Maternal Deaths ...

Collateral Damage?

A crisis is brewing in Texas, where I live. Rural areas of Texas already feel the pinch, but women all over the state will soon feel the effects of dwindling OB-GYN services. There are multiple factors contributing to this coming catastrophe, but most could be avoided if the Texas legislature were to prioritize the health of women. I’m not optimistic.

In 2022, the same year Roe v. Wade was overturned, Texas enacted an abortion ban that prohibits almost all abortions unless the mother has a life-threatening condition or is at risk of death or “substantial impairment of a major bodily function.” A physician must also try to save the life of the fetus in this situation, unless their action would increase risk of the patient’s death or impairment.

What isn’t clear, to me or to most physicians apparently, is how a substantial impairment of major bodily function might be defined by a judge or jury. The legislature has insisted it’s clear and refuses to further clarify the issue. Perhaps they desire—eagerly, and with gleeful anticipation—an opportunity to make an example of anyone daring to test the criteria.

According to information in the Texas State Law Library, penalties for anyone performing an abortion are severe enough to discourage testing. A care provider is subject to first or second degree felony charges if the abortion results in the death of the fetus. There’s no penalty for the death of the mother. Providers could have their license revoked if they’re a physician or other healthcare professional. In addition, there are civil penalties of at least $100,000 plus attorney’s fees and court costs, none of which is insubstantial.

Perhaps Nevaeh Crain would still be alive if physicians had been willing to demonstrate the vagaries of the law when a pregnant woman’s life is in danger. Crain was an eighteen-year-old Texas teen who died in 2023 after several emergency room visits for increasingly dire symptoms. Physicians couldn’t remove her fetus until several ultrasounds confirmed the fetus was dead, within hours of Nevaeh’s death.

Photo by Sandy Millar on Unsplash

Because physicians are charged with saving the fetus at almost any cost, they lost both Nevaeh and her much-anticipated child. Perhaps Nevaeh’s death is considered acceptable collateral damage to the Texas Legislature, since her body was no longer of use to her child.

It isn’t surprising that many OB-GYNs have chosen to leave Texas or refuse to practice here, due to laws that restrict them from using their expertise to save patients’ lives. It’s predicted that by 2030, there will not be enough to meet demand. That would be disastrous enough for the nearly 400,000 women who give birth in Texas each year. But those physicians do more than deliver babies.

Many women who are not pregnant or not of childbearing age obtain the majority of their healthcare from OB-GYNs. They will have a more difficult time in the near future having those needs met. In this case, other healthcare providers may be unable to fill the gap in attending to the range of women’s health needs, like cervical cancer, endometriosis, ovarian cysts, and many more common or rare conditions.

This problem is exacerbated in rural areas of Texas, where almost half of Texas counties offer no maternity care services at all. Another significant number of women in rural areas live more than 30 minutes from the nearest provider. The situation has been called a “maternity care desert” by the Texas Tribune. The issue in rural counties is closure of smaller hospitals that depend on state funding to survive. Even where those hospitals survive, labor and delivery departments have not.

A recent Tribune article describes the situation as dangerous for all rural residents, but particularly so for women. Pregnancy and childbirth may be perceived as “normal” conditions by legislators (overwhelmingly male), but every woman knows that is hardly the case. A small group of advocates is pushing for reforms that will keep the rural health care system responsive to the needs of pregnant residents.

One of the significant issues is Medicaid funding. Texas declined to accept Medicaid assistance from the federal government, which would have provided a larger pot to draw from. They did extend some postpartum maternity care in the last legislative session, thankfully, but state dollars will only stretch so far. Strengthening maternal healthcare is really a bipartisan issue, but I have little hope this will happen in the session that begins in January.

Medicaid pays for half of births in Texas as a whole, but that portion is higher in rural counties. Because the state administers Medicaid funding without national dollars, it has absolute control over how the money is spent. Advocates from Texans Cares for Children (or not?) propose funding care based on actual cost rather than a fixed rate, as is currently the case. This will be helpful, but if OB-GYNs are vacating the state due to Texas’s abortion ban, I’m not sure how much it will help.

It may take a few years for this brewing crisis to reach a head, but women will die in the meantime. Unfortunately, an increase in pregnancy-related deaths may be the only statistic that will convince Texas legislators that a change of course is necessary. Until then, women who die due to pregnancy complications will simply be collateral damage.