Physicians’ Rights and Patients’ Safety: Protecting Miscarriage Care Access in Texas

Executive Summary

Following the 2022 Dobbs v. Jackson Women’s Health Organization ruling, abortion access in Texas was banned, and, thus, health care providers who perform or aid in an abortion face severe legal consequences. However, unclear guidelines blur the distinction between miscarriage care and abortion. As a result, Texas health care providers, pregnant individuals, and lawmakers live in a climate of uncertainty and even fear regarding legal miscarriage treatment, putting the lives of pregnant individuals at risk. 

In this report, we focus on the impact of Texas laws and the use of therapeutic abortion in cases of emergent conditions and miscarriages. The abortion laws passed in 2021 resulted in unclear guidance for differentiating between miscarriage and elective abortion care. This places legal pressure on physicians, builds barriers to treatment, and puts patients’ lives at risk. To address this, we recommend the Texas Medical Board clarify standards for medical procedures used to treat miscarriage, which involve abortion-inducing medications and operations, and the creation of a Continuing Medical Education (CME) module to keep physicians up-to-date on these policies. By addressing these challenges, the state’s medical agencies and providers can transcend the boundaries of politics and improve access to reproductive health care, protecting the lives of pregnant individuals. 

Legal Barriers to Essential Miscarriage Care in Texas

Miscarriage is defined as the sudden loss of pregnancy before 20 weeks.[1] Up to 20% of confirmed pregnancies end in miscarriage and half of these cases require medical intervention.[2] If left untreated, miscarriage can be life-threatening for the pregnant individual. However, treatment of miscarriage could be considered illegal under current Texas law, which blurs the line between miscarriage and abortion treatments. In some miscarriage cases, physicians must decide whether to leave a pregnant patient in critical condition or risk legal repercussions and the loss of their medical license for performing an abortion. 

Definitions: Miscarriage and Medical Abortion

To interpret the impact of the law, it is crucial to distinguish between miscarriage and medical abortion. According to the National Institutes of Health’s medical encyclopedia, miscarriage — also known as spontaneous abortion — is defined as the natural and “spontaneous loss of a fetus before the 20th week of pregnancy.”[3] This may occur for various reasons, including genetic abnormalities, drug abuse, exposure to toxins, smoking, or failure of the fetus to thrive for unknown reasons. Medication abortion is clinically defined as “the use of medicine to end an undesired pregnancy” and can be performed for elective or therapeutic reasons.[4] Elective abortions are performed because a woman chooses to end a pregnancy, while therapeutic abortions are conducted to preserve the health of the woman.[5] 

Current Texas Abortion Policy

Current Texas policy on abortions is guided by two laws — H.B. 1280 and S.B. 8 — both passed in 2021 and went into effect with the overturning of Roe v. Wade. H.B. 1280 — which we refer to as the abortion ban trigger law —outlawed abortion at any stage of pregnancy and subjected doctors to criminal and civil penalties unless the pregnant patient is facing a “life-threatening physical condition.”[6] A life-threatening physical condition, is determined by a physician’s “reasonable medical judgment,” and is defined as a “condition aggravated by, caused by, or arising from a pregnancy that places the female at risk of death or poses a serious risk of substantial impairment of a major bodily function unless the abortion is performed or induced.”[7] S.B. 8 — which we refer to as the Texas Heartbeat Act — prohibited abortions once a fetal heartbeat is detected (at approximately six weeks), except in situations where “a physician believes a medical emergency” exists, yet the bill does not define what medical emergency means in cases of miscarriage.[8] Ultimately, the language used in the laws leaves the physician responsible for interpreting what qualifies as life-threatening or a medical emergency and when they can legally act. 

In June 2022, the Supreme Court case, Dobbs v. Jackson Women’s Health Organization, overturned Roe v. Wade, a ruling that established the constitutional right to abortion for almost 50 years.[9] The court determined that states are responsible for abortion policies. As a result, the Texas abortion ban trigger law went into effect, prohibiting all abortions except in cases where there is a life-threatening condition to the pregnant person. A physician can be charged with a first-degree felony punishable by an up to life-long prison sentence, “if an unborn child dies as a result of [an abortion].”[10] The physician also faces civil penalties, punishable by over a $100,000 fine for each charge and revocation of their medical license.[11] 

However, the lack of clarity on what is legally defined as a medical emergency or life-threatening condition forces physicians to place their patients’ miscarriage into one of three categories: 

• Emergent. 
• High risk to become emergent. 
• Nonemergent. 

Only patients qualifying as an emergent case, whose health is in serious jeopardy or is at immediate  risk of serious impairment to bodily function or serious dysfunction, can be treated for their miscarriage within the bounds of Texas law. But Texas courts have defined emergent as meaning within a few hours without care. For high-risk cases, if a patient is at high risk of having a maternal health concern or miscarriage later in the pregnancy, either days or months later, the physician must wait to perform any treatment until their condition becomes emergent. By the time a high-risk condition is considered emergent, the health of the pregnant individual may be severely compromised, including their ability to conceive and carry a pregnancy to term in the future. 

In addition, for all cases, if a fetus’ condition is terminal within or outside of the womb, the patient must continue the pregnancy. This mentally and physically impacts the pregnant individual, who is forced to continue a dangerous pregnancy knowing the fetus will likely die and risk their own life or future fertility. The lack of a clear directive on how physicians can practice miscarriage and reproductive care has and continues to put the state at the forefront of abortion litigation.[12]

The Evolution of Texas’ Politics on Reproductive Care

The near-total restriction to life-saving miscarriage care is the culmination of decades of increasingly restrictive abortion policies in Texas. In 2003, H.B. 15 — or the Woman’s Right to Know Act — placed delays in treatment by requiring pregnant individuals to wait 24 hours between consultation and getting an abortion.[13] This act also restricts abortion procedures after 16 weeks to ambulatory surgical centers or licensed hospitals. At the time, none of Texas’ 54 nonhospital abortion providers met this standard, which consequently limited pregnant patients’ access to facilities able to perform an abortion procedure.[14] 

In 2005, all abortion was banned after 24 weeks.[15] In 2011, H.B. 15 — or the Texas Sonogram Law — amended the Woman’s Right to Know Act and required individuals seeking an abortion to undergo an ultrasound and hear the fetal heartbeat before waiting 24 hours for the procedure.[16] Additionally, effective in 2013, Texas cut family planning grants and directed funding away from family planning providers, such as Planned Parenthood clinics.[17] The subsequent closure of 82 family planning clinics affected low-income women in Texas, as seen in the reduced usage of highly effective methods of contraception and increased number of Medicaid-paid deliveries.[18]

Other restrictive abortion laws were passed in the following decade as a result of lobbying efforts. The Texas Abortion Insurance Opt-Out Act (H.B. 214) was passed in 2017 and removed insurance coverage for abortions and forced pregnant patients to pay for the procedure out of pocket.[19] Later in 2021, the Affiliate Ban Rule (Tex. Govt. Code §2273.003), prevented the allocation of state funds to facilities that provide abortion care as a service.[20] This and further deprivation of state funding led to the large-scale closure of many family planning clinics and reduced access to abortion services and general reproductive care — such as cancer screening, preventative health care, and effective birth control — across Texas.[21] 

As a result of restrictive abortion laws and decreased funding to family planning providers, Texas observed reduced access to reproductive care and a corresponding increase in maternal mortality rates.[22] In 2012, the maternal mortality rate in Texas was nearly double the national rate, highlighting the tangible consequences of these strict Texas laws in maternal health.[23] More recent data has observed increased infant and neonatal deaths in Texas in 2022 following abortion restrictions.[24] The stringent restrictions toward abortion access extend beyond abortion services into women’s and individuals’ access to reproductive health information and care, contraceptives, and family planning resources.[25]

Total abortion restriction laws have dire consequences for women’s and pregnant individuals’ health care overall. They compromise physicians’ ability to provide the best standard of care for their patients. Nearly 6.3 million women of childbearing age in Texas are at risk of lowered access to quality health care.[26] These laws create barriers in the physician-patient relationship, with doctors being forced to worry about their livelihood instead of the pregnant patient’s best interests. For the safety of pregnant patients in Texas, it is critical to transcend political boundaries and ensure access to timely and life-saving care.

Barriers To Adequate Miscarriage Care

The Texas Heartbeat Act restricts abortion in the state with exceptions for medical emergencies. Unfortunately, the Texas Heartbeat Act fails to account for complicated miscarriages that are not immediately emergent. 

Several Texas patients have publicly shared their stories describing the impact of these bans on their health, including Erin Snider.[27] Snider was denied care for her miscarriage despite no fetal heartbeat. Instead, Snider was sent home with a pain reliever not strong enough to deal with her pain or her other symptoms. Ensuing symptoms prevented her from going to work and drove her to the bathroom floor. After returning to the emergency room, she was finally treated for the miscarriage. Afterward, the doctor informed her that the Dobbs decision now affects how pregnant patients are treated; as Snider noted, “Lawyers, not women’s lives, were now the overriding concern” in the emergency room.[28]

The experience shared by Snider is not an isolated incident. Rather, many physicians find themselves torn between prioritizing a patient’s well-being and following the law.[29] A physician’s commitment to the Hippocratic Oath to “do no harm” is compromised by the threat of legal persecution for providing necessary care.[30] This threat leads to delayed or denied care for patients seeking miscarriage treatment. Lack or denial of treatment puts the patient at higher risk for dangerous complications as well as physical and emotional distress. 

In March 2024, as a result of pressure from the Texas Supreme Court, the Texas Medical Board proposed guidelines for “medical emergency” exemptions to the Texas Heartbeat Act.[31] However, the published guidelines use the same vague language from existing state legislation, and require documentation of alternative treatments “attempted and failed or were ruled out” and determination of “whether there was adequate time to transfer the patient to a facility or physician with a higher level of care or expertise to avoid performing an abortion.”[32] This vague language continues to force physicians to be unnecessarily cautious and take costly, dangerous delays in deciding how to care for their patients. 

Furthermore, the guideline’s requirement that an “abortion is performed in response to a medical emergency” fails on two accounts: 1) to address cases of miscarriage, and 2) to recognize that the therapeutic abortion procedures may be necessary due to a multitude of medical factors that do not immediately cause severe impairment to the health of the pregnant individual.[33] 

This was evident in the court case Cox v. Texas.[34] Kate Cox sued the state of Texas for denying her an emergency abortion. At the time, Cox was 20 weeks pregnant with an infant diagnosed with Trisomy 18.[35] Carrying the fetus to term would result in infant death in utero and risk her future ability to bear children. The Texas Supreme Court ruled against Cox, citing that her pregnancy complications did not constitute a medical emergency outlined by the current legislation. Judges also indicated the conditions “do not pose the heightened risks to the mother that the exception encompassed.”[36] Cox ultimately left the state to obtain an abortion as her pregnancy condition worsened. 

Cases such as Cox’s highlight the double bind physicians are in: Texas law dictates that physicians should exercise medical discretion; however, in practice, the legal system necessitates costly and time-consuming proceedings for physicians to justify medical interventions. This hinders physicians’ ability to act in their patient’s interest and for their safety. Necessary reforms, such as a more detailed outline of emergent and nonemergent medical risks, will provide a legal framework for physicians to make emergency decisions without facing legal repercussions. 

Texas’ Policy Impacts on Maternal Health Care 

Restrictive laws in Texas passed over the past two decades have created maternal health care deserts in Texas. In 2022, 46.5% of Texas counties are maternity care deserts.[37] This means that almost half of the counties within the state have no hospital providing obstetric care, no birth centers, no obstetricians, and no certified nurse midwives. 

The state is also facing difficulty with recruiting and retaining obstetricians and gynecologists (OB-GYN). From 2022–23, Texas has seen a 6.5% decrease in applications for OB-GYN residency programs.[38] In 2022, the Accreditation Council for Graduate Medical Education updated the requirements for OB-GYN residency programs requiring that programs offer “clinical experience or access to clinical experience in the provision of abortions.”[39] For Texas-based programs, this means residents will have to leave the state for abortion training. In addition, trained medical providers are choosing to leave Texas rather than stay under the threat of legal persecution and watch their patients suffer.[40] As medical students and health care providers continue to leave or choose different specialties, the maternal health care crisis will continue to worsen needlessly. 

Texas needs adept health care providers to improve the maternal mortality crisis. In order to do so, Texas also needs to provide health care practitioners with assistance to navigate the landscape of restrictive abortion law, especially as the current climate is driving them from the state. It is time for the Texas Medical Board to end the atmosphere of uncertainty surrounding miscarriage care by providing clarity to medical professionals on what actions they can take for the well-being of their patients.

Policy Recommendations To Improve Miscarriage Care in Texas

The implications of overturning Roe v. Wade and other Supreme Court rulings continue to impact the relationship between individuals and the health care system in broad and complex ways. Our report focuses on how these policy changes impact those who require miscarriage-related care in Texas. By protecting the rights of patients and their physicians, we seek to open the door to more equitable care in the future and recommend two primary ways the miscarriage care can move forward in Texas: 

• Recommendation 1: Texas policymakers should establish standardized criteria and guidelines that better define miscarriage-related care. 
• Recommendation 2: Texas policymakers should protect physicians’ rights to provide information about all possible relevant procedures for pregnant individuals.

Action Items To Establish Standardized Criteria and Guidelines

The state must have clear guidelines for physicians to follow that protect pregnant patients. To accomplish this, the state should: 1) initiate a task force to develop guidelines for the effective use of therapeutic abortion to ensure patient safety and well-being, 2) integrate these guidelines into the Texas Medical Board’s existing guidelines, and 3) ultimately, amend state law. Three actions to accomplish this are outlined as follows: 

1. We recommend the creation of the Nonpartisan Texas Maternal Health Care Task Force to address issues associated with reproductive and maternal care. The board should be composed of medical experts on miscarriage, including obstetricians and gynecologists, emergency room doctors, and professionals from reproductive health clinics. The board should also include individuals engaged in reproductive health care and abortion laws — such as reproductive rights lawyers, hospital administrators, and lawmakers — and representatives from advocacy groups dedicated to protecting pregnant individuals. The board would function similarly to the existing Texas Maternal Mortality and Morbidity Review Committee but should focus on all areas of maternal and reproductive health care, starting by addressing timely care for pregnant individuals having miscarriages.[41] The board should be independent from any government association.  
    
2. We recommend the Nonpartisan Texas Maternal Health Care Task Force convenes to facilitate civic engagement, gather public statements, and develop guidelines. Texas has a maternal health care crisis. A nonpartisan board focused on tackling the crisis could help reverse the trend. The board should first focus on treatments for miscarriages and provide more concrete guidelines on: 1) emergent conditions warranting therapeutic, medical abortion-inducing operations, 2) medical procedures prohibited by the Texas law that should be exempt in cases of miscarriage, and 3) an emergent-condition checklist to ensure patient safety and well-being, and medical professional security.  
   
   The board should conduct investigations to accurately determine symptoms prevalent in emergent conditions. Task force members should conduct needs assessments and interviews with relevant stakeholders, gather data, and host open sessions in locations throughout the state. Data and information should be shared among members and the public to promote an effective environment for building policy. The board should consider what attributes define an emergent condition. In addition to mortality, the definition of an emergent condition should include considerations of mental health conditions, future fertility, and viability of the pregnancy and the fetus. Mechanisms for evaluating the effectiveness of the emergent-condition checklist should be drafted and implemented to remain updated.  
    
3. We recommend the task force provide the Texas Medical Board with new guidelines for emergent miscarriage care. The Texas Medical Board is responsible for providing full guidance to help physicians better understand what is and is not permitted under state laws. The task force should provide the Texas Medical Board with specific details to include in their guidance.

Action Items To Protect Physicians’ Right to Inform Patients

As a result of the changing legal landscape across the country and in Texas, doctors are hesitant to disclose any information that could be related to abortion due to potential legal consequences.[42] The lack of transparency from health care providers ultimately leads to delays in seeking care, the spread of misinformation, and barriers to accessing reproductive services. We urge Texas policymakers to shield clinicians from professional and legal consequences for sharing health care-related information. We seek to ensure the right to accurate and comprehensive care and protect the integrity of the patient-doctor relationship. These policies align with the state’s ideal of free speech.

1. We recommend lawmakers, in consultation with Texas-based physicians providing reproductive care, pass a law explicitly protecting a physician’s right to provide comprehensive information about medical procedures to patients. Ensuring physicians’ rights to discuss various treatment options, irrespective of their ability to perform them, is crucial. Based on the principle of informed consent, patients are entitled to comprehensive information and resources to make informed choices about their reproductive health care.  
    
2. We recommend implementing a CME module for health care providers focusing on effectively communicating information about abortion and alternative options to patients. Texas health care providers are required to have 48 hours of CME approved by the American Medical Association (AMA), American Academy of Family Physicians (AAFP), Texas Medical Association, or the Texas Medical Board every 24 months.[43] Two of these hours must be dedicated to medical ethics and/or professional responsibility.  
   
   We recommend the creation of a CME that will fulfill this requirement directed at gaining an in-depth understanding of the legal landscape in Texas, including restrictions and requirements related to abortion and distinguishing abortion and miscarriage procedures. The course would be ideal for OB-GYN physicians as well as other adjacent specialty providers, including emergency care physicians and family care doctors. The CME should provide knowledge of what is and is not permissible within state laws regarding care related to pregnancies and up-to-date referral resources for patients seeking abortion and abortion-related services both within Texas and in nearby states, even if they cannot offer these services themselves.  
   
   The CME can be modeled after the Family Medicine Pregnancy Care Post-Dobbs CME offered by the American Academy of Family Physicians (AAFP).[44] This course includes an outline of current medical options for first-trimester miscarriage and abortion management, summarizes health equity issues related to first-trimester care, assesses psychological needs, and offers ways to provide patient support. With similar modules as outlined by the AAFP and further Texas-specific adaptations, these educational materials can better equip health care providers navigate abortion-related services with their patients. 

Conclusion

The current legal landscape in Texas has created obstacles to adequate access to reproductive health care services and resources impacting maternal care, especially during miscarriage. The guidelines surrounding miscarriages and abortions are unclear, leading physicians to leave many patients suffering from miscarriage untreated or delayed treatment. Access to adequate procedures, medications, and resources for miscarriages is vital. The current ambiguous guidelines force physicians into difficult positions, putting them at risk of facing legal repercussions when providing medically necessary care and, more importantly, putting patient’s lives at risk.

Moving forward, we urge policymakers in Texas to consider the ethical implications and medical complexities regarding abortion and miscarriage care. A collaboration between lawmakers and health care professionals is imperative to clarify the differences between therapeutic and elective abortion in cases of overlap. This will ensure timely and effective care in cases requiring therapeutic termination of pregnancy to protect the safety of the pregnant individual. It is crucial to legally protect physicians’ rights to provide information regarding therapeutic abortion and alternative procedures. 

In doing so, we hope to foster safe communication between patients and health care providers and ensure transparency without delays in care. We recommend further education to target the upstream effects of restrictive abortion laws. By implementing CME modules for health care providers, we hope to ensure providers are trained to engage in conversations regarding abortion and provide patients with necessary and accurate information to make informed decisions regarding their pregnancy. 

By addressing these issues through collaboration and connections among policymakers, advocacy groups, health care providers, and patients, Texas can work toward a more equitable health care system. We strongly advocate for a system that respects the rights and autonomy of patients and all individuals involved to ensure the prioritization of the health of pregnant individuals and the rights of physicians to deliver efficient and accessible care. If we do not act now, maternal health care deserts in Texas will undoubtedly grow, placing the lives of many at risk. 

Acknowledgements

The authors would like to thank Emma Tippett, Elena M. Marks, Rekha Lakshmanan, and Dr. Keri Sprung for their guidance in the writing of this report.

This report was part of Rice University course BIOS 370/670: “Current Biosciences and Health Policy Topics.” Authors are students and mentors who participated in the course in the spring of 2024.

Notes

[1] María Méndez, “Texas Laws Say Treatments for Miscarriages, Ectopic Pregnancies Remain Legal But Leave Lots of Space for Confusion,” Texas Tribune, July 20, 2022, https://www.texastribune.org/2022/07/20/texas-abortion-law-miscarriages-ectopic-pregnancies/. 

[2] Méndez; Cleveland Clinic, “Dilation and Curettage (D & C),” last reviewed February 9, 2024, https://my.clevelandclinic.org/health/procedures/dilation-and-curettage. 

[3] MedlinePlus, “miscarriage,” National Library of Medicine, National Institutes of Health (NIH), last reviewed November 2022, accessed July 2024, https://medlineplus.gov/ency/article/001488.htm. 

[4] MedlinePlus, “abortion — medication,” National Library of Medicine, NIH, last reviewed November 2022, accessed July 2024, https://medlineplus.gov/ency/article/007382.htm. 

[5] Ester di Giacomo et al., “Therapeutic Termination of Pregnancy and Women’s Mental Health: Determinants and Consequences,” World Journal of Psychiatry 11, no. 11 (November 2021): 937–53, https://doi.org/10.5498/wjp.v11.i11.937.

[6] H.B. 1280, 87th Leg., Prior Sess. (Tx. 2021), https://legiscan.com/TX/text/HB1280/2021. 

[7] H.B. 1280.

[8] S.B. 8, 87th Leg., Prior Sess. (Tx. 2021), https://legiscan.com/TX/text/SB8/id/2395961. 

[9] Dobbs v. Jackson Women’s Health Organization, 597 U.S. 1 (2021), https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf. 

[10] H.B. 1280.

[11] H.B. 1280.

[12] Mallory Moench, “Court Says Texas Can Ban Certain Emergency Abortions. What That Means,” Time, last modified January 4, 2024, https://time.com/6551740/texas-ban-emergency-abortions-appeals-ruling/. 

[13] H.B. 15, 78th Leg., Reg. Sess. (Tx. 2003), https://capitol.texas.gov/billlookup/History.aspx?LegSess=78R&Bill=HB15; “The Woman’s Right to Know Act,” Texas Administrative Code, bit.ly/4cdS86g.

[14] American Civil Liberties Union (ACLU) Texas, “A Recent History of Restrictive Abortion Laws in Texas,” accessed July 2024, https://www.aclutx.org/en/recent-history-restrictive-abortion-laws-texas. 

[15] ACLU Texas. 

[16] H.B. 15, 82nd Leg., Prior Sess. (Tx. 2011), https://legiscan.com/TX/bill/HB15/2011.

[17] Amanda J. Stevenson et al., “Effect of Removal of Planned Parenthood from Texas Women’s Health Program,” New England Journal of Medicine 374, no. 9 (March 2016): 853–60, https://doi.org/10.1056/NEJMsa1511902. 

[18] Stevenson et al.

[19] H.B. 214, 85th Leg., 1st Special Sess. (Tx. 2017), https://legiscan.com/TX/bill/HB214/2017/X1. 

[20] 10 Tex. Govt. Code §2273.003 (2023), https://statutes.capitol.texas.gov/Docs/GV/htm/GV.2273.htm#:~:text=2273.003. 

[21] Eleanor Klibanoff, “Even After Planned Parenthood Stopped Performing Abortions, Texas Is Still Trying to Shut It Down,” Texas Tribune, August 5, 2023, https://www.texastribune.org/2023/08/15/texas-abortion-planned-parenthood-lawsuit/; Planned Parenthood, “Health Services,” accessed July 2024, https://www.plannedparenthood.org/planned-parenthood-greater-texas/patient-resources/health-services. 

[22] Marian F. MacDorman, Eugene Declercq, and Marie E. Thoma, “Trends in Texas Maternal Mortality by Maternal Age, Race/Ethnicity, and Cause of Death, 2006–2015,” Birth 45, no. 2 (January 2018): 169–77, https://doi.org/10.1111/birt.12330. 

[23] MacDorman, Declercq, and Thoma.

[24] Alison Gemmill et al., “Infant Deaths after Texas’ 2021 Ban on Abortion in Early Pregnancy,” JAMA Pediatrics 330, no. 3 (June 2023): 281–2, https://doi.org/10.1001/jama.2023.12034.

[25] Rachel Benson Gold and Kinsey Hasstedt, “Lessons from Texas: Widespread Consequences of Assaults on Abortion Access,” American Journal of Public Health 106, no. 6 (June 2016): 970–1, https://doi.org/10.2105/AJPH.2016.303220. 

[26] March of Dimes, “Population: Data from Texas,” last modified February 2024, https://www.marchofdimes.org/peristats/data?reg=99&top=14&stop=125&lev=1&slev=4&obj=3&sreg=48. 

[27] Erin A. Snider, “I Miscarried in Texas. My Doctors Put Abortion Law First,” Newsweek, January 21, 2024, https://www.newsweek.com/i-miscarried-texas-doctors-abortion-law-1861677. 

[28] Snider. 

[29] Selena Simmons-Duffin, “For Doctors, Abortion Restrictions Create an ‘Impossible Choice’ When Providing Care,” National Public Radio, June 24, 2022, https://www.npr.org/sections/health-shots/2022/06/24/1107316711/doctors-ethical-bind-abortion. 

[30] “Ancient Greek Medicine,” National Library of Medicine, https://www.nlm.nih.gov/hmd/topics/greek-medicine/index.html. 

[31] Olivia Goldhill, “Abortion Law Emergency-Exemption Guidance Proposed by Texas Medical Board,” STAT, March 22, 2024, https://www.statnews.com/2024/03/22/texas-abortion-law-emergency-exemption-guidance-proposed/. 

[32] 22 Tex. Admin. Code §165.8 (2024). For the full text of the guidelines, see https://www.tmb.state.tx.us/idl/1C5CBA1C-052B-403F-A0D1-FAF22ADD05CB. 

[33] 22 Tex. Admin. Code §165.8. 

[34] Center for Reproductive Rights, “Cox. v. Texas: The Case in Depth,” https://reproductiverights.org/case/cox-v-texas/cox-v-texas-case-in-depth/. To view the case file submitted to the Texas state court, see https://reproductiverights.org/wp-content/uploads/2023/12/Cox-v.-Texas-original-petition-FINAL-1.pdf. 

[35] “Trisomy 18,” Genetic and Rare Diseases Information Center, National Center for Advancing Translational Sciences, last modified June 2024, https://rarediseases.info.nih.gov/diseases/6321/trisomy-18. 

[36] Paul J. Weber and Jamie Stengle, “Texas Woman Who Sought Court Permission for Abortion Leaves State for the Procedure, Attorneys Say,” Associated Press, last modified December 11, 2023, https://apnews.com/article/abortion-texas-ban-7d865cdfd75bdc6b2f4186f4d1e6e8bd. 

[37] March of Dimes, “Maternal Care Desert: Data for Texas,” last modified December 2023, https://www.marchofdimes.org/peristats/data?reg=99&top=23&stop=641&lev=1&slev=4&obj=9&sreg=48; March of Dimes, “Maternal Care Desert Report: Map,” 2022, https://www.marchofdimes.org/maternity-care-deserts-report#map. 

[38] Kendal Orgera, Hasan Mahmood, and Atul Grover, “Training Location Preferences of U.S. Medical School Graduates Post Dobbs v. Jackson Women’s Health,” Association of American Medical Colleges’ Research and Action Institute, April 2023, https://www.aamcresearchinstitute.org/our-work/data-snapshot/training-location-preferences-us-medical-school-graduates-post-dobbs-v-jackson-women-s-health. 

[39] Accreditation Council for Graduate Medical Education (ACGME), “ACGME Program Requirements for Graduate Medical Education in Obstetrics and Gynecology,” September 17, 2022, 29, bit.ly/3WS40pR. 

[40] Sophie Novack, “‘You Know What? I’m Not Doing This Anymore,’” Slate, March 21, 2023, https://slate.com/news-and-politics/2023/03/texas-abortion-law-doctors-nurses-care-supreme-court.html. 

[41] Tex. Health & Safety Code § 34 (2023), https://statutes.capitol.texas.gov/Docs/HS/htm/HS.34.htm. 

[42] Michelle Oberman and Lisa Soleymani Lehmann, “Doctors’ Duty to Provide Abortion Information,” Journal of Law and the Biosciences 10, no. 2 (July–December 2023): 1–27, https://doi.org/10.1093/jlb/lsad024. 

[43] Tex. Admin. Code Rule §166.2 (2020), https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=166&rl=2. 

[44] American Academy of Family Medicine, “Family Medicine Pregnancy Care Post-Dobbs,” 2024, https://www.aafp.org/cme/all/maternity/pregnancy-care-post-dobbs.html. 

This material may be quoted or reproduced without prior permission, provided appropriate credit is given to the author and Rice University’s Baker Institute for Public Policy. The views expressed herein are those of the individual author(s), and do not necessarily represent the views of Rice University’s Baker Institute for Public Policy.