Teresa Kim Pecinovsky is terrified she will have a miscarriage.
The 38-year-old Houston mother of two children is in the second trimester of a high-risk pregnancy, but uncertainty about Texas abortion laws means that she 鈥� and her gynecologist 鈥� are worried about her access to proper medical care if that nightmare were to come true.
鈥淪he actually couldn't give me a solid answer, which was horrifying to me,鈥� said Pecinovsky, who is an ordained minister.
Late last year, the lesser-known abortion restriction known as went into effect, in Texas for medical personnel to administer the ulcer drug misoprostol to induce an abortion after seven weeks of pregnancy.
Misoprostol is commonly used for miscarriages, and the law doesn鈥檛 outlaw the drug鈥檚 use for that.
But Pecinovsky鈥檚 doctor worried that a pharmacist will misinterpret the drug鈥檚 prescribed use and refuse to provide misoprostol for a miscarriage. Already, are reporting prescription holdups due to the confusion about the law.
鈥淚t鈥檚 awful and hard enough when you have a pregnancy and you miscarry. And then to have to think about all of this extra layer of legality, psychological and emotional distress placed on you now that these laws are in effect,鈥� Pecinovsky said.
The new state abortion restrictions, including , which passed last year and bans most abortions after about six weeks of pregnancy, have made care for pregnant people more challenging than ever, providers say.
Some say they are holding back when they need to outline medical options for their pregnant patients, particularly in the cases of those with high-risk pregnancies.
鈥淚t's a challenging situation where politicians are interfering with the patient-physician relationship,鈥� said Dr. John Thoppil, president of the Texas Association of Obstetricians and Gynecologists.
The impact of Texas abortion restrictions doesn鈥檛 stop with current patients. For medical students considering obstetrics and gynecology as a career, it means they now have to leave Texas if they want to get hands-on training in abortion care 鈥� what doctors call a vital part of comprehensive women鈥檚 health care and needed training in case a pregnant patient鈥檚 life is at risk.
鈥淭heir training is diminished because they鈥檙e very interested in comprehensive women鈥檚 health care, which includes women having pregnancies that they might not want to continue either electively or because of the health issue or because it鈥檚 a product of sexual violence,鈥� said Dr. Tony Ogburn, professor and chair of the University of Texas Rio Grande Valley鈥檚 Department of Obstetrics and Gynecology. 鈥淎nd those things are not really available to them now.鈥�
Now, Texas lawmakers are set to ban most abortions altogether if the U.S. Supreme Court overturns the landmark abortion ruling Roe v. Wade in deciding a challenge to , expected next month.
That seems likely considering a from the court, and if that happens, caring for 鈥� and even counseling 鈥� patients with high-risk pregnancies will become even more complicated, medical providers say.
Post-Roe threats to health care
If Roe is overturned, a 鈥� in Texas would go into effect 30 days later that would ban abortion from the moment of fertilization, and it offers no exceptions for rape, incest or conditions in utero that are likely to result in the death of the baby. Violators of that law 鈥� those who perform an illegal abortion, and those who aid someone who is seeking one 鈥� would face second-degree felony charges.
Under SB 8, anyone who performs an abortion or helps someone with obtaining an abortion after cardiac activity is detected in an embryo 鈥� usually about six weeks into a pregnancy 鈥� could face a lawsuit. Diagnosis and treatment of patients experiencing pregnancy complications often occur well beyond that point.
But OB-GYNs and others who care for pregnant people say that if Roe v. Wade is overturned, even early detection and treatment of potentially life-threatening problems will become more difficult, and sometimes impossible.
鈥淭he changes in the laws and the regulations that may potentially come into play [with new laws triggered by the overturning of Roe v. Wade] will make it more challenging to provide optimal women鈥檚 health care,鈥� Ogburn said. 鈥淭hat does worry patients, and it worries providers, too.鈥�
For health care providers, navigating last year鈥檚 new restrictions has meant constantly evaluating what they need to do as caretakers and considering what they can tell patients without risking costly lawsuits or worse.
鈥淭he whole atmosphere [brought by the restrictions] 鈥� has created a real cloud of suspicion and fear among a lot of people,鈥� Ogburn said. 鈥淭here鈥檚 concern that if you even talk to someone about what their options are, that you鈥檙e at risk of someone filing suit against you. 鈥� There鈥檚 just been a lot of anxiety around that.鈥�
Threat to life
While supporters of Texas鈥� abortion restrictions only target those wanting to terminate their pregnancies, those restrictions could mean higher maternal mortality rates among those who want to carry a pregnancy safely to term, said Dr. Stephanie Mischell, a provider at a medical facility in Dallas and a fellow with Physicians for Reproductive Health.
鈥淓ven things like miscarriages can be impacted by abortion bans because so many of the treatments are regulated the same way,鈥� Mischell said. 鈥淭his is something that I think really impacts everybody, not only the people who are seeking abortions.鈥�
In Houston, Pecinovsky is at a high risk of miscarriage and complications not only because of her age but also because she has rheumatoid arthritis, which increases the likelihood of premature delivery.What worried Pecinovsky鈥檚 gynecologist is the lesser-known SB 4 that and singled out two popular OB-GYN drugs, mifepristone and misoprostol.
Thoppil said pharmacists across the state have expressed apprehension to the Texas Association of Obstetricians and Gynecologists about providing OB-GYN medication. One Austin pharmacy refused to fill a prescription for the treatment of an ectopic pregnancy 鈥� when a fertilized egg grows outside the uterus 鈥� due to misunderstanding around Texas鈥� new anti-abortion laws.
鈥淭hey鈥檙e also afraid. We鈥檝e had some pharmacists reach out to us as an organization, asking for clarity because they鈥檙e concerned about their scenario,鈥� Thoppil said. 鈥淭here鈥檚 a lot of unknown here.鈥�
Abortion-inducing medication is , according to Texas Health and Human Services.
But it also has a broad range of other uses in obstetrics and gynecology, according to the U.S. National Institutes of Health, including medical management of miscarriage, induction of labor, cervical dilation before surgical procedures, and treatment of postpartum hemorrhage.
The medication, developed in 1973 to treat peptic ulcers, is on the World Health Organization Model Lists of Essential Medicines because of its wide range of uses in the area of reproductive health.
鈥淕iven its low cost and ease of use, misoprostol has the potential to improve women鈥檚 health worldwide,鈥� a 2009 says.
Without medical assistance during a miscarriage, especially later in the pregnancy, the patient faces risks such as deadly hemorrhaging and sepsis.
Texas abortion laws make exceptions for the procedure if the mother鈥檚 life is in danger, but even that is fraught with uncertainty, doctors say.
鈥淧hysicians can now be second-guessed about, 鈥榃ell, was her life really in danger?鈥� and it鈥檚 always somebody looking in hindsight,鈥� Ogburn said. 鈥淚f your kidneys are failing because of your severe preeclampsia at 18 weeks, is that life-threatening? Some people will say, 鈥極h, no, you could have dialysis,鈥� whereas others would say, 鈥楴o, that is life-threatening.鈥� 鈥� It鈥檚 not spelled out in the law.鈥�
Dr. CeCe Cheng, a maternal fetal medicine specialist in San Antonio, performs abortions as only a small part of her practice, but sometimes she has to help expectant parents make difficult, life-saving decisions about terminating a pregnancy for medical reasons.
Today, her hospital requires her to involve leadership and staff across departments when deciding whether a complication threatens a pregnant patient鈥檚 life.
Most of her patients are well into their pregnancies, referred to her when they have concerns about complications like fetal abnormalities or other medical conditions, and sometimes a mother鈥檚 health risk may not be immediate or obvious.
A pregnant patient may need chemotherapy for cancer but in the rare case that the fetus can鈥檛 tolerate the prescribed dosage, termination of the pregnancy may be the only way to allow her to get life-saving treatment.
For those and other potentially life-threatening complications, Cheng said, 鈥渕y only options now are to refer out of state or wait.鈥�
鈥淚 have to wait until my patient comes in with an emergency,鈥� Cheng told The Texas Tribune after the new restrictions went into effect last year. 鈥淲ait until the patient is bleeding profusely. Wait until there are signs of infection. Wait until the patient goes into labor, which for some may not ever happen.鈥�
The lack of an exception in the current restrictions and in the trigger law for what are known as 鈥渓ethal fetal anomalies鈥� 鈥� conditions that are typically diagnosed well past the first six weeks of pregnancy and make it impossible for an embryo to develop or a fetus to survive 鈥� can have some devastating outcomes for both the patient and the fetus, doctors say.
A striking example is , a fetal congenital condition in which the baby develops without most of its brain and skull. The problem typically develops early in the pregnancy, and if the fetus survives through birth, the baby dies within hours or days. Anencephaly is considered one of the most lethal congenital defects, with a death rate of 100% in the first year of life.
And as long as the fetus has a heartbeat 鈥� even if there is no brain activity and never will be 鈥� terminating a pregnancy for anencephaly is illegal. If Roe v. Wade is overturned, it won鈥檛 be allowed from the moment the egg is fertilized.
鈥淚f [a fetus] is diagnosed with something that鈥檚 truly incompatible with life, such as anencephaly, that woman then has to carry that pregnancy to term鈥� if it can鈥檛 be terminated, Ogburn said. 鈥淭hat increases her risk, because carrying a pregnancy to term physically is more dangerous than terminating when that鈥檚 diagnosed 鈥� but it鈥檚 also the emotional toil of that.鈥�
Overhauling the script
When one of Thoppil鈥檚 patients became pregnant unintentionally while using an intrauterine device 鈥� one of the most effective forms of birth control 鈥� the Austin OB-GYN said he felt like his hands were tied.
His patient was at high risk of complications for other reasons, he said, but because fetal cardiac activity had been detected, she fell under the current Texas abortion ban.
Thoppil did not believe he was free to explicitly mention abortion as a medical option without risking a lawsuit because of the way the law is written.
鈥淚 can鈥檛 really talk about what options are available to you due to the current legal climate,鈥� he said he tells patients now. He pointed out the state鈥檚 new laws and hoped she would be able to think through her situation on her own.
Cheng, in San Antonio, doesn鈥檛 use the word abortion anymore in her conversations with patients about their medical options 鈥� her hospital has asked her to try to be nonspecific.
But she gives them as much information as she can because she sees counseling patients about their options as part of her responsibility.
鈥淚 don鈥檛 say anything specific, but I do still talk about the options and let them know that there are other options out of state if that鈥檚 what they need,鈥� Cheng said.
Since Texas鈥� new abortion restrictions went into effect, three lawsuits have been filed against Dr. Alan Braid, a San Antonio doctor to bring a challenge to the law. There have been no public reports of additional lawsuits.
Limiting training
It鈥檚 too early to tell if Texas鈥� restrictions, both the current ones and any new restrictions that may come this summer, will have any effect on overall interest in the field of obstetrics and gynecology here, Ogburn said. But the state鈥檚 abortion laws have hindered the ability of Texas medical schools to offer the range of training most OB-GYN students want.
National standards for medical schools require them to offer abortion care training and residency rotations to OB-GYN students. The training is not required to complete a medical degree, said Ogburn, a member of the Accreditation Council for Graduate Medical Education that reviews OB-GYN programs鈥� course requirements.
Even so, most students ask for the training, he said 鈥� but the number of abortions in Texas has drastically fallen both in clinics and at the UTRGV medical school, where they were mostly done for medical reasons. That has made the on-site training opportunities practically disappear for medical students in residency in Texas, he said.
Instead, UTRGV is sending its OB-GYN students out of state to get that training, and Ogburn said he knows other Texas schools are doing the same. It鈥檚 unclear how long that would be sustainable, he said, and many students may not be able to leave their lives, jobs or families for weeks on end to do residential training somewhere else.
Current students could decide to leave Texas once they graduate so they can practice in a state that allows them to give women the full spectrum of pregnancy and abortion care.
Also, prospective students could choose to attend medical school in another state to get the skill set they want.
鈥淚 can tell you that the residents are frustrated and angry, and disappointed,鈥� Ogburn said. 鈥淣ame an emotion, and I鈥檝e experienced that with my residents over the last six months. Because the patients haven鈥檛 gone away.鈥�
Meanwhile, in Houston, Pecinovsky is entering the most critical period for her pregnancy.
As a patient who was once excited about bringing her third baby into the world, the uncertainty around whether she鈥檇 be able to get necessary treatment should tragedy strike 鈥� compounded by her own doctor鈥檚 trepidation about it 鈥� has 鈥渃louded the joy I initially felt.鈥�
She said she鈥檚 felt a dramatic difference navigating pregnancy care this time around.
鈥淚t鈥檚 just really unbelievable,鈥� she said. 鈥淎nd yet it is believable because of the day and age we live in.鈥�