HOUSTON — Dr. Amanda Horton, an OB-GYN who specializes in high-risk pregnancies, was counseling pregnant patients at a small hospital in rural Texas last month when a woman arrived in crisis: She was only 17 weeks pregnant and her water had broken.
The fetus would not be viable outside the womb, and without the protection of the amniotic sac, the woman was vulnerable to a potentially life-threatening infection. In Colorado or Illinois, states where Dr. Horton also practices and where abortion is generally legal, has the option to terminate her pregnancy.
Texas has a ban on most abortions, granting an exception when the woman’s life is in danger. But the patient’s life in this case is not in immediate danger – yet. The hospital sent her home to wait for signs of infection or labor, Dr. Horton said.
Worried and with nowhere else to turn, the woman instead traveled hundreds of miles to New Mexico for an abortion.
“She ended up taking matters into her own hands,” Dr. Horton said. Her patient, she said, had made a choice “for his life.”
Each of the 13 states with abortion bans allows some exception to save the mother’s life or to address a serious risk of “substantial and irreversible impairment of an essential bodily function.”
But making that decision is fraught with uncertainty and legal risk, doctors in several states said, with many adding that they have already been forced to significantly change the care they provide to women whose pregnancy complications put them at high risk of impairment.
Last week, Texas Attorney General Ken Paxton sued the Biden administration over federal guidelines that require doctors to perform abortions, even in states with abortion bans, if they determine it is necessary to treat dangerous pregnancy complications.
Amid legal disputes, hospitals are grappling with where and how to draw the line. Some have brought in special committees of doctors and lawyers to decide when a pregnancy can be terminated prematurely. Others require multiple doctors to sign off on each such decision and document in detail why an abortion was necessary.
The result is delayed treatment and increased risk, doctors said.
“It’s like putting a lot of people on top of a skyscraper, pushing them to the edge and then catching them before they fall,” said Dr. Alireza A. Shamshirsaz, an obstetrician and fetal surgeon who practiced in Houston until last month. “This is a very dangerous way to practice. We all know some of them will die.
The impact in these cases is on women who want to have children only to encounter complications during pregnancy. The option of terminating a pregnancy has long been part of the standard care offered by doctors in situations where there is a risk of harm or even death to the mother.
The effect is most visible in Texas, which passed a law banning most abortions after six weeks of pregnancy last September — well before the bans that went into effect after the Supreme Court’s decision to overturn Roe v. Wade on June 24.
A new study of two Dallas County hospitals found that after the Texas law went into effect, pregnant women facing serious complications before fetal viability — mostly because their water broke prematurely — suffered because they weren’t allowed to terminate your pregnancy.
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Of the 28 women who met the study’s criteria, more than half had “significant” medical problems, including infections and bleeding, in the face of state-imposed treatment restrictions, the study found. One woman needed a hysterectomy. And the rate of maternal health problems was much higher than the rate in other states where patients were offered the option to terminate their pregnancies, according to the study, which has been accepted for publication in the American Journal of Obstetrics and Gynecology.
“You’ve almost doubled the complication rate for the mother,” said Dr. Judy Levison, an obstetrician-gynecologist in Houston, referring to the study, in which she was not involved. She added that all but one of the pregnancies ended in fetal death. “So why did they put them through this?” she said of the women.
Last week, the Texas Medical Association sent a letter to state regulators asking them to intervene after the association received complaints from doctors that hospitals were preventing them from performing abortions when it was medically necessary for women for fear of running afoul of the law , The Dallas Morning News reports.
In Missouri, the abortion ban went into effect in June with an exception for medical emergencies that require immediate abortions to avoid death or injury. The word “immediate” is being debated by hospital administrations across the state, with questions over whether it refers to imminent danger of death or an urgent threat to the woman’s health.
Some hospitals, such as in Texas, have considered internal review boards to approve medically necessary abortions to reduce their legal liability. Others require the signature of multiple doctors.
“The law does not require two doctors,” said Dr. David Eisenberg, who specializes in comprehensive family planning at Washington University in St. Louis. “But many institutions believe it is best for more than one physician to document the nature of the medical emergency and the need for abortion care.”
Care can vary from city to city and hospital to hospital, doctors said.
The uncertain legal landscape has made even medical associations across the country wary of providing guidance on what treatments the “mother’s life” exemptions provide.
“It’s unconventional for us to sit on the sidelines,” said Dave Dillon, a spokesman for the Missouri Hospital Association. Ultimately, he said, the meaning of the exception “will probably be decided through litigation.”
Until then, he said, hospitals will have to make decisions based on “whatever their individual pain threshold is.” For doctors, this means making decisions knowing that lawsuits or prosecutions may come later. In Texas, doctors accused of violating abortion laws face fines and an unlimited number of civil suits; when the trigger law goes into effect in the coming weeks, it could lead to felony charges.
“All the doctors are complaining, but no one wants to talk because of the possible consequences; we can be fired,” said Dr. Shamshirsaz, the Houston surgeon.
He described a colleague who had a patient with twins. At 15 weeks, she gave birth to one stillborn child and asked to abort the other because of the risk of infection. Her case was presented to the hospital’s committee – what Dr Shamshirsaz called a “termination committee” – but the abortion was refused because the fetus still had a heartbeat.
“We sent the patient home against her will,” he said.
The woman returned to the hospital about two weeks later feeling ill. Her pregnancy was terminated out of concern for her health, Dr. Shamshirsaz said, but she had to be admitted to the intensive care unit for sepsis and acute kidney injury, both life-threatening conditions.
“We have to wait until the mother comes with these symptoms,” he said.
Every pregnancy is associated with risks to the health and life of the mother. The researchers found that the risk of complications and death were higher in pregnancy than in abortion. Determining whether a woman’s life is at risk at any given moment has always been a gray area, changing as medicine advances and as social mores change around acceptance of abortion.
While abortion was once mostly legal, by 1900 every state outlawed abortion at all stages of pregnancy, with the only exception if the mother’s life was in danger, said Jennifer Holland, a historian at the University of Oklahoma. Some of these laws, such as the 1925 Texas law, have recently been reinstated by Roe’s overturn.
The reality during this period was that abortion decisions were left to the family physician.
There was some “flexibility” about what constituted a threat to the mother, Dr. Holland said, “especially if you had access to a sympathetic family doctor.”
After Roe was decided in 1973, states began passing legislation that banned abortion after fetal viability but made exceptions for “life and health,” said Elizabeth Nash, a state policy analyst at the Guttmacher Institute, which supports abortion rights. . Over the past decade, as state legislatures have steadily passed hundreds of abortion restrictions, that language has narrowed considerably, but it has rarely been challenged in court.
Now with the new restrictions on abortion, women — and their doctors — have found themselves in uncertain legal territory.
An intensive care nurse in Texas, who spoke on the condition of anonymity to discuss her experience, became pregnant just after the restrictive abortion law went into effect last year. It was a happy occasion, but then her water broke at 19 weeks. She went to the hospital emergency room, terrified. She already knew her baby would probably die. But as a nurse, she also knew her own condition was precarious. She wanted to abort the fetus but was told all she could do was wait.
“I argued with the doctors for a while, but none of them helped me until I was actively sick,” she said. “I was just amazed. I was so confused. Especially as a nurse, no one comes to the emergency room and we wait to see how sick they get.”
She and her husband flew to Colorado for an abortion. On the day of the procedure, she had a fever of 101 degrees. “I started getting sick that day,” she said.
Miscarriages occur in 15 percent of all pregnancies and may require a procedure — also used in some abortions — to remove the fetus. Preeclampsia, or pregnancy-induced high blood pressure, occurs in 5 to 8 percent of all pregnancies and can be fatal. There is a 2 percent chance…
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