Marijuana is the most used illicit drug among females of childbearing age and during pregnancy in the United States.

 This prevalence is largely secondary to the recent state level legalization of marijuana, resulting in both its availability and perceived safety. 

The existing research suggests that marijuana use can adversely affect female reproductive health, and because its main active ingredient, Δ-9-tetrahydrocannabinol (THC), can cross the placenta

 there also is concern about harm to the developing fetus and offspring. 

Public health initiatives have advised those attempting to conceive, those who are pregnant, and lactating patients to abstain from using marijuana. However, because the available safety data and literature are limited, many continue marijuana use during pregnancy. 

This is troublesome considering that the potency of marijuana has significantly increased in the past decade.

 The average concentration of THC in products sold in dispensaries can range from 17.7% to 23.2% but can be as high as 75.9%.

Also, only 17% to 31% of the THC content in products sold through state-licensed and internet dispensaries is accurately labeled.

With growing public endorsement of the potential benefits of marijuana, it is important for health care providers to effectively counsel patients regarding its effects on fertility and future offspring.

 plant, which contains over 600 chemicals and has medicinal and psychoactive properties mediated by compounds called cannabinoids.

 The main psychoactive component is THC, a small, highly lipophilic molecule that is metabolized by the liver with a half-life ranging from 20 to 36 hours in occasional users to 4 to 5 days in heavy users and that can require up to 30 days for complete excretion.

Common forms and methods of marijuana use

There are different vehicles for marijuana delivery 

. Inhalation is the quickest method for THC to enter systemically, carries less risk of overdosing, and includes smoking, vaporizing, and dabbing. Of these, smoking historically has been the most popular method and provides a rapid onset (1-3 minutes) and short duration (1-3 hours) of symptoms.

Oral absorption includes drops, tinctures, sprays, lollipops, or breath strips and can take approximately 20 minutes before occurrence of symptoms, which can last 1 to 3 hours. In contrast, gastrointestinal absorption includes edibles, candies, drinks, snacks, and capsules that require digestion before feeling an effect, which can occur between 30 and 90 minutes after consumption and last 6 to 8 hours. 

Of these, edibles are popular, especially during pregnancy, because they are palatable and discreet and their effects can last for hours. Because of the delay in onset of symptoms, these methods lend themselves to a higher likelihood of overconsumption. There are also other methods such as skin absorption through topicals, transdermals, and suppositories.

EFFECTS OF MARIJUANA USE ON FERTILITY AND REPRODUCTIVE HEALTH

In general, the literature supports some degree of effect from marijuana use on ovulation and menstrual cyclicity. Preclinical studies have largely shown that acute and chronic exposure to high levels of THC can affect sex hormones (ie, follicle-stimulating hormone, luteinizing hormone), disrupt ovulation, and result in menstrual irregularities including amenorrhea.

However, in females, the literature is less consistent, ranging from no effect or increased cycle length only with frequent marijuana use more than 3 times in the prior 3 months to possibly increased anovulation and suppressed reproductive hormone levels.

Overall, marijuana use has not been demonstrated to significantly affect fecundability. A large prospective observational study that focused on North American couples attempting to conceive found no significant association between female and male marijuana use and fecundability after controlling for confounders.

Similarly, a retrospective observational study using cross-sectional survey data concluded that marijuana use in any frequency does not prolong the time to conception.

 Most recently, a study (NCT00467363) highlighted the potential risks of preconception marijuana use on fecundability among women with a history of pregnancy loss.

The literature suggests that preconception use of marijuana negatively affects in vitro fertilization (IVF) success. In females who smoked marijuana within 1 year prior to IVF and gamete intrafallopian transfer, 25% fewer oocytes were retrieved and 28% fewer were fertilized.

Additionally, in a recent prospective study of females utilizing assisted reproductive technology, those who smoked marijuana at the time of study enrollment had twice the adjusted probability of pregnancy loss as those who were former marijuana smokers or had never used (54% vs 26%; 

Approximately half of females who use marijuana before conception continue to use throughout pregnancy, especially for its antiemetic properties, particularly in the first trimester during a developmentally vulnerable period. 

Most studies report a 2% to 5% prevalence of prenatal marijuana use with up to approximately 30% among young, urban, and socioeconomically disadvantaged females.

 They are more likely to be younger, use multiple substances, report nausea and/or vomiting in pregnancy, have other life stressors or mental health conditions, and have limited or disrupted prenatal care. 

In pregnancy, patterns of marijuana use reflect smoking as most popular followed by edibles and then vaping, with most using only 1 mode of marijuana delivery.

The available studies on prenatal marijuana exposure are largely observational or retrospective, confounded by polysubstance use and small sample size and reliant on self-report.

 This is problematic because studies have found that more females are positive for marijuana use by toxicology screen than self-reported use.

However, the existing evidence supports some degree of adverse outcomes with maternal marijuana use including intrauterine growth restriction, fetal neurodevelopmental consequences, neonatal intensive care unit admission, and impaired cognitive development of offspring.

At present, based on the available evidence, the US surgeon general,

 American College of Obstetricians and Gynecologists (ACOG),

 advise pregnant and lactating patients to abstain from using marijuana. However, all acknowledge that further research is needed to understand all the effects of THC on the developing brain and offspring.

The most common reason reported for marijuana use in pregnancy involves the perceived benefits, specifically for self-treatment of nausea or hyperemesis. Currently, the effect of marijuana use on nausea and vomiting during pregnancy is unknown. Marijuana also is used during pregnancy for depression, anxiety, sleep, stress, and pain. These are all conditions that have alternative treatments better characterized in the context of pregnancy.


The existing data are mixed but support an increased risk of preterm birth with marijuana use. A prior systematic review and meta-analysis adjusted for concomitant tobacco use found that only females using marijuana at least weekly in pregnancy had a significantly increased risk for preterm delivery, but not in those using less than weekly.

This association was not seen when only using pooled adjusted estimates from individual studies that had adjusted for confounders. More recently, a large population-based retrospective cohort study (N= 661,617) in Ontario, Canada, noted an increased risk of preterm birth associated with maternal marijuana use (RR 1.41; 95% CI, 1.36-1.47).

Fetal growth restriction and low birth weight

One of the most studied topics is the association between prenatal marijuana exposure and fetal growth restriction or low birth weight. There have been multiple systematic reviews, meta-analyses, and retrospective and prospective studies on this subject that suggest there is an association ranging from an 84-gram to 256-gram difference.

However, a portion of studies did not adjust for confounders like nicotine use. A more recent, large systematic review reported a significantly increased risk of low birth weight was observed in females who used marijuana more than weekly after adjusting for cigarette smoking, but this trend was not seen when only estimates from individual studies that adjusted for all confounders were used.

There are studies addressing the role of marijuana and its association with structural fetal anatomic defects.

 Anomalies previously described involve the cardiac, genitourinary, gastrointestinal, and central nervous system in addition to craniofacial defects such as cleft lip and/or palate.

 Most commonly reported were cardiac abnormalities, specifically ventricular septal defects

However, overall most studies did not consistently find a positive association between periconceptional marijuana use and congenital abnormalities.

The available literature does not appear to support any significant association between prenatal marijuana use and an increased risk of miscarriage or stillbirth.

However, the literature is variable, in part because studies reporting an association are confounded by polysubstance use, especially tobacco, or are too small to detect a true relationship. 

A recent study (NCT00467363) of females with a history of a prior first-trimester loss found no correlation between preconception marijuana use and miscarriage.

 A previous study focused on the impact of illicit drug use and smoking on stillbirth did detect a significant association between marijuana use and stillbirth but this effect was diminished after adjusting for tobacco use.

Regarding other obstetric complications, there have been no associations found between in utero exposure to cannabis and fetal distress, maternal diabetes, rupture of membranes, abruption, hypertension, maternal weight gain, hemorrhage, or duration of maternal hospital stay.

Offspring neurodevelopment and behavioral outcomes

Currently, the literature does not strongly support an association between prenatal marijuana exposure and longer-term offspring outcomes such as sudden infant death syndrome, cognition, or academic achievement.

Existing studies have described an effect on offspring neurological development from prenatal or postnatal marijuana exposure including trembling and a high-pitched cry in babies, decreased fine motor skills and abnormal social behavior in infants, decreased problem-solving skills and memory, symptoms of depression and anxiety, decreased attention span in school-aged children, and a predisposition toward delinquent behavior and vulnerability to drug addiction, including marijuana.

Most recently, a large retrospective Canadian study found a significant association between maternal marijuana use in pregnancy and the incidence of autism spectrum disorder (ASD) in the offspring.

 The rate of ASD diagnosis was 2.2% among children with in utero marijuana exposure. The incidence of ASD diagnosis was 4.00 per 1000 person-years (95% CI, 3.65-4.38) among children exposed to cannabis compared with 2.42 (95% CI, 2.39-2.44) among unexposed children.

The incidence of intellectual disability and learning disorders also was higher among offspring by age 10 years who were exposed to marijuana prenatally, although this was less statistically robust likely because of residual confounding not adjusted for.

 The study was unable to examine the association between the amount or timing of THC exposure in pregnancy and observed childhood health outcomes.

Prior human and animal studies have demonstrated that offspring prenatally exposed to THC have an increased risk for later substance use, delinquency of behavior, enhanced heroin-seeking profiles, and altered areas of the brain known to modify behavioral responses to various environmental stimuli associated with reward behaviors.

The available evidence suggests a potential harmful effect of prenatal marijuana exposure on offspring, including decreased fetal weight or low birth weight.

Additionally, most studies did not consistently demonstrate an increased risk between periconceptional marijuana use and structural anatomic defects, but both fetal congenital abnormalities and dysmorphic features associated with Fetal Alcohol Syndrome Disorder have been described.

Thus, a detailed fetal anatomic survey and serial growth ultrasounds should be considered in pregnancies complicated by maternal marijuana use, especially if maternal pattern of use is chronic and/or heavy.

The prevalence of marijuana use among breastfeeding females in states with legalized marijuana is about 5%.

 This is concerning because THC is highly lipid soluble and transferred into breast milk, where it is stored in lipid-filled tissues like the offspring’s brain, which can potentially affect neurodevelopmental processes. 

It has been demonstrated that when THC is smoked, levels peak in breast milk 1 hour post inhalation and remain detectable for 6 days after use.

 Exclusively breastfed infants ingest a mean of 2.5% of the maternal dose of THC.

 Prior studies have demonstrated that at 1 year of age, offspring exposed to marijuana in utero and through breastfeeding had decreased motor development compared with those not exposed.

Other observations reported in the literature of infants exposed to THC through breast milk include lethargy, less frequent feeding, and shorter feeding times.

 At this time, no studies have adequately addressed the effects of marijuana exposure through breastfeeding on long-term neurodevelopment.

This is a condition that is difficult to diagnose during pregnancy and characterized by paradoxical cyclic vomiting occurring in patients with a history of chronic cannabis use.

 The classic presentation is severe nausea, intractable vomiting, abdominal pain, and abnormal, compulsive bathing behaviors 

Additional symptoms include agitation, diaphoresis, tachycardia, postural hypotension, subjective fevers/chills, and weight loss. It is also unresponsive to antiemetics and episodes usually last 24 to 48 hours at a time but will recur if marijuana use is continued. Long-term therapy is marijuana cessation for approximately 2 weeks.

Options for maternal testing include serum (detects use in the past 2-3 days), urine (detects the past 2-3 days in occasional users or the past few weeks in chronic users) and hair (detects use up to 90 days prior). 

Medications such as nonsteroidal anti-inflammatory drugs or proton-pump inhibitors have been reported to cause false positives on drug screens, and testing can be affected by body mass index, frequency of use, when marijuana was last used, and the delivery vehicle of marijuana used. 

Currently, synthetic or designer cannabinoids are not detected by routine urine drug screens.

Neonatal methods for testing include umbilical cord homogenate and meconium. Umbilical cord homogenate is easier to collect than meconium and because THC deposits evenly across the length of the cord, the location of the segment of cord sent is irrelevant. 

Meconium may be more sensitive than cord homogenate testing but is only available after approximately 24 weeks’ gestation, usually passed within 48 hours of birth, and often requires coordinated effort for collection.

The landscape of marijuana use is continuing to shift, and health care providers need to be adaptable in the approach taken to patients who use marijuana who are attempting to conceive, are pregnant, or are lactating. 

As legalization increases, the perception of safety will continue to be promoted. This is concerning because the potency of marijuana is still rising, which means that our limited current understanding of the risks of marijuana use will soon be outdated. 

There is now sufficient evidence of harm to warrant avoiding use when attempting to conceive or when pregnant or lactating. ACOG recommends that health care providers universally screen all patients before conception and in early pregnancy regarding marijuana and drug use 

, facilitate access to accurate information, provide counseling, and make referrals for treatment.

Center for Behavioral Health Statistics and Quality. 2019 National Survey on Drug Use and Health: methodological summary and definitions. Substance Abuse and Mental Health Services Administration; 2020. Accessed September 2, 2021 https://www.samhsa.gov/data/report/2019-methodological-summary-and-definitions

Martin CE, Longinaker N, Mark K, Chisolm MS, Terplan M. Recent trends in treatment admissions for marijuana use during pregnancy. 

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Richardson KA, Hester AK, McLemore GL. Prenatal cannabis exposure – the “first hit” to the endocannabinoid system. 

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Committee opinion no. 722: marijuana use during pregnancy and lactation. 

. 2017;130(4):e205-e209. doi:10.1097/AOG.0000000000002354

Bertrand KA, Hanan NJ, Honerkamp-Smith G, Best BM, Chambers CD. Marijuana use by breastfeeding mothers and cannabinoid concentrations in breast milk. 

. 2018;142(3):e20181076. doi:10.1542/peds.2018-1076

ElSohly MA, Chandra S, Radwan M, Majumdar CG, Church JC. A comprehensive review of cannabis potency in the United States in the last decade. 

Biol Psychiatry Cogn Neurosci Neuroimaging

. 2021;6(6):603-606. doi:10.1016/j.bpsc.2020.12.016

Alzghari SK, Fung V, Rickner SS, Chacko L, Fleming SW. To dab or not to dab: rising concerns regarding the toxicity of cannabis concentrates. 

. 2017;9(9):e1676. doi:10.7759/cureus.1676

Vandrey R, Raber JC, Raber ME, Douglass B, Miller C, Bonn-Miller MO. Cannabinoid dose and label accuracy in edible medical cannabis products. 

. 2015;313(24):2491-2493. doi:10.1001/jama/2015.6613

Bonn-Miller MO, Loflin MJE, Thomas BF, Marcu JP, Hyke T, Vandrey R. Labeling accuracy of cannabidiol extracts sold online. 

. 2017;318(17):1708-1709. doi:10.1001/jama.2017.11909

Ryan KS, Mahalingaiah S, Campbell LR, et al. The effects of delta-9-tetrahydrocannabinol exposure on female menstrual cyclicity and reproductive health in rhesus macaques. 

. 2021;2(3):287-294. doi:10.1016/j.xfss.2021.05.001

Ayalon D, Nir I, Cordova T, et al. Acute effect of delta1-tetrahydrocannabinol on hypothalamo-pituitary-ovarian axis in the rat. 

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Asch RH, Smith CG, Siler-Khodr TM, Pauerstein CJ. Effects of delta 9-tetrahydrocannabinol during the follicular phase of the rhesus monkey (Macaca mulatta). 

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Brents LK. Marijuana, the endocannabinoid system and the female reproductive system. 

Wise LA, Wesselink AK, Hatch EE, et al. Marijuana use and fecundability in a North American preconception cohort study. 

Kasman AM, Thoma ME, McLain AC, Eisenberg ML. Association between use of marijuana and time to pregnancy in men and women: findings from the National Survey of Family Growth. 

Mumford SL, Flannagan KS, Radoc JG, et al. Cannabis use while trying to conceive: a prospective cohort study evaluating associations with fecundability, live birth and pregnancy loss. 

Articles

As the landscape continues to shift, 3 experts offer guidance on how to advise patients who may want to use this substance.

Effects of marijuana use  on female reproductive health and pregnancy

Kathryn Flynn, PhD, of the Department of Medicine in the Division of Hematology and Oncology at the Medical College of Wisconsin, and colleagues collected data from 100 postmenopausal patients from Memorial Sloan Kettering Cancer Center with history of endometrial or breast cancer who sought treatment for vulvovaginal symptoms.

Researchers performed a single-site, single-arm prospective trial where they collected data from standard gynecologic examinations. The exams were designed to evaluate sexual function, outcome measures of vulvovaginal pain and dryness as reported by clinicians (ClinRO), and patient-reported outcomes (PROs) of sexual function, including PROMIS Sexual Function and Satisfaction (SexFS) lubrication, clitoral discomfort, labial discomfort, and vaginal discomfort, and Female Sexual Function Index (FSFI) pain and lubrication. 

One hundred women participated at baseline, and 77 remained 12 to 14 weeks in. The mean age of women was 55 years (range, 31-78). Sixty-eight percent were partnered, 77% were White, and 60% were sexually active. Seven percent of women were in menopause for more than 1 year, 48% between 1 and 5 years, and 45% for less than 5 years, they said.

Authors analyzed between the different measures, the baseline, and time points and reported that ClinRO and PRO variables all had positive relationships as expected. However, they noted that the relationship strength greatly differed. They reported that at 12 to 14 weeks, “there were medium-to-large correlations between ClinRO vaginal dryness and SexFS Lubrication (0.64), ClinRO vulvar dryness and SexFS Lubrication (0.46), ClinRO vulvar discomfort and SexFS Labial Discomfort (0.70), and ClinRO vulvar discomfort and SexFS Clitoral Discomfort (0.43).” Researchers said that “the correlations between the exam variables and the corresponding PRO scores were small (range, 0.01-0.27),” with 1 exception.

Among study strengths, researchers said use of the specialized gynecologic exam to evaluate sexual function was comprehensive and standardized. “This allowed for a relatively granular analysis of the relationships between exam findings and patient-reported experiences,” authors said. 

Another strength of the study was the use of PROMIS and FSFI PRO measures, which researchers said provide a great amount of valid evidence. Study limitations included a small sample size. Flynn emphasized that for providers in practice, the most important takeaway is that in the diagnosis and treatment of sexual dysfunction after cancer, PRO measures offer “a unique and important complement to clinical measures.”

She said this study is significant because researchers described the correlations between vulvovaginal health from clinician interviews, clinical gynecologic exams, and patient self-reported vulvar and vaginal discomfort with sexual activity among survivors of cancer. 

“Our study used high-quality measures, and we found that the clinician-reported and patient-reported scores were moderately correlated with each other but distinct from clinical gynecologic exam findings,” she said. 

Regarding next steps, Flynn said findings needed to be confirmed using other samples, including those involving women who have not had cancer treatment.

“The magnitudes of the relationships documented here are consistent with the idea that sexual function is influenced by a host of biological, psychosocial, and environmental factors,” investigators said.

Analyzing the relationship between data from patient self-reports and clinician ratings of vulvovaginal tissue health following cancer can help provide better sexual function treatment for patients, according to a recent study. 

Data aid in treatment for vulvovaginal health, sexual function after cancer

Despite recommendations for vaccination from physicians, professional organizations and the Centers for Disease Control and Prevention (CDC), only 25% of pregnant women have received greater than or equal to 1 dose of a COVID vaccine. 

Data from 3 CDC systems set up to evaluate for COVID-19 vaccine safety in pregnancy has been reassuring and the v-safe After Vaccination Health Checker pregnancy registry evaluating vaccination early in pregnancy did not find alterations in miscarriage rates.

 With reports of increased severity of COVID infection in pregnancy with the delta variant,

 vaccination is an important strategy to optimize maternal health.

A number of groups, including hospitals, employers, and the federal government, have issued mandates to ensure vaccination of their employees with a goal to curb the pandemic. These mandates commonly include options for exemption to the mandate, due to a medical condition such as having an immediate or severe allergic reaction to any ingredient to the COVID-19 vaccine or a religious belief. 

Some exemptions include pregnancy as a category for exemption. Having pregnancy as a choice for exemption puts health care providers in a bind as the vaccine is not contraindicated in pregnancy and may be life-saving. 

Although an opportunity for education, this conflict has the potential for mistrust between the woman and her provider, especially given the available data that suggests the risks of COVID infection outweigh the risk of vaccination.

Similarly, recent legislation as highlighted in 

, impacts our ability to provide the highest quality care to our patients. Beyond the many concerns of the legislation as Ivey outlines, the unintended consequence of the legislation not only puts the patients, but also the providers—all health care workers—at risk. 

Legislation, policies, and external requirements obfuscates our ability to provide the highest quality care. Momentum is building among our medical societies to take a stand against such legislation, illustrated especially in the September 21 announcement by the American College of Obstetricians and Gynecologists (ACOG) that it is leading a groundbreaking coalition. 

Joining 24 other medical organizations and leading the charge, ACOG filed an amicus brief to the US Supreme Court in the case of Dobbs vs. Jackson Women’s Health Organization. If you are not familiar with this case, it is one that challenges the Mississippi law that imposes a ban on the provision of abortion after 15 weeks of pregnancy for most individuals, according to ACOG.

In its press release, ACOG explained that the brief asks the Court to recognize that Mississippi’s attempt to ban nearly all abortions after 15 weeks of pregnancy is fundamentally at odds with the provision of safe and essential health care, with scientific evidence, and with medical ethics. In part, the brief states, “The Ban dangerously limits the ability of women at or near 15 weeks’ gestation to obtain the health care they need: some will be forced to travel outside the State to obtain an abortion; others will attempt self-induced abortion; and others still will be forced to carry their pregnancy to term. Each of these outcomes increases the likelihood of negative consequences to a woman’s physical and psychological health that could be avoided if care were available.”

Women’s health care is facing very challenging times. In this issue, we also address a collaborative care approach to reducing maternal morbidity and mortality in a piece by Larry Veltman, MD. To do this it is going to take a concerted effort among all practicing ob-gyns to address these issues. Do not stay silent. Our patients’ lives depend on it. 

1. COVID Data Tracker. Centers for Disease Control and Prevention. Accessed September 23, 2021. https://covid.cdc.gov/covid-data-tracker/#vaccinations-pregnant-women

2. Adhikari EA, SoRelle JA, McIntire DD, Spong CY. Increasing severity of COVID-19 in pregnancy with Delta (B.1.617.2) variant surge. 

 2021: S0002-9378(21)01005-X. Published online

September 13, 2021. doi: 10.1016/j.ajog.2021.09.008.

3. New CDC Data: COVID-19 vaccination safe for pregnant people. Accessed September 23, 2021. 

https://www.cdc.gov/media/releases/2021/s0811-vaccine-safe-pregnant.html

4. Ivey, RT. Texas Senate Bill 8 (SB8): Not just another anti-abortion bill. 

5. ACOG leads groundbreaking coalition in Dobbs v. Jackson women’s health organization. News release. The American College of Obstetricians and Gynecologists. September 21, 2021. Accessed September 25, 2021. 

https://www.acog.org/news/news-releases/2021/09/acog-leads-coalition-in-dobbs-v-jackson-womens-health-organization

As physicians, our goal is to provide appropriate, expert medical care—the highest quality—to our patients. Increasingly, external policies and legislation encroach on our ability to provide this care.

Policies, politics, and medicine – hard to mix

In the United States, maternal mortality is an outlier, and you may understand better what this means if you have read Malcolm Gladwell’s 

 The book covers outlier success stories, such as The Beatles, Steve Jobs, and Bill Gates, but it also addresses negative outliers. When it came to a spate of plane crashes that had plagued Korean Air, what was the underlying issue?

The numbers are there for us to see why maternal mortality in the United States is an outlier. In his article, Larry Veltman, MD, details some of the numbers and addresses the need for a stronger model of collaborative care and a culture of perinatal safety. He discusses several areas in which systems can improve, including strengthening the “speak up climate” of each perinatal unit.

Korean Air ended up being a success story, after it addressed cultural underpinnings that were leading to the plane crashes. One of those was “cockpit culture,” and the communication it allowed or did not. When planes crash, it is human nature to want to blame the individual pilot or someone else who was in charge, perhaps even an air traffic controller, but it’s a complex organizational structure that inevitably lets a plane take off, fly safely, and make those safe landings. When a mother dies, it is tempting to do the same. Who should get the blame?

On September 15, 2021, the U.S. Commission on Civil Rights released its report “Racial Disparities in Maternal Health,” which examined the federal role in addressing such disparities in maternal health, including negative pregnancy-related health outcomes and pregnancy-related deaths of women in the United States.

“At the federal level, efforts can be made to improve hospital quality, particularly for women of color if maternal health disparities are to be eliminated,” said Norma V. Cantú, chair of the US Commission on Civil Rights, in a news release. “Improvements in safety culture are linked with improved maternal health outcomes. One recommendation for improving safety in maternal health care is to implement standardized care practices across hospitals and health systems and to standardize data collection systems.”

When we delve deeper into the maternal mortality rate in the United States, we know there are many subcultures at play in this complex world of health care: the health care system itself, training culture, individual cultures of hospitals, the dynamics between health care staff within a given hospital environment, and the patients themselves. Obstetricians and other health care professionals want answers and seek to understand how to improve outcomes.

Korean Air ended up being a success story, after it addressed cultural underpinnings that were leading to the plane crashes. We look to the future to improve these outcomes and seek insight from you as you practice for how this matter can be effectively addressed. Please email us at cogeditorial@mmhgroup.com. We all want to push maternal health outcomes to become a positive outlier. 

Chairman and Founder, MJH Life Sciences™

1. Gladwell, M. Outliers: The Story of Success. Little, Brown & Company; 2008.

2. US Commission on Civil Rights releases report: Racial Disparities in Maternal Health. News Release. US Commission on Civil Rights. September 15, 2021. Accessed

September 16, 2021. https://www.usccr.gov/fi les/2021/09-15-Press-Release-Maternal-Health-Report.pdf

In the United States, maternal mortality is an outlier, and you may understand better what this means if you have read Malcolm Gladwell’s Outliers: The Story of Success.

Making maternal health a positive outlier

As the state of origin of Roe v. Wade, Texas has a history of restricting access to abortion including requirements of transvaginal ultrasounds, pre-procedure waiting periods, burial of fetal remains, provision of state-mandated medically inaccurate information to patients seeking an abortion, and burdensome regulations for providers and facilities providing abortion care.

The goal is to eliminate termination of pregnancy while ignoring the overwhelming evidence that improved access to contraception would be more effective in decreasing elective termination rates. Their legislative approach has been direct with oversight provided by state agencies.

But 2021 is a different time with different issues. We are living in a global pandemic fraught with marginal vaccination rates, lack of mask mandates in the name of personal liberty, and prioritization of politics over science. We are living in a nation deeply divided in political beliefs concerning voting rights, economic policies, immigration policies, climate crisis, military policies, civil rights, human rights, and reproductive rights. 

With the current 2 party system, moderates of both parties are often omitted and voters are ultimately influenced by just 1 or 2 issues. Access to abortion is often one of those issues. Most Texans and most Americans support access to termination of pregnancy at some level.

 The deep division over this right exists within our own specialty. But even the most conservative agree, there are circumstances that necessitate this procedure.

Restriction of abortion services has been a priority for the Texas Legislature for some time. But the law passed this year — described as clever by some and devious by others — was quite different. 

The law comes in addition to existing restrictions and now prohibits the termination of a pregnancy once fetal cardiac activity is detected by “standard medical practice” which “includes employing the appropriate means of detecting the heartbeat based on the estimated gestational age of the unborn child and the condition of the woman and her pregnancy.”

This reflects a marked departure in the previous claims of anti-abortion legislators that their proposed restrictions are in the best interest of the pregnant woman. The only exception to this would be a “medical emergency” for the mother, which is defined as “a life-threatening physical condition aggravated by, caused by, or arising from a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed.”

To add further alarm, SB8 also prohibits anyone from “aiding and abetting” a prohibited abortion, so loosely defined that it could be construed to ban related counseling, information, and referrals for care.

The law ignores medical conditions that are common indications for termination: selective reduction in higher order multiple gestations, fetal reduction for severe twin-twin transfusion syndrome, pre-viable preterm premature rupture of membranes, and inevitable abortions. 

It also ignores maternal medical conditions in which pregnancy may increase maternal morbidity and mortality while not placing the patient in imminent danger at the time of pregnancy diagnosis such as cardiomyopathy, lupus, nephrotic syndrome, and TTP. 

In short, these are not considered exceptions unless life-threatening maternal illness is present.

Noticeably absent from the statute are the long-accepted exceptions of rape, incest, trafficking, and fetal anomalies/chromosomal abnormalities. 

It has been suggested that the right-to-life movement feels that the termination of pregnancy as a result of abuse is ideologically indefensible and weakens their political argument. Their focus is on the fetus — regardless of the circumstances of conception.

This law will worsen the stark disparities in women’s health outcomes. Those who may not have the resources, ability to take off time from work, or secure childcare to travel out of state for this service, will be disproportionately harmed. 

Many physicians, aware of data from countries where abortion is illegal or highly restricted, fear this ban will lead to an increase in septic abortion rates and other complications of unsafe procedures that are rarely seen today.

Furthermore, this law “shall be enforced exclusively through private civil action.” In Texas, civil liability requires personal damage or loss. That is, until now. Damage or harm is not a requirement in this statute, and the cause of action can be initiated by any person. 

Instead of giving state official enforcement power, SB8 deputizes any private citizen, regardless of whether they have suffered personal damage or loss, to initiate civil action against a person who they claim has violated the law. Statutory damages are defined as a minimum of $10,000 for each violation (there is no maximum), on top of costs and attorney’s fees, and a statute of limitation of 4 years.

This may expose physicians to potentially endless civil lawsuits if the law is allowed to stay in effect. This approach is out of step for a state that, in 2003, led the nation in tort reform—something which many obstetrician-gynecologists, myself included, have celebrated.

Another major concern is the lack of support if a provider is named in a cause of action. Most carriers have made it clear that defending SB8 claims would not be covered by medical malpractice insurance. Most hospitals and health care institutions have indicated that they will not offer coverage to providers sued under SB8. And even if the defendant is cleared, one cannot countersue for defamation. Patients seeking terminations will not be sued. This law is aimed directly at physicians. 

We cannot yet measure the extent of how this chaos will impact our ability to practice medicine.

This law has been described as “creative” in that it is enforced using civil liability therefore the state of Texas and its officials cannot be directly sued. The Supreme Court of the United States declined to stop the enactment of the law. They did not address the constitutionality of the law. According to Chief Justice John Roberts, “It can promptly do so when that question is properly presented.”

To get into the court system, the challenge to the law can present only after a cause of action is filed. The first cause of action was filed against Alan R. Braid, MD. The plaintiff is a former lawyer and convicted felon from Arkansas who is asking for $100,000 compensation. This type of law creates a dangerous precedent. 

What will stop similar laws from being enacted allowing civil liability in other controversial issues such as gun ownership or criticism of public officials?

In a special session, the Texas legislature recently passed SB4 - a law that regulates the prescription and dispensation of medications commonly used in pregnancy termination along with increased reporting requirements for complications. Mifeprex, misoprostol, and methotrexate are specifically named in this law. These are the very drugs often used in early pregnancy loss, ectopic pregnancies, and postpartum hemorrhage. 

As the bill is currently written, it is unclear if providers will be criminally liable for the use of these medications in those circumstances. SB4 also criminalizes the failure to report “complications of abortion” without specification of a time frame and includes a list of events that physicians may not typically recognize as a complication of abortion. This bill was signed into law on September 17, 2021.

Legislators in other states have already signaled plans to replicate SB8. Our colleagues in Texas and across the country should be alarmed and dismayed. It is critical that physicians across specialties speak out against this affront to our profession.

Texas is again ground zero for the abortion fight.

Regardless of your personal view, this is no longer about elective termination of pregnancy. It is about the practice of medicine and our ability to provide patient care.

Texas Health and Safety Code. Section 171. Abortion. Accessed September 22, 2021. https://statutes.capitol.texas.gov/Docs/HS/htm/HS.171.htm#

Ward, M.Poll: Most Texans support abortion rights.

. August 2, 2018.Accessed September 22, 2021. https://www.houstonchronicle.com/politics/texas/article/Poll-Most-Texans-support-abortion-rights-13126814.php

Texas Health and Safety Code. Section 171.203. Accessed September 22, 2021. https://statutes.capitol.texas.gov/Docs/HS/pdf/HS.171.pdf

Texas Health and Safety Code. Section 171.046. Accessed September 22, 2021. https://statutes.capitol.texas.gov/Docs/HS/pdf/HS.171.pdf

Texas Health and Safety Code. Section 171.208. Accessed September 22, 2021. https://statutes.capitol.texas.gov/Docs/HS/pdf/HS.171.pdf

United States Supreme Court. Whole Woman’s Health et al v. Austin Reeve Jackson, Judge, et al. Accessed September 22, 2021. https://www.supremecourt.gov/opinions/20pdf/21a24_8759.pdf

On May 19, 2021, Governor Greg Abbott signed Texas Senate Bill 8 (also known as the Fetal Heartbeat Bill) into law with the statement that this will save lives in the state of Texas.  This law is recognized as the most restrictive anti-abortion regulation in the United States today.  

Texas Senate Bill 8 (SB 8): NOT just another anti-abortion bill

The length of labor and delivery was also the shortest with concurrent Foley-oxytocin.

“Many pregnant women undergo induction of labor in everyday clinical practice,” said primary author Maria Andrikopoulou, an assistant professor of maternal fetal medicine at Columbia University Irving Medical Center in New York City. “There is a wide variety or combination of methods that are used in cervical ripening; however, the safest and most efficacious method is not yet established.”

The current study was a secondary analysis of the ARRIVE trial: a randomized trial of induction versus expectant management, which was conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network.

For full-term, low-risk, nulliparous patients, induction of labor with a Foley balloon alone or concurrent with prostaglandins (PGE) is associated with a significantly lower risk of adverse neonatal outcomes than with PGE alone, according to a study in the American Journal of Perinatology.

Vol 66 No 10

Effects of marijuana use on female reproductive health and pregnancy

Data aid in treatment for vulvovaginal health, sexual function after cancer

Policies, politics, and medicine – hard to mix

Making maternal health a positive outlier

Texas Senate Bill 8 (SB 8): NOT just another anti-abortion bill

Maternal and neonatal outcomes by cervical ripening agent

Oral contraceptive use during adolescence has small but meaningful link to future depression

Lower risk of peripheral arterial disease linked to dietary patterns