Six disturbing medical issues in the case of Purvi Patel, and one hopeful one

Editor’s note: Reporter Amy Gastelum, who has been covering the case of Purvi Patel for PRI’s The World, is a registered nurse from Indiana who has worked in antenatal and postnatal care units. We asked her to explain more of the medical context of the story — in which Patel was convicted of feticide and sentenced to 20 years after the stillbirth of her fetus — and what concerns doctors and nurses most about this case.

1. Why was there such a dispute about a fetus's gestational age in Purvi Patel’s trial, and why is it important to know?

It’s not always easy to determine a fetus’s gestational age. Typically, obstetricians calculate a pregnant woman’s due date based on her last menstrual period. They also do an ultrasound in the first trimester to help confirm a due date. The earlier the ultrasound is done, the more reliable it is. Patel never got an ultrasound.

So in Patel’s case, the pathologists for the state and the defense relied on things like the weight of the fetus and physical developmental structures of the fetus and placenta that can give clues about how far along it was. However, these “clues” are not absolute and do vary from fetus to fetus. Additionally, Dr. Kelly McGuire testified about gestational age based on his assessment of the body in a parking lot in the middle of the night.

While it’s difficult to determine the exact age of a preterm fetus, the ability of a fetus to live outside its mother’s womb depends heavily on its gestational age. For extremely preterm babies (those born before 28 weeks), extra-uterine survival can depend on only a few days’ extra time inside the mother’s womb. That extra time is vital for fetal lung development in particular. If born too early, many babies die from respiratory distress.

2. What are the implications of this medical gray area for legal cases like this one?

Now that Purvi Patel has been convicted of causing the death of her preterm baby by “abandoning” it, prosecutors all over Indiana can point to this case and use it as rationale for convicting other women who experience preterm birth. This case also sets precedent for charging women for harming their fetuses, and reproductive rights advocates worry that could possibly be used to convict women who do things like drink alcohol or use illicit drugs while pregnant.

3. What concerns does medical community have about use of fetal homicide laws?

Major medical associations have condemned the use of fetal homicide laws against pregnant women. They say the use of these laws could send a message that if pregnant women inadvertently harm their fetuses, they could end up in prison. Doctors worry this fear could keep women from seeking prenatal care, especially pregnant women who might be addicted to illicit drugs, alcohol and perhaps even cigarettes. Smoking is a known cause of preterm birth.

While many states have fetal homicide laws on the books, some state legislators took health care providers’ concerns into account and and crafted exemptions specifically for pregnant women so they can’t be charged for outcomes of their own pregnancies. Not so in Indiana and 22 other states.

4. What’s the rate of miscarriage and stillbirths in the US now?

Miscarriage is defined medically as pregnancy loss before 20 weeks gestation, and this accounts for the majority of pregnancy losses. But these losses are not reported to the Center for Disease Control and Prevention. Death rates of fetuses over 20 weeks gestation are less common, but still accounted for 6.05 per 1000 live births and fetal deaths in the US in 2006. These recorded losses are among women receiving timely medical intervention in a hospital. Most of them probably also received prenatal care.  However, pregnancy loss is more likely for women who do not get prenatal care. Problems like diabetes, hypertension, and infection can cause pregnancy loss for any woman, but receiving no care for these issues is much more dangerous. On top of that, pregnancy loss can also be caused solely by problems with the developing fetus. It’s sometimes impossible for doctors to determine exactly why a pregnancy is lost. 

5. Are things getting better in the US for miscarriage rates?

Preterm babies are surviving more now than ever before because of incredible advancements in perinatal care. Women are being screened and treated for health problems like diabetes and high blood pressure while pregnant, lowering their chances of losing pregnancies. Women at risk for preterm births are given corticosteroids to mature fetal lungs. Also, neonatal teams are ready in hospitals to immediately intubate these tiny babies and provide life-saving interventions at births.

Many people now know someone who was saved at a very early gestation, and that might give people the impression that, “Of course a 25-week-old fetus can live. My nephew did.” But your nephew was most likely born in a hospital and received immediate care.

6. What’s surprising about some of the realities of pregnancy and birth that you’ve witnessed as a registered nurse?

Pregnant women are simply a sample of society. So if society is getting sicker from obesity-related illness, so are pregnant women. If society is binge-drinking or using illicit drugs or smoking cigarettes, so are pregnant women. Pregnant women are asked to be better than everyone else when it comes to these things, but that’s not how it often works out.

I’ve also heard many patients and even child-bearing friends confess, “this crazy thing happened to me when I was pregnant (or during labor), and I had NO idea this would happen! Why doesn’t anybody talk about this stuff?” They’re referring to things like proscribed bed-rest or preeclampsia or a big one: depression. We tend to have this sunny picture of pregnancy always resulting in a healthy, bouncing baby (and maybe some stretch marks on mom). But the fact is, pregnancy can still be a dangerous and unpredictable time for mothers and babies and fetuses.

7. What are some hopeful solutions for better pregnancies and healthier moms?

Hospitals and public health departments around the country are promoting things like taking folic acid supplements to prevent birth defects (starting even before pregnancy if possible). And they offer non-judgmental smoking cessation support. Another way pregnant women are getting support is with evidence-based nurse home-visiting programs like Nurse Family Partnership. There are also text-message delivery services like txt4baby that send supportive health messages to women based on their gestation.

Beyond public health, more people are starting to talk about real issues relating to childbirth and pregnancy by using media in creative ways like these drawings and stories of women who experienced miscarriage, or via podcasts like Longest Shortest Time, and on the burgeoning “parenting” pages that all major media outlets now have. These are places women and men can go to discuss their real experiences of pregnancy and childbirth and thankfully, that discussion is growing.