More pregnant women died and stillbirths increased steeply during the pandemic, studies show.

A nurse helping a pregnant woman at a hospital in Paris last November.

By Apoorva Mandavilli

More pregnant women died, experienced complications or delivered stillborn babies during the pandemic than in previous years, according to an analysis of 40 studies in 17 countries published on Wednesday in the journal Lancet Global Health.

Pregnant women face a heightened risk of severe illness and death if infected with the coronavirus. But the researchers, in Turkey and the United Kingdom, wanted to assess collateral damage from the pandemic on pregnancy and delivery, and so excluded from their analysis those studies that focused only on pregnant women who were infected.

Reviewing data on more than six million pregnancies, the investigators found evidence that disruptions to health care systems and patients’ fear of becoming infected at clinics may have led to avoidable deaths of mothers and babies, especially in low- and middle-income countries.

Data from a dozen studies showed that the chances of a stillbirth increased by 28 percent. And the risk of women dying while pregnant or during childbirth increased by more than a third in two countries: Mexico and India. A subset of studies that assessed mental health showed that postpartum depression and anxiety were also heightened during the pandemic.

Nearly six times as many women needed surgery for ectopic pregnancies — in which a fertilized egg grows outside the uterus — during the pandemic than before. Ectopic pregnancies can be treated with medications if detected early, so the results suggest that the surgeries may have resulted from delays in care.

The analysis did not find differences in other conditions associated with pregnancy, like gestational diabetes or high blood pressure, or in the rates of cesarean sections or induced labor.

The rates of preterm birth also did not change significantly during the pandemic in low- and middle-income countries. But in high-income countries, preterm births fell by nearly 10 percent.

The drop may be a result of changes in health care delivery and in pregnant women’s behavior during the pandemic, the researchers said, indicating that the pandemic has exacerbated disparities between low- and high-income countries.

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Last Responders Comfort Others, While Managing Their Own Grief

by Lindsay Wilson

When Tom Belford’s mother died in May, her family was faced with the impossible task of limiting her funeral to 10 people. Belford, who is the owner and funeral director of John. A Gentleman Mortuaries and Crematory, recalled the difficult months leading up to his mother’s death.

“From March until May nobody was allowed in the building, and she was on the second floor. So we couldn’t go up to the window or anything,” he said.

The end of a life is a difficult time under any circumstances, but COVID-19 has made grieving even more difficult.

“COVID is taking people suddenly, and it’s affecting the families that have suffered, that go through a death at a time where maybe they shouldn’t,” Belford said.

Belford said in many cases families are losing people who are in their 50s and 60s due to complications from the virus.

“We’re here to help them make that first step back to a normal life after suffering a loss,” he said.

Chapel, 1010 N. 72nd St location (Real Yellow Pages)

John. A Gentleman has seen a steady number of virus-related deaths since the beginning of the pandemic, from March or April through today. Though numbers in Omaha aren’t what New York City or cities in California are seeing, deaths have risen from this time last year, according to last responders such as Belford.

Though the increase in business has been a change, the way Belford and his staff handle virus-related deaths has stayed the same.

“We practice something called universal precautions. We treat everyone as if they had COVID.”

These precautions, which include personal protective equipment used for both funeral directors and the deceased they are working with, have kept Belford’s staff safe since the beginning of the pandemic.

“We don’t treat anybody differently because they had COVID,” he said.

While the practices in caring for the deceased haven’t changed, funeral services have changed, in some cases dramatically, due to the virus.

“The biggest changes we see in the services is the social distancing,” Belford said. “For a while, the services were limited.”

Casket selection, 7010 N. 72nd St location (Real Yellow Pages)

Many churches and chapels continue to limit the capacity of funerals for everyone’s safety. In response to this, John. A. Gentleman has broadened its focus to include videocasting of services for loved ones who are unable to make it to the service.

“Before this started, we had one or two cameras for filming services,” Belford said. “We have six or seven now.”

Recorded services are helpful to many family members, but one important aspect of support is still missing.

“The families,” Belford explained, “they can’t socialize and get the support from their friends. And that’s probably the biggest disappointment families will see. Our interactions are the same. The care we give them is the same. But the care they get from their friends is different.”

Limiting social contact in a time of grief also directly curtails the level of support families would normally receive at the funeral and beyond. John A. Gentleman had to pause its bereavement programs due to the virus, though they recently started back up.

Many families are postponing memorial services for their deceased loved ones until after the virus is under better control. In March and April, some families planned to postpone services until summertime. But then those were pushed back, too. Some families are now pushing memorial services to summer 2021.

“Everybody’s pushing things back,” Belford said. “Hopefully the shots will come in and everybody will get vaccinated.”

Fortunately, Belford and his staff are currently on a waitlist for vaccinations and hope to receive their first shots in the next couple of weeks. In the meantime, Belford is more careful to protect himself and his family from the virus than the average person.

“I wouldn’t say I’m freaked out, but I would say that I’m cautious.” Belford said. “I’m very cautious about where I go and what I do. I have a big bottle of sanitizer in my car.”

Note of thanks, photo from John A. Gentleman

Being a funeral director is a tradition that has passed down for three generations in Belford’s family. While the virus has changed the way he conducts his services, one tradition that remains is the mortuary’s memorial plantings at Lauritzen Gardens, which Belford said is part of the service for every funeral. But even that has been altered slightly. The dedications are now posted online.

The coronavirus has rendered many aspects of life a moving target, and for last responders, more changes are likely to come. However, Tom Belford is prepared to continue to adapt to support families even as his own family mourns their loss. “No matter what happens to people, we’re here to help them,” he said.

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Getting a Prescription to Die Remains Tricky Even as Aid-in-Dying Bills Gain Momentum

Those who back the bills say the aid is morally wrong while opponents say criminalizing the practice would be a backstep for patients’ rights.

Valium, also known by the name diazepam, is one drug used in a mixture of aid-in-dying medications.

By Katheryn Houghton

KEY TAKEAWAYS

Every session of the biennial Montana state legislature since then, a lawmaker has proposed a bill to formally criminalize physician-assisted death.

Those who back the bills say the aid is morally wrong while opponents say criminalizing the practice would be a backstep for patients’ rights.

But so far, lawmakers haven’t gained enough support to pass any legislation on the issue, though it has been close. The latest effort stalled on March 1, on a split vote.

Linda Heim knew her dad didn’t plan to wait for the cancer to kill him. For decades, he’d lived in Montana, which they’d thought was one of the few places where terminally ill people could get a prescription to end their life.

After two years of being sick, Heim’s dad got the diagnosis in 2019: stage 4 kidney cancer. His physician offered treatments that might extend his life by months. Instead, the 81-year-old asked the doctor for help dying. Heim said her parents left the appointment in their hometown of Billings with two takeaways: The legality of medically assisted death was questionable in Montana, and her father’s physician didn’t seem willing to risk his career to put that question to the test.

“My parents knew when they left there that was the end of that conversation,” said Heim, now 54. “My dad was upset and mad.”

The day after the appointment, Heim’s mother went grocery shopping. While she was gone, Heim’s dad went to the backyard and fatally shot himself. (Heim asked that her father’s name not be published due to the lingering stigma of suicide.)

About a decade earlier, in 2009, the Montana Supreme Court had, in theory, cracked open the door to sanctioned medically assisted death. The court ruled physicians could use a dying patient’s consent as a defense if charged with homicide for prescribing life-ending medication.

However, the ruling sidestepped whether terminally ill patients have a constitutional right to that aid. Whether that case made aid in dying legal in Montana has been debated ever since. “There is just no right to medical aid in dying in Montana, at least no right a patient can rely on, like in the other states,” said former state Supreme Court Justice Jim Nelson. “Every time a physician does it, the physician rolls the dice.”

Every session of the biennial Montana state legislature since then, a lawmaker has proposed a bill to formally criminalize physician-assisted death. Those who back the bills say the aid is morally wrong while opponents say criminalizing the practice would be a backstep for patients’ rights. But so far, lawmakers haven’t gained enough support to pass any legislation on the issue, though it has been close. The latest effort stalled on March 1, on a split vote.

Even the terminology to describe the practice is disputed. Some say it’s “suicide” anytime someone intentionally ends their life. Others say it’s “death with dignity” when choosing to expedite a painful end. Such debates have gone on for decades. But Montana remains the sole state stuck in a legal gray zone, even if the practice can still seem taboo in many states with clear laws. Such continued uncertainty makes it especially hard for Montana patients like Heim’s dad and their doctors to navigate what’s allowed.

“Doctors are risk-averse,” said Dr. David Orentlicher, director of the health law program at the University of Nevada-Las Vegas, who helped write clinical aid-in-dying guidelines published in the Journal of Palliative Medicine in 2016. “The fear of being sued or prosecuted is still there.”

Despite that, access to medical aid in dying is gaining momentum across the U.S. Outside Montana, eight states and the District of Columbia allow the life-ending aid — six of them since 2014. So far in 2021, legislators in at least 19 states have pushed aid-in-dying bills, most seeking to legalize the practice and some seeking to drop barriers to existing aid such as expanding which medical professionals can offer it. Many are repeat legalization efforts with some, like in New York, dating as far back as 1995. Only the Montana bill this year specifically sought to criminalize it.

North Dakota considered legislation to legalize medically assisted death for the first time. Rep. Pamela Anderson, a Democrat from Fargo who proposed the measure after hearing from a cancer patient, said she wasn’t surprised when the bill failed in February in a 9-85 vote. The state’s medical association said it was “incompatible with the physician’s role as healer.” Angry voters called Anderson asking why she wanted to kill people.

“But I heard from just as many people that this was a good bill,” Anderson said. “There is momentum to not let this concept go away.”

Back in Montana, now retired state Supreme Court Justice Nelson said he has always regretted joining the majority in the case that allowed the practice because the narrow ruling focused on physicians’ legal defense, not patients’ rights. Having watched a friend die slowly from disease, Nelson, 77, wants the choice himself if ever needed.

Despite — or because of — the court decision, some Montana doctors do today feel that they can accommodate such patient decisions. For example, Dr. Colette Kirchhoff, a hospice and palliative care physician, said until she retired from private practice last year she considered patients’ requests for life-ending drugs.

Physicians who help in such cases follow well-established guidelines set by other states, Kirchhoff said. A patient must have six months or less to live — a fact corroborated by a second physician; can’t be clinically depressed; needs to ask for the aid; and be an adult capable of making healthcare decisions, which is determined by the attending physician. They must also administer the life-ending medication themselves.

“You’re obviously not going to do a case that is vague or nebulous or has family discord,” Kirchhoff said. “The doctors who are prescribing have felt comfortable and that they’re doing the right thing for their patient, alleviating their suffering.” Of her few patients who qualified for a prescription, she said, none actually took the drugs. Kirchhoff noted that, in some cases, getting the prescription seemed to provide comfort to her patients — it was enough knowing they had the option if their illness became unbearable.

For the past six legislative sessions — dating to 2011 — a Montana lawmaker has proposed a bill to clarify that state law doesn’t allow physician-assisted death. Republican Sen. Carl Glimm picked up that effort the past two sessions. Glimm said the current status, based on the more than decade-old court decision, sends a mixed message in a state that the Centers for Disease Control and Prevention ranks as having among the nation’s highest suicide rates. Glimm said allowing someone to end their life because of pain from a terminal illness could normalize suicide for people living with depression, which is also a form of pain.

“It’s really hard because I do sympathize with them,” Glimm said. “What it boils down to is, if you’re going to take your own life, then that’s suicide.”

Kim Callinan, president and CEO of national nonprofit Compassion & Choices, said the comparison to suicide is frustrating. “People who are seeking medical aid in dying want to live, but they are stricken with a life-ending illness,” she said.

Glimm and his bill’s supporters say that some patients could be pressured into it by family members with something to gain, and doctors could prescribe it more often than they should.

But Callinan, whose group advocates for aid in dying, said that since Oregon first legalized it in 1997, no data has shown any merit to the warnings about abuse and coercion. One study showed no evidence of heightened risk of abuse within the practice for vulnerable populations such as the elderly. But critics have said states aren’t doing enough to track the issue.

By now, Leslie Mutchler, 60, knows most of the people on all sides of the debate after years of testifying in support of protecting aid in dying. Her dad, Bob Baxter, was a plaintiff in the case that eventually led to the 2009 Montana Supreme Court decision on medically assisted death. After leukemia whittled his body for years, he died in 2008 without the option, the same day a lower court ruled in his favor.

Mutchler said she didn’t understand how complicated the Supreme Court’s ultimate ruling was until her son TJ was diagnosed with terminal metastatic pancreatic cancer in 2016.

He was 36 and lived in Billings, Montana. By then, the 6-foot-5 man had lost 125 pounds off what had been a 240-pound frame. He couldn’t keep food down and needed a feeding tube for medicine and water. TJ Mutchler wanted to have the choice his grandfather never got. But when he went to his physician and asked for aid in dying, the response was it wasn’t legal. Eventually, Mutchler found a doctor to evaluate her son and write the prescriptions for phenobarbital and amitriptyline. TJ took the drugs more than two months later and died.

“People contact me asking how to find someone and it’s difficult,” Mutchler said. “That’s why people end up taking matters into their own hands.” Research into terminally ill populations is limited, but one national study published in 2019 found the risk of someone with cancer taking their own life is four times higher than the general population.

For Roberta King, another one of Baxter’s daughters, the ongoing fight over aid in dying in Montana means she knows every other winter she’ll make the more than 200-mile round trip from her Missoula home to the state capital. King, 58, has testified against all six bills that sought to ban aid in dying following her dad’s case. She memorized a speech about how her dad became so thin after his medicine stopped working that it hurt for him to sit.

“It’s still terrible, you still have to get up there in front of everybody and they know what you’re going to say because it’s the same people doing the same thing,” King said. But skipping a hearing doesn’t feel like an option. “If something were to happen to this and I didn’t try, I would never forgive myself,” she said.

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