Women face risks as doctors battle abortion medical exceptions

HOUSTON – Dr. Amanda Horton, an obstetrician who specializes in high-risk pregnancies, was counseling pregnant patients at a small hospital in rural Texas last month when the woman was admitted in critical condition: she was only 17 weeks pregnant and her water broke.

The fetus would not be viable outside the uterus, and without the protection of the amniotic sac, the woman was vulnerable to infection that could threaten her life. In Colorado or Illinois, it says where Dr. Horton also practices, and where abortion is generally legal, she had the option of terminating the pregnancy.

Texas prohibits most abortions unless the woman’s life is in danger. But the patient’s life was not in immediate danger in this case—yet. The hospital sent her home to wait for signs of infection or labor. Horton said.

Worried and with nowhere to turn, the woman instead traveled hundreds of miles to New Mexico to have an abortion.

“She ended up taking matters into her own hands,” the doctor said. Horton said. Her patient, she said, made a choice “for her life.”

In each of the 13 states where abortion is illegal, some exceptions to save the mother’s life or to eliminate the serious risk of “substantial and irreversible impairment of essential bodily functions”.

But making such a decision has become 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 harm.

Last week, Texas Attorney General Ken Paxton, sued the Biden administration against federal regulations that required doctors to perform abortions, even in states where abortion is illegal, if they determined it was necessary to treat dangerous complications of pregnancy.

Amid legal wrangling, hospitals struggled with where and how to draw the line. Some brought in special teams of doctors and lawyers to decide when the pregnancy could be terminated early. Others required multiple doctors to sign any such decision and document in detail why the abortion was necessary.

According to doctors, as a result, treatment is delayed and the risk increases.

“It’s like you take a lot of people to the top of a tall building and push them to the edge and then catch them before they fall,” the doctor said. Alireza A. Shamshirsaz, an obstetrician and fetal surgeon who practiced in Houston until last month. “It’s a very dangerous way to train. We all know that some of them will die.”

The impact in these cases is on women who want to have children, only to face 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 has been most pronounced in Texas, where a law was passed last September banning most abortions after six weeks of pregnancy, much earlier than the bans that took effect after the Supreme Court’s decision to overturn the ruling against Rowe. Wade June 24th.

A new study from two Dallas County hospitals found that after the Texas law went into effect, pregnant women faced serious complications before the fetus became viable – mostly due to premature water breakage – suffered because they were not allowed to terminate the pregnancy.

Of the 28 women who met study criteria, more than half experienced “significant” medical problems, including infections and bleeding, while government-imposed restrictions on treatment, the study found. One woman required a hysterectomy. And the rate of maternal health problems was much higher than the rate in other states where patients were offered the option of terminating pregnancies, according to a study that was accepted for publication in the American Journal of Obstetrics and Gynecology.

“You almost doubled the maternal complication rate,” the doctor said. Judy Levison, an obstetrician in Houston, cites a study she was not part of. She added that all but one of the pregnancies ended in fetal death. “So why did they put them through this?” she said about 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 women from having abortions when medically necessary for fear of breaking the law. This was reported by the Dallas Morning News..

Missouri bans abortion It entered into force in June from exception for medical emergencies requiring immediate abortions to avoid death or injury. Hospital officials across the state are scrutinizing the word “immediately” with questions about whether it refers to an imminent danger of death or an immediate threat to a woman’s health.

Some hospitals, like those in Texas, have considered having internal review boards approve medically necessary abortions to reduce their legal liability. Others require multiple physicians to sign up.

“The law does not require two doctors,” the doctor said. David Eisenberg, Comprehensive Family Planning Specialist at Washington University in St. Louis. Louis. “But many institutions feel it’s best if multiple doctors document the nature of the medical emergency and the need for an abortion.”

According to doctors, care may vary by city and hospital.

The uncertain legal situation has led even the state’s medical associations to be wary of guidance on what treatment the “mother’s life” exemptions provide.

“It’s not traditional 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 “is likely to be decided by the courts.”

Until then, he says, hospitals will have to make decisions based on “whatever their pain threshold is on a case-by-case basis.” For physicians, this means making decisions knowing that lawsuits or prosecutions may come later. In Texas, doctors accused of violating abortion laws face fines and unlimited civil lawsuits; when the trigger law goes into effect in the coming weeks, it could lead to a criminal charge.

“All doctors complain, but no one wants to speak out because of the possible consequences; we can be fired,” the doctor said. Shamshirsaz, surgeon from Houston.

He described a colleague who had a patient with twins. At 15 weeks she gave birth to one stillborn and asked for another abortion due to the risk of infection. Her case was referred to the hospital committee – that Dr. Shamshirsaz called a “terminal board” – 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 unwell. 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 failure, both life-threatening conditions.

“We have to wait until mom comes back with these symptoms,” he said.

All pregnancies involve risks to the health and life of the mother. The researchers found that the risk of complications and death higher during pregnancy than during abortion. Determining whether a woman’s life is in danger at any given moment has always been a gray area, changing as medicine advances and social mores change around the acceptance of abortion.

Although abortion was once largely legal, by 1900 all states had banned abortion at all stages of pregnancy except when the mother’s life was in danger, says Jennifer Holland, a historian at the University of Oklahoma. Some of these laws, such as the 1925 law in Texas, have recently been re-instated after Roe was overthrown.

The reality of that period was that decisions about abortions were left to the family doctor.

There was a certain “flexibility” about what was a threat to the mother, says the doctor. Holland said, “Especially if you had access to a sympathetic family doctor.”

After Roe’s decision in 1973, states began passing laws banning abortion after a viable fetus but making exceptions for “life and health,” said Elizabeth Nash, a public policy analyst at the Guttmacher Institute who supports abortion rights. Above last decadeAs state legislatures have steadily passed hundreds of restrictions on abortion, this language has narrowed considerably, but has rarely been challenged in the courts.

Now, with new restrictions on abortion, women and their doctors are in undefined legal territory.

A Texas intensive care nurse who did not want to be named to talk about her experience became pregnant immediately after a restrictive abortion law went into effect last year. It was a lucky break, but then her water broke at 19 weeks. She went to the emergency room at the hospital terrified. She already knew that her child would probably die. But as a nurse, she also knew that her own condition was precarious. She wanted to have an abortion, but she was told that all she had to do was wait.

“For a while I fought with the doctors, but none of them helped me until I got sick,” she said. “I was just stunned. I was so confused. Especially since as a nurse, no one comes to the emergency room and we wait to see how sick they can get.”

She and her husband flew to Colorado to have an abortion. On the day of the procedure, she had a temperature 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% of all pregnancies and can be fatal. There is a 2 percent chance that the pregnancy may be ectopic, meaning that the fertilized egg implants outside the uterus, making the pregnancy unviable and seriously endangering the mother’s life.

But in the new legal landscape, no one is sure how severe these conditions must be before they justify legal abortion.

“That’s all there is to it,” the doctor said. Charles Brown, District Chairman of the American College of Obstetricians and Gynecologists in Texas. “What high percentage must be for everyone to agree that this woman’s life is in danger?”

After Abortion ban in Oklahoma entered into force in May, Dr. Christine Bourne received a call from a patient who had an ectopic pregnancy that her obstetrician refused to treat.

Dr. Bourne is the medical director of two abortion clinics, one in Oklahoma City and one just across the state line in Wichita, Kansas, where abortions are performed. still legal. According to her, after consulting with the lawyers of the clinics, the woman was sent to their clinic in Wichita. By that time, she already had stomach pains and bleeding and had to be transferred to the hospital for treatment; where the doctors terminated the pregnancy.

“The people we see are much sicker than before,” the doctor said. Born said. “We see the consequences of a failed system. Pregnancy is the place where all failed systems come together.”