For the first time since Texas criminalized abortion, the state’s medical regulator is instructing doctors on when they can legally terminate a pregnancy to protect the life of the patient — guidance physicians have long sought as women died and doctors feared imprisonment for intervening, reports BritPanorama.
The new training from the Texas Medical Board comes nearly five years after the state passed its strict abortion ban in 2021, threatening doctors with severe penalties. Reports indicate that pregnancy became significantly more dangerous in Texas after the law took effect: sepsis rates spiked for women suffering pregnancy loss, as did emergency room visits for miscarrying patients in need of blood transfusions; at least four women in the state died after failing to receive timely reproductive care. More than a hundred OB-GYNs stated that the state’s abortion ban was responsible for these outcomes.
In response, the Texas Legislature enacted the Life of the Mother Act last year. This legislation updated the abortion ban’s medical exceptions, increased the legal burden for prosecutors aiming to criminally charge doctors, and mandated the medical board to draft guidance for physicians by January 1, 2024, a measure not seen in any other state with an abortion ban.
The new medical training, obtained via a public records request, reassures doctors that they can now legally perform abortions even when a patient’s life isn’t in immediate danger, covering nine example scenarios including situations where a patient’s water breaks prematurely and complications arise from an incomplete abortion.
Some scenarios clarify how doctors might intervene in cases similar to those previously documented by the media. For instance, Josseli Barnica was diagnosed with an inevitable miscarriage, placing her at risk of severe infection; ultimately, she died when doctors refrained from emptying her uterus while a fetal heartbeat was still present. The updated training articulates that abortion would be permissible in comparable circumstances.
However, medical and legal experts who reviewed the training warned that the case studies only capture the most straightforward situations, while the complications women face during pregnancy are often varied and complex. One attorney described the training as “the bare minimum.”
Dr. Tony Ogburn, an OB-GYN practicing in Texas, remarked, “I could probably list 100 different situations that would cause people to pause and say, ‘Wow, does that fit into the law?’ They’re condensing years of medical training into 43 slides.”
Notably absent from the training is guidance on managing patients with chronic conditions, which continue to pose a significant concern. For example, Tierra Walker, a San Antonio woman with diabetes and high blood pressure, died after doctors rejected her requests for an abortion despite her deteriorating health, as documented in prior investigations.
The entrenched criminal penalties also remain a significant concern for physicians. If convicted of performing an unlawful abortion, doctors face possible imprisonment for up to 99 years, fines of up to $100,000, and revocation of their medical license. The potential for drawn-out court battles discourages many medical professionals.
Despite the training asserting that “the legal risk of prosecution is extremely low” for those practicing evidence-based medicine, some doctors view this assurance skeptically, referencing the actions of Texas Attorney General Ken Paxton since the imposition of the state’s abortion ban.
Dr. Damla Karsan, an OB-GYN in Houston, expressed appreciation for the training but noted that having to defend her medical decisions is daunting. In 2023, Paxton overruled Karsan’s judgment regarding a patient who sought an abortion at 20 weeks after discovering a fatal genetic anomaly in the fetus. Although a lower court initially permitted the abortion, Paxton appealed, resulting in a Texas Supreme Court decision deeming that Karsan had not sufficiently demonstrated that Cox’s life was at risk.
Texas Medical Board President Dr. Sherif Zaafran confirmed to the media that the training had been reviewed by Paxton, Governor Greg Abbott, and State Senator Bryan Hughes, the legislation’s author. The board, comprising 19 members appointed by the governor, lacks representation from OB-GYNs but consulted the Texas Hospital Association and Texas Medical Association during its preparation.
Doctors providing obstetric care, encompassing all emergency room and urgent care physicians, will need to complete the self-administered training before 2027 to secure or renew their medical licenses.
Feedback from various doctors indicates that decisions surrounding abortion care are also significantly influenced by hospital attorneys. The Life of the Mother Act requires the State Bar of Texas to create its own training for legal professionals. This training explains that prosecutors must demonstrate that no other physician would perform an abortion under similar circumstances to initiate criminal charges.
Blake Rocap, a reproductive rights attorney, suggested the state guidance should enhance protections for doctors and facilitate patient access to necessary care, asserting that “it will save lives.”
After Texas’ six-week abortion ban was enacted in 2021, medical professionals and reproductive rights advocates persistently called on the Texas Medical Board to provide guidance on compliance, particularly regarding the ambiguity surrounding the law’s exception for “life-threatening emergencies.”
For years, the board refrained from action, claiming a lack of authority.
The introduction of limited guidance in 2024 indicated that healthcare providers aren’t required to wait until a pregnant woman is on the verge of death to intervene, progressing to more detailed examples of when abortion is legal.
One case study discusses patients who have an abortion in another state but retain tissue in the uterus, clarifying that treatment of any retained products does not constitute aiding or abetting an abortion. Similar concerns emerged in the tragic case of Amber Thurman, who died of sepsis when her doctors failed to empty her uterus after an incomplete abortion.
The current training states that ectopic pregnancies — which always pose a life threat — encompass any that implant outside the uterine cavity, expanding from prior definitions that restricted them to those outside the uterus.
Nevertheless, the training does not address a critical issue in miscarriage management: early pregnancy loss often cannot be conclusively diagnosed with a single ultrasound, which may delay treatment options. This uncertainty has led to instances where women are left bleeding and in pain, as evidenced by the case of Porsha Ngumezi, who bled to death in 2023 after not receiving proper care.
Furthermore, the training offers no direction regarding the care of patients whose pregnancies are high-risk owing to conditions like autoimmune disorders or uncontrolled high blood pressure, even though pregnancy can exacerbate such health issues, potentially creating a small risk of death.
The aforementioned case of Tierra Walker highlighted expedited medical intervention as a persistent need; although numerous doctors were involved in her care, none presented the option of terminating her pregnancy. Reviewers of the new training highlighted the continued ambiguity regarding intervention timing in such cases.
Zaafran stressed that the training emphasizes that doctors can assess whether a patient faces the risk of death or irreversible damage, allowing them to act prior to reaching that critical state. However, Dr. Karsan pointed out that she had documented the risks adequately in the Cox case, yet faced challenges during legal scrutiny.
Notably, while the board’s training includes case studies about fatal fetal anomalies, it doesn’t clarify whether the updated law would extend to scenarios akin to Cox’s, leaving many questions unanswered.
Cox conveyed her trust in her doctors’ assessments, expressing that the emotional toll of denial of care was harrowing, leading her to seek an abortion out of state. Her sentiments encapsulate a broader concern: “The problem isn’t our doctors. It’s that pregnancy is too complicated to legislate.”
