Abortion Access and Medically Complex Pregnancies Before and After Texas Senate Bill 8

Abstract

Objective:

To evaluate how Texas health care professionals who care for patients experiencing medically complex pregnancies navigate abortion restrictions.

Methods:

We conducted qualitative in-depth interviews with health care professionals across Texas who cared for patients with life-limiting fetal diagnoses or who had existing or developed health conditions that adversely affected pregnancy. We conducted the first round of interviews March-June 2021, and the second round January-May 2022 after the implementation of Texas Senate Bill 8 (SB8), which prohibited most abortions after detection of embryonic cardiac activity. We used inductive and deductive qualitative analysis to identify themes and changes in practice after implementation of SB8.

Results:

We conducted a total of 50 interviews: 25 before SB8 and 25 after the law’s implementation. We interviewed 21 maternal fetal medicine (MFM) specialists, 19 obstetrician-gynecologists, eight physicians whose primary practice is provision of abortion care, and two genetic counselors. Participants reported presenting their patients with information about health risks and outcomes of continued pregnancy in each policy period; however, counseling on these options was curtailed after SB8. Even in cases in which a patient’s health, and, in some cases life, would be compromised, narrow criteria for abortions at hospitals limited care prior to SB8, and criteria often became more stringent after SB8. Administrative approval processes and referrals for abortion delayed care and endangered patients’ health, which worsened after in-state options were eliminated following SB8. Participants noted that patients with more limited resources, who were unable to travel out of state, often had to continue pregnancies, further increasing their risk of morbidity.

Conclusion:

Texas health care professionals’ abilities to provide evidence-based abortion care to patients with medically complex pregnancies were constrained by institutional policies, and care options narrowed further after implementation of SB8. Abortion restrictions limit shared decision making, compromise patient care, and put pregnant people’s health at risk.

Précis:

Restrictive abortion policies did not align with health care professionals’ more nuanced views of options for care and patient autonomy.

Introduction

Even before the United States Supreme Court’s June 2022 decision overturning Roe v. Wade, abortion care was highly regulated by state laws. These laws often arbitrarily distinguish which abortions are permissible based on whether or not they are considered ‘medically indicated.’^1–3 Organizational and individual interpretations complicate these distinctions, resulting in written and unwritten policies that often place stricter limitations on abortion provision than those codified in state laws.^4–5 Together these restrictions substantially decrease health care professionals’ autonomy about the care they are allowed to provide patients, including those who experience complications during pregnancy.⁴

Until September 2021, Texas law permitted abortions up to 22 weeks of gestation for any reason, but prohibited both Medicaid and private health insurance plans from covering abortion care unless it was ‘medically indicated.’⁶ Therefore, pregnant patients who experienced complications and could not be seen at an ambulatory facility had more limited options because many hospitals, especially those with certain religious affiliations and in designated “hospital districts,” restrict abortion provision with few exceptions.^7–11 On September 1, 2021, implementation of Texas Senate Bill 8 (SB8) further narrowed options for care by prohibiting abortion after detection of embryonic cardiac activity, except for physician-documented medical emergencies.¹² Studies on SB8 have largely focused on trends in abortion volume and gestational duration.^13–17 Provision of a prohibited abortion, or aiding or abetting a prohibited abortion, could result in civil litigation and penalties. In this qualitative study, we explore how Texas health care professionals cared for patients experiencing medically complex pregnancies before SB8, and how implementation of the law changed their clinical practice.

Methods

We recruited health care professionals from the major metropolitan cities and regions of Texas, where many patients with medically complex pregnancies are referred and Texas’ abortion facilities were located. Health care professionals were eligible if they provided care to medically complex pregnant patients in Texas. We defined “medically complex pregnancies” as those in which a person’s medical condition increases maternal health risks associated with continuing their pregnancy or a pregnant person receives a fetal diagnosis that could complicate birth or is associated with greater neonatal morbidity and mortality [Box 1].

Box 1. Defining medically complex conditions that may necessitate abortion, examples from interviews with Texas health care professionals.

Maternal health conditions: cardiac disease or cardiomyopathy, diabetes, renal diseases, lupus and auto-immune disorders, neurological issues, placental abnormalities, seizure disorders, psychiatric disorders, cancers, anemia, ruptured membranes, mental health disorders, and substance use

Fetal health conditions: trisomy disorders, monosomy X, lethal skeletal dysplasia, fetal edemas, anencephaly, and other genetic, structural, and developmental issues

Between March and July 2021, we used snowball sampling - an established recruitment method for sensitive research topics¹⁸ - to recruit general obstetrician-gynecologists and maternal-fetal medicine (MFM) specialists practicing in academic and non-academic health care settings, as well as health care professionals involved in ambulatory abortion care (including counseling), to participate in the study. Starting with referrals from our professional contacts, interviewers asked participants to refer them to at least one other potential interviewee. Interviewers sent emails describing the research study to potential participants and followed up by phone and email to answer questions and schedule the interview.

Between January and May 2022, we added a second round of interviews to assess how SB8 changed clinical care for patients with medically complex pregnancies. We invited health care professionals who participated in the initial interviews and used snowball sampling to recruit other participants. We also included genetic counselors, to capture concerns about SB8’s aiding and abetting provision related to their counseling and referral practices. Because most medically complex conditions are recognized after development of embryonic cardiac activity, we did not interview health care professionals who primarily worked in ambulatory abortion facilities after SB8. In both rounds, we continued interviewing participants until we reached concept saturation.

We developed semi-structured interview guides based on previous research,⁴ the clinical and policy expertise of the study team, and conversations with community partners. The pre-SB8 interview guide explored conditions considered as allowable indications for medically indicated abortions, counseling for patients with medical complexities about potential risks and management options, and barriers to abortion provision in hospital and outpatient settings, including institutional and insurance policies. The post-SB8 interview guide was shorter and focused on how practice changed after implementation of the law, including changes in criteria for hospital-based abortion care, counseling and referrals.

Eligible participants provided verbal consent. Interviews took place over video conference or telephone and were recorded with participants’ permission. Participants received a $50 gift card for the 60-minute, pre-SB8 interviews and a $30 gift card for the 30-minute, post-SB8 interviews. Interviewers wrote summaries after each interview. The University of Texas at Austin Institutional Review Board approved the study protocol.

Four members of the study team read a sample of de-identified transcripts and post-interview summaries from the pre-SB8 interviews to develop a set of codes and code definitions (i.e., codebook) to categorize themes or concepts that reoccurred across the interviews. The codebook included codes based on the interview guide questions, referred to as deductive qualitative analysis, and new ideas and themes that emerged in the interviews, referred to as inductive analysis. Study team members independently coded two transcripts using this preliminary codebook and met to further refine the list of codes and definitions. For the remaining transcripts, they used a dual coding process, in which two people independently coded each transcript to ensure a consistent and thorough application of the codes to the interview data. At regular meetings, the study team members discussed coding discrepancies and resolved differences through consensus.

For the post-SB8 interviews, the study team added codes to capture changes related to the law and followed the same coding approach. The coders used NVivo 14 (QSR International, Burlington, MA) for analysis and data management.

Results

We conducted 50 interviews: 25 before SB8 and 25 after the law’s implementation (Figure 1, Table 1). Six physicians participated in both pre- and post-SB8 interviews. The sample included 21 MFM specialists, 19 obstetrician-gynecologists, including generalists and complex family planning specialists, eight health care professionals who primarily worked in ambulatory abortion facilities with training in family medicine, internal medicine, obstetrics and gynecology, or nursing, and two genetic counselors. Primary themes identified in the interviews (Box 2) were: changes in counseling practices for medically complex patients before and after SB8; variation in the operationalization of medically indicated abortion care; and how connecting patients to other sources of care exacerbated health conditions and inequities.

Figure 1.

Flow diagram of interview participant recruitment and enrollment in round 1 and round 2, before and after implementation of Texas Senate Bill 8, respectively.

Table 1.

Characteristics of health care professionals caring for medically complex pregnant patients in Texas (n=50)

	Interviews before SB8 (Mar-Jul 2021)	Interviews after SB8 (Jan-May 2022)	Total
	N=25	N=25	N=50 (%)
Health care Professional Type
Obstetrician-Gynecologist	9	10	19 (38.0)
Maternal-Fetal Medicine Specialist	8	13	21 (42.0)
Health care Professional, Abortion Facility	8	0	8 (16.0)
Genetic Counselor	0	2	2 (4.0)
Practice Type*
Academic Institution	10	23	33 (66.0)
Abortion Facility	8	0	8 (16.0)
Other community hospital or Private OBGyn practice	7	2	11 (22.0)
Religiously Affiliated Institution	5	9	14 (28.0)
Median number of years practicing in Texas (range)	8 (1–51)	7 (1–32)	8 (1–51)

^*Health care professionals often had multiple appointments at different types of facilities, which are reflected here.

Box 2. Primary Themes From Health Care Professionals’ Experiences Caring for Medically Complex Patients Before and After Texas Senate Bill 8 (SB8).

Theme: Counseling patients with medically complex pregnancies

Pre-SB8 (Mar-Jul 2021)

Once the high-risk doctors confirm that there is an anomaly, I’ll call the patient and review the findings. What I tell them is, they are given the option to either continue with the pregnancy with the expectations that the baby will not do very well, or they have the option to terminate pregnancy with a provider that will provide that kind of care. And I inform them that I am not one of the physicians that do that. But I let them know that that is an option available to them. And then being in Texas I try to also inform them that I’m not pressuring them to make a decision quickly, but there are time restraints in Texas. I make that clear to them as well.

-Ob-gyn, private hospital

Post-SB8 (Jan-May 2022)

I tell them straight up, “In the state of Texas, we cannot legally do this.” And then at our institution, I can’t even document that I had the conversation, but I tell [the patients], “These are [the] options. These are websites where you can find options.” We’re not allowed to pass out a handout or anything. So in my prior institution, our clinic had a list of places, and we would just provide them the list and all the contacts. Here, we’re not allowed to do that. So it’s more back alley - being, “These are your options if you were to go somewhere - for you to find that.”

-Maternal–fetal medicine specialist, academic institution

Pre-SB8 (Mar-Jul 2021)

I am not restricted in my ability in a generalist OBGYN practice to do full options counseling, including discussion of different methods of termination. So, I believe that that is a requirement of me as a OBGYN to be able to meet the patient where she is and provide information that is factual and non-biased and non-directional and answer the question she has, which often gets into the details of what can I expect with the various approaches that she might choose.

-Ob-gyn, academic institution

Post-SB8 (Jan-May 2022)

We talk to them about the options of if you continue the pregnancy, here’s how we will take care of you and how we will plan for the infant and the pediatric specialist talks a little bit about what to expect with this kind of fetus.

If there’s a circumstance in which that particular pregnancy poses some additional health risks to the mother, we talk about that. Normally, we would say, ‘some couples in this circumstance choose to terminate pregnancy, here’s how that would look at this stage of pregnancy, here are some options.’ And my role is to help that mother and or couple figure out the best solution for them. What the SB8 has done is curtail how I am allowed to be supportive and non-directive in that counseling.

-Ob-gyn, academic institution

Theme: Operationalizing medically indicated abortions

Pre-SB8 (Mar-Jul 2021)

I do medically indicated abortion care. In my organization, we are not allowed to perform elective abortion, or abortion upon request. Sometimes we’re required to go through a [ethics committee], but if it’s a pregnancy loss, then I don’t require any approval to perform a medical or surgical completion of abortion.

-Ob-gyn, academic institution

Post-SB8 (Jan-May 2022)

For the patients that we do have, who maybe come in as inevitable ABs, we sit and we wait until they get infected or have some other reason that will allow us to intervene. So, it definitely, like knowing that the inevitable conclusion to this story will be a pregnancy loss, it’s hard that you have to then wait for them to then develop a complication like infection in order to do anything.

-Ob-gyn, academic institution

Pre-SB8 (Mar-Jul 2021)

For our hospital setting, the indications that we have are either threat to maternal life or a fetal condition that is non compatible with life. The procedure involves-- we have to have very clear documentation by two physicians who are caring for the patient that the condition is life threatening and that continuing the pregnancy would increase that risk of threat to the maternal life. Then with that documentation then we just have to get approval from our hospital chief after that. The process usually takes, I would say, probably about an hour to two hours to coordinate all of the notes and emails and things like that… I think the hardest thing in all of these cases is that every hospital has a very different policy. And for this patient, she had a condition in which she needed subspecialty care that only exists at two hospitals. It’s really a matter of which place do you show up.

-Maternal–fetal medicine specialist, academic institution

Post-SB8 (Jan-May 2022)

I got pulled aside in the corner of labor and delivery, and ended up saying I would assume care of this patient. And this was from someone who normally would’ve just augmented previable premature rupture of membranes like it was no big deal, really, like it was a standard part of practice. But now [my colleague] was scared, and he transferred care to me, and we went and spoke to the patient together and saw the patient, but he wouldn’t actually document officially transferring care. So, the only documentation was mine as the abortion clinician, and then she got augmented medically instead of getting the dilation and evacuation that she wanted. And I had a very awkward conversation with her where all I could say was that I thought it would be fastest and safest for her to induce her labor. And I didn’t feel like it was appropriate for me to explicitly tell her that I couldn’t offer her a dilation and evacuation because the hospital wouldn’t do it. I didn’t want to put that on her, but I felt in some ways like I wasn’t being totally transparent.

-Ob-gyn, academic institution

Theme: Connecting patients to other sources of care exacerbated health conditions and inequities

Pre-SB8 (Mar-Jul 2021)

I think the one thing that would have allowed this to all happen earlier is if her insurance would have acknowledged the fact that it was a lethal anomaly and that that would be a reason to allow her to end her pregnancy earlier than having to wait until she is completely symptomatic and now her life is at risk, whereas before it wasn’t at risk. It’s almost like I felt forced to make her get sick in order to be able to do something because they couldn’t afford to pay for the associated or expected costs, whether it be in our hospital system or going to New Mexico as an outpatient.

-Maternal–fetal medicine specialist, academic institution

Post-SB8 (Jan-May 2022)

You really can barely imagine what it’s like for a woman or a couple to be faced with a devastating diagnosis for the fetus that they’ve just learned about maybe days or weeks before. They have grappled with this terrible, heartbreaking decision. And, then they’re told by the doctor, “Well, good luck to you. Jump on Google and see where you can find a place to get your termination.” It’s just horrifying.

- Maternal–fetal medicine specialist, academic institution

Pre-SB8 (Mar-Jul 2021)

After 22 weeks, I’ve heard [the cost of abortion] runs above $2,000, so most patients don’t have the money for that. Not only is it $2,000 for the procedure per se, but also the travel expenses, the lodging, everything. Pretty significant bill. Most patients opt not to proceed, but I can’t really tell you what percent is doing it or not. There’s usually this sense of hopelessness. It’s clear to me that they are disappointed that this is the only option. That it’s an expensive option, that they have to travel for this, it’s a huge burden for them.

- Maternal–fetal medicine, academic institution

Post-SB8 (Jan-May 2022)

Over 40% of my practice is women who have limited means. Now, the Senate Bill 8, it is a pro-life bill. It’s not a pro-family bill. There’s no mechanism to help these women that are going to continue [their pregnancies]. They’re not insured. They’re stuck. It doesn’t matter. It has a significant impact. I’ve had more cases recently of anencephaly -- that are forced to either decide to continue, which has its own set of risks, in many respects, or to leave the state and try to find means to get there.

- Maternal–fetal medicine, academic institution

Before SB8, nearly all participants talked with patients who had a suspected or diagnosed medical complication about the possible risk of further impairment or death. Although some participants felt maternal health conditions, such as certain cardiac conditions, were easier to discuss because of clearer evidence about the risks for adverse outcomes, many stressed the importance of recognizing the nuanced array of maternal, fetal, social, and environmental conditions that could make a pregnancy medically complex. Participants further noted that they had an ethical responsibility to comprehensively discuss all management options, including abortion, with patients in their care. This often included referring patients to another specialist for confirmation or additional counseling and allowing the patient to take the time they needed to make a decision - while remaining cognizant of Texas’ 22-week gestational limit for abortion. Despite variation in when and how participants advised patients about abortion, they noted that pregnancy continuation or abortion was the patient’s decision. An obstetrician-gynecologist offered a perspective shared by many, saying: “It’s hard when you don’t agree with the patient. It’s hard to separate yourself and say, ‘You know what, this is patient autonomy. They get to choose.’”

After SB8, options counseling became more complicated. Most health care professionals did not change how they counseled patients about potential risks, but the law adversely affected the options they could offer. Participants’ descriptions of their institutional guidance about SB8’s aiding and abetting provision, along with their own interpretations and concerns, led to greater variation in counseling and referrals. Some indicated that they were restricted from mentioning abortion as an option, while others informed patients about abortion with the caveat that it “unfortunately [was] no longer an option in the state of Texas.” As one MFM-specialist described: “My counseling has become very limited. We received guidance from our overarching medical organization about what we can tell patients and what we cannot say. I say there is the option of ending the pregnancy. It’s not an option available to you in Texas, and I can’t discuss it further.”

Health care professionals’ assessment of medically complex pregnancies for which abortion care could lessen the risk of maternal harm were often more expansive than what their institution, hospital system, or the patient’s insurance allowed before SB8. Thus, not all patients qualified for hospital-based care, even if their health was at risk of deteriorating and they desired an abortion. Before SB8, the majority of participants’ institutions allowed abortions for life-limiting fetal diagnoses, whereas abortions for other conditions, such as Monosomy X, were less often considered ‘medically indicated’ and were frequently not covered under a patient’s insurance. However, even within the same institution, there was wide variability in the range of fetal diagnoses that would be considered medically indicated or life-limiting. An obstetrician-gynecologist described discussions about a patient who received a fetal diagnosis of Monosomy X with fetal edema and cardiac anomalies that would eventually result in demise, saying: “Some people see it as non-elective and some people see it as elective.”

Prior to SB8, participants also reported that they were required to go through a variety of administrative procedures before proceeding with an abortion. Several participants’ institutions offered a streamlined approval process, but more described having to navigate approvals that required obtaining signatures from multiple consulting physicians or administrators or review by ethics committees. Participants at institutions with more cumbersome approval processes often noted that this created delays that risked compromising patients’ health. Texas’ pre-SB8 gestational limit was also a concern. An obstetrician gynecologist said: “Time is of the essence…You only have so much time to get the ethics committee together, get them to approve it, schedule her, and get it all done before the gestational limit.” Even when a patient met hospital criteria and a health care professional had obtained proper approvals, participants were sometimes unable to provide an abortion because of insurance denials or lack of support staff willing to participate in the care. An MFM-specialist recalled their Chief Medical Officer denying an abortion to a patient with severe cardiovascular disease when operating room staff were uncomfortable assisting with an abortion.

After SB8, participants stated that it was more difficult to provide hospital-based abortions for patients who might have been able to receive care previously. A life-limiting fetal diagnosis was no longer considered a medical indication at participants’ institutions. One MFM-specialist relayed that for “anencephaly, acrania, bilateral renal agenesis, or trisomy 18 or 13 - we haven’t been able to offer termination, whereas in the past, before 22 weeks, we would’ve been able to.” Participants also were no longer able to offer reductions for multifetal gestations or twin-to-twin transfusion syndrome after SB8. One MFM-specialist described the case of a patient who originally presented at another hospital in Texas:

They watched her for 24–48 hours. She chose to leave [that hospital], then ruptured from Twin A, then came directly to [our] hospital. Twin A was dead. [I] delivered that one, but then Twin B is still alive. Never mind that the placenta of Twin A is still in situ, essentially a wick for bacteria and infection - I’m forced to watch her for the next 24 hours until she gets febrile to 39 degrees, tachycardic to the 120s, literally septic before I can start the process of induction.

Maternal health conditions like cancer, cardiac disease, or kidney failure similarly required additional permissions or review by legal counsel to be considered a medical exemption under SB8. Many participants noted that they had to wait for a patients’ health to decline before they could receive further care, including an MFM-specialist who stated that the “red tape” and fear of violating SB8 negatively impacted standard of care for patients who had life-threatening medical indications. Participants frequently cited their inability to provide evidence-based treatment for previable premature rupture of membranes (PPROM) after SB8. Although a few health care professionals mentioned having to delay intervention for PPROM prior to SB8, most health care professionals after SB8 reported they had to delay treatment until patients developed significant complications that met the definition of a medical emergency, such as sepsis. In one such case, a participant was advised to try multiple interventions to avoid a procedural abortion for a patient who presented in the second trimester with bleeding and PPROM:

Even with her septic, it was an attempt at an induction first, which we know is substandard care. After essentially failing her induction, she’s having fevers in the 103–104 [range]. I called the MFM staff that was on, and that initial recommendation was still not termination. It was hysterotomy. I’ve never done that and that morbidity is going to be insane. Then, I had to call the division director, and their recommendation was actually a high dose oxytocin induction and to avoid a termination.

The patient eventually expelled the pregnancy, but the delays in care resulted in the patient needing a dilation and curettage, losing three liters of blood, and ultimately being intubated in the intensive care unit.

Prior to SB8, participants explained that they would often refer patients who were unable to receive care at their facility to specialists, area hospitals with different policies, or ambulatory abortion facilities in Texas. When doing so, they frequently leveraged personal relationships with colleagues to ensure patients received needed services. However, some participants noted that these referrals, which could involve additional testing and counseling, increased patients’ costs and contributed to delays in care. A patient’s health could also deteriorate during the time that elapsed between multiple consultations. An ambulatory abortion health care professional described deliberations before SB8 for a patient who had been repeatedly hospitalized for severe hyperemesis gravidarum and severe diabetic gastroparesis:

There was a discussion of ‘Is she sick enough to qualify as this is a severe threat to her life? And if not, could she have that termination done in the outpatient clinic?’ …There was a lot of discussion about what was safe and what line do you stretch to get somebody access where she wasn’t able to stay out of the hospital longer than a couple of days at a time.

The patient was able to get an abortion only after her condition posed a severe threat to her life and supportive colleagues advocated for hospital-based care.

For patients who had passed Texas’ 22-week gestational limit before SB8, out-of-state abortion care was the only option, but participants recognized that not all patients could travel, especially those who had limited economic resources or who were unable to pass through interior immigration checkpoints. These compounding barriers decreased abortion access for people already in marginalized circumstances. An MFM-specialist who frequently saw people with immigration concerns said of the situation prior to SB8: “If a patient has a non-lethal fetal anomaly and she’s past 18-weeks [the limit at the local abortion facility], we cannot take care of her, and many patients can’t leave [this area] because of those checkpoints.” As a result, they likely had to continue their pregnancy, often increasing their risk of medical complications.

Difficulties in patient referrals worsened after SB8. Participants could no longer refer patients past five or six weeks of gestation to ambulatory abortion care in Texas. However, not all participants felt that they were allowed to offer specific information about out-of-state clinics or coordinate care with outside health care professionals. An obstetrician-generalist described having seen three patients with Monosomy X who they were unable to refer after SB8, saying: “It was a very bad prognosis for the fetus, and they strongly desired termination. We couldn’t really even offer any guidance of where to go anymore, which really put a strain on those patients.” Conversely, several MFM-specialists and the genetic counselors felt obligated to help patients find appropriate care and discussed calling multiple out-of-state facilities on behalf of their patients to do so.

Several participants also anticipated a growing need for neonatal palliative care for patients who continue their pregnancies after SB8. An MFM-specialist reported that one of their patients had received a fetal diagnosis of anencephaly and was denied an abortion because the hospital did not view her condition as a medical emergency; the patient was subsequently referred to a neonatologist to plan for comfort care only after delivery, “because [abortion] was no longer realistically available to them.” Participants commented on the incredible emotional and financial toll they observed on patients and their families. An MFM-specialist cited additional challenges of counseling people in the face of increasingly limited options after SB8, saying:

I sometimes think I spend more time as a psychiatrist than I do as an [obstetrician-gynecologist]. The toll that that takes on the patient, the toll it takes on their families, and I’ve seen countless relationships that have been destroyed by the stress and anxiety and of having to keep a pregnancy when they would not have chosen to do so under any other circumstance.

Discussion

Before implementation of SB8, abortion restrictions – including those at the state, hospital and insurance levels – limited the care that could be provided in Texas to patients with medically complex pregnancies. Health care professionals we interviewed could offer patients the information needed to make a decision about their pregnancy, but frequently felt they could not help patients carry out their abortion decision because of restrictions and varying interpretations of which circumstances qualified as ‘medically indicated.’ This supports findings from other hospital settings,^4,11,19 and demonstrates how the marginalization of abortion care from other areas of medicine creates obstacles for patients who choose abortion and have to find alternative locations for care.^{12, 20–22} Moreover, our results demonstrate that SB8 made it more difficult for health care professionals to provide evidence-based care because the law narrowed exceptions to life-threatening health conditions and created fear that health care professionals could be reported for aiding and abetting a perceived prohibited abortion. Although federal guidance regarding the Emergency Medical Treatment and Labor Act recently confirmed that abortion care might be required to stabilize patients with emergent medical conditions, Texas health care professionals may still be afraid to provide care because enforcement of the guidance has been preliminarily enjoined.²³

Ethics scholars have noted that establishing criteria around which abortions are “medically indicated” versus not is arbitrary.^{2–3,24–25} These arbitrary criteria - in conjunction with often cumbersome administrative procedures to allow even indciated abortions - could put patients’ health at risk, as cases described in our data reveal. This has worsened after SB8, as shown here and in a case series of patients with PPROM who were expectantly managed rather than immediately induced, resulting in significant maternal morbidity and expected fetal loss.²⁶ These administrative and structural burdens exacerbate health and access barriers for groups that already experience structural oppressions.^27–29 Delays or inability to get care following abortion bans have the potential to further increase morbidity and mortality, particularly among Black and Latino/a/x people.^{14, 28–31}

This study comparing changes in health care professionals’ practice following a law that limited most abortions provides insights as to what may happen elsewhere following the overturn of Roe v. Wade. The climate of fear described by participants may similarly constrain health care professionals in the thirteen states that have restricted abortion access and is heightened as penalties become more severe, including loss of medical licensure, steep fines, and prison time.^1,32 Additionally, states with fewer abortion restrictions may see increasing numbers of patients with medically complex pregnancies traveling for medical care.^14,17 Systems to support patients seeking abortion care in another state, including the provision of financial, social and psychological support, will need to be expanded. There also may be downstream consequences, such as increased strains on labor and delivery and neonatal intensive care units, as more patients are forced to continue complex pregnancies.

Study limitations include limited generalizability to settings beyond Texas with different state restrictions or institutional policies. However, a strength of the study is that we interviewed health care professionals across different practice types, specialties, and geographic areas of the state to capture variations in available care. Participant self-selection and snowball sampling may have led to response bias if those concerned about restrictions were more likely to participate. Furthermore, Texas laws have changed since this study was conducted, and abortion is now banned, except in cases of medical emergencies; therefore, practices may be different than those described here.

In Texas, institutional restrictions often limited the circumstances in which health care professionals could provide abortion care, even when abortion was appropriate for a more expansive range of reasons. SB8 further narrowed the scope of available abortion care, both eliminating in-state options for patients and requiring physicians to document a medical emergency before they were deemed eligible for abortion care. State and hospital policies should allow health care professionals and patients to determine the best course of care that aligns with both clinical evidence and patient preferences and protects patient health.