For doctors who work with high-risk pregnancies, Texas’ abortion ban has added an extra layer of pressure and paperwork when making life-or-death decisions.
After the U.S. Supreme Court struck down Roe v. Wade, Texas’ trigger law banned nearly all abortions starting on Aug. 25 and added criminal charges for doctors, who could face life in prison and fines up to $100,000 for an illegal abortion.
The law applies even in cases of rape and incest; the only exception is medical emergencies when the mother’s life is at risk. That has put obstetricians in the difficult position of following the letter of the law while caring for patients who may need medically indicated abortions.
Dr. Patrick Ramsey, who practices at University Hospital and serves as the Maternal-Fetal Medicine Fellowship director at UT Health San Antonio, spoke to the San Antonio Report last month about the adjustments obstetricians have had to make in treating pregnant patients with medical issues or those whose fetuses develop severe birth defects.
Rural doctors, who may not have the training or legal help to wade through the complexities of the risk-to-life exemption, are especially impacted by the state’s abortion restrictions, said Ramsey.
Ramsey said he has received several calls from panicked colleagues across the state since the trigger law went into effect.
“A mom recently came into one of those hospitals bleeding profusely at 15 weeks and the doctor was calling me to see if they should perform a dilation and curettage procedure, to resolve the serious bleeding,” he said, referring to the medical term for one of the most common forms of abortion.
“The fact that they had to call me to ask if they need to do the right thing for this patient really gives me heartburn,” he continued. “I may not be pausing when I see medical emergencies, but if there are other providers worried about losing their license or committing a felony, that’s a concern.”
In the Q&A below with Ramsey, he describes how the new laws have changed the doctor-patient relationship, what it’s meant for rural providers and their patients and how additional documentation can delay patient care.
This interview has been edited for length and clarity.
San Antonio Report: What made you want to specialize in maternal-fetal medicine?
Dr. Patrick Ramsey: I love taking care of complex pregnancies. Maternal-fetal medicine gives me the opportunity to basically do internal medicine for mothers who are pregnant.
And then to be able to watch the fetus develop with ultrasound was really pretty spectacular. So it was a really nice blend of things that I really enjoyed about medicine.
Working directly with families is so rewarding. For most people, 99% of the time, everything goes fine. But if you’ve never been there before — just the anticipation and the excitement and uncertainty for patients, I’m sure, is intense.
SAR: Have you had to change the words you use when talking to patients since the overturning of Roe v. Wade?
PR: The majority of what we talk to patients about for regular pregnancies is the same. We’ve always had a balanced discussion when we find things on ultrasound — about what those findings mean and what pregnancy options are if we discover a concerning birth defect.
The way some of the Texas laws that are written, they prohibit us from speaking directly about access to abortion services. We’re always willing to have a patient have a second opinion with another provider and that’s kind of the approach we’ve used.
SAR: So you don’t even talk about abortions with patients anymore?
PR: Certainly we mention that these are all the different options that are available, about any interventions that can be done for the pregnancy and what the outcomes would be like if the patient continues the pregnancy.
We’re just a little more cautious. Rather than directly talking about abortion access, we talk about referring them to second opinions — which may be out of state.
SAR: Does that include even when the life of the mother is at risk?
PR: That’s a little bit of a different story. If we know mom has a life-threatening condition that will be either exacerbated by pregnancy or make her pregnancy potentially have substantial serious morbidity and mortality, we will convene not only our high-risk pregnancy team together, but the other specialist teams.
So if a mom has a heart problem, we’ll get the cardiologists involved and we’ll get the intensive care providers involved and have a real robust discussion about what the true risk would be for the mom if she stays pregnant at the current time and what it would be for delivery.
If there’s something that is a significant risk to mom from morbidity complications or mortality, then we go through a process of getting cleared to offer the patient pregnancy termination.
It has to be a consensus. Everybody agrees that this is definitely something that puts mom at serious risk for morbidity and mortality and that not being pregnant would be the best course of action to prevent those things from happening.
Those situations aren’t very often, but there are some significant medical problems that can emerge.
SAR: Did that type of conferencing occur before all the recent legal changes surrounding abortion?
PR: It actually did. Because we’re a state-funded institution, we’ve never done abortions here for fetal reasons or genetic causes, it’s only situations where the risk was to the life of the mother.
We always had a process in place to have at least several different attending physicians from different services attest that the risk of pregnancy was too great, in order for an abortion to be performed.
Since Roe got overturned, we’ve beefed up that process so that it’s even more of a care team discussion, to make sure we have more people involved with that consensus development.
And it’s a lot more documentation. The law is very, very, very specific about what needs to be documented. It’s created a little more delay in the process.
SAR: Are attorneys now involved in that conferencing?
PR: No, just the doctors. When Senate Bill 8 first came out, University Hospital and UT Health met with our attorneys to talk about what is the impact of those laws and the current processes in place.
They gave us some guidance about how to make that process more robust and to be more compliant, especially with the documentation part, to be consistent with the laws.
SAR: You mentioned that this documentation can create some delays — does that apply to emergency situations when the life of a mother is at risk? Does this get in the way of patient care?
PR: There’s probably some situation where it may delay things to make sure documentation is in place, but if it’s truly an emergency, we act first and then take care of the paperwork afterward.
SAR: Have these legal changes made it harder to make these medical decisions?
PR: I think it has, because maybe our process goes a little too far for the redundancy to have extra people attest to the risk of life to mother for the medically indicated abortions that we’re counseling patients about.
It’s crazy levels of documentation that we didn’t have to do before. I don’t know if having all the extra legal documentation put in the medical record is providing any help for improving care for patients. If anything, it’s maybe diluting or delaying that caring for patients.
SAR: Do you feel that you or your colleagues have ever had to not perform an abortion that you probably would have before?
PR: I think there’s more pause. One example scenario is a pregnancy of unknown location — those are usually tubal or ectopic pregnancies [a potentially life-threatening condition in which the fertilized egg implants outside the uterus]. We have very clear clinical criteria that define when we should see a pregnancy in the uterus. If we have a high suspicion of tubal pregnancy, those situations become a little more gray as far as when we can intervene by inducing a termination.
SAR: Have you seen a decrease in abortions performed to save the mother’s life?
PR: Not so far. We’re probably getting more volume because some rural hospitals or regional hospitals don’t feel comfortable taking care of those patients. Before they had access to abortion clinics in town, but those clinics are no longer there.
I’ve had some phone calls from rural providers who are just not sure if they can manage a patient by delivering them because they’re bleeding or because they’re concerned about legal risk.
SAR: Do you ever refer patients to seek abortions outside of Texas?
PR: The laws are pretty specific about not referring patients for that. We’ve just given them kind of information for Google searches and things they could do if they were seeking any of that type of information.
That’s where the bills get into a little bit of intrusion in the doctor-patient relationship, preventing us from talking about options and making appropriate referrals.
SAR: Is there a conflict between this legal environment and the pledge that doctors take to do no harm?
PR: I would say yes. Just like a lawyer can’t divulge anything they have on the client that would harm them, we have clients who we should have independent autonomy to talk to about what is appropriate medical care.
Some laws probably shouldn’t be in the exam room.
SAR: What’s the most common situation you see that demonstrates that conflict?
PR: We see a lot of complex birth defects here, and it’s clearly something that the baby won’t survive after delivery. And we know that from experience from years of observations.
For example, fetal anencephaly, which is when babies lack large portions of skull and brain tissue. The babies survive through the pregnancy, but as soon as they deliver, there’s no respiratory function. They pass away shortly after delivery.
These laws don’t give that patient an option to avoid a whole pregnancy and face that certain demise. It’s really unfortunate, because the patient has to live with the thought of that happening for six months.
SAR: What other consequences will this abortion ban have further down the road?
PR: I think the other thing that we haven’t seen yet but we know will eventually happen is an increase in complications from partially completed abortions from medication abortions.
Patients can get medications that can induce abortions over the counter, or they get them in the mail, they can get them in Mexico or Canada.
Pre-Roe it was very common for people to have abortions done outside medical facilities and come in with septic abortions and uterine injuries. I think we will probably see that again.
If abortion gets taken out of the clinical space because of the laws, I think it’ll eventually go into the public space. And then we’re going to be taking care of the complications, which will harm all the mothers and babies.
UT Health San Antonio and University Health are financial supporters of the San Antonio Report. For a full list of business members, click here.