Editor note: This is a guest post by nurse scientist, fencer and WFencing member Lisa Adams Wolf.
On June 24th, the Supreme Court issued a ruling on a case that essentially overturned Roe v Wade. This ruling returned legislative control of reproductive decision-making back to individual states. Currently, 13 states have total bans. Of those states, NACs are scheduled to be held in Texas, Missouri, and Kentucky. Arizona’s law is currently blocked, but summer nationals are scheduled for July 2023.
Why does this matter? For women and other pregnancy-capable people, it may determine whether they have the option to terminate an unplanned pregnancy (or not). We often think of Roe as pertaining only to abortion care, and really, fencers will not be pairing their trip to a NAC with an appointment for an abortion. However, the implications of this decision reach much farther into reproductive care issues and pose not just a threat to bodily autonomy for all folks, but specifically a safety concern for all pregnancy-capable people in our fencing community.
The current situation around abortion bans creates major issues for not only USA Fencing, but for all sports that hold competitions in states where abortions are banned and pregnancy-capable people are competing or attending as coaches, parents/partners, bout committee, and referee corps.
This is because our pregnancy-capable fencers, coaches, parents, bout committee, and referee and medical corps are in danger should any presentation of an unknown pregnancy (ectopic, miscarriage) or complications of a known/wanted pregnancy (miscarriage, pregnancy complications, premature rupture of membranes, pre-eclampsia, etc...) occur. People in these medical situations simply won't get care in these states until their lives are undeniably in danger and depending on the situation, possibly not even then (Tanne, 2022). There is also now concern about ability to travel across state lines to receive care once a pregnancy is documented, as seen in the current Texas filing against the Biden Administration’s clarification of the Emergency Medical Treatment & Labor Act (EMTALA).
The current abortion bans in states that are often used for NACs create a real tension for the fencing community that goes far beyond a difference of political opinion. Because competitive fencers must attend NACs and ROCs to qualify for nationals, to allow tournaments in states that are not safe is coercive and requires that only pregnancy-capable fencers or other participants weigh their fencing opportunities against their safety. I see this problem as comprising three main parts: clinical safety, ethical care, and equity in competition.
Clinical safety: some pregnancy complications are emergencies. Simply put, people with ectopic pregnancies or sepsis will die without rapid appropriate care. You can't just send them back home to access appropriate medical care. Therefore, states where care cannot be provided are not safe for a large percentage of USA Fencing participants. The pregnancy rate for ages 15-44 is approximately 104 per thousand. The rate of ectopic pregnancy is 2/100 (Brown et al., 2017), and the rate of complications is about 234/1000 pregnancies. These numbers suggest that there is a real risk of someone attending a NAC having a medical problem that cannot be addressed in the state in which they are attending or participating.
Case 1: a junior foil fencer attends a NAC in Kentucky. They do not know they are pregnant. They develop acute lower quadrant abdominal pain. They are sent to the local emergency department to rule out appendicitis. It is discovered that the fencer is pregnant, but the pregnancy is ectopic. This is a surgical emergency. If the fallopian tube where the embryo is implanted ruptures, the risk is that the patient bleeds out and dies, and so transfer opportunities are limited by the urgency of the problem. A study in the New England Journal of Medicine (Arey et al., 2022) reports that the sequelae of SB8 challenges appropriate and accepted care: “Many clinicians have also been advised that they cannot provide information about out-of-state abortion facilities or directly contact out-of-state clinicians to transfer patient information. These fears have disrupted continuity of care and left patients to find services on their own.” There is also concern about travel across state lines to seek care if time allows, as there are several bills pending that would limit travel for pregnant people (dear gods I cannot believe I am writing this in 2022). This creates issues for the obvious solution of transfer planning.
Case 2: a parent accompanies their Y10 fencer to a NAC in Texas. The parent is 20 weeks pregnant, still quite safe to fly. While at the NAC, they have a premature rupture of membranes (PROM), which happens in 2-3 of every 100 pregnancies (Siegler et al., 2020). At the local emergency department, the patient develops a fever, suggesting sepsis. The fetus will not survive, but no care can be provided to remove the pregnancy until fetal heart tones are absent for fear of prosecution. A New England Journal of Medicine study reported that “As an MFM (maternal-fetal medicine) specialist summarized, “People have to be on death’s door to qualify for maternal exemptions to SB8.”(Arey et al., 2022)
Case 3: A 21-week pregnant coach has a seizure at the venue at a NAC in St Louis. Their blood pressure is high, and eclampsia (pregnancy-induced hypertension that progresses to seizure) is suspected. The treatment for pre-eclampsia if the blood pressure cannot be controlled is to deliver the fetus. Delivering a pre-viable fetus will result in the death of the fetus. Non-delivery of the fetus will result in the potential death of the pregnant person.
Case 4: A referee is 14 weeks pregnant. They begin to bleed during their day, and by the end of the day, they are bleeding heavily and they nearly pass out. Brought to the local emergency department, they continue to bleed. The patient needs a D&C to evacuate the uterus and stop the bleeding. Care is delayed as providers weigh whether the patient is “sick enough” to remove the pregnancy and evacuate the uterus. The patient’s blood pressure continues to drop, risking multisystem organ failure due to inadequate perfusion of organs.
Ethical care: USA Fencing has an obligation to provide fencers with competition sites where appropriate medical care for illness or injury can be provided. In states where emergencies of a specific type cannot be managed, there is potential for harm outside the normal expectation of sports-related injury. It is a violation of principles of non-maleficence, fidelity, veracity, and justice to hold tournaments in states where all fencers and the surrounding people are not able to access necessary care should they require it.
Justice/equity: this becomes an equity issue when only certain members of USA Fencing are denied appropriate care; pregnancy-capable members are affected, and those who are not pregnancy-capable are unaffected. If this were a matter of disagreement with a political position, then members could choose their responses appropriately. But because the political climate creates an unequally-safe clinical environment, specific members of USA Fencing are putting themselves at a much higher risk clinically than others if tournaments are held in states where abortion care is banned. An analogous situation might be if we held a tournament in a state where cardiac care was unavailable. We could say “stay home if you have any kind of cardiac condition, or if you might develop one because we can’t guarantee medical care if you need it,” but that would mean that each individual (coaches, parents, referees, other personnel) would be making a decision based on individual risk. This makes sense if cardiac care was unavailable in lots of places. But given the number of people who would be participating in the tournament in those capacities, we might look to a structural, rather than a personal set of solutions. Similarly, rather than ask each pregnancy-capable person to determine that they are not pregnant before going to a NAC in a state with abortion bans, or to not take their child to the tournament, or to not referee or coach or otherwise participate when that would not be a concern in other states, we are placing an unjust burden on individuals rather than addressing the system.
Where do we go from here?
USA Fencing needs to maintain the safety of its pregnancy-capable members and those around them by creating policies and protocols for fencers and others to receive appropriate care as needed while deciding on how to hold tournaments in safe areas. As of its announcement of November 3, 2022, USA Fencing has taken an important step and committed to give preference to areas where the fencing community can receive rapid, safe, equitable, and appropriate care for any obstetric emergency.
Arey, W., Lerma, K., Beasley, A., Harper, L., Moayedi, G., & White, K. (2022). A Preview of the Dangerous Future of Abortion Bans—Texas Senate Bill 8. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMp2207423
Brown, M. D., Byyny, R., Diercks, D. B., Gemme, S. R., Gerardo, C. J., Godwin, S. A., ... & Whitson, R. R. (2017). Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Annals of Emergency Medicine, 69(2), 241-250. https://www.annemergmed.com/article/S0196-0644(16)31344-0/fulltext
Nambiar, A., Patel, S., Santiago-Munoz, P., Spong, C. Y., & Nelson, D. B. (2022). Maternal morbidity and fetal outcomes among pregnant women at 22 weeks’ gestation or less with complications in 2 Texas hospitals after legislation on abortion. American Journal of Obstetrics & Gynecology, 227(4), 648-650. https://www.ajog.org/article/S0002-9378(22)00536-1/fulltext
Siegler, Y., Weiner, Z., & Solt, I. (2020). ACOG practice bulletin No. 217: prelabor rupture of membranes. Obstetrics & Gynecology, 136(5), 1061. https://journals.lww.com/greenjournal/Citation/2020/11000/ACOG_Practice_Bulletin_No__217__Prelabor_Rupture.32.aspx?context=LatestArticles
Tanne, J. H. (2022). After Roe v Wade: US doctors are harassed, confused, and fearful, and maternal morbidity is increasing. https://www.bmj.com/content/378/bmj.o1920.abstract
Lisa Adams Wolf, PhD, RN is an emergency care-focused nurse scientist at the Emergency Nurses Association. Her latest projects involve joint work with the American College of Obstetricians and Gynecologists, and the Association of Women’s Health, Obstetric, and Neonatal Nurses in teaching emergency nurses to manage obstetric emergencies in what are called "obstetric deserts,'' areas where there are no OB/GYNs or midwives. She teaches ethics, research, and nursing at Elms College and at the University of Massachusetts, Amherst. She fences epee at the Riverside Fencing Club in Hadley, MA. She is pictured on the right fencing.