Doctors weigh odds on abortion exceptions
Hesitation risky for pregnant women with complications
HOUSTON — Dr. Amanda Horton, an obstetrician who specializes in high-risk pregnancies, had been counseling pregnant patients at a small hospital in rural Texas last month when a woman arrived in crisis: It was only 17 weeks into her pregnancy, 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 an infection that could threaten her life. In Colorado or Illinois, states where Horton also practices and where abortion is generally legal, there would have been an option to end her pregnancy.
Texas has a ban on most abortions, providing an exception when a woman’s life is threatened. But the patient’s life in this case was not in immediate danger — yet. The hospital sent her home to wait for signs of infection or labor, Horton said.
Worried and with nowhere else to turn, the woman instead traveled hundreds of miles to New Mexico for an abortion.
Her patient, Horton said, made a choice “for her life.”
Each of the 13 states with bans on abortions allows for some exemption to save the life of the woman or to address a serious risk of “substantial and irreversible impairment of a major bodily function.”
But making that determination has become fraught with uncertainty and legal risk, doctors in several states said, with many adding that they have already been forced to significantly alter the care they provide to women whose pregnancy complications put them at high risk of harm.
Last week, Texas Attorney General Ken Paxton sued the Biden administration over federal guidelines that required doctors to perform an abortion, even in states with abortion bans, if they determined it was necessary to treat dangerous pregnancy complications.
Amid the legal wrangling, hospitals have struggled with where and how to draw the line. Some have enlisted special panels of doctors and lawyers to decide when a pregnancy can be prematurely ended. Others have required multiple doctors to sign off on any such decision and document in detail why an abortion was necessary.
The result has delayed treatment and heightened risk, doctors said.
“It’s like you bring lots of people to the top of a high-rise and push them to the edge and then catch them before they fall,” said Dr. Alireza Shamshirsaz, an obstetrician and fetal surgeon who practiced in
Houston until last month. “It’s a very dangerous way of practicing. All of us 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 to terminate the 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 has been most visible in Texas, which passed a law prohibiting most abortions after six weeks of pregnancy last September.
A new study of two hospitals in Dallas County 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 were not allowed to end their pregnancies.
Out of 28 women who met the criteria for the study, more than half experienced “significant” medical problems, including infections and hemorrhaging, in the face of state-mandated limits on treatment, the study found. One woman required a hysterectomy. And the rate of maternal health problems was far higher than the rate in other states where patients were offered the option to end their pregnancies, according to the study.
“You nearly doubled the complication rate for the mother,” said Dr. Judy Levison, a Houston obstetrician, referring to the study, which she was not involved in. She added that all but one of the pregnancies ended with the death of the fetus.
“So why did they put them through that?” she said of the women.
This month, the Texas Medical Association sent a letter to state regulators asking them to step in after the association received
complaints from doctors that hospitals were preventing them from providing abortions when medically necessary to women because of fear of running afoul of the law, The Dallas Morning News reported.
In Missouri, an abortion ban went into effect in June with an exception for medical emergencies that required immediate abortions to avoid death or injury. The word “immediate” is being pored over by hospital administrations across the state, with questions about whether it refers to an imminent danger of death or an urgent threat to a woman’s health.
Some hospitals, as in Texas, have considered internal review panels to approve medically necessary abortions to reduce their legal liability. Others are requiring that multiple doctors sign off.
“All the physicians are complaining, but no one wants to speak up because of the possible consequences; we can be fired,” said Shamshirsaz, the Houston surgeon.
He described a colleague who had a patient with twins. At 15 weeks, she delivered one stillborn and asked to abort the other because of the risk of infection. Her case went before the hospital’s committee, but the abortion was denied 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 sick. Her pregnancy was terminated out of concern for her health, 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 mom comes with those symptoms,” he said.
All pregnancies come with risks to the health and life of the woman. Researchers have found the risk of complications and death are higher for pregnancy than for abortion.
Miscarriages occur in 15% 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%-8% of all pregnancies and can be deadly. There is a 2% chance a pregnancy can be ectopic, meaning the fertilized egg has implanted outside of the uterus, making the pregnancy nonviable and threatening the life of the woman.
But in the new legal landscape, no one is certain how serious those conditions must get before they justify an abortion under the law.
“It’s all odds,” said Dr. Charles Brown, the Texas district chair of the American College of Obstetricians and Gynecologists. “How high a percentage does it need to take before you get everyone to agree this woman’s life is in danger?”