Ectopic pregnancy remains a serious, time-sensitive gynaecologic emergency with a high risk of maternal morbidity and mortality 1. While this condition remains a persistent public health challenge, the discussion surrounding it has often focused on generalised risk, despite recent research consistently demonstrating significant disparities in care. Although inequities tied to socioeconomic status and race have been documented, in this issue of Paediatric and Perinatal Epidemiology, a new population-based cross-sectional study by Scime and colleagues 2 highlights a deeply concerning and previously under-examined gap in reproductive healthcare: the unequal experience of women with disabilities. Analysing over 9700 hospitalisations for surgically managed ectopic pregnancy in the U.S. National Inpatient Sample (NIS) from 2016–2021, Scime and colleagues provide compelling evidence of disparities in care for women with disabilities. The study identified that the rate of surgically managed ectopic pregnancy is slightly higher in females with a disability (2.8 per 1000 obstetrical deliveries) compared to non-disabled females (2.3 per 1000 obstetrical deliveries). This elevated incidence suggested that women with disabilities may have underlying biological and social risk factors that cumulatively increase their risk for ectopic pregnancy requiring hospitalisation. These factors could include a higher prevalence of sexually transmitted infections and endometriosis, significant challenges accessing adequate preconception and prenatal care, leading to delayed diagnoses and more advanced presentations. More importantly, the study found substantial differences in surgical management and outcomes on ectopic pregnancy between women with and without disability. Disabled women were more likely to experience a prolonged length of stay and underwent more extensive procedures, including hysterectomy, oophorectomy and bilateral salpingectomy. The disproportionate use of more extensive surgical procedures, especially those that result in permanent sterilisation, requires further assessment. While clinical complexity may partially explain the need for more extensive surgical procedures, the authors raised a concerning point of the possibility of reproductive disparity. Reproductive healthcare for disabled women in the United States has a history rooted in eugenics, where forced or coerced sterilisation was practiced for decades 3. Although the widespread use of these practices was discontinued long ago, the legacy of ableism may persist. The high rates of hysterectomy and other sterilising procedures for ectopic pregnancy among disabled women observed align with prior reports of increased extensive gynaecologic surgery among women with disabilities 4-6. In the context of an emergent medical situation like an ectopic pregnancy, performing a non-medically necessary procedure like voluntary sterilisation is widely considered ethically inappropriate. This is due to concerns about informed consent and decision-making capacity under distress. The data suggested that for disabled women, the threshold for these invasive procedures, which can permanently affect long-term health, may be inappropriately lowered. The study by Scime and colleagues is a further call for reproductive justice, in particular, the importance of recognising women with disabilities who potentially are subjected to reproductive health disparities. To address this issue, the medical community could consider the following actions. First, patient education for women with disabilities. To eliminate access barriers to early pregnancy and gynaecologic care among this group of women, we should provide targeted, accessible education on ectopic pregnancy risks and symptoms as a routine component of preconception, contraception and sexual health counselling for all women with disabilities. Second, equity-focused guidance. Gynaecologic surgeons should consider the potential biases in treatment decision-making for women with disabilities. Despite the existence of the current practice guideline 7, there is an urgent need to develop an equity-focused guideline for the surgical management of ectopic pregnancy. This new guideline must explicitly address the need for vigilance against ableist bias. The decision to perform a hysterectomy, oophorectomy or bilateral salpingectomy in an emergent setting must be strongly supported by medical necessity and not influenced by presumptions about a patient's reproductive capacity or welfare. The work of Scime and colleagues provides the evidence; it is now incumbent upon clinicians, healthcare systems and policymakers to dismantle the systemic biases that perpetuate these disparities and ensure truly equitable care for all women to avoid reproductive justice issues among women with disability. Intira Sriprasert: conceptualization, writing, and approval. Jason D. Wright: conceptualization, writing, and approval. The authors have nothing to report. Dr. Wright has received honoraria from the American College of Obstetricians and Gynaecologists and UpToDate, as well as research funding from Merck. Jason D. Wright—Honoraria from the American College of Obstetricians and Gynecologists, honoraria UpToDate. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Sriprasert et al. (Fri,) studied this question.