Landscape of reproductive health in the US…Where are we now?

The United States continues to have the highest rate of maternal mortality of any high-income country; 80% deaths are considered preventable, and there are clear disparities in outcomes for non-white individuals. ^{Reference Bailey, Justo and Nori1,2} Infections, including sepsis and vaccine-preventable illnesses, are among the most common causes of maternal mortality.

Unacceptably high mortality rates in the U.S. existed prior to the 2022 Dobbs v. Jackson Women’s Health Organization decision by the Supreme Court to remove federal protections for abortion. ³ Since that decision, 13 states have enacted total ban of all abortion procedures, an additional 28 states have passed bans with strict gestational age limits. ⁴ Aside from concerns about these new barriers to care increasing the numbers of people seeking unsafe abortions, estimates project that a total abortion ban in the United States would increase pregnancy-related deaths from 675 to 724, with an additional 49 deaths annually. Non-Hispanic Black individuals would experience the greatest increase (33%), but all races and ethnicities would experience increases. ^{Reference Stevenson5,Reference Qian, Wolfson, Kramer and Creanga6}

Abortion bans were enacted within a tapestry of existing restrictions, including parental notification requirements, ultrasound requirements, and state-mandated waiting periods. Furthermore, many of these bans have vaguely worded exemptions for risks to maternal health, serious fetal anomalies, and pregnancies resulting from rape or incest. Confusion regarding the status of laws at the state or local level and ambiguity of the legislative language leaves providers uncertain about the type and timing of medical care they can lawfully provide. Conditions of concern include treatment of ectopic pregnancies, care for rupture of membranes before fetal viability, or care for incomplete spontaneous abortions (“miscarriage”). While stressful for healthcare providers, patients note “feeling hurt and confused” when trying to navigate medical care for reproductive health, especially after receiving news of lethal fetal conditions. ^{Reference Arey, Lerma, Beasley, Harper, Moayedi and White7}

Confusion among both providers and patients impedes timely medical care if a medical crisis arises during pregnancy. Timely treatment within the “golden hour,” is as critical for maternal sepsis as it is for other serious medical conditions. ^{Reference Escobar, Echavarría, Zambrano, Ramos and Kusanovic8} The legal quagmire around reproductive healthcare means time ticks by while patients receive no or suboptimal care and experience increased complications—as predicted. ^{Reference Bailey, Justo and Nori1,Reference Wall and Yemane9}

What should the infectious diseases community expect?

In the post-Dobbs era, ID specialists may encounter more patients with infectious complications of pregnancy. Maternal and infant morbidity and mortality are significantly impacted by access to obstetric care, particularly for rural residents and racially minoritized women; (42.4%) of all hospitals and (52.4%) of rural hospitals did not have obstetric care in 2022. ^{Reference Kozhimannil, Interrante, Carroll, Sheffield, Fritz and McGregor10} Downstream delays in treatment of obstetric complications such as maternal sepsis are expected to worsen if obstetric care is inaccessible. Timely treatment by emergency medicine, internal medicine, and ID specialists provides a critical linkage to care. For this reason, ID specialists must familiarize themselves with local laws and exemptions for patients in crisis seeking reproductive healthcare, as well as up-to-date recommendations, like ACOG’s liberalization of initiation of antibiotics if chorioamnionitis is suspected. ¹¹ Additionally, ID specialists working in institutions without an in-house obstetric service can develop institutional “sepsis in pregnancy” pathways to expedite care.

The ID specialty has long served as a primary advocate for vaccines, and we must continue to advocate for protecting pregnant patients and providing passive immunity for neonates. National trends of decreasing confidence in vaccines have also touched obstetric patients, particularly as COVID-19 and RSV vaccines were added to the 3^rd trimester recommendations. ¹² Compounding the harm are record high numbers of pertussis cases in 2024 compared to prior years. ¹³ ID specialists must continue to lead conversations on vaccines as a public health priority.

Another preventable condition with an unfortunate resurgence is congenital syphilis. Between 2012 and 2021, congenital syphilis cases increased (755%) in the United States, to 3,761 cases in 2022 with 231 (6%) stillbirths and 51 (1%) infant deaths. ^{Reference McDonald14} Lack of timely testing and adequate treatment contributed to almost (90%) congenital syphilis cases in the United States—across all regions and racial/ethnic groups. ^{Reference McDonald14} ID specialists play a pivotal role in the timely diagnosis and treatment of maternal and congenital syphilis.

Call to action

Ensuring providers understand current abortion laws in their state

To best counsel our patients on their healthcare options, we must stay up to date on the changing legal restrictions at the federal, state, and local level (Figure 1). We must appreciate complex obstetric access issues in rural versus urban areas of the U.S. and be well-versed in newer telehealth modalities for accessing reproductive care in light of the medicolegal complexities. ^{Reference Shachar, Chary and Carmen27}

Figure 1.

Action items for infectious diseases clinicians.