Lizzie Presser, Propublica

Before states banned abortion, one of the gravest outcomes of early miscarriage could easily be avoided: Doctors could offer a dilation and curettage procedure, which quickly empties the uterus and allows it to close, protecting against a life-threatening hemorrhage.

But because the procedures, known as D&Cs, are also used to end pregnancies, they have gotten tangled up in state legislation that restricts abortion. Reports now abound of doctors hesitating to provide them and women who are bleeding heavily being discharged from emergency rooms without care, only to return in such dire condition that they need blood transfusions to survive. As ProPublica reported last year, one woman died of hemorrhage after 10 hours in a Houston hospital that didn’t perform the procedure.

Now, a new ProPublica data analysis adds empirical weight to the mounting evidence that abortion bans have made the common experience of miscarriage — which occurs in up to 30% of pregnancies — far more dangerous. It is based on hospital discharge data from Texas, the largest state to ban abortion, and captures emergency department visits from 2017 to 2023, the most recent year available.

After Texas made performing abortions a felony in August 2022, ProPublica found, the number of blood transfusions during emergency room visits for first-trimester miscarriage shot up by 54%.

The number of emergency room visits for early miscarriage also rose, by 25%, compared with the three years before the COVID-19 pandemic — a sign that women who didn’t receive D&Cs initially may be returning to hospitals in worse condition, more than a dozen experts told ProPublica.

While that phenomenon can’t be confirmed by the discharge data, which tracks visits rather than individuals, doctors and researchers who reviewed ProPublica’s findings say these spikes, along with the stories patients have shared, paint a troubling picture of the harm that results from unnecessary delays in care.

“This is striking,” said Dr. Elliott Main, a hemorrhage expert and former medical director for the California Maternal Quality Care Collaborative. “The trend is very clear.”

The data mirrors a sharp rise in cases of sepsis — a life-threatening reaction to infection — ProPublica previously identified during second-trimester miscarriage in Texas.

Blood loss is expected during early miscarriage, which usually ends without complication. Some cases, however, can turn deadly very quickly. Main said ProPublica’s analysis suggested to him that “physicians are sitting on nonviable pregnancies longer and longer before they’re doing a D&C — until patients are really bleeding.”

That’s what happened to Sarah De Pablos Velez in Austin last summer. As she was miscarrying and bleeding profusely, she said physicians didn’t explain that she had options for care. Sent home from the emergency room without a D&C two times, she ultimately needed blood transfusions so that she wouldn’t die, according to medical records. “What happened to me was just so wrong,” she told ProPublica. "Doctors need to be providing care to pregnant women — that needs to be a baseline.”

After ProPublica exposed preventable deaths following delays in care, the Texas Legislature passed a bill this year to clarify that doctors can provide abortions when a patient is facing a life-threatening emergency, even if it is not imminent.

But many Texas doctors say the reform does not address the difficulty of treating women experiencing early miscarriages, which almost always involve blood loss; they say it’s hard to know when the expected bleeding might evolve into a life-threatening emergency — one that could have been prevented with a D&C. Women can bleed and remain stable for a long time, until they crash.

Texas forbids abortion at all stages of pregnancy — even before there is cardiac activity or a visible embryo. And while the law allows doctors to “remove a dead, unborn child,” it can be difficult to determine what that means during early miscarriage, when an array of factors can signal that a pregnancy is not progressing.

An embryo might fail to develop. Cardiac activity may not emerge when it should. Hormone levels might dip or bleeding might increase. Even if a doctor strongly suspects a miscarriage is underway, it can take weeks to conclusively document that a pregnancy has ended, and all the while, a patient might be losing blood.

Some OB-GYNs and emergency room physicians have long been advising patients to complete their miscarriage at home, especially at Catholic hospitals, even if that is not the standard of care. But now, physicians across the state are faced with a law that threatens up to 99 years in prison, and more are making a new calculus around whether to intervene or even tell patients they are likely miscarrying, said Dr. Anitra Beasley, an OB-GYN in Houston. “What ends up happening is patients have to present multiple times before a diagnosis can be made,” she added, and some of those patients wind up needing blood transfusions.

While they can be lifesaving, transfusions do not stop the bleeding, experts told ProPublica, and they can introduce complications, such as severe allergic reactions, autoimmune disorders or, in rare events, blood cancer. The dangers of hemorrhage are far greater, from organ failure to kidney damage to loss of sensation in the fingers and toes. “There’s a finite amount of blood,” said Dr. Sarah Prager, a professor of obstetrics and gynecology at the University of Washington. “And when it all comes out, you’re dead.”

ProPublica’s findings about the rise in blood transfusions make clear that women who experience early miscarriages in abortion ban states are living in a more dangerous medical climate than many believe, said Amanda Nagle, a doctoral student investigating the same blood transfusion data for a forthcoming paper in the American Journal of Public Health.

“If people are seeking care at an emergency department,” Nagle said, “there are serious health risks to delaying that care.”

Waiting for Certainty

In some clinics and hospitals across Texas, the pressure to definitively diagnose a miscarriage has led to delays in offering D&Cs.

Considering the chance of criminal prosecution, some doctors now default to what many pregnancy loss experts view as an overly cautious method for diagnosing miscarriage: ultrasound images alone, using criteria from the Society of Radiologists in Ultrasound. Relying only on images to diagnose — and discounting other factors, like lab results or clinical symptoms — can take days or even weeks.

Dr. Gabrielle Taper was a resident at a Catholic hospital in Austin when the ban was enacted, and a culture of fear took hold among her colleagues, she told ProPublica. “We started asking, ‘Are we certain that we can document that we’ve met the radiology guidelines?’ as opposed to just treating the patient in front of us,” she said.

If they couldn’t show that the likely miscarriage met the criteria, they often felt they had to discharge patients without offering a D&C. “People are already in distress, and you are giving them confusion, a false sense of hope,” she told ProPublica. “Having to send a patient home knowing they may bleed so much they would need a blood transfusion — when I know there are procedures I could do or medicine I could offer — is just excruciating.”

The hospital where she worked did not respond to ProPublica’s request for comment.

The American College of Obstetricians and Gynecologists does not recommend this approach, advising doctors instead to review the ultrasound as one piece of information among many and counsel patients on all their options.

The Society of Radiologists in Ultrasound said that the guidelines “are not meant to apply in the setting of a life-threatening situation, such as heavy bleeding,” but did not respond to a question about whether it agreed with ACOG that doctors should use a combination of ultrasound images and clinical judgment to assess a pregnancy loss.

Dr. Courtney A. Schreiber, an obstetrics and gynecology professor and expert in early pregnancy care, said that even if a patient wants to let a likely miscarriage complete at home, the medical team should still explain different management options, including medication to speed up the process or a D&C, should symptoms like bleeding get worse.

“It’s our obligation to share information, help manage expectations and keep women safe,” she said.

What happened to Porsha Ngumezi shows how dangerous it can be to delay care, according to more than a dozen doctors who previously reviewed a detailed summary of her case for ProPublica.

When the mother of two showed up bleeding at Houston Methodist Sugar Land in June 2023, at 11 weeks pregnant, her sonogram suggested an “ongoing miscarriage” was “likely,” her doctor noted. She had no previous ultrasounds to compare it with, and the radiologist did not locate an embryo or fetus — which Ngumezi said she thought she had passed in a toilet; her doctors did not make a definitive diagnosis, calling it a pregnancy of “unknown location.” After hours bleeding, passing “clots the size of grapefruit,” according to a nurse’s notes, she received two blood transfusions — a short-term remedy. But she did not get a procedure to empty her uterus, which medical experts agree is the most effective way to stop the bleeding. Hours later, she died of hemorrhage, leaving behind her husband and young sons.

Doctors and nurses involved in Ngumezi’s care did not respond to multiple requests for comment for ProPublica’s story last fall, and the hospital did not answer questions about her care when asked about it again for this story. A spokesperson from Methodist Hospital said its OB-GYNs follow ACOG’s miscarriage diagnosis guidelines, which recommend considering clinical factors in addition to ultrasounds.

Visit After Visit

Even in circumstances in which the abortion ban allows a doctor to intervene — to treat a life-threatening emergency, for example, or to “remove a dead, unborn baby” — there’s plenty of evidence, detailed in lawsuits and federal investigations, that doctors in Texas still aren’t offering procedures.

As soon as Sarah De Pablos Velez, a 30-year-old media director, learned she was pregnant last summer, she began attending regular checkups at St. David’s Women’s Care, in Austin. During her third appointment at about nine weeks, a resident, Dr. Carla Vilardo, and her supervisor, Dr. Cynthia Mingea, reviewed the ultrasound, according to medical records, which indicated her pregnancy wasn’t viable. Instead of being offered treatment for a miscarriage, De Pablos Velez says she was advised to hold out hope and come back for the next checkup.

Five maternal health experts and practicing OB-GYNs who reviewed the records for ProPublica said by that ultrasound visit, doctors would have had enough information to determine that the pregnancy wasn’t viable, even under the most conservative guidelines. If they wanted to be extra sure, they could have done blood work or one more ultrasound during that visit.

Instead, De Pablos Velez was told to come back in two weeks, according to medical records. During a visit when she should have been nearly 11 weeks pregnant, Mingea wrote in her chart she was “not optimistic” about the pregnancy's viability. Still, De Pablos Velez was advised to return in another week to be sure.

Within a few days, when the cramping got so bad she could barely walk, De Pablos Velez went to the emergency room at St. David’s Medical Center, unaware that a D&C could stop the pain and the bleeding. “I’ve never researched what it looks like for women who have a miscarriage,” she told ProPublica. “I always thought you go to the bathroom and have a little bit of blood.”

Over two visits to the emergency room, doctors told her that she could complete the miscarriage at home, even as she reported filling up three toilet bowls with blood and a nurse remarked that they needed a janitor to clean the floor, De Pablos Velez and her husband recalled. No obstetrician ever came to assess her condition, according to medical records, and while her hospital chart says “all management options have been discussed with the patient and her husband,” De Pablos Velez and her husband both told ProPublica no one offered her a D&C.

She was told to follow up with her OB at her next appointment in three days. Six hours after discharge, though, she was trying to ride out the pain at home when her husband heard her muttering “lightheaded” in the bathroom and ran to her in time to catch her as she collapsed. “She was pale as a ghost, sweating, convulsing,” said her husband, Sergio De Pablos Velez. “There was blood on the toilet, the trash can — like a scene out of a horror movie.”

An ambulance rushed her to the hospital, where doctors realized she no longer had enough blood flowing to her organs. She received two blood transfusions. Without them, several doctors who reviewed her records told ProPublica, she would have soon lost her life.

Vilardo and the doctors who saw De Pablos Velez in the emergency room did not respond to requests to speak with ProPublica or declined to be interviewed. St. David’s Medical Center, which is owned by HCA, the largest for-profit hospital chain in America, said it could not discuss her case unless she signed privacy waivers. The hospital did not respond to ProPublica’s questions even after she submitted them. The De Pablos Velezes say that a hospital patient liaison told them after the ordeal that the hospital would conduct an internal investigation, educate the emergency department on best practices and share the results. It never shared anything. When ProPublica asked about the status of the investigation, neither the liaison nor the hospital responded.

Mingea, who supervised Vilardo’s care during checkups, reviewed the clinic’s records with ProPublica and agreed that De Pablos Velez should have been counseled about miscarriage management options at the clinic, weeks before she ended up in the ER. She said she did not know why she wasn’t but pointed ProPublica to the Society of Radiologists in Ultrasound criteria, which is hanging on the clinic’s wall and is used to teach residents.

She was adamant that her clinic, which she described as “very pro-choice — about as much as we can be in Texas,” regularly provides D&Cs for miscarrying patients. “I feel badly that Sarah had this experience, I really do,” she said. “Everybody deserves to be counseled about all their options.”

Doctors had five opportunities to counsel De Pablos Velez about her options and offer her a D&C, said Dr. Jodi Abbott, an associate professor of obstetrics and gynecology at Boston University School of Medicine, who reviewed case records. If they had, the life-or-death risks could have been avoided.

De Pablos Velez “basically received the same care Porsha Ngumezi did, only Porsha died and she survived,” said Abbott. “She was lucky.”

Nearly four years ago in Texas, the state’s new abortion law started getting in the way of basic miscarriage care: As women waited in hospitals cramping, fluid running down their legs, doctors told them they couldn’t empty their uterus to guard against deadly complications.

The state banned most abortions, even in pregnancies that were no longer viable; then, it added criminal penalties, threatening to imprison doctors for life and punish hospitals. The law had one exception, for a life-threatening emergency.

Heeding the advice of hospital lawyers, many doctors withheld treatment until they could document patients were in peril. They sent tests to labs, praying for signs of infection, and watched as women lost so much blood that they needed transfusions.“You would see the pain in peoples’ eyes,” one doctor said of her patients.

Not every hospital tolerated this new normal, ProPublica found. A seismic split emerged in how medical institutions in the state’s two largest metro areas treated miscarrying patients — and in how these women fared.

Leaders of influential hospitals in Dallas empowered doctors to intervene before patients’ conditions worsened, allowing them to induce deliveries or perform procedures to empty the uterus.

In Houston, most did not.

The result, according to a first-of-its-kind ProPublica analysis of state hospital discharge data, is that while the rates of dangerous infections spiked across Texas after it banned abortion in 2021, women in Houston were far more likely to get gravely ill than those in Dallas.

As ProPublica reported earlier this year, the statewide rate of sepsis — a life-threatening reaction to infection — shot up more than 50% for women hospitalized when they lost a second-trimester pregnancy.

A new analysis zooms in: In the region surrounding Dallas-Fort Worth, it rose 29%. In the Houston area, it surged 63%.

ProPublica has documented widespread differences in how hospitals across the countryhave translated abortion bans into policy. Some have supported doctors in treating active miscarriages and high-risk cases with procedures technically considered abortions; others have forbidden physicians from doing so, or left them on their own to decide, with no legal backing in case of arrest.

This marks the first analysis in the wake of abortion bans that connects disparities in hospital policies to patient outcomes. It shows that when a state law is unclear and punitive, how an institution interprets it can make all the difference for patients.

Yet the public has no way to know which hospitals or doctors will offer options during miscarriages. Hospitals in states where abortion is banned have been largely unwilling to disclose their protocols for handling common complications. When ProPublica asked, most in Texas declined to say.

ProPublica’s Texas reporting is based on interviews with 22 doctors in both the Houston and Dallas-Fort Worth metro areas who had insight into policies at 10 institutions covering more than 75% of the births and pregnancy-loss hospitalizations in those areas.

The findings come as evidence of the fatal consequences of abortion bans continue to mount, with a new report just last month showing that the risk of maternal mortality is nearly twice as high for women living in states that ban abortion. Last year, ProPublica documented five preventable maternal deaths, including three in Texas.

One second-trimester pregnancy complication that threatens patients’ lives is previable premature rupture of membranes, called PPROM, when a woman’s water breaks before the fetus can live on its own. Without amniotic fluid, the likelihood of the fetus surviving is low. But with every passing hour that a patient waits for treatment or for labor to start, the risk of sepsis increases.

The Texas Supreme Court has said that doctors can legally provide abortions in PPROM cases, even when an emergency is not imminent.

Yet legal departments at many major Houston hospitals still advise physicians not to perform abortions in these cases, doctors there told ProPublica, until they can document serious infection.

Dr. John Thoppil, the immediate past president of the Texas Association of Obstetricians and Gynecologists, said he was “blown away” by this finding. He said it’s time for hospitals to stop worrying about hypothetical legal consequences of the ban and start worrying more about the real threats to patients’ lives.

“I think you’re risking legal harm the opposite way for not intervening,” he said, “and putting somebody at risk.”

“We Have Your Back”

In the summer of 2021, Dr. Robyn Horsager-Boehrer, a Dallas specialist in high-risk pregnancy, listened as hospital lawyers explained to a group of UT Southwestern Medical Center doctors that they would no longer be able to act on their clinical judgment.

For decades, these UT Southwestern physicians had followed the guidance of major medical organizations: They offered patients with PPROM the option to end the pregnancy to protect against serious infection. But under the state’s new abortion ban, they would no longer be allowed to do so while practicing at the county’s safety net hospital, Parkland Memorial, which delivers more babies than almost any other in the country. Nor would they be permitted at UT Southwestern’s William P. Clements Jr. University Hospital.

Lawyers from the two hospitals explained in a meeting that the law’s only exception was for a “medical emergency” — but it wasn’t clear how the courts would define that. With no precedent or guidance from the state, they advised the doctors that they should offer to intervene only if they could document severe infection or bleeding — signs of a life-threatening condition, Horsager-Boehrer recalled. They would need to notify the state every time they terminated a pregnancy. ProPublica also spoke with six of Horsager-Boehrer’s colleagues who described similar meetings.

As the new policy kicked in, the doctors worried the lawyers didn’t understand how fast sepsis could develop and how difficult it could be to control. Many patients with PPROM can appear stable even while an infection is taking hold. During excruciating waits, Dr. Austin Dennard said she would tell patients at Clements, “We need something to be abnormal so that we can offer you all of the options that someone in New York would have.” Then she would return to the physicians’ lounge, lay down her head and cry.

Their only hope, the doctors felt, was to collect data and build a case that the hospital’s policy needed to change.

Within eight months, 28 women with severe pregnancy complications before fetal viability had come through the doors of Parkland and Clements. Twenty-six of them were cases in which the patients’ water broke early. Analyzing the medical charts, a group of researchers led by Dr. Anjali Nambiar, a UT Southwestern OB-GYN, found that a dozen women experienced complications including hemorrhage and infection. Only one baby survived.

The research team compared the results with another study in which patients were offered pregnancy terminations. They found that of patients who followed the “watch and wait” protocol, more than half experienced serious complications, compared with 33% who immediately terminated their pregnancies.

Armed with the research, the doctors, including Horsager-Boehrer, returned to the lawyers for the two hospitals. Everyone agreed the data demanded action. Alongside physicians, the lawyers helped develop language that doctors could include in medical charts to explain why they terminated a pregnancy due to a PPROM diagnosis, Dennard said.

At Parkland, the new protocol required doctors to get signoff from one additional physician, attach the study as proof of the risk of serious bodily harm — part of the “medical emergency” definition in the law — and notify hospital leaders. At Clements, doctors also needed to get CEO approval to end a pregnancy, which could create delays if patients came in on a weekend, doctors said. But it was vastly better than the alternative, Dennard said. The message from the lawyers, she said, was: “We have your back. We are going to take care of you.”

A spokesperson for UT Southwestern said “no internal protocols delay care or otherwise compromise patient safety.” A spokesperson for Parkland said that “physicians are empowered to document care as they deem appropriate” and that hospital attorneys had “helped review and translate the doctors’ proposed language to make sure it followed the law.”

Parkland and UT Southwestern are not the only ones providing this care in Dallas. ProPublica spoke with doctors who have privileges at hospitals that oversee 60% of births and pregnancy loss hospitalizations in the Dallas-Fort Worth region, including Baylor Scott & White and Texas Health Resources. They said that their institutions support offering terminations to patients with high-risk second-trimester pregnancy complications like PPROM.

At Baylor Scott & White, doctors said, the leadership always stood by this interpretation of the law. (When asked, a spokesperson said miscarrying patients are counseled on surgical options, and that its hospitals follow state and federal laws. “Our policies are developed to comply with those laws, and we educate our teams on those policies.”)

Texas Health and other hospitals in the region did not respond to requests for comment.

While efforts to be proactive have meant more patients are able to receive the standard of care in Dallas, that is still not the case at every medical campus in the region. Doctors at Parkland said they have seen patients come to them after they were turned away from hospitals nearby.

In other parts of the state, however, it’s been impossible to know where to turn.

“No Interventions Can Be Performed”

In Houston, one of America’s most prestigious medical hubs, Dr. Judy Levison mounted her own campaign.

The veteran OB-GYN at Baylor College of Medicine wanted hospital leaders to support intervening in high-risk complications in line with widely accepted medical standards. In 2022, she emailed her department chair, Dr. Michael Belfort, who is also the OB-GYN-in-chief at Texas Children’s. She told him colleagues had shared “feelings of helplessness, moral distress and increasing concerns about the safety of our patients.”

They needed training on how to protect patients within the bounds of the law, she said, and language they could include in charts to justify medically necessary abortions. But in a meeting, Belfort told her he couldn’t make these changes, Levison recalled.

He said that if he supported abortions in medically complicated cases like PPROM, the hospital could lose tens of millions of dollars from the state, she told ProPublica. “I came to realize that he was in a really difficult place because he risked losing funding for our residency program if Baylor and Texas Children’s didn't interpret the law the way they thought the governor did.” She wondered if he was deferring to hospital lawyers.

Belfort did not respond to requests for comment about his stance. Nor did Baylor or Texas Children’s.

Although Texas Attorney General Ken Paxton has threatened hospitals with civil action if they allow a doctor to perform what he views as an “unlawful” abortion, he hasn’t filed any such actions. And in the years since the ban, there have been no reports of the state pulling funding from a hospital on account of its abortion policy.

A spokesperson at only one major Houston hospital chain, Houston Methodist, said that it considered PPROM a medical emergency and supported terminations for “the health and safety of the patient.”

Five other major hospital groups that, together, provide the vast majority of maternal care in the Houston region either continue to advise doctors not to offer pregnancy terminations for PPROM cases or leave it up to the physicians to decide, with no promise of legal support if they’re charged with a crime. This is according to interviews with a dozen doctors about the policies at HCA, Texas Children’s, Memorial Hermann, Harris Health and The University of Texas Medical Branch. Together, they account for about 8 in 10 hospitalizations in the region for births or pregnancy loss.

Most of the doctors spoke with ProPublica on the condition of anonymity, as they feared retaliation for violating what some described as a hospital “gag order” against discussing abortion. In a sign of how secretive this decision-making has become, most said their hospitals had not written down these new policies, only communicated them orally.

Several doctors told ProPublica that Dr. Sean Blackwell, chair of the obstetrics and gynecology department at Houston’s University of Texas Health Science Center, which staffs Harris Health Lyndon B. Johnson Hospital and Memorial Hermann hospitals, had conveyed a message similar to Belfort’s: He wasn’t sure he would be able to defend providers if they intervened in these cases. He did not respond to multiple requests for comment, and his institution, UTHealth Houston, declined to comment.

ProPublica reached out to officials at all five hospital groups, asking if they offer terminations at the point of a PPROM diagnosis. Only one responded. Bryan McLeod at Harris Health pointed to the hospital system’s written policy, which ProPublica reviewed, stating that an emergency doesn’t need to be imminent for a doctor to intervene. But McLeod did not respond to follow-up questions asking if patients with PPROM are offered pregnancy terminations if they show no signs of infection — and several doctors familiar with the chain’s practices said they are not.

The state Senate unanimously passed a bill last week to clarify that doctors can terminate pregnancies if a woman faces a risk of death that is not imminent. ProPublica asked the hospitals if they would change their policies on PPROM if this is signed into law. They did not respond.

Last fall, ProPublica reported that Josseli Barnica died in Houston after her doctors did not evacuate her uterus for 40 hours during an “inevitable” miscarriage, waiting until the fetal heartbeat stopped. Two days later, sepsis killed her.

Barnica was treated at HCA, the nation’s largest for-profit hospital chain, which did not respond to a detailed list of questions about her care. With 70% of its campuses in states where abortion is restricted, the company leaves the decision of whether to take the legal risk up to the physicians, without the explicit legal support provided in Dallas, according to a written policy viewed by ProPublica and interviews with doctors. A spokesperson for the chain said doctors with privileges at its hospitals are expected to exercise their independent medical judgment “within applicable laws and regulations.” As a result, patients with potentially life-threatening conditions have no way of knowing which HCA doctors will treat them and which won’t.

Brooklyn Leonard, a 29-year-old esthetician eager for her first child, learned this in February. She was 14 weeks pregnant when her water broke. At HCA Houston Healthcare Kingwood, her doctor Arielle Lofton wrote in her chart, “No interventions can be performed at this time legally because her fetus has a heartbeat.” The doctor added that she could only intervene when there was “concern for maternal mortality.” Leonard and her husband had trouble getting answers about whether she was miscarrying, she said. “I could feel that they were not going to do anything for me there.” Lofton and HCA did not respond to a request for comment.

It was only after visits to three Houston hospitals over five days that Leonard was able to get a dilation and evacuation to empty her uterus. A doctor at Texas Children’s referred her to Dr. Damla Karsan, who works in private practice and is known for her part in an unsuccessful lawsuit against the state seeking permission to allow an abortion for a woman whose fetus was diagnosed with a fatal anomaly. Karsan felt there was no question PPROM cases fell under the law’s exception. She performed the procedure at The Woman’s Hospital of Texas, another HCA hospital. “She’s lucky she didn’t get sick,” Karsan said of Leonard.

Many Houston doctors said they have continued to call on their leadership to change their stance to proactively support patients with PPROM, pointing to data analyses from Dallas hospitals and ProPublica and referring to the Texas Supreme Court ruling. It hasn’t worked.

Houston hospitals haven’t taken action even in light of alarming research in their own city. Earlier this year, UTHealth Houston medical staff, including department chair Blackwell, revealed early findings from a study very similar to the one out of Dallas.

It showed what happened after patients at three partner hospitals stopped being offered terminations for PPROM under the ban: The rate of sepsis tripled.

Still, nothing changed.

Pregnancy became far more dangerous in Texas after the state banned abortion in 2021, ProPublica found in a first-of-its-kind data analysis.

The rate of sepsis shot up more than 50% for women hospitalized when they lost their pregnancies in the second trimester, ProPublica found.

The surge in this life-threatening condition, caused by infection, was most pronounced for patients whose fetus may still have had a heartbeat when they arrived at the hospital.

ProPublica previously reported on two such cases in which miscarrying women in Texas died of sepsis after doctors delayed evacuating their uteruses. Doing so would have been considered an abortion.

The new reporting shows that, after the state banned abortion, dozens more pregnant and postpartum women died in Texas hospitals than had in pre-pandemic years, which ProPublica used as a baseline to avoid COVID-19-related distortions. As the maternal mortality rate dropped nationally, ProPublica found, it rose substantially in Texas.

ProPublica’s analysis is the most detailed look yet at a rise in life-threatening complications for women losing a pregnancy after Texas banned abortion. It raises concerns that the same pattern may be occurring in more than a dozen other states with similar bans.

To chart the scope of pregnancy-related infections, ProPublica purchased and analyzed seven years of Texas’ hospital discharge data.

“This is exactly what we predicted would happen and exactly what we were afraid would happen,” said Dr. Lorie Harper, a maternal-fetal medicine specialist in Austin.

She and a dozen other maternal health experts who reviewed ProPublica’s findings say they add to the evidence that the state’s abortion ban is leading to dangerous delays in care. Texas law threatens up to 99 years in prison for providing an abortion. Though the ban includes an exception for a “medical emergency,” the definition of what constitutes an emergency has been subject to confusion and debate.

Many said the ban is the only explanation they could see for the sudden jump in sepsis cases.

The new analysis comes as Texas legislators consider amending the abortion ban in the wake of ProPublica’s previous reporting, and as doctors, federal lawmakers and the state’s largest newspaper have urged Texas officials to review pregnancy-related deaths from the first full years after the ban was enacted; the state maternal mortality review committee has, thus far, opted not to examine the death data for 2022 and 2023.

The standard of care for miscarrying patients in the second trimester is to offer to empty the uterus, according to leading medical organizations, which can lower the risk of contracting an infection and developing sepsis. If a patient’s water breaks or her cervix opens, that risk rises with every passing hour.

Sepsis can lead to permanent kidney failure, brain damage and dangerous blood clotting. Nationally, it is one of the leading causes of deaths in hospitals.

While some Texas doctors have told ProPublica they regularly offer to empty the uterus in these cases, others say their hospitals don’t allow them to do so until the fetal heartbeat stops or they can document a life-threatening complication.

Last year, ProPublica reported on the repercussions of these kinds of delays.

Forced to wait 40 hours as her dying fetus pressed against her cervix, Josseli Barnica risked a dangerous infection. Doctors didn’t induce labor until her fetus no longer had a heartbeat.

Physicians waited, too, as Nevaeh Crain’s organs failed. Before rushing the pregnant teenager to the operating room, they ran an extra test to confirm her fetus had expired.

Both women had hoped to carry their pregnancies to term, both suffered miscarriages and both died.

In response to their stories, 111 doctors wrote a letter to the Legislature saying the abortion ban kept them from providing lifesaving care and demanding a change.

“It’s black and white in the law, but it’s very vague when you’re in the moment,” said Dr. Tony Ogburn, an OB-GYN in San Antonio. When the fetus has a heartbeat, doctors can’t simply follow the usual evidence-based guidelines, he said. Instead, there is a legal obligation to assess whether a woman’s condition is dire enough to merit an abortion under a prosecutor’s interpretation of the law.

Some prominent Texas Republicans who helped write and pass Texas’ strict abortion bans have recently said that the law should be changed to protect women’s lives — though it’s unclear if proposed amendments will receive a public hearing during the current legislative session.

ProPublica’s findings indicate that the law is getting in the way of providing abortions that can protect against life-threatening infections, said Dr. Sarah Prager, a professor of obstetrics and gynecology at the University of Washington.

“We have the ability to intervene before these patients get sick,” she said. “This is evidence that we aren’t doing that.”

A New View

Health experts, specially equipped to study maternal deaths, sit on federal agencies and state-appointed review panels. But, as ProPublica previously reported, none of these bodies have systematically assessed the consequences of abortion bans.

So ProPublica set out to do so, first by investigating preventable deaths, and now by using data to take a broader view, looking at what happened in Texas hospitals after the state banned abortion, in particular as women faced miscarriages.

“It is kind of mindblowing that even before the bans researchers barely looked into complications of pregnancy loss in hospitals,” said perinatal epidemiologist Alison Gemmill, an expert on miscarriage at Johns Hopkins Bloomberg School of Public Health.

In consultation with Gemmill and more than a dozen other maternal health researchers and obstetricians, ProPublica built a framework for analyzing Texas hospital discharge data from 2017 to 2023, the most recent full year available. This billing data, kept by hospitals and collected by the state, catalogues what happens in every hospitalization. It is anonymized but remarkable in its granularity, including details such as gestational age, complications and procedures.

To study infections during pregnancy loss, ProPublica identified all hospitalizations that included miscarriages, terminations and births from the beginning of the second trimester up to 22 weeks’ gestation, before fetal viability. Since first-trimester miscarriage is often managed in an outpatient setting, ProPublica did not include those cases in this analysis.

When looking at stays for second-trimester pregnancy loss, ProPublica found a relatively steady rate of sepsis before Texas made abortion a crime. In late 2021, the state made it a civil offense to end a pregnancy after a fetus developed cardiac activity, and in the summer of 2022, the state made it a felony to terminate any pregnancy, with few exceptions.

In 2021, 67 patients who lost a pregnancy in the second trimester were diagnosed with sepsis — as in the previous years, they accounted for about 3% of the hospitalizations.

In 2022, that number jumped to 90.

The following year, it climbed to 99.

ProPublica’s analysis was conservative and likely missed some cases. It doesn’t capture what happened to miscarrying patients who were turned away from emergency rooms or those like Barnica who were made to wait, then discharged home before they returned with sepsis.

Our analysis showed that patients who were admitted while their fetus was still believed to have a heartbeat were far more likely to develop sepsis.

“What this says to me is that once a fetal death is diagnosed, doctors can appropriately take care of someone to prevent sepsis, but if the fetus still has a heartbeat, then they aren’t able to act and the risk for maternal sepsis goes way up,” said Dr. Kristina Adams Waldorf, professor of obstetrics and gynecology at UW Medicine and an expert in pregnancy complications. “This is needlessly putting a woman’s life in danger.”

Studies indicate that waiting to evacuate the uterus increases rates of sepsis for patients whose water breaks before the fetus can survive outside the womb, a condition called previable premature rupture of membranes or PPROM. Because of the risk of infection, major medical organizations like the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists advise doctors to always offer abortions.

Researchers in Dallas and Houston examined cases of previable pregnancy complications at their local hospitals after the state ban. Both studies found that when women weren’t able to end their pregnancies right away, they were significantly more likely to develop dangerous conditions than before the ban. The study of the University of Texas Health Science Center in Houston, not yet published, found that the rate of sepsis tripled after the ban.

Dr. Emily Fahl, a co-author of that study, recently urged professional societies and state medical boards to “explicitly clarify” that doctors need to recommend evacuating the uterus for patients with a PPROM diagnosis, even with no sign of infection, according to MedPage Today.

UTHealth Houston did not respond to several requests for comment.

ProPublica zoomed out beyond the second trimester to look at deaths of all women hospitalized in Texas while pregnant or up to six weeks postpartum. Deaths peaked amid the COVID-19 pandemic, and most patients who died then were diagnosed with the virus. But looking at the two years before the pandemic, 2018 and 2019, and the two most recent years of data, 2022 and 2023, there is a clear shift:

In the two earlier years, there were 79 maternal hospital deaths.

In the two most recent, there were 120.

Caitlin Myers, an economist at Middlebury College, said it’s crucial to examine these deaths from different angles, as ProPublica has done. Data analyses help illuminate trends but can’t reveal a patient’s history or wishes, as a detailed medical chart might. Diving deep into individual cases can reveal the timeline of treatment and how doctors behave. “When you see them together, it tells a really compelling story that people are dying as a result of the abortion restrictions.”

Texas has no plans to scrutinize those deaths. The chair of the maternal mortality review committee said the group is skipping data from 2022 and 2023 and picking up its analysis with 2024 to get a more “contemporary” view of deaths. She added that the decision had “absolutely no nefarious intent.”

“The fact that Texas is not reviewing those years does a disservice to the 120 individuals you identified who died inpatient and were pregnant,” said Dr. Jonas Swartz, an assistant professor of obstetrics and gynecology at Duke University. “And that is an underestimation of the number of people who died.”

The committee is also prohibited by law from reviewing cases that include an abortion medication or procedure, which can also be used during miscarriages. In response to ProPublica’s reporting, a Democratic state representative filed a bill to overturn that prohibition and order those cases to be examined.

Because not all maternal deaths take place in hospitals and the Texas hospital data did not include cause of death, ProPublica also looked at data compiled from death certificates by the Centers for Disease Control and Prevention.

It shows that the rate of maternal deaths in Texas rose 33% between 2019 and 2023 even as the national rate fell by 7.5%.

A New Imperative

Texas’ abortion law is under review this legislative session. Even the party that championed it and the senator who authored it say they would consider a change.

On a local television program last month, Republican Lt. Gov. Dan Patrick said the law should be amended.

“I do think we need to clarify any language,” Patrick said, “so that doctors are not in fear of being penalized if they think the life of the mother is at risk.”

State Sen. Bryan Hughes, who once argued that the abortion ban he wrote was “plenty clear,” has since reversed course, saying he is working to propose language to amend the ban. Texas Gov. Greg Abbott told ProPublica, through a spokesperson, that he would “look forward to seeing any clarifying language in any proposed legislation from the Legislature.”

Patrick, Hughes and Attorney General Ken Paxton did not respond to ProPublica’s questions about what changes they would like to see made this session and did not comment on findings ProPublica shared.

In response to ProPublica’s analysis, Abbott’s office said in a statement that Texas law is clear and pointed to Texas health department data that shows 135 abortions have been performed since Roe was overturned without resulting in prosecution. The vast majority of the abortions were categorized as responses to an emergency but the data did not specify what kind. Only five were solely to “preserve [the] health of [the] woman.”

At least seven bills related to repealing or creating new exceptions to the abortion laws have been introduced in Texas.

Doctors told ProPublica they would most like to see the bans overturned so all patients could receive standard care, including the option to terminate pregnancies for health considerations, regardless of whether it’s an emergency. No list of exceptions can encompass every situation and risk a patient might face, obstetricians said.

“A list of exceptions is always going to exclude people,” said Dallas OB-GYN Dr. Allison Gilbert.

It seems unlikely a Republican-controlled Legislature would overturn the ban. Gilbert and others are advocating to at least end criminal and civil penalties for doctors. Though no doctor has been prosecuted for violating the ban, the mere threat of criminal charges continues to obstruct care, she said.

In 2023, an amendment was passed that permitted physicians to intervene when patients are diagnosed with PPROM. But it is written in such a way that still exposes physicians to prosecution; it allows them to offer an “affirmative defense,” like arguing self-defense when charged with murder.

“Anything that can reduce those severe penalties that have really chilled physicians in Texas would be helpful,” Gilbert said. “I think it will mean that we save patients’ lives.”

Rep. Mihaela Plesa, a Democrat from outside Dallas who filed a bill to create new health exceptions, said that ProPublica’s latest findings were “infuriating.”

She is urging Republicans to bring the bills to a hearing for debate and discussion.

Last session, there were no public hearings, even as women have sued the state after being denied treatment for their pregnancy complications. This year, though some Republicans appeared open to change, others have gone a different direction.

One recently filed a bill that would allow the state to charge women who get an abortion with homicide, for which they could face the death penalty.

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