Period 36: It's complicated
So it’s been a while – between activism, parenting, book writing, and professoring it’s been hard to prioritize the newsletter. Here and on Bluesky, I feel like I’ve lost my voice a little bit. I’ve felt quiet in the face of so much Palestinian death, quiet in the face of repercussions for speaking up about genocide (I’ve been vocal at local events and on the local news – and getting vicious hate mail for it), quiet amid lots of Blueskies who are still acting like they are still on Twitter writing posts for algorithmic clout.
I don’t want to perform on social media. I want to contribute when my voice, expertise, or experience matter; I want to find community and help others; of course I want to get the word out about my own research and my book. And then these feelings extend into the newsletter.
It’s been getting me thinking a lot about my place in the world and the difference I want to make in it. Not just in local politics and how it affects the global. But in my own career, my writing, my research, and my mentoring.
All justice movements are connected. The genocide in Palestine is connected to all genocides, to all settler colonial efforts, to all acts of apartheid, to all reproductive justice efforts. Even when there are differences, when the origins or stories are not quite the same. Even when everyone wants to tell you how complicated it all is – when “complicated” is a stand in for “permission to bypass morals I would hold about this exact same thing if it happened to someone I knew and loved.”
And let me tell you, it’s amazing how often issues within reproductive justice are also framed as “complicated.”
Playing to my strengths
I finally decided to write today because I was reading about the effect of covid on the placenta, and how many people have stopped trying to reduce transmission at all even though covid is dangerous during pregnancy. It increases the risk of miscarriage, stillbirth, intrauterine growth restriction, and preeclampsia. Yet there are not a lot of studies on this, and even fewer in the last few years when we could look at vaccinated cohorts to see if vaccination is helping!
Something that many loss parents – and researchers – have told me is how frustrating it is that on the whole physicians don’t seem to care much about miscarriage or stillbirth. There are a variety of responses that they get:
—It’s really common, oh well.
—It’s probably because you’re old/sick/fat/unhealthy in some way we haven’t identified but that we’ll make you feel vaguely guilty about.
—It’s ok, you can just try again!
—Are you sure there’s nothing you did to make it happen?
—It’s probably because you’re pro-choice. (Yes really.)—
—It’s really not worth doing any testing – just get back in there and try again!
I’ve talked to stillbirth moms who had to pay for their baby’s autopsies. I’ve talked to people who have miscarried multiple times and still been given no option to test or otherwise gain insight into why it’s happening.
When we look at various types of outcomes – like the extent to which lead in our water, or covid in our air, is harming pregnancies or babies, most of the time papers compare exposed and unexposed living humans. Rarely in any of these analyses are the following included: pregnancies that ended in miscarriage, medical termination for fetal anomaly, abortion, or stillbirth. Stillbirths, and some medical terminations, are often issued certificates of death. But these are notoriously inaccurate and, even if follow up pathology reports show something different than the initial estimated cause of death, they are rarely fixed.
I spoke to someone recently who told me that earlier in the pandemic, the CDC considered collecting data on whether birthing parents of stillbirths had been infected with covid at the time of delivery, then decided not to do so because it was too hard. So, it’s not anywhere on the certificate of death unless the doctor was especially motivated to include it on their own. They did decide to collect this for living births. This means if we care about the effects of covid exposure on pregnancy we only have decent epidemiological data for live births.
There has been a real reticence to collect a lot of data about miscarriage, medical terminations, abortions, and stillbirths, in some ways especially among the pro-choice set. Anything we may do that appears to put any value on the fetus is wrong, right? Because it’s all about mothers and reproductive autonomy!
I get the hesitancy, and the initial draw to think of personhood as scarce – that if we pay attention to the fetus that necessarily takes attention away from the pregnant person. That it’s complicated. But that’s not reproductive justice. What’s more, that’s not what many pregnant people themselves want. When they have miscarriage, stillbirths, medical terminations (and to some extent abortions even though I’m parsing a VERY fine line here between termination and abortion around the concept of “wanted” pregnancy – something that is slippery and problematic), they are devastated, in pain, endure not only painful procedures but often weeks of bleeding, fatigue, and other side effects. A particular imagined future, with what they thought would become a particular baby, is over. It is awful mentally, physically, psychically.
People who get pregnant, and then are not, typically want to know why their pregnancy ended. The treatments, time lost, physical pain and suffering endured – all of this matters too. When we avoid understanding how and why pregnancies end we aren’t just decentering the fetus, we are decentering the pregnant person. They just went through all of that, and without an answer we are telling them, “hmm, so weird. Well, just try again!” As though they did not want this pregnancy, this fetus – maybe this baby. Any baby will do?
The very poor level of data collection around pregnancy losses, especially stillbirths (in the US defined as losses over 20 weeks but in other countries the miscarriage/stillbirth line is 24 or even 28 weeks) means tens of thousands of people in the US every year have one of the worst days of their lives, then live the rest of it without knowing why, or whether trying again will just lead to the same outcome (in the US there are at least 20,000 stillbirths a year).
So, does covid increase the risk of stillbirth? Probably. Do vaccines reduce the risk? Yes, though I found a few papers where the effect was not significant. It’s still not a great idea to get covid while pregnant. I wear my seat belt every time I’m in the car, AND I appreciate things like stop signs and speed limits. People need vaccines, AND they need broader structures that reduce the risk of infection like cleaner indoor air and more of a masking culture.
Stillbirths are complicated, sure – complicated because we know so little about the placenta and placental pathology, complicated because it’s hard to collect data on a stigmatized experience, complicated because culturally and legally every possible barrier is in the way to develop good epidemiological knowledge. Would you throw up your hands if it happened to you or someone you love? Or would you do your best to demand answers?
Until we know more about stillbirths it is a lie to say that they are just like miscarriages and mostly a result of genetic errors. And there is ample evidence that some (possibly large) number of them are due to infections – not just covid but flu, other pathogens that can harm the placenta, and of course TORCH pathogens (those that can cross the placenta and cause fetal damage).
The lives, the time, the harm of this moment matters. Even if the way a parent considers fetal personhood varies, not only with time (whether we’re talking about an embryo, a fetus, a baby) but for a variety of other reasons, understanding pregnancy endings matters because the parent and what they are going through matters. A pregnancy loss is not the death of a child, no. But that does not mean pregnancy losses don’t matter.
References
Celik, E. et al. Placental deficiency during maternal SARS-CoV-2 infection. Placenta 117, 47–56 (2022).
Donley, G. & Lens, J. W. Abortion, Pregnancy Loss, & Subjective Fetal Personhood. Vand. L. Rev. 75, 1649 (2022).
Lens, J. W. Counting Stillbirths. SSRN Scholarly Paper at https://doi.org/10.2139/ssrn.4066782 (2022).
Medel-Martinez, A. et al. Placental Infection Associated with SARS-CoV-2 Wildtype Variant and Variants of Concern. Viruses 15, 1918 (2023).
Reagan, L. J. From Hazard to Blessing to Tragedy: Representations of Miscarriage in Twentieth-Century America. Feminist Studies 29, 357–378 (2003).
Vila-Candel, R., Martin-Arribas, A., Castro-Sánchez, E., Escuriet, R. & Martin-Moreno, J. M. Perinatal Outcomes at Birth in Women Infected and Non-Infected with SARS-CoV-2: A Retrospective Study. Healthcare (Basel) 11, 2833 (2023).
Vimercati, A. et al. Adverse Maternal Outcomes in Pregnant Women Affected by Severe-Critical COVID-19 Illness: Correlation with Vaccination Status in the Time of Different Viral Strains’ Dominancy. Vaccines (Basel) 10, 2061 (2022).
Zhang, M. et al. Intrauterine transmission of SARS-CoV-2 to and prenatal ultrasound abnormal findings in the fetus of a pregnant woman with mild COVID-19. BMC Pregnancy Childbirth 23, 723 (2023).