Pero todo cambió en agosto. Tras intentar concebir un segundo hijo durante “mucho tiempo”, un fin de semana sufrió en casa un aborto espontáneo temprano. Ese lunes no pudo ir a trabajar. “Estaba muy traumatizada”, contó. “Toda esa primera semana fue emocionalmente muy dura para mí”.

Además, tenía una cita con el médico para asegurarse de que no se trataba de un embarazo ectópico, que habría requerido una intervención quirúrgica inmediata.

Había enviado un correo electrónico a sus jefes, informándoles del aborto y de la necesidad de tomarse el lunes libre, para lo que contaba con suficientes permisos pagos. Debido a la pandemia, había estado trabajando desde casa varios días a la semana y optó por hacerlo de nuevo el martes porque seguía sangrando y tenía la cara “muy hinchada de tanto llorar”, contó.

Regresó al trabajo, como estaba previsto, el miércoles, y luego, dado que sus jefes estaban fuera de la oficina, trabajó desde casa el resto de la semana.

A la semana siguiente, 10 días después de su aborto, uno de los dueños de la empresa la llamó y la despidió, supuestamente por trabajar desde casa repetidamente, a pesar de que otros empleados tenían horarios híbridos similares, según Makkar. Para ella “fue un shock”.

Cuando Makkar le recordó que había trabajado desde casa por su aborto, dijo que le respondió: “Cuando mi mujer tuvo un aborto al principio de nuestro matrimonio, solo se tomó medio día libre en el trabajo”.

Que la despidieran justo después de sufrir un aborto espontáneo “fue verdaderamente horrible”, sollozó. “Te sientes devastada, y recibes un golpe más”.

Makkar presentó una queja contra J&B ante la División de Derechos Civiles de Colorado, acusando a la empresa de discriminación por género y embarazo al despedirla, en violación de las leyes del estado de Colorado. “Esto no debería ocurrirle a ninguna otra mujer”, dijo.

Un abogado de J&B dijo que la empresa no comenta sobre los litigios en curso y se negó a proporcionar las alegaciones que la compañía pudo haber presentado ante el estado. “Solo confiamos en que, una vez que se revisen los hechos, la empresa será reivindicada”, señaló.

El aborto espontáneo, que se produce en , es la forma más común de pérdida de un embarazo. Y, sin embargo, no hay leyes nacionales que protejan a las personas cuando necesitan tomarse un tiempo para afrontar la pérdida.

Las necesidades físicas de quien sufre un aborto espontáneo varían mucho. En la primera o segunda semana, los síntomas pueden parecerse a los de una menstruación abundante, con calambres y algo de dolor.

Cuanto más tarde en el embarazo se produzca un aborto espontáneo, es más probable que se sufra una hemorragia importante, “hasta el punto de provocar anemia en algunos casos”, afirmó , endocrinólogo de reproducción y especialista en fertilidad del CCRM de San Francisco.

Algunas personas tienen contracciones tan intensas que necesitan tratamiento del dolor, añadió. Los abortos espontáneos en el segundo trimestre, o más tarde, pueden requerir procedimientos en el hospital. Las secuelas suelen ser imprevisibles y pueden durar semanas o meses.

“El aborto espontáneo no es algo que ocurre una vez y se termina”, dijo Salem. “Se prolonga física, mental y emocionalmente”.

En el aspecto emocional “puede ser una experiencia muy traumática”, señaló , profesora de comunicación en la Universidad de Indiana, que ha estudiado el aborto espontáneo durante una década.

Hay quien se culpa a sí misma, aunque la gran mayoría de los abortos espontáneos tempranos se deben a anomalías cromosómicas que escapan al control de las personas. El dolor se ve agravado porque no existen rituales establecidos como los que acompañan a otras pérdidas, y por el estigma asociado al aborto espontáneo.

Luego de este trauma, “es muy difícil concentrarse”, explicó Brann. “Y tu productividad probablemente va a ser menor”.

“Es realmente importante que animemos a las mujeres a cuidarse”, dijo Brann. De lo contrario, el duelo no se procesará adecuadamente y puede “causar una angustia mental aún mayor más adelante”.

Cada vez son más las personas que hablan sobre la experiencia del aborto espontáneo, entre ellas mujeres de alto perfil como Michelle Obama, y la actriz .

Pero a muchas trabajadoras les resulta difícil conseguir este tiempo libre. La Ley Federal de Discriminación por Embarazo prohíbe a los empleadores tratar a las trabajadoras embarazadas, que dan a luz o que padecen enfermedades relacionadas —incluido el aborto espontáneo— peor que a sus compañeros de trabajo.

Los tribunales, sin embargo, han interpretado esa ley de forma diferente, incluso después de que una fallara a favor de una demandante que alegaba discriminación por embarazo. Los jueces han desestimado posteriores, según un estudio realizado por A Better Balance, una organización jurídica nacional sin fines de lucro que promueve los derechos en el lugar de trabajo.

—incluido Colorado— han promulgado leyes que obligan a los empresarios a ofrecer a las trabajadoras ayuda relacionada con el embarazo, que puede incluir tiempo libre para recuperarse de un aborto. Pero fuera de esos estados, las trabajadoras sólo están protegidas por la ley del embarazo o la Ley de Estadounidenses con Discapacidades, si un aborto espontáneo es lo suficientemente grave como para limitar sustancialmente una “actividad vital”.

En la actualidad, , entre los que también se encuentra Colorado, han promulgado leyes que obligan a algunas empresas a conceder a los trabajadores una baja laboral remunerada por necesidades médicas, como los efectos en la salud física y mental del aborto espontáneo. No se exige que los empleados digan por qué necesitan el tiempo libre, solo presentar una nota del médico.

“No hay que hacer recaer sobre la trabajadora la responsabilidad de revelar algo que puede ser muy personal y muy delicado”, expresó , consejera de A Better Balance.

cuentan con programas de baja familiar remunerada, que pueden utilizarse para las complicaciones más graves derivadas de un aborto espontáneo. En otros lugares, los trabajadores pueden tomar una licencia no remunerada bajo la Ley de Licencia Familiar y Médica si cumplen los requisitos.

Para llenar los vacíos que existen, la senadora Tammy Duckworth (demócrata de Illinois) y la diputada Ayanna Pressley (demócrata de Massachusetts) que garantizaría tres días de permiso remunerado por aborto espontáneo y otros problemas de fertilidad.

Los demócratas también han presentado una para garantizar la baja por enfermedad remunerada, y han incluido esta licencia en el plan de gasto social del presidente Joe Biden, aunque esa disposición ha encontrado un fuerte rechazo por parte de algunos legisladores.

Makkar vive con las secuelas de su aborto. “Todavía estoy muy traumatizada”, dijo. Intenta encontrar un nuevo trabajo, pero la búsqueda es complicada. Se siente “aterrada de volver a vivir la misma situación”, añadió, porque quiere tener más hijos. “No quiero trabajar en un lugar donde eso no se apoye”.

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That changed in August. After trying for “a really long time” to conceive a second child, she suffered an early miscarriage at home one weekend. She couldn’t go to work that Monday. “I was really traumatized,” she said. “That entire first week was like a heightened level of emotion that I hadn’t really been through before.” She also had a doctor’s appointment to ensure she wasn’t experiencing an ectopic pregnancy, which would have required immediate surgery.

She had emailed her bosses, informing them of the miscarriage and her need to take Monday off, which she had enough paid leave to cover. Because of the pandemic, she had been working from home several days a week and opted to do that again Tuesday because she was still bleeding and her face was “so puffy from crying,” she said. She returned to the office, as scheduled, on Wednesday, she said, and then, given that her managers were out of the office, worked from home the rest of the week.

The following week, 10 days after her miscarriage, one of the company owners called her and fired her, allegedly for working from home repeatedly, even though others at the firm had similar hybrid schedules, according to Makkar. She was “shocked.”

When Makkar reminded him that she had worked from home because of her miscarriage, she said he responded, “When my wife had a miscarriage in the beginning of our marriage, she only took a half a day off work.”

Getting fired right after her miscarriage “was really, really awful,” she said through tears. “You’re already so devastated, and it’s just another blow.”

Makker filed a complaint based on her allegations against J&B with the Colorado Civil Rights Division, accusing the company of gender and pregnancy discrimination for her firing, in violation of Colorado state laws. “This shouldn’t have to happen to other women,” she said.

Makkar’s lawyer, David E. Gottlieb, said they “intend to file a lawsuit in the coming months in Colorado state court.”

A lawyer for J&B said its policy is not to comment on ongoing litigation and declined to provide any responses the company may have filed with the state. “We’re just confident that once the facts are reviewed the company will be vindicated,” he said.

Miscarriage, which occurs in of all pregnancies, is the most common form of loss of a pregnancy. And yet there are no national laws that protect people when they need time off from work to deal with the loss.

The physical needs of someone who experiences a miscarriage vary greatly. Within the first week or two, symptoms may resemble a heavy menstrual period with cramping and some pain. The later in the pregnancy that a miscarriage occurs, the more likely there will be significant bleeding, “to the point where it leads to anemia in some cases,” said , a reproductive endocrinologist and fertility specialist with CCRM San Francisco. Some people have such heavy contractions that they need pain management, he added. Miscarriages in the second trimester or later may require procedures needing hospital admission. The aftereffects are often unpredictable and can last for weeks or months.

“Miscarriage is not a one-and-done thing at all,” Salem said. “It drags on physically, mentally, and emotionally.”

The emotional aspect “can be a very traumatic experience,” noted , a professor of communications studies at Indiana University who has studied miscarriage for a decade. Some people blame themselves even though the vast majority of early miscarriages are due to chromosomal abnormalities beyond people’s control. Compounding the grief is the lack of established rituals that accompany other losses, as well as a stigma some people attach to miscarriage.

In the wake of such trauma, “it’s very difficult to focus,” Brann said. “An individual is probably not going to be as productive.”

“It is really important that we encourage women to take care of themselves,” Brann said. Otherwise, the grief won’t be processed and it can “cause even greater mental anguish later on.”

More people are speaking out about the experience of miscarriage, including high-profile women like Michelle Obama, , and actress .

But many workers find it difficult to get time off from work. The federal Pregnancy Discrimination Act prohibits employers from treating workers who are pregnant, give birth, or have related medical conditions — including miscarriage — worse than comparable co-workers. Courts, however, have interpreted that law differently, even after a decided in favor of a plaintiff who claimed pregnancy discrimination. Judges have dismissed in the aftermath, according to a review by A Better Balance, a national legal nonprofit promoting workplace rights.

— including Colorado — have enacted laws that require employers to offer workers accommodations related to pregnancy, which can include time off to recover from a miscarriage. But outside those states, workers are protected only by the pregnancy act or the Americans with Disabilities Act, if a miscarriage is severe enough to substantially limit a “life activity.”

Currently, , also including Colorado, have enacted laws requiring some employers to provide paid sick leave to workers for medical needs, such as for the physical and mental health impacts of miscarriage. They don’t require employees to say why they need the time off, other than perhaps producing a doctor’s note.

“It’s not putting the onus on the worker to have to reveal something that might be very personal and very sensitive,” said , a senior policy counsel at A Better Balance.

have paid family leave programs, which can be used for more serious complications resulting from miscarriage. Elsewhere workers can take unpaid leave through the Family and Medical Leave Act if they qualify.

To fill the gaps, Sen. Tammy Duckworth (D-Ill.) and Rep. Ayanna Pressley (D-Mass.) that would ensure three days of paid leave for miscarriage and other fertility challenges. Democrats have also put forward to guarantee paid sick leave, and they’ve included paid family leave in President Joe Biden’s social spending plan, although that provision is meeting stiff opposition from some lawmakers and the bill is languishing in Congress.

Makkar is living with the repercussions of her miscarriage. “It’s all so traumatizing still,” she said. She’s trying to find a new job, but the search is complicated. She’s “terrified of getting myself in this situation again,” she said, because she wants to have more children. “I don’t want to be somewhere that that’s not going to be supported.”

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It was all explained “super quick,” she said, with no details on what the insurance would cover. When she arrived in the United States, she recalled, a representative of the au pair agency recommended she buy extra coverage for sports, because even an accident caused by jumping could be considered sports-related. Mabel opted to purchase the extra policy for an additional $180.

In August 2017, she had her birth control implant removed because it had expired, something she assumed would be covered by her insurance, given birth control coverage is of Mexico’s . Instead, she said, she got a bill for about $4,500. Her insurance didn’t cover contraception or other reproductive health care, she said.

According to the State Department, 14 au pair agencies operate in the U.S. These private companies are required to offer their au pairs basic health coverage under State Department regulations. But some of the plans amount to emergency or travel insurance, excluding many types of necessary care, according to Natalia Friedlander, a staff attorney at the , a nonprofit public interest law center. After an au pair she employed had problems with health coverage, Friedlander examined insurance offered by about half those agencies in 2020 and her center posted to help au pairs find comprehensive coverage.

She found that agencies might not mention that au pairs are eligible to enroll in comprehensive coverage on the Affordable Care Act marketplaces or that many au pairs may qualify for subsidies to help pay their premiums. By failing to enroll, au pairs could wind up with huge medical bills if they need care.

A spokesperson for the State Department said those 14 agencies are subject to the as other groups that sponsor exchange visitor programs and must require the au pairs to “have insurance in effect that covers the exchange visitors for sickness or accidents during the period of time that they participate in the sponsor’s exchange visitor program.” The criteria laid out in the federal regulations include medical benefits of at least $100,000 per accident or illness, a deductible limit of $500 per accident or illness, and a maximum coinsurance limit of 25% of the cost of covered benefits — but they don’t stipulate that the comprehensive coverage required for Americans must be provided.

Neither do the regulations suggest au pairs or other exchange visitors be informed about access to ACA marketplace plans. Mabel and two other former au pairs, whose time working in the program spanned 2014 to June of this year, told KHN that no one ever mentioned the ACA to them when they signed up for work or after they arrived in the U.S.

KHN reached out to each of the 14 au pair agencies under the purview of the State Department about the insurance plans they offer employees. Only one responded.

Terence Burke, a spokesperson for Cultural Care Au Pair, said the insurance offered to its au pairs exceeds regulations set up by the State Department to meet medical expenses and other travel coverage, and provides emergency evacuation from the country if needed, another State Department requirement.

“Au pairs with Cultural Care are given detailed information on exactly what is and what is not covered in their insurance coverage. Knowing that information, au pairs are always free to supplement or add to the insurance coverage they must have in accordance with the U.S. State Department regulations and can choose to enroll in an ACA exchange to supplement their medical coverage,” he wrote in an email.

At least two of the agencies with some of the longest-running programs in the U.S. are owned by companies that also offer insurance. Cultural Care insurance through Erika Insurance, and both companies are EF Education First, a Swedish company. Au Pair in America insurance through Cultural Insurance Services International, both part of the British company American Institute for Foreign Study.

Friedlander found that the insurance plans offered to many au pairs before they arrive exclude certain categories of care deemed essential under the ACA. Many didn’t cover routine or preventive services, or care for preexisting conditions, mental health, and maternity and reproductive health, she said. Some plans are advertised as “comprehensive,” “exceptional” or “worry free,” although they do note the coverage exclusions.

In addition, she said, the insurance coverage summaries or orientation materials she reviewed did not mention ACA marketplace plans as an option.

Au pairs on J-1 visas are classified as foreign nationals living in the U.S. on non-immigrant visas, because they’re not on a path to citizenship. The ACA such non-immigrants. According to a spokesperson for the Centers for Medicare & Medicaid Services, the federal agency that oversees the ACA marketplaces, “We encourage organizations that facilitate the J-1 visa exchange programs to communicate the opportunity to enroll in quality, affordable healthcare through the Marketplace. J-1 visa holders are considered lawfully present and are therefore eligible to enroll in a qualified health plan through the Marketplace, and for financial assistance, if otherwise eligible.”

CMS noted, however, that anyone seeking subsidies to help cover the cost of premiums must plan to file a federal income tax return for that year.

If the insurance au pairs carry through their agencies doesn’t meet the minimum coverage requirements under the ACA, Friedlander said, they are free to enroll.

But the enrollment window is strict: People in the U.S. to sign up for ACA plans outside the annual open enrollment period.

Friedlander said that, when she first looked into insurance for her au pair, “I assumed she would have comprehensive coverage.” She said she was surprised to see large limitations.

Having previously worked at a health insurance-related nonprofit, Friedlander first investigated whether the au pair could enroll in ACA coverage. It took effort because the ACA marketplace navigators weren’t familiar with J-1 visa holders, but she managed to get her au pair enrolled. She has since signed up two of her other au pairs.

But for many au pairs, ACA coverage is not an obvious option. They are typically not native English speakers, very young and living with their employers, which leaves them dependent on their host families. “That’s a situation where they really are reliant on the agencies to provide them information that they need to know while in the United States,” Friedlander said.

For Mabel, her medical bills changed her experience in the U.S. What she owed the hospital and doctor, she noted, would have been enough to buy round-trip tickets to Mexico to have her implant removed there. To save the money to pay off her debt, she said, she stopped doing anything outside of working. “Basically, the purpose of the exchange, go traveling around, it stopped there, it finished, because I acquired this responsibility,” she said. She was able to pay it off over the course of two years, she said.

“It was my biggest mistake, financially talking, of my whole life,” she said.

Estefania Weinbach, of Colombia, said that in 2016, two years after coming to the U.S. to work as an au pair, she experienced a sharp pain in her abdomen that felt like being stabbed. At an emergency room, she was diagnosed with endometriosis and was told she needed surgery within weeks, she recalled.

She said she was told by a representative of her au pair agency that the surgery would be covered in her home country and was advised to fly back immediately. Weinbach refused. The agency told her the insurance would cover surgery expenses up to $7,000, she said, and she found a doctor willing to perform the operation for that payment. But it was a “very traumatic experience,” one that made her feel “everything is against you.”

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