"You know what? I'm not doing this any more."
https://slate.com/news-and-politics/2023/03/texas-abortion-law-doctors-nurses-care-supreme-court.html
or three days last fall, Leah Wilson entered her pregnant patient's hospital room and checked the fetus for a heartbeat. She was waiting for it to stop. The woman's water had broken at just 19 weeks of pregnancy, well before viability, causing an infection in her uterus. The fetus would not survive, but until it died, or the woman's condition worsened, there was little the hospital would do, said Wilson, who was her nurse at the time.
Typically in this kind of situation, doctors would terminate the pregnancy to prevent a life-threatening infection or other serious complication. But this patient was in Texas, where abortion is no longer legal.
So they waited. The smell of the infection filled the room, Wilson said. She tried to help the patient stay clean. She watched her vitals and monitored her for sepsisif the infection got bad enough, if it spread through her body, then the doctors would finally intervene, to save her life. Wilson struggled to explain to the woman slowly losing her pregnancy why they weren't doing anything else to help. Finally, on the third day, she said, the heartbeat stopped.
By the time Wilson cared for this patient, she had been working as a labor and delivery nurse at the San Antonio hospital for about a year and a half. She decided to go into nursing after seven years at home raising her young kids, inspired by the complicated birth of her own son and the impact her nurses at the time had on both their recoveries. At the hospital, which sees a large number of high-risk pregnant patients from across the region, Wilson said she often volunteered to work on difficult cases involving fetal loss. Several of her friends had miscarried, and she wanted to be the nurse who supported other patients through it: "It's always hard, but usually, you know, you go and you cry for your five minutes in the closet once things are over, and then you move on."
By September 2021, though, caring for these patients became much scarier in Texas. That's when Senate Bill 8 went into effect, banning nearly all abortions after about six weeks of pregnancy, and allowing virtually any person to sue anyone they suspected of "aiding and abetting" the procedure. The most restrictive abortion law in the country at the time, S.B. 8 included only an ambiguous exception for "medical emergencies," resulting in hospitals delaying or denying care to people with pregnancy complications for fear of liability, and leaving providers worried they could be sued for tasks they had previously been doing without a second thought in their day-to-day work, including miscarriage management. By last summer, things had become even harder at Wilson's hospital and across the state: Following the Supreme Court's June 2022 decision in Dobbs v. Jackson Women's Health Organization, Texas banned all abortions, with only narrow yet vague exceptions to save the life of the pregnant person and a potential penalty of life in prison for physicians. "It meant no longer providing the standard of care that we would have prior to Dobbs," Wilson said. "It meant patients sitting there for days, actively losing nonviable pregnancies, and us waiting for something to go bad enough that we could help them."
Wilson left her job soon after. "There were a couple of cases just within a few weeks of each other that I really, really, really struggled with," she told me, including the patient who miscarried at 19 weeks pregnant. "And it was enough to say, You know what? I'm not doing this anymore."
Almost every provider I spoke with has thought about leaving their practice or leaving Texas in the wake of S.B. 8 and Dobbs.
She's not the only one. More than a year and a half after Texas implemented its six-week abortion ban, and months after Dobbs, medical providers say they are facing impossible situations that pit their ethical obligation to patients who are dealing with traumatic and dangerous pregnancy complications against the fear of lawsuits, loss of their medical licenses, and incarceration. The problem is encapsulated by a lawsuit filed this month in Texas, in which five women and two OB-GYNs sued the state over the abortion bans that they say have created so much confusion and fear among providers that it has affected women's health and even threatened their lives. Unsure of how to comply with the new rules, hospitals have interpreted them differently, with some requiring approval from attorneys or ethics boards for physicians to provide abortion care in medical emergencies, and others leaving it up to individual doctors, with little guidance or support. This has meant that some physicians wait until patients are near death to intervene in medical emergencies, according to recent research, court filings, news reports, and interviews. "I'll get consults from another doctor asking me what to do in a particular casea mother bleeding, or a pregnancy where there's an infection in the womb before the baby can survive outside the womb. I have doctors calling me, hesitating, not quite knowing what to do because the baby has a heartbeat, when clearly the mother's life is at risk," John Visintine, a maternal fetal medicine specialist in McAllen, Texas, told me. "These are things that I haven't seen in, you know, 20 years of practicing OB, 14 years of practicing high-risk OBI've never run into these situations where people are wondering what to do."
The inability to provide what they say is the standard of care to pregnant patients is taking a toll, personally and professionally, according to interviews with more than a dozen doctors and nurses across Texas. And it's causing many, like Wilson, to reconsider the future of their career in the state. Almost every provider I spoke with for this story has thought about leaving their practice or leaving Texas in the wake of S.B. 8 and Dobbs. Several have already moved or stopped seeing patients here, at least in large part because of the abortion bans. "If I was ever touch a patient again, it won't be in the state of Texas," said Charles Brown, chair of the Texas district of the American College of Obstetricians and Gynecologists (ACOG), who stopped seeing patients last year after decades working as a maternal fetal medicine specialist. Many asked that their hospital affiliation not be included in this story, in some cases because they feared consequences from their employer or the public for speaking out about these laws, even though they're not breaking them. Some worry about what will happen to their own kids if they are targeted. Several cried through the interviews. Many of those I spoke with who haven't left yet are still thinking about it regularlypeople who have family and homes and lives in Texas and would not otherwise have considered moving.
Brown put the stakes bluntly: "Are people quitting? … The answer is yes," he said. "I hope I'm 100 percent wrong about this, but I think it's a much bigger trend that's going to become obvious pretty quickly."
After she finished her OB-GYN residency in Chicago in 2020, Yue Guan took a job in Fort Worth to be close to her family and support system in Texas. But the past year and a half has put in stark relief the differences in basic maternity care between Illinois, where abortions are legal up to about 24 weeks, and where she now practices.
This is especially true for patients at her hospital, many of whom are uninsured and don't have access to preventive health care or early prenatal care. "For some of them, an issue with the pregnancy, like a fetal anomaly that wouldn't be compatible with life, would not be discovered until much later," she said. "So it's so many more degrees more difficult for them." At that point, if they wanted to terminate a nonviable pregnancy, their options for traveling out of state would be even more limited, and would require financial resources that many don't have. The current abortion bans do not include any exception for severe fetal anomalies. Since the six-week ban went into effect, Guan said she's had patients carry and deliver babies that they knew wouldn't survive, because they didn't have another option: "This definitely hits this population in a different, much more malicious way."
In one case, she said a patient came to the hospital with a premature rupture of membranes, then found out the fetus had a severe anomaly that it likely would not survive. Generally, when a patient's water breaks early and they are close to viability, they may be given antibiotics to try to prolong the pregnancy, Guan said. "This patient told us she wanted to decline the antibiotics so she could get sick enough so that we would offer her an abortion. And eventually she did get infected, and was delivered for that reason."
Guan said she questions her future practicing in Texas each time she sees a case like this. "It doesn't feel very sustainable for me in the long run, to feel like I'm not allowed to be a doctor," she said. Most of her friends stayed in Chicago where they trained, or moved to other states that aren't subject to abortion bans. "A lot of them feel like, If this is the toll that it's going to take on me, I should just move, or find some other kind of position where I'm not going to be exposed to these patient cases. But I also feel like if anything, that makes the problem worse, right? If every OBlet's say every OB you talk to who felt similarlydecides to leave the state, we just have fewer OBs here, even less access for these patients. And that doesn't feel like a viable solution."
This is all happening as Texans can't afford to lose more access to medical care. In 2022, 15 percent of the state's 254 counties had no doctor, according to data from the state health department, and about two-thirds had no OB-GYN. Texas has one of the most significant physician shortages in the country, with a shortfall that is expected to increase by more than 50 percent over the next decade, according to the state's projections. The shortage of registered nurses, around 30,000, is expected to nearly double over the same period. Already, Texans in large swaths of the state must drive hours for medical care, including to give birth. According to recent research from the nonprofit March of Dimes, it is among the worst states for maternity care access, which has decreased in a dozen Texas counties in the past two years, mostly due to a loss of obstetrics providers.
This doesn't yet take into account the effects of increased criminalization of abortion care, which is further compounded by dramatic pandemic-induced burnout among clinicians. As physicians retire, hospitals are struggling to replace them; as nurses burn out or leave for more lucrative travel nursing roles, their positions are sitting open. There have been a string of policies and factors that have stretched providers in Texas for many years, from having the highest uninsured rate in the country to low Medicaid reimbursement rates to the demonization of science to attacks on transgender health care, and now the abortion bans, according to Tom Banning, the CEO of the Texas Academy of Family Physicians. "The first rule of holes, when you're trying to get out of the hole, is to stop digging," he said. "We just continue to dig the hole that we're in deeper."
"It's crisis-level staffing for the majority of rural Texas hospitals."
John Henderson
This is an issue for both urban and rural areas, but it's felt most acutely outside major metros, where one retirement or move can be the difference between having access to medical care near home or having to drive an extra several hours. The state has experienced the most rural hospital closures in the country in recent years. Less than half of rural hospitals nationwide still have labor and delivery services, according to recent research from the Chartis Center for Rural Health; in Texas, that number is just 40 percent. John Henderson, the president and CEO of the Texas Organization of Rural and Community Hospitals, said he gave a presentation this fall for a group of representatives from about 100 rural Texas hospitals where he asked them to raise their hand if they don't currently have openings for registered nurses. "There were three out of 100 that were fully staffed, and I was actually surprised that there were three," he said. "It's crisis-level staffing for the majority of rural Texas hospitals." Maternity wards have long been the sacrificial lamb for cash-strapped rural hospitals trying to save money and keep their doors open, but more recently, it's short staffing that has forced closures and cuts to services in Texas and across the country.
For more than a year during the pandemic, for example, Big Bend Regional Medical Center in Alpine, the only hospital for 12,000 square miles, regularly closed its labor and delivery unit for days at a time after most of the unit's nurses quit. Hereford Regional Medical Center, in the Texas Panhandle, sometimes sent patients 50 miles northeast to Amarillo when the hospital didn't have enough nurses to deliver babies. Doctors spanning from Huntsville, in East Texas, to the Permian Basin told me they've had to fill in more and more as their hospitals have struggled to recruit new physicians after others retired.
In Sweetwater, 40 miles west of Abilene, Rolling Plains Memorial Hospital's labor and delivery unit lost at least four nurses who left for higher-paying travel nurse positions during the pandemic, according to Jennifer Liedtke, a family medicine physician and the unit's director. The hospital has been actively trying to hire a full-time OB-GYN for more than two years. Even under normal circumstances, in an overstretched hospital like hers, she said, "You're not just the postpartum nurse, you're not just the laboring nurse, you're not just the newborn nurse, you're all of those things."
And when there isn't a fully staffed hospital nearby, it can be harrowing for patients. After one local hospital, about 30 miles from Sweetwater, closed its maternity ward years ago, it started sending patients in need to Liedtke's unit. Recently, a patient was transferred to her care who was hemorrhaging and needed a common procedure to stop the bleedingbut because no one at the other hospital could do the surgery, she had to instruct the nurse over the phone on how to slow the bleeding and tell her to get the patient to Sweetwater as fast as possible.
Liedtke and others are concerned these gaps will only grow now that new doctors training in obstetrics are unable to learn the full scope of pregnancy and abortion care in Texas. Already, residencies and recruiters are reporting a hesitancy among new and seasoned doctors to practice in states with abortion bans, and some programs are sending current residents out of state for training rotations where available so they can meet medical standards. Guan, who works with residents at her hospital, said she reminds them that certain ways pregnancy complications are now managed in Texas are not the standard of carethat this is not the way these situations are treated everywhere. The scarcity also raises the stakes: When there are limited providers, the importance of each one knowing how to deal with complicated situations is higher, Banning said: "There's no safety net."
Unlike what she's heard from physicians at some larger hospitals, Liedtke said she hasn't yet had a problem treating pregnancy complications under the abortion bans. It's not that she's not getting these patients, but each time she does, she's able to call up her boss on the hospital's administrative team to get permission to intervene, which thus far has been granted.
Still, she's felt the impact of the new laws on her practice. On the day we spoke in November, Liedtke said she had gone to three different pharmacies in town to try to get a prescription filled for methotrexate. The drug can be used to end a pregnancy, and Liedtke needed it for a patient who came to the emergency room with an ectopic pregnancy, which is nonviable and life-threatening if left untreated. Despite an explicit exception for ectopic pregnancies in Texas abortion law, Liedtke said the physician who first saw the patient didn't want to prescribe the drug, and the big pharmacies in town won't fill it anymore. Eventually, her neighbor, who's a pharmacist, agreed, provided she fax over the ultrasound. The personal relationships are critical, she said: "My neighbor knows that I don't do elective abortions, I only do them when there's medical indication. And we go to church together, and he knows that."
Across Texas, physicians and nurses described a sense of being pulled between the individual stress of trying to navigate care in this environment and broader concerns about who will fill in the gap if they leave. In the Rio Grande Valley, on the Texas-Mexico border, John Visintine, the McAllen OB-GYN, said he is one of just a few maternal fetal medicine specialists who provide care for people with high-risk pregnancies, complications, and fetal anomalies in a region of about 1.5 million people. The population is predominantly poor, with one of the highest uninsured rates in the country, and many people can't travel out of the region because of their immigration status. Visintine said he's been told by attorneys not to even discuss the option of going out of state for an abortion with patients, including when the fetus has such severe birth defects that it will not survive. He's not the only one receiving this message. But withholding that information feels so unethical that he, too, has contemplated leaving his practice. "To be left with the option of either potentially breaking the law and putting myself, my family, at risk, or not offering the options to a patient and not meeting her needs and providing careI think it's a tragic, horrible situation to be in," he said. "And then if you leave, you know, there's so many women that need care in this area. Do we just abandon the women of South Texas?"
Some providers have moved to states like New Mexico and Colorado following S.B. 8 and Dobbs to continue to care for Texans now traveling out of state. Alireza Shamshirsaz, an OB-GYN and fetal surgeon who for more than a decade worked at Texas Children's Hospital in Houston and saw patients from Texas and across the South, told me that the new restrictions prompted him to accept another job offer after years of declining them. Last summer, he left his home in Houston and moved with his family across the country for a position at Boston Children's Hospital. For Lee Bar-Eli, a family medicine physician in Houston and board member of Doctors in Politics, the abortion ban was the latest in a slew of factorsincluding feeling unsupported and disillusioned during the pandemic as a doctor and later as a long-COVID patientthat led her to take a break from practicing medicine, beginning last January.
"So far I haven't left. You think, Well, if this happens, then I'm leaving. You know, I said the same thing before the Dobbs case was decided."
Shanna Combs, OB-GYN in Fort Worth
Others are considering what their breaking point would be. "We talk about what we take on as health care providers," said Shanna Combs, an OB-GYN in Fort Worth. "Something happens, just throw it in the bag, just throw it in the bag. So you have this constant weight, being weighted down by this heavy backpack of burdens, and this has just continued to add to that," she said of the abortion ban. "At the end of the day, I just want to take care of my patients and provide the best care for them. And this is just another layer that makes you question what you're doing." In November, Combs, who is president-elect of the Texas Association of Obstetricians and Gynecologists, told me that if contraception is further restricted, that would be the final straw for her to move. When we spoke again early this year, I mentioned a recent court ruling that bans Texas teens from getting birth control from federally funded clinics without their parents' consent. So, has anything changed? "So far I haven't left," she said, laughing. "You think, Well, if this happens, then I'm leaving. You know, I said the same thing before the Dobbs case was decided."
The Texas lawsuit filed this month, the first of its kind, does not seek to block the abortion bans, just to clarify the scope of the medical exceptions and affirm that doctors have discretion to provide abortion care when the pregnant person's health is at risk. At the Texas Capitol, Democrats have filed bills in the current legislative sessionthe first time the state Legislature has met since 2021that also seek to clarify current exemptions, and widen them slightly to include lethal fetal anomalies, rape, and incest. But supporters of the restrictive laws have generally shown little appetite for even these changes, instead blaming doctors for denying care to pregnant patients and medical associations for not giving clear guidance. They've instead pushed measures to further criminalize abortion access.
Charles Brown, the ACOG chair, worries that absent clarity and changes from state leaders, a mass exodus could soon occur. "We have not had the front-page photo of the doctor in handcuffs yet. When that happens, I think that will be the napalm," he said. "Once that first arrest is on the front page of the paper, that will be a defining moment for a lot of people." For Combs, who recently traveled to Austin to meet with legislators about changes to the abortion laws, the question of whether to leave Texas is "something that sits in the back of my mindprobably not a day that goes by where I don't think, Huh, is this where I really want to be?" she said. "I like to say, 'I choose every day to stay.' "
The precariousness of this moment informs every conversation: What if Liedtke's neighbor wasn't a pharmacist? What if a patient sent home to wait for sepsis lived just a few minutes too far from the hospital to make it back in time? (Has this happened already?) What is the breaking point for so many doctors and nurses who are already thinking about leavinghow much heavier can the backpack get before it rips? How much deeper can we dig this hole before we can't get back out?
Providers in Texas have been navigating care under a near-total abortion ban for the longest time of any state in America. But this conflict over whether to stay or go is also playing out across the dozen other states that have banned abortion care following Dobbs. And while those working in reproductive health care are most directly affected by these abortion bans, doctors I've spoken to warned it doesn't end with them. Cancer doctors are wondering if they can treat pregnant patients. Some providers who can become or want to become pregnant are considering moving away or are hesitating to come to states with abortion bans for their own safety, physicians told me. Others with kids already are making similar calculations. "It's everything," Brown said. "They don't want to live in a state where their children can't get health care."
Before the Dobbs decision, Leah Wilson, the nurse in San Antonio, had the next few yearseven the rest of her careermapped out. She would continue to work at the hospital as a labor and delivery nurse, then get a master's degree in midwifery and become a certified nurse midwife. She and her husband would raise their three kids in the Texas city where she grew up, and where the two of them met at church more than a decade ago.
Now, everything has changed. She and her family are packing up their home to put it on the market. Later this spring, they'll move to Utah, where her husband will be stationed with the Air Force.
In October, Wilson quit working in the hospital in favor of a new job, as a nurse home visitor. She gets to help new mothers that way, and she'll be able to keep that job in Utah. But she's watching as further abortion restrictions now wind their way through the Utah Legislature and courts. At this point, she doubts she'll ever go back to working with patients in a hospital setting. "It's just too uncertain," she said. When her husband retires from the Air Force in three years, they may move the family to Colorado, or perhaps farther west. But they won't return to Texas.
"I loved coming back, being able to share that with my children. And it is hard to leave a place that really does feel like home. But we don't want them growing up here," she said. "I definitely don't want my daughters having kids in Texas. I know that."
https://slate.com/news-and-politics/2023/03/texas-abortion-law-doctors-nurses-care-supreme-court.html
or three days last fall, Leah Wilson entered her pregnant patient's hospital room and checked the fetus for a heartbeat. She was waiting for it to stop. The woman's water had broken at just 19 weeks of pregnancy, well before viability, causing an infection in her uterus. The fetus would not survive, but until it died, or the woman's condition worsened, there was little the hospital would do, said Wilson, who was her nurse at the time.
Typically in this kind of situation, doctors would terminate the pregnancy to prevent a life-threatening infection or other serious complication. But this patient was in Texas, where abortion is no longer legal.
So they waited. The smell of the infection filled the room, Wilson said. She tried to help the patient stay clean. She watched her vitals and monitored her for sepsisif the infection got bad enough, if it spread through her body, then the doctors would finally intervene, to save her life. Wilson struggled to explain to the woman slowly losing her pregnancy why they weren't doing anything else to help. Finally, on the third day, she said, the heartbeat stopped.
By the time Wilson cared for this patient, she had been working as a labor and delivery nurse at the San Antonio hospital for about a year and a half. She decided to go into nursing after seven years at home raising her young kids, inspired by the complicated birth of her own son and the impact her nurses at the time had on both their recoveries. At the hospital, which sees a large number of high-risk pregnant patients from across the region, Wilson said she often volunteered to work on difficult cases involving fetal loss. Several of her friends had miscarried, and she wanted to be the nurse who supported other patients through it: "It's always hard, but usually, you know, you go and you cry for your five minutes in the closet once things are over, and then you move on."
By September 2021, though, caring for these patients became much scarier in Texas. That's when Senate Bill 8 went into effect, banning nearly all abortions after about six weeks of pregnancy, and allowing virtually any person to sue anyone they suspected of "aiding and abetting" the procedure. The most restrictive abortion law in the country at the time, S.B. 8 included only an ambiguous exception for "medical emergencies," resulting in hospitals delaying or denying care to people with pregnancy complications for fear of liability, and leaving providers worried they could be sued for tasks they had previously been doing without a second thought in their day-to-day work, including miscarriage management. By last summer, things had become even harder at Wilson's hospital and across the state: Following the Supreme Court's June 2022 decision in Dobbs v. Jackson Women's Health Organization, Texas banned all abortions, with only narrow yet vague exceptions to save the life of the pregnant person and a potential penalty of life in prison for physicians. "It meant no longer providing the standard of care that we would have prior to Dobbs," Wilson said. "It meant patients sitting there for days, actively losing nonviable pregnancies, and us waiting for something to go bad enough that we could help them."
Wilson left her job soon after. "There were a couple of cases just within a few weeks of each other that I really, really, really struggled with," she told me, including the patient who miscarried at 19 weeks pregnant. "And it was enough to say, You know what? I'm not doing this anymore."
Almost every provider I spoke with has thought about leaving their practice or leaving Texas in the wake of S.B. 8 and Dobbs.
She's not the only one. More than a year and a half after Texas implemented its six-week abortion ban, and months after Dobbs, medical providers say they are facing impossible situations that pit their ethical obligation to patients who are dealing with traumatic and dangerous pregnancy complications against the fear of lawsuits, loss of their medical licenses, and incarceration. The problem is encapsulated by a lawsuit filed this month in Texas, in which five women and two OB-GYNs sued the state over the abortion bans that they say have created so much confusion and fear among providers that it has affected women's health and even threatened their lives. Unsure of how to comply with the new rules, hospitals have interpreted them differently, with some requiring approval from attorneys or ethics boards for physicians to provide abortion care in medical emergencies, and others leaving it up to individual doctors, with little guidance or support. This has meant that some physicians wait until patients are near death to intervene in medical emergencies, according to recent research, court filings, news reports, and interviews. "I'll get consults from another doctor asking me what to do in a particular casea mother bleeding, or a pregnancy where there's an infection in the womb before the baby can survive outside the womb. I have doctors calling me, hesitating, not quite knowing what to do because the baby has a heartbeat, when clearly the mother's life is at risk," John Visintine, a maternal fetal medicine specialist in McAllen, Texas, told me. "These are things that I haven't seen in, you know, 20 years of practicing OB, 14 years of practicing high-risk OBI've never run into these situations where people are wondering what to do."
The inability to provide what they say is the standard of care to pregnant patients is taking a toll, personally and professionally, according to interviews with more than a dozen doctors and nurses across Texas. And it's causing many, like Wilson, to reconsider the future of their career in the state. Almost every provider I spoke with for this story has thought about leaving their practice or leaving Texas in the wake of S.B. 8 and Dobbs. Several have already moved or stopped seeing patients here, at least in large part because of the abortion bans. "If I was ever touch a patient again, it won't be in the state of Texas," said Charles Brown, chair of the Texas district of the American College of Obstetricians and Gynecologists (ACOG), who stopped seeing patients last year after decades working as a maternal fetal medicine specialist. Many asked that their hospital affiliation not be included in this story, in some cases because they feared consequences from their employer or the public for speaking out about these laws, even though they're not breaking them. Some worry about what will happen to their own kids if they are targeted. Several cried through the interviews. Many of those I spoke with who haven't left yet are still thinking about it regularlypeople who have family and homes and lives in Texas and would not otherwise have considered moving.
Brown put the stakes bluntly: "Are people quitting? … The answer is yes," he said. "I hope I'm 100 percent wrong about this, but I think it's a much bigger trend that's going to become obvious pretty quickly."
After she finished her OB-GYN residency in Chicago in 2020, Yue Guan took a job in Fort Worth to be close to her family and support system in Texas. But the past year and a half has put in stark relief the differences in basic maternity care between Illinois, where abortions are legal up to about 24 weeks, and where she now practices.
This is especially true for patients at her hospital, many of whom are uninsured and don't have access to preventive health care or early prenatal care. "For some of them, an issue with the pregnancy, like a fetal anomaly that wouldn't be compatible with life, would not be discovered until much later," she said. "So it's so many more degrees more difficult for them." At that point, if they wanted to terminate a nonviable pregnancy, their options for traveling out of state would be even more limited, and would require financial resources that many don't have. The current abortion bans do not include any exception for severe fetal anomalies. Since the six-week ban went into effect, Guan said she's had patients carry and deliver babies that they knew wouldn't survive, because they didn't have another option: "This definitely hits this population in a different, much more malicious way."
In one case, she said a patient came to the hospital with a premature rupture of membranes, then found out the fetus had a severe anomaly that it likely would not survive. Generally, when a patient's water breaks early and they are close to viability, they may be given antibiotics to try to prolong the pregnancy, Guan said. "This patient told us she wanted to decline the antibiotics so she could get sick enough so that we would offer her an abortion. And eventually she did get infected, and was delivered for that reason."
Guan said she questions her future practicing in Texas each time she sees a case like this. "It doesn't feel very sustainable for me in the long run, to feel like I'm not allowed to be a doctor," she said. Most of her friends stayed in Chicago where they trained, or moved to other states that aren't subject to abortion bans. "A lot of them feel like, If this is the toll that it's going to take on me, I should just move, or find some other kind of position where I'm not going to be exposed to these patient cases. But I also feel like if anything, that makes the problem worse, right? If every OBlet's say every OB you talk to who felt similarlydecides to leave the state, we just have fewer OBs here, even less access for these patients. And that doesn't feel like a viable solution."
This is all happening as Texans can't afford to lose more access to medical care. In 2022, 15 percent of the state's 254 counties had no doctor, according to data from the state health department, and about two-thirds had no OB-GYN. Texas has one of the most significant physician shortages in the country, with a shortfall that is expected to increase by more than 50 percent over the next decade, according to the state's projections. The shortage of registered nurses, around 30,000, is expected to nearly double over the same period. Already, Texans in large swaths of the state must drive hours for medical care, including to give birth. According to recent research from the nonprofit March of Dimes, it is among the worst states for maternity care access, which has decreased in a dozen Texas counties in the past two years, mostly due to a loss of obstetrics providers.
This doesn't yet take into account the effects of increased criminalization of abortion care, which is further compounded by dramatic pandemic-induced burnout among clinicians. As physicians retire, hospitals are struggling to replace them; as nurses burn out or leave for more lucrative travel nursing roles, their positions are sitting open. There have been a string of policies and factors that have stretched providers in Texas for many years, from having the highest uninsured rate in the country to low Medicaid reimbursement rates to the demonization of science to attacks on transgender health care, and now the abortion bans, according to Tom Banning, the CEO of the Texas Academy of Family Physicians. "The first rule of holes, when you're trying to get out of the hole, is to stop digging," he said. "We just continue to dig the hole that we're in deeper."
"It's crisis-level staffing for the majority of rural Texas hospitals."
John Henderson
This is an issue for both urban and rural areas, but it's felt most acutely outside major metros, where one retirement or move can be the difference between having access to medical care near home or having to drive an extra several hours. The state has experienced the most rural hospital closures in the country in recent years. Less than half of rural hospitals nationwide still have labor and delivery services, according to recent research from the Chartis Center for Rural Health; in Texas, that number is just 40 percent. John Henderson, the president and CEO of the Texas Organization of Rural and Community Hospitals, said he gave a presentation this fall for a group of representatives from about 100 rural Texas hospitals where he asked them to raise their hand if they don't currently have openings for registered nurses. "There were three out of 100 that were fully staffed, and I was actually surprised that there were three," he said. "It's crisis-level staffing for the majority of rural Texas hospitals." Maternity wards have long been the sacrificial lamb for cash-strapped rural hospitals trying to save money and keep their doors open, but more recently, it's short staffing that has forced closures and cuts to services in Texas and across the country.
For more than a year during the pandemic, for example, Big Bend Regional Medical Center in Alpine, the only hospital for 12,000 square miles, regularly closed its labor and delivery unit for days at a time after most of the unit's nurses quit. Hereford Regional Medical Center, in the Texas Panhandle, sometimes sent patients 50 miles northeast to Amarillo when the hospital didn't have enough nurses to deliver babies. Doctors spanning from Huntsville, in East Texas, to the Permian Basin told me they've had to fill in more and more as their hospitals have struggled to recruit new physicians after others retired.
In Sweetwater, 40 miles west of Abilene, Rolling Plains Memorial Hospital's labor and delivery unit lost at least four nurses who left for higher-paying travel nurse positions during the pandemic, according to Jennifer Liedtke, a family medicine physician and the unit's director. The hospital has been actively trying to hire a full-time OB-GYN for more than two years. Even under normal circumstances, in an overstretched hospital like hers, she said, "You're not just the postpartum nurse, you're not just the laboring nurse, you're not just the newborn nurse, you're all of those things."
And when there isn't a fully staffed hospital nearby, it can be harrowing for patients. After one local hospital, about 30 miles from Sweetwater, closed its maternity ward years ago, it started sending patients in need to Liedtke's unit. Recently, a patient was transferred to her care who was hemorrhaging and needed a common procedure to stop the bleedingbut because no one at the other hospital could do the surgery, she had to instruct the nurse over the phone on how to slow the bleeding and tell her to get the patient to Sweetwater as fast as possible.
Liedtke and others are concerned these gaps will only grow now that new doctors training in obstetrics are unable to learn the full scope of pregnancy and abortion care in Texas. Already, residencies and recruiters are reporting a hesitancy among new and seasoned doctors to practice in states with abortion bans, and some programs are sending current residents out of state for training rotations where available so they can meet medical standards. Guan, who works with residents at her hospital, said she reminds them that certain ways pregnancy complications are now managed in Texas are not the standard of carethat this is not the way these situations are treated everywhere. The scarcity also raises the stakes: When there are limited providers, the importance of each one knowing how to deal with complicated situations is higher, Banning said: "There's no safety net."
Unlike what she's heard from physicians at some larger hospitals, Liedtke said she hasn't yet had a problem treating pregnancy complications under the abortion bans. It's not that she's not getting these patients, but each time she does, she's able to call up her boss on the hospital's administrative team to get permission to intervene, which thus far has been granted.
Still, she's felt the impact of the new laws on her practice. On the day we spoke in November, Liedtke said she had gone to three different pharmacies in town to try to get a prescription filled for methotrexate. The drug can be used to end a pregnancy, and Liedtke needed it for a patient who came to the emergency room with an ectopic pregnancy, which is nonviable and life-threatening if left untreated. Despite an explicit exception for ectopic pregnancies in Texas abortion law, Liedtke said the physician who first saw the patient didn't want to prescribe the drug, and the big pharmacies in town won't fill it anymore. Eventually, her neighbor, who's a pharmacist, agreed, provided she fax over the ultrasound. The personal relationships are critical, she said: "My neighbor knows that I don't do elective abortions, I only do them when there's medical indication. And we go to church together, and he knows that."
Across Texas, physicians and nurses described a sense of being pulled between the individual stress of trying to navigate care in this environment and broader concerns about who will fill in the gap if they leave. In the Rio Grande Valley, on the Texas-Mexico border, John Visintine, the McAllen OB-GYN, said he is one of just a few maternal fetal medicine specialists who provide care for people with high-risk pregnancies, complications, and fetal anomalies in a region of about 1.5 million people. The population is predominantly poor, with one of the highest uninsured rates in the country, and many people can't travel out of the region because of their immigration status. Visintine said he's been told by attorneys not to even discuss the option of going out of state for an abortion with patients, including when the fetus has such severe birth defects that it will not survive. He's not the only one receiving this message. But withholding that information feels so unethical that he, too, has contemplated leaving his practice. "To be left with the option of either potentially breaking the law and putting myself, my family, at risk, or not offering the options to a patient and not meeting her needs and providing careI think it's a tragic, horrible situation to be in," he said. "And then if you leave, you know, there's so many women that need care in this area. Do we just abandon the women of South Texas?"
Some providers have moved to states like New Mexico and Colorado following S.B. 8 and Dobbs to continue to care for Texans now traveling out of state. Alireza Shamshirsaz, an OB-GYN and fetal surgeon who for more than a decade worked at Texas Children's Hospital in Houston and saw patients from Texas and across the South, told me that the new restrictions prompted him to accept another job offer after years of declining them. Last summer, he left his home in Houston and moved with his family across the country for a position at Boston Children's Hospital. For Lee Bar-Eli, a family medicine physician in Houston and board member of Doctors in Politics, the abortion ban was the latest in a slew of factorsincluding feeling unsupported and disillusioned during the pandemic as a doctor and later as a long-COVID patientthat led her to take a break from practicing medicine, beginning last January.
"So far I haven't left. You think, Well, if this happens, then I'm leaving. You know, I said the same thing before the Dobbs case was decided."
Shanna Combs, OB-GYN in Fort Worth
Others are considering what their breaking point would be. "We talk about what we take on as health care providers," said Shanna Combs, an OB-GYN in Fort Worth. "Something happens, just throw it in the bag, just throw it in the bag. So you have this constant weight, being weighted down by this heavy backpack of burdens, and this has just continued to add to that," she said of the abortion ban. "At the end of the day, I just want to take care of my patients and provide the best care for them. And this is just another layer that makes you question what you're doing." In November, Combs, who is president-elect of the Texas Association of Obstetricians and Gynecologists, told me that if contraception is further restricted, that would be the final straw for her to move. When we spoke again early this year, I mentioned a recent court ruling that bans Texas teens from getting birth control from federally funded clinics without their parents' consent. So, has anything changed? "So far I haven't left," she said, laughing. "You think, Well, if this happens, then I'm leaving. You know, I said the same thing before the Dobbs case was decided."
The Texas lawsuit filed this month, the first of its kind, does not seek to block the abortion bans, just to clarify the scope of the medical exceptions and affirm that doctors have discretion to provide abortion care when the pregnant person's health is at risk. At the Texas Capitol, Democrats have filed bills in the current legislative sessionthe first time the state Legislature has met since 2021that also seek to clarify current exemptions, and widen them slightly to include lethal fetal anomalies, rape, and incest. But supporters of the restrictive laws have generally shown little appetite for even these changes, instead blaming doctors for denying care to pregnant patients and medical associations for not giving clear guidance. They've instead pushed measures to further criminalize abortion access.
Charles Brown, the ACOG chair, worries that absent clarity and changes from state leaders, a mass exodus could soon occur. "We have not had the front-page photo of the doctor in handcuffs yet. When that happens, I think that will be the napalm," he said. "Once that first arrest is on the front page of the paper, that will be a defining moment for a lot of people." For Combs, who recently traveled to Austin to meet with legislators about changes to the abortion laws, the question of whether to leave Texas is "something that sits in the back of my mindprobably not a day that goes by where I don't think, Huh, is this where I really want to be?" she said. "I like to say, 'I choose every day to stay.' "
The precariousness of this moment informs every conversation: What if Liedtke's neighbor wasn't a pharmacist? What if a patient sent home to wait for sepsis lived just a few minutes too far from the hospital to make it back in time? (Has this happened already?) What is the breaking point for so many doctors and nurses who are already thinking about leavinghow much heavier can the backpack get before it rips? How much deeper can we dig this hole before we can't get back out?
Providers in Texas have been navigating care under a near-total abortion ban for the longest time of any state in America. But this conflict over whether to stay or go is also playing out across the dozen other states that have banned abortion care following Dobbs. And while those working in reproductive health care are most directly affected by these abortion bans, doctors I've spoken to warned it doesn't end with them. Cancer doctors are wondering if they can treat pregnant patients. Some providers who can become or want to become pregnant are considering moving away or are hesitating to come to states with abortion bans for their own safety, physicians told me. Others with kids already are making similar calculations. "It's everything," Brown said. "They don't want to live in a state where their children can't get health care."
Before the Dobbs decision, Leah Wilson, the nurse in San Antonio, had the next few yearseven the rest of her careermapped out. She would continue to work at the hospital as a labor and delivery nurse, then get a master's degree in midwifery and become a certified nurse midwife. She and her husband would raise their three kids in the Texas city where she grew up, and where the two of them met at church more than a decade ago.
Now, everything has changed. She and her family are packing up their home to put it on the market. Later this spring, they'll move to Utah, where her husband will be stationed with the Air Force.
In October, Wilson quit working in the hospital in favor of a new job, as a nurse home visitor. She gets to help new mothers that way, and she'll be able to keep that job in Utah. But she's watching as further abortion restrictions now wind their way through the Utah Legislature and courts. At this point, she doubts she'll ever go back to working with patients in a hospital setting. "It's just too uncertain," she said. When her husband retires from the Air Force in three years, they may move the family to Colorado, or perhaps farther west. But they won't return to Texas.
"I loved coming back, being able to share that with my children. And it is hard to leave a place that really does feel like home. But we don't want them growing up here," she said. "I definitely don't want my daughters having kids in Texas. I know that."
