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Although approximately one million women experience miscarriages per year, there is little research into complications associated with loss of pregnancy during the first gestational period when most miscarriages occur. The need to explore this stage is urgent, experts told Propublica.
Most early miscarriages resolve without complications, but patients with severe bleeding may be bleeding if appropriate. As the woman said she was left to lose a dangerous amount of blood, Propobrica told the story of her mother, who died at a hospital in Houston while seeking miscarriage care, reporters looked for a way to understand more broadly what is happening in the state.
We consulted dozens of researchers and clinicians to develop our methodology and understand how to see the outcomes of early miscarriage in the emergency department.
The latest analysis of discharge data from Texas found that after the state had an abortion in August 2022, the number of blood transfusions during emergency room visits for the first-degree pregnancy, which stated.
The number of emergency room visits during early pregnancy miscarriages also increased by 25%. This is a sign that women could potentially return to hospital in worse condition after being sent home, more than a dozen experts told Propublica.
Experts say spikes are a troubling indicator of delayed care.
The most effective way to prevent severe blood loss during a miscarriage is D&C, which can use aspiration to remove remaining tissue and close the uterus, said D&C is D&C, according to experts. This procedure is also used to end pregnancy.
Dr. Elliot Maine, a maternal hemorrhage expert and former medical director of California’s Cooperative Maternal Care Cooperative, said the increase in blood transfusions suggested to him that doctors working under the abortion ban would delay patients for longer and fatally.
These findings were added to Propublica’s growing reporting agency, revealing that mothers’ outcomes worsened after the national abortion was banned. In February, we published an analysis of hospitalizations for mid-term pregnancy loss. This found that the rate of sepsis rose by more than 50% after the state banned abortion. The study focused solely on inpatient stays at Texas Hospital. But many of the clinicians and researchers who spoke to us told us that it would limit what we could say about miscarriage care in the early stages of pregnancy. Most people experiencing the complications of a mid-pregnancy pregnancy may be seen on shorter emergency department visits rather than inpatient stays.
This methodology describes the steps we took to examine the outcomes of early abortions in the emergency department to help experts and interested readers understand our approach and their limitations.
Identify emergency visits in early pregnancy
We purchased seven years of discharge records for inpatient and outpatient encounters. These records contain identified data for the visit and include information about the encounter, including patient demographic information and billing data, including recorded diagnosis and procedures.
We limited our analysis to visits with pregnancy loss diagnosed in both inpatient and outpatient datasets. We followed a methodology that has been used by maternal health researchers for many years and has identified “abortion outcomes.” This is a case of pregnancy loss less than 20 weeks, including diagnosis of ectopic pregnancy or miscarriage. Researchers typically identified these cases to exclude them from indicators assessing childbirth complications. In contrast, analysis was focused only on encounters with pregnancy loss diagnosis. Health professionals suggested that more women could have self-controlled abortions at home. However, self-controlled medication abortion exists like spontaneous miscarriage, and therefore it is not possible to distinguish between patients in the data.
We also restricted the analysis to either emergency department visits or hospitalized patients beginning in the emergency department. The state’s outpatient data also includes encounters of outpatient procedures and data from outpatient surgery centers. Finally, our analysis focused on first pregnancy visits of 35,500 people a year who entered hospitals through the emergency department.
“Impressive” trend: More women nearly bleed to death during miscarriage after Texas banned abortion
To limit the analysis to pregnancy losses in early pregnancy, we looked for diagnostic codes indicating weeks of pregnancy. If a long hospitalization recorded multiple pregnancy week codes during the stay, we took the latest one. We excluded columns with pregnancy week codes of 13 weeks or more. This indicates the start of the second period. The majority of emergency department visits for pregnancy loss (78%) had codes indicating that there was no diagnostic code for the unknown week or pregnancy week. These visits are included in the first pregnancy specimen category. The clinician said pregnant patients who come to the emergency department early in pregnancy are unlikely to have been appointed a physician to establish their gestational age. The loss of pregnancy in the late or third stage of pregnancy is more severe and it is easier to establish a pregnancy age during pregnancy, so emergency department doctors may be able to establish a pregnancy age in the course of treatment in these cases.
Next, the patient was female, and we filtered out a list of visits between the ages of 10 and 54, and excluded the rows with potential errors. This removed 2,692 visits or 1.1% of all identified visits.
The number of first mid-pregnancy hospitalizations in the emergency department was relatively stable prior to Covid-19. In 2022, the first year the state passed a six-week abortion ban, the number of encounters rose 11%. And in 2023, the year after the state criminalized abortion, they rose again, up 25% from pre-Covid levels.
Although we were able to identify an increase in visits, we were unable to identify patients visiting. This means that of these visits, it cannot represent the same person who has returned to the emergency department multiple times due to the same pregnancy loss. Texas has seen an increase in births since the state banned abortions – about 2.7% in 2022 and a slight decline in 2023.
Clinicians also said the threshold for diagnosing pregnancy losses increased after the state banned abortion. To assess the number of related visits, we assessed whether the analysis was excluded and whether no more visits were made after hospital policy changes, and looked for visits that were diagnosed with “threatening abortion” or “early pregnancy bleeding” without a pregnancy loss code, and showed uterine convulsions or bleeding in early pregnancy. Clinicians said these diagnoses could range from light spots to significant bleeding, so these visits were not included in the main analyses as bleeding during pregnancy is common and does not always indicate ongoing miscarriage. However, we also identified a 23% increase in visits with these codes. This ranges from an average annual average of 70,936 before Covid to 87,431 in 2023.
Identifying blood transfusions
We then identified visits to loss of pregnancy due to blood transfusions. This usually indicates a dangerous loss of blood.
For hospitalization datasets where procedures performed during hospitalization were recorded as ICD-10-PCS codes, we used a list of codes defined by the Centers for Disease Control and Prevention to identify transfusion visits. There is only one code (36430) for transfusion in the outpatient dataset that uses current procedural term codes.
Prior to Covid-19, on average, there were 840 first pregnancy pregnancy pregnancy loss emergency department visits each year when blood transfusions were given. Transfusions rose to 1,076 in 2022, the first year the state passed its first abortion ban. This is an increase of 28% from the year before Covid. By 2023, the first year after abortion, that number had risen to 1,290. This is a 54% increase compared to the previous Covid. This was 450 visits in 2023 than the average pre-transfusion visit.
Blood transfusions have skyrocketed visits for first pregnancy pregnancy loss ER after Texas bans abortion
Transfusions have increased after the state’s first abortion ban came into effect in September 2021. They’ve increased even more after abortion became a felony in August 2022.
Note: For emergency department visits that include pregnancy loss under 13 weeks of pregnancy, or unknown week of pregnancy.
Even with the increase in visits to the emergency department, the proportion of visits by blood transfusions also rose, up from 2.5% in 2022 to 2.8% and 3% in 2023.
Experts who reviewed Propublica’s data wondered whether an increase in blood transfusions could promote more women who are experiencing ectopic or molar pregnancy complications. The data did not carry this. The increase in the number of pregnancy loss transfusions was even higher when ectopic and molar pregnancy diagnosis visits were excluded. By 2023 it had increased by 61%.
To understand whether transfusion numbers increased at other mothers’ visits over the same period, we also looked into transfusions at birth events to identify birth complications using federal methodology. At hospital births, the number of blood transfusions increased by 6.7% in 2022 and 9.9% in 2023. This was increased compared to the pre-Covid average.
Sophie Chou provided a data report.
