop skip and a jump apart. If you can deny contraception to your employees based on your own personal religion, then why can’t you deny lifesaving care to your patients?

While there is a lot of press over this legal tactic, we must not lose sight of a crucial fact. If the events as reported are supported by the medical record Ms. Means was the victim of medical malpractice.

It is standard to care to offer termination at 18 weeks with grossly ruptured membranes. This is because the risk of infection is 30-40% just walking in the door with ruptured membranes at 18 weeks (meaning 30-40% of the time membranes ruptured because of an infection). If an infection isn’t there initially, it almost always develops. This is because once the membranes ruptured there is no barrier preventing the vaginal bacteria from ascending into the uterus. Regardless of gestational age. Regardless of viability. This kind of infections kills women. One needs to look no further than the Savita tragedy for a terrible reminder. And so, because the risks are very great, it is standard of care to include the discussion of termination at 18 weeks with ruptured membranes.

The facts tell us that with grossly ruptured membranes at 18 weeks subsequent prolongation of the pregnancy with the hopes of getting to viability is essentially non-existent. A study from 2006 looking at this exact scenario found no surviving fetuses with ruptured membranes up to 19 weeks. It is important to remember that at 22 weeks viability, meaning the percentage of babies who will survive to go home, is around 3%.

So what is the standard of care with ruptured membranes at 18 weeks?

  • Confirmation that the membranes have ruptured
  • Evaluation for infection
  • If infection is present, recommend delivery (either a dilation and evacuation or an induction). Infection = delivery. Full stop.
  • If no evidence of infection, discuss odds of fetal survival (reported as <1% with prolongation of the pregnancy) and overall risk that with each day infection becomes more of a concern. Some women, once fully informed, and who have no evidence of infection, do chose expectant management. It is very hard to make a decision to end a wanted pregnancy no matter how medically indicated the decision might be. In this scenario the patient requires extensive education about the signs of infection and must know when she should return to the hospital. If an infection develops, delivery is indicated.

There are several medically troublesome parts of Ms. Means care.

1) Reports that she was given medication to stop her contractions. If she had contractions she had an infection. If she received a tocolytic, medication to try to stop contractions, that is gross negligence. If she received a pain medication, that is standard of care. However, if she had pain, then she likely had an infection.

2) How did the doctors rule out an infection at her first ER visit? To safely send a patient home this must happen. Again, if she had contractions at 18 weeks with ruptured membranes infection is almost always a given.

3) The fact that she returned to the hospital two more times, delivering spontaneously the third time. What symptoms brought her two the hospital the second time? How did the doctors rule out infection at this visit?

4) Why wasn’t Ms. Means told that the odds her fetus would survive grossly ruptured membranes at 18 weeks* is essentially unheard of and offered a termination or transfer to a facility where one could be performed?

Without seeing Ms. Means chart the first three points I raised could have valid explanations.

It is also highly likely no doctor at Mercy Health Partners had the skill to do a dilation and evacuation, although as they have a birth center and a full-time laborist they have the ability to give oxytocin or misoprostol to induce labor. So, the technical ability to deliver Ms. Means at Mercy Health Partners existed.

It medically acceptable to deny to perform a non-emergent procedure based on personal beliefs. It is, however, medically unacceptable to refuse to refer a women who needs medical care to someone else who can.

Doctors can choose to work where there like. They can choose to not do procedures for a variety of reasons. They can even chose to work in hospitals that do not allow abortion and they can certainly feel that abortion is unethical and refuse to provide perform these procedures. However, it is malpractice to have a patient who requires a medically indicated procedure and to not arrange a transfer to a physician or facility where she can get that care or, at the very least, inform her of her options if  you are unable to render that care yourself.

A bishops cassock is no acceptable defense against malpractice.

*ruptured membranes after an amniocentesis has a different prognosis.

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  1. Hmm okay, but I for one I’m torn on all of this. Especially, been born and raised in pretty non observant Roman Catholic Family. At the same time would love further explanation on all of this. In which doesn’t have to be here, but can be from elsewhere.

    1. What’s to be torn about? Here’s the deal – you either think that the life of a woman is of value, or you don’t. Simple.

      Anyone who has to think for even five seconds about whether a non-viable foetus is worth risking the life of a woman, clearly does not value the life of women. Anyone who looks to a bible instead of a giving immediate lifesaving medical care does not value the lives of women.

      As Dr Gunter clearly explained, foetuses never survive events like this. They are at least a month away from even a 3% chance of survival, and I’m the vast majority of cases those 22 week survivors rarely make it to. their original due date and spend their short little lives in awful conditions. Those that get to leave the hospital are usually left with multiple physical, developmental, and sensory disabilities.

      The Catholic Church may venerate one mythical woman but it hates actual living women. Anybody who is prepared to let a woman die because she’s carrying a soon-to-be-dead-anyway foetus is not someone who should be within half a mile of pregnant women.

      The fact that any woman swallows the foetus-fetishist doctrine that values the products of conception over the person who conceived, is terrifying. That this hi happening in 2013 is an absolute tragedy.

  2. I live in an area where almost every nearby hospital is Catholic-run; my husband and I have had many a talk about not only the risks to pregnant women, but the likelihood of such hospitals possibly ignoring DNR orders and Living Will directives. I’d like my freedom FROM religion right about now, please.

  3. Jen – I couldn’t agree more. As an old L&D nurse – I’ve seen it all – and certainly have seen the results of ruptured membranes that early – results to the non-viable fetus and to the mother.
    I’ve worked at several different faith-based institutions and women with ruptured membranes, less than 19 weeks – and especially with evidence of infection – were treated as the patients that they were: women with a medical problem that had to be treated by emptying the uterus. And — Catholic hospital or not — it was treated appropriately.

    An elective procedure is one thing —-having a patient with a uterine infection — is another.

    Semmelweis proved that ‘childbed fever’ kills women….and that was in 1847!!! I don’t think we need to test it again.

  4. wonderful article dr. gunter!

    you touched on so many different points, including offering respect for the personal beliefs of medical staff.

    a matter of a woman’s health can turn into a matter of a woman’s life in a second. this would not have been an elective abortion for her.

    things should NEVER have been allowed to get as far as they did with this poor woman.

    i am catholic and i am an anti. but sometimes in life we have to reconcile what we may not like.

  5. Kansas passed a law earlier this year that made it perfectly acceptable and legal for a physician to lie to or withhold critical health information from a pregnant woman about her own health or the health of her fetus if the physician feels that, based on that information, the woman will abort. I suggest you research it.

    1. Not sure why you’re suggesting Dr. Gunter research a Kansas statute when the above-referenced case is from Michigan; a Kansas law wouldn’t apply. Is your suggestion of research for Dr. Gunter’s personal edification?

  6. I live in this area. This is the only hospital in the county. She would have to be transferred to Spectrum Grand Rapids about 40 miles away on hospital bedrest to try the keep the baby inside for PROM; I don’t know why she didn’t go there the 2nd or 3rd time she went in unless transportation was the issue.

    Five years ago, I miscarried at 12 weeks. I know this was earlier in the pregnancy (this person was 18 weeks; I was 12) but I eventually had a D&C performed at THIS hospital so they are available. My OB/GYN has surgical priviledges and when I called him after bleeding all night and the bleeding was getting heavier/more clotty, he told me to meet him there and I had surgery 1 hour later. The ultrasound for me though showed no heartbeat anymore and maybe that was the difference; perhaps this woman’s baby still had a heartbeat.

    If the hospital was truly negligent, there is an issue. The lawsuit/ review of the chart/ etc will tell the whole story. Who knows, maybe she was given the option to be transferred to Spectrum and refused. I have never seen anything different or not done due to this being a Catholic hospital except birth control pills are not a part of the employees benefit package.

    1. The difference is indeed that your fetus had no heartbeat. That means that, unfortunately (or perhaps fortunately for you, as horrible as that sounds!), it was already dead and thus the D&C wouldn’t cause the death of a fetus. If the fetus had still had a heartbeat, you too would have been turned out of the hospital.

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