As the state’s 15-week abortion ban heads to the Supreme Court, Mississippi doctors talk reproductive health care access, fetal viablity, and maternal health.
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In the nearly 50 years since Roe v. Wade was decided, the landscape of the United States has changed. The first woman was inaugurated to the Supreme Court; three more have followed since. The first Black man was elected president. We have our first woman Vice President. Same-sex marriage is now the law of the land. In many social and political aspects, the country is vastly different. Yet the abortion debate wages on.
With the 1973 decision, the Court ruled that a woman’s right to privacy superseded that of the state’s right to protect a fetus. That ruling was upheld with Planned Parenthood v. Casey in 1992, namely stating that a woman’s right to choose was constitutional pre-viability, or at 24 weeks gestation. Now a case out of Mississippi, Dobbs v. Jackson Women’s Health Organization, regarding the state’s 15-week abortion ban, has put the debate front and center yet again.
The Mississippi legislature passed the state’s 15-week abortion ban in 2018. The ban was signed into law by then Gov. Phil Bryant but overturned by the U.S. District Judge Carlton Reeves. The U.S. Court of Appeals for the Fifth Circuit held Reeve’s ruling in 2019. Then, Mississippi passed a six-week abortion ban, known as a “heartbeat ban.” That ruling was also overturned. After years of waiting by advocates on both sides, in May of this year, the Supreme Court decided to hear the case on the grounds of whether banning abortion pre-viability is constitutional.
In celebrating the Court’s decision to take up the ban, Mississippi Gov. Tate Reeves (R), no relation to Judge Reeves, took to social media to declare partial victory, tweeting he and others had been “praying” for the day the Court would decide to hear the case. He noted there are three new judges on the now solidly conservative Court, all appointees of former President Donald Trump, but Reeves claimed the Court was hearing the case not because the makeup of the judges had changed but “the science has changed.”
Yet doctors on the ground in Mississippi say politicians often use narrow talking points or sound bites regarding science but don’t dig deeper into what pregnancy looks like, especially for those who have limited access to care. Twenty percent of Mississippians currently live under the poverty line. And in a state that has repeatedly declined to expand Medicaid, many people don’t see a doctor until they’re already pregnant. Mississippi continuously ranks toward the bottom when it comes to health care: It has the highest rate of obesity in the nation and only falls behind West Virginia in those living with diabetes. The state also ranks 50th for infant mortality, according to the Mississippi Department of Health (MSDH). Mississippi’s maternal mortality also ranks 50th, with 33.2 deaths per 100,000 live births, markedly higher than the national average of 17.3 per 100,000 live births. The disparity is often widened by race. For example, the pregnancy-related mortality ratio for Black women was 51.9 deaths per 100,000 live births, nearly three times the white ratio of 18.9, according to a report issued by MSDH.
And on top of it all: There is just one abortion clinic in the state. It’s located in the capital city of Jackson, and activists say it is mainly frequented by Black women from inside the city and the nearby Mississippi Delta.
DAME spoke to two health providers (neither of whom are abortion providers) in an effort to better understand the realities of providing health care in the state.
Dr. Natasha Phillips, D.O., 38, graduated medical school in 2013 and completed her obstetrics and gynecology residency in 2017. She recently left her job as an OBGYN at a group practice in Flowood, Mississippi to move to California. The earliest preemie she has delivered was at 18 weeks gestation, and the baby did not survive.
Dr. Romero Midgett, M.D., 54, is an OBGYN who says he “loves delivering babies.” He graduated medical school from Wayne State University in 2003 and completed his residency at the University of Tennessee in Memphis in 2009. He works as an OBGYN at a community health center in Canton, Mississippi.
The following are their thoughts on the 15-week ban, viability, maternal health in the state, and access to care.
What was your reaction to hearing the Supreme Court’s decision to take up Mississippi’s 15-week abortion ban?
Natasha Phillips: I think it’s concerning, for sure. Because it’s coming out of Mississippi, to me it’s just something else to be embarrassed about. We’re always behind, and we just keep making decisions that keep us behind that prevent us from moving forward. When that continues to happen and continues to happen, that’s when you get people like myself who are a statistic when they return and are a statistic when they leave. (Mississippi ranks near the top when it comes to population decline, particularly with millennials.)
Romero Midgett: I was surprised a little bit. When I saw ‘a fetus is viable’ at 16 weeks, I think I saw it on TV or read about it, I was like, ‘That’s not correct.’
Yet politicians across the state have said “science has changed” in regards to how a fetus develops and what viability looks like. Has it?
Phillips: Science can evolve and we can learn more, but it doesn’t really change. If technology improves then maybe we can expand on the viability but that’s not true today by any means.
RM: I think they’re [the politicians] having feelings from a moral standpoint; they’re laymen, not a doctor. If I wasn’t who I was, I would think the same thing. But knowing that the babies lungs don’t have a chance to mature until at least 23–24 weeks, that young gestational age, if a baby comes out at 16 weeks, it’s a spontaneous abortion, ruptured membrane, or incompetent cervix. The baby would not survive on its own. It just can’t.
A fetus is considered “viable,” or when a baby has a chance to survive outside of the womb, at 24 weeks. What does that look like, and does a fetus have any chance of survival before then?
Midgett: Nothing has changed since I was a resident, a medical student. Nothing has changed, no advancement. We can keep you pregnant, keep you in the hospital, give you steroids, get you the necessary medicine to try to keep you pregnant, but if you deliver before that 23 [mark] and five, six, seven weeks without help, the baby is going to die. The baby is not viable at 15 weeks, it’s just not.
With assistance in medical technology, at 23 weeks and five days, with steroids, magnesium, and time, if I can buy them [that]or even two weeks, they usually can live. [But] can they survive but before that? No. No.
I had one patient who was 22 weeks and five days and there was nothing I could do. She spontaneously ruptured a membrane and the baby died. We can’t intervene, we don’t want to give them [parents] false hope the baby will survive. It never does at that age.
Phillips: Even looking at ACOG (American College of Obstetricians and Gynecologists) recommendations, it’s 24 weeks. There has been some flexibility in that 23rd week in the last couple of years, but the chance of survivability is low and, even with survival, the chance of what we call “intact survival” is really low as well. So, that means being neurodevelopmentally intact and having basically a normal life. The other marker is a 500-gram baby. Babies born less than that weight, they can’t be intubated. That’s the big deal. Especially at less than 23 weeks, the eyes can still be fused. These babies aren’t ready to be outside of mom yet.
So developmentally, where is a fetus at 15 weeks?
Phillips: The way lungs develop is underwater. Babies live in water. Until we figure out how to put them in an aquarium, essentially, then they are not going to survive outside of the mother prior to lung development.
The structure of the lungs, the trunk of the tree if you will, is completed during the 16th week. “Adult” lung functioning isn’t even completed until five weeks after delivery.
Think about cows and horses and other animals, those babies are born walking. Humans, we don’t even walk for a year. So, if you think about it, we are already born prematurely at term….We’re not ready at 15 weeks.”
What are your thoughts on abortion?
Phillips: In my practice, I came across a few women who decided to have an abortion instead of having their babies. I think it’s really important that it doesn’t matter why they make that choice. Some of them, it was their third child and they just couldn’t emotionally do it, they just couldn’t, and, in order to keep their other babies healthy and themselves, that was the choice they needed to make. Another lady was older and obese and [had] blood pressure and diabetes and just wasn’t the time for her.
It’s so stereotyped, it’s not always the woman you think it is. One out of four women will have an abortion in their lifetime. Think about that if you’re in a group. It’s not simple. No one makes that choice overnight, no one makes that choice lightly. And to impart on them these insane rules that aren’t scientific, that aren’t real, that are lies and disinformation, is really unfair to the medical community and the female population.
Midgett: Women have the right to choose. That’s it. I love what I do, I love delivering babies. I delivered three yesterday, I have some more this weekend. I just love delivering babies, but a woman has the right to choose.
According to a report issued by the Mississippi Department of Health, Mississippi has a rate of 33.2 deaths per 100,000 live births, 1.9 times higher than the U.S. average. What does maternal health look like in the state?
Midgett: I’m from Detroit, Michigan, I went to medical school at a place called Wayne State University, and I did my residency at the University of Tennessee. So I am an outsider, but I’ve been here since 2009. From what I’ve seen, in Mississippi, we have poor access to medical care. Most women who I take care of don’t see a doctor until they get pregnant until they have Medicaid. A lot of them come with poor mobility, they are already diabetic, hypertensive, they’ve lost babies before. Until Medicaid turns on, that’s the only time they see a doctor. I think that’s poor health care—only seeing a doctor only when you’re pregnant, when you have the means, have the money.
In other states, Michigan [for example], I’m sure it’s a more liberal state, but we have [more] access to things. Mississippi is rural, that’s just the way it is, it’s a rural place. My wife is an attorney and I’m a physician, we’re fortunate to make a living. But if it wasn’t for that… It’s hard. It’s hard.”
Phillips: In general, the pregnant or nonpregnant population in Mississippi is more unhealthy than other places in the country, In all of America, obesity rates are rising, higher in Mississippi in other states, there are higher rates of chronic hypertension and diabetes, all of those things dramatically increase the risk of bad outcomes for mother and baby.
I think access to care, especially when you get out into rural areas and low-income areas become a really important factor as well. Making sure that physicians are up to date on their medicine that they’re practicing is important too. Sometimes after you get out of academics you can kind of drift and continue to practice what you were taught at that time versus keeping up with some of the more up-to-date recommendations. That’s important from the health care side and what we can control as a health care provider versus making sure moms take their medicine. We’re ultimately educators and advisors; I can’t hold her down and make sure she’s doing all the things, I can only make sure she’s well-informed.
What does postpartum health care look like?
Phillips: There’s been a big push for fourth-trimester care. That goes back to making sure you’re practicing up-to-date medicine. ACOG now recommends seeing patients two to three weeks out versus the standard six. Whether it’s your first baby or your eleventh baby, every pregnancy, every child is different so it can add different stressors and can have more concerns with mental health, breastfeeding issues. Through all that, Mom is maybe focusing on Baby so her health deteriorates whether she realizes it or not. That is a very, very important portion of becoming a mother that does get overlooked. Probably especially in Mississippi because we already have limited funding, we have so many in the poverty zone that they already have trouble with having any insurance at all to even get adequate care on the front end.
For people outside the state, describe what many in Mississippi face when it comes to health care access.
Phillips: There is limited access to healthcare, aka contraception, which leads to increased desire for abortion. “Across the nation, 20 percent of Americans live in rural areas, but in Mississippi, it’s just over 50 percent. We don’t have access to things. We’re doing the best we can down here with what we have, but there are so many divisions between economics and race and education and all the list of things that is Mississippi. All of these things add up to affect access. Whether it’s access to the grocery store, access to health care, those divisions make it difficult for us to overcome hurdles. But we are trying… I feel like the rest of the country thinks we’re just not trying.”
Speaking of access to care, Mississippi has repeatedly declined to expand Medicaid. How does that impact Mississippi mothers?
Midgett: If you want a baby to mature from 15, 16, 24 weeks and beyond and that mother doesn’t have a way to take care of Baby because of her situation at home or she’s single,, if you don’t give her assistance, it’s hard to maintain a family. It’s hard to maintain life, really.
Medicaid comes off (for the mother) six weeks after childbirth. You might get family planning to help with birth control, but that’s about it. It’s hard to raise a child. Our state should expand Medicaid on that basis. If they believe there should be no abortion, there should be other means to take care of a baby after it’s born.