Under Texas’ abortion ban, where a pregnant woman lives can determine her risk of developing sepsis

This story was originally published by ProPublica, a nonprofit newsroom that investigates abuses of power. Sign up to receive its biggest stories as soon as they’re published. Nearly four years ago in Texas, the state’s new abortion law started getting in the way of basic miscarriage care: As women waited in hospitals cramping, fluid running down their legs, doctors told them they couldn’t empty their uterus to guard against deadly complications. The state banned most abortions, even in pregnancies that were no longer viable; then, it added criminal penalties, threatening to imprison doctors for life and punish hospitals. The law had one exception, for a life-threatening emergency. Heeding the advice of hospital lawyers, many doctors withheld treatment until they could document patients were in peril. They sent tests to labs, praying for signs of infection, and watched as women lost so much blood that they needed transfusions.“You would see the pain in peoples’ eyes,” one doctor said of her patients. Not every hospital tolerated this new normal, ProPublica found. A seismic split emerged in how medical institutions in the state’s two largest metro areas treated miscarrying patients — and in how these women fared. Leaders of influential hospitals in Dallas empowered doctors to intervene before patients’ conditions worsened, allowing them to induce deliveries or perform procedures to empty the uterus. In Houston, most did not. The result, according to a first-of-its-kind ProPublica analysis of state hospital discharge data, is that while the rates of dangerous infections spiked across Texas after it banned abortion in 2021, women in Houston were far more likely to get gravely ill than those in Dallas. As ProPublica reported earlier this year, the statewide rate of sepsis — a life-threatening reaction to infection — shot up more than 50% for women hospitalized when they lost a second-trimester pregnancy. A new analysis zooms in: In the region surrounding Dallas-Fort Worth, it rose 29%. In the Houston area, it surged 63%. ProPublica has documented widespread differences in how hospitals across the country have translated abortion bans into policy. Some have supported doctors in treating active miscarriages and high-risk cases with procedures technically considered abortions; others have forbidden physicians from doing so, or left them on their own to decide, with no legal backing in case of arrest. This marks the first analysis in the wake of abortion bans that connects disparities in hospital policies to patient outcomes. It shows that when a state law is unclear and punitive, how an institution interprets it can make all the difference for patients. Yet the public has no way to know which hospitals or doctors will offer options during miscarriages. Hospitals in states where abortion is banned have been largely unwilling to disclose their protocols for handling common complications. When ProPublica asked, most in Texas declined to say. ProPublica’s Texas reporting is based on interviews with 22 doctors in both the Houston and Dallas-Fort Worth metro areas who had insight into policies at 10 institutions covering more than 75% of the births and pregnancy-loss hospitalizations in those areas. The findings come as evidence of the fatal consequences of abortion bans continue to mount, with a new report just last month showing that the risk of maternal mortality is nearly twice as high for women living in states that ban abortion. Last year, ProPublica documented five preventable maternal deaths, including three in Texas. One second-trimester pregnancy complication that threatens patients’ lives is previable premature rupture of membranes, called PPROM, when a woman’s water breaks before the fetus can live on its own. Without amniotic fluid, the likelihood of the fetus surviving is low. But with every passing hour that a patient waits for treatment or for labor to start, the risk of sepsis increases. The Texas Supreme Court has said that doctors can legally provide abortions in PPROM cases, even when an emergency is not imminent. Yet legal departments at many major Houston hospitals still advise physicians not to perform abortions in these cases, doctors there told ProPublica, until they can document serious infection. Dr. John Thoppil, the immediate past president of the Texas Association of Obstetricians and Gynecologists, said he was “blown away” by this finding. He said it’s time for hospitals to stop worrying about hypothetical legal consequences of the ban and start worrying more about the real threats to patients’ lives. “I think you’re risking legal harm the opposite way for not intervening,” he said, “and putting somebody at risk.” ‘We have your back’ In the summer of 2021, Dr. Robyn Horsager-Boehrer, a Dallas specialist in high-risk pregnancy, listened as hospital lawyers explained to a group of UT Southwestern Medical Center doctors that they would no longer be able to act on their clinical judgment. For decades, these UT Southwestern physicians had followed the guidance of major medical organizations: They offered patients with PPROM the option to end the pregnancy to protect against serious infection. But under the state’s new abortion ban, they would no longer be allowed to do so while practicing at the county’s safety net hospital, Parkland Memorial, which delivers more babies than almost any other in the country. Nor would they be permitted at UT Southwestern’s William P. Clements Jr. University Hospital. Lawyers from the two hospitals explained in a meeting that the law’s only exception was for a “medical emergency” — but it wasn’t clear how the courts would define that. With no precedent or guidance from the state, they advised the doctors that they should offer to intervene only if they could document severe infection or bleeding — signs of a life-threatening condition, Horsager-Boehrer recalled. They would need to notify the state every time they terminated a pregnancy. ProPublica also spoke with six of Horsager-Boehrer’s colleagues who described similar meetings. As the new policy kicked in, the doctors worried the lawyers didn’t understand how fast sepsis could develop and how difficult it could be to control. Many patients with PPROM can appear stable even while an infection is taking hold. During excruciating waits, Dr. Austin Dennard said she would tell patients at Clements, “We need something to be abnormal so that we can offer you all of the options that someone in New York would have.” Then she would return to the physicians’ lounge, lay down her head and cry. Their only hope, the doctors felt, was to collect data and build a case that the hospital’s policy needed to change. Within eight months, 28 women with severe pregnancy complications before fetal viability had come through the doors of Parkland and Clements. Twenty-six of them were cases in which the patients’ water broke early. Analyzing the medical charts, a group of researchers led by Dr. Anjali Nambiar, a UT Southwestern OB-GYN, found that a dozen women experienced complications including hemorrhage and infection. Only one baby survived. The research team compared the results with another study in which patients were offered pregnancy terminations. They found that of patients who followed the “watch and wait” protocol, more than half experienced serious complications, compared with 33% who immediately terminated their pregnancies. Armed with the research, the doctors, including Horsager-Boehrer, returned to the lawyers for the two hospitals. Everyone agreed the data demanded action. Alongside physicians, the lawyers helped develop language that doctors could include in medical charts to explain why they terminated a pregnancy due to a PPROM diagnosis, Dennard said. At Parkland, the new protocol required doctors to get signoff from one additional physician, attach the study as proof of the risk of serious bodily harm — part of the “medical emergency” definition in the law — and notify hospital leaders. At Clements, doctors also needed to get CEO approval to end a pregnancy, which could create delays if patients came in on a weekend, doctors said. But it was vastly better than the alternative, Dennard said. The message from the lawyers, she said, was: “We have your back. We are going to take care of you.” A spokesperson for UT Southwestern said “no internal protocols delay care or otherwise compromise patient safety.” A spokesperson for Parkland said that “physicians are empowered to document care as they deem appropriate” and that hospital attorneys had “helped review and translate the doctors’ proposed language to make sure it followed the law.” Parkland and UT Southwestern are not the only ones providing this care in Dallas. ProPublica spoke with doctors who have privileges at hospitals that oversee 60% of births and pregnancy loss hospitalizations in the Dallas-Fort Worth region, including Baylor Scott & White and Texas Health Resources. They said that their institutions support offering terminations to patients with high-risk second-trimester pregnancy complications like PPROM. At Baylor Scott & White, doctors said, the leadership always stood by this interpretation of the law. (When asked, a spokesperson said miscarrying patients are counseled on surgical options, and that its hospitals follow state and federal laws. “Our policies are developed to comply with those laws, and we educate our teams on those policies.”) Texas Health and other hospitals in the region did not respond to requests for comment. While efforts to be proactive have meant more patients are able to receive the standard of care in Dallas, that is still not the case at every medical campus in the region. Doctors at Parkland said they have seen patients come to them after they were turned away from hospitals nearby. In other parts of the state, however, it’s been impossible to know where to turn. ‘No interventions can be performed’ In Houston, one of America’s most prestigious medical hubs, Dr. Judy Levison mounted her own campaign. The veteran OB-GYN at Baylor College of Medicine wanted hospital leaders to support intervening in high-risk complications in line with widely accepted medical standards. In 2022, she emailed her department chair, Dr. Michael Belfort, who is also the OB-GYN-in-chief at Texas Children’s. She told him colleagues had shared “feelings of helplessness, moral distress and increasing concerns about the safety of our patients.” They needed training on how to protect patients within the bounds of the law, she said, and language they could include in charts to justify medically necessary abortions. But in a meeting, Belfort told her he couldn’t make these changes, Levison recalled. He said that if he supported abortions in medically complicated cases like PPROM, the hospital could lose tens of millions of dollars from the state, she told ProPublica. “I came to realize that he was in a really difficult place because he risked losing funding for our residency program if Baylor and Texas Children’s didn’t interpret the law the way they thought the governor did.” She wondered if he was deferring to hospital lawyers. Belfort did not respond to requests for comment about his stance. Nor did Baylor or Texas Children’s. Although Texas Attorney General Ken Paxton has threatened hospitals with civil action if they allow a doctor to perform what he views as an “unlawful” abortion, he hasn’t filed any such actions. And in the years since the ban, there have been no reports of the state pulling funding from a hospital on account of its abortion policy. A spokesperson at only one major Houston hospital chain, Houston Methodist, said that it considered PPROM a medical emergency and supported terminations for “the health and safety of the patient.” Five other major hospital groups that, together, provide the vast majority of maternal care in the Houston region either continue to advise doctors not to offer pregnancy terminations for PPROM cases or leave it up to the physicians to decide, with no promise of legal support if they’re charged with a crime. This is according to interviews with a dozen doctors about the policies at HCA, Texas Children’s, Memorial Hermann, Harris Health and The University of Texas Medical Branch. Together, they account for about 8 in 10 hospitalizations in the region for births or pregnancy loss. Most of the doctors spoke with ProPublica on the condition of anonymity, as they feared retaliation for violating what some described as a hospital “gag order” against discussing abortion. In a sign of how secretive this decision-making has become, most said their hospitals had not written down these new policies, only communicated them orally. Several doctors told ProPublica that Dr. Sean Blackwell, chair of the obstetrics and gynecology department at Houston’s University of Texas Health Science Center, which staffs Harris Health Lyndon B. Johnson Hospital and Memorial Hermann hospitals, had conveyed a message similar to Belfort’s: He wasn’t sure he would be able to defend providers if they intervened in these cases. He did not respond to multiple requests for comment, and his institution, UTHealth Houston, declined to comment. ProPublica reached out to officials at all five hospital groups, asking if they offer terminations at the point of a PPROM diagnosis. Only one responded. Bryan McLeod at Harris Health pointed to the hospital system’s written policy, which ProPublica reviewed, stating that an emergency doesn’t need to be imminent for a doctor to intervene. But McLeod did not respond to follow-up questions asking if patients with PPROM are offered pregnancy terminations if they show no signs of infection — and several doctors familiar with the chain’s practices said they are not. The state Senate unanimously passed a bill last week to clarify that doctors can terminate pregnancies if a woman faces a risk of death that is not imminent. ProPublica asked the hospitals if they would change their policies on PPROM if this is signed into law. They did not respond. Last fall, ProPublica reported that Josseli Barnica died in Houston after her doctors did not evacuate her uterus for 40 hours during an “inevitable” miscarriage, waiting until the fetal heartbeat stopped. Two days later, sepsis killed her. Barnica was treated at HCA, the nation’s largest for-profit hospital chain, which did not respond to a detailed list of questions about her care. With 70% of its campuses in states where abortion is restricted, the company leaves the decision of whether to take the legal risk up to the physicians, without the explicit legal support provided in Dallas, according to a written policy viewed by ProPublica and interviews with doctors. A spokesperson for the chain said doctors with privileges at its hospitals are expected to exercise their independent medical judgment “within applicable laws and regulations.” As a result, patients with potentially life-threatening conditions have no way of knowing which HCA doctors will treat them and which won’t. Brooklyn Leonard, a 29-year-old esthetician eager for her first child, learned this in February. She was 14 weeks pregnant when her water broke. At HCA Houston Healthcare Kingwood, her doctor Arielle Lofton wrote in her chart, “No interventions can be performed at this time legally because her fetus has a heartbeat.” The doctor added that she could only intervene when there was “concern for maternal mortality.” Leonard and her husband had trouble getting answers about whether she was miscarrying, she said. “I could feel that they were not going to do anything for me there.” Lofton and HCA did not respond to a request for comment. It was only after visits to three Houston hospitals over five days that Leonard was able to get a dilation and evacuation to empty her uterus. A doctor at Texas Children’s referred her to Dr. Damla Karsan, who works in private practice and is known for her part in an unsuccessful lawsuit against the state seeking permission to allow an abortion for a woman whose fetus was diagnosed with a fatal anomaly. Karsan felt there was no question PPROM cases fell under the law’s exception. She performed the procedure at The Woman’s Hospital of Texas, another HCA hospital. “She’s lucky she didn’t get sick,” Karsan said of Leonard. Many Houston doctors said they have continued to call on their leadership to change their stance to proactively support patients with PPROM, pointing to data analyses from Dallas hospitals and ProPublica and referring to the Texas Supreme Court ruling. It hasn’t worked. Houston hospitals haven’t taken action even in light of alarming research in their own city. Earlier this year, UTHealth Houston medical staff, including department chair Blackwell, revealed early findings from a study very similar to the one out of Dallas. It showed what happened after patients at three partner hospitals stopped being offered terminations for PPROM under the ban: The rate of sepsis tripled. Still, nothing changed. Sophie Chou contributed data reporting, and Mariam Elba contributed research.