This story was originally published by ProPublica.
For the first time since Texas criminalized abortion, the state’s medical regulator is instructing doctors on when they can legally terminate a pregnancy to protect the life of the patient — guidance physicians have long sought as women died and doctors feared imprisonment for intervening.
The new training from the Texas Medical Board comes nearly five years after the state passed its strict abortion ban in 2021, threatening doctors with severe penalties. ProPublica’s reporting has shown that pregnancy became far more dangerous in the state after the law took effect: Sepsis rates spiked for women suffering a pregnancy loss, as did emergency room visits in which miscarrying patients needed a blood transfusion; at least four women in the state died after they didn’t receive timely reproductive care. More than a hundred OB-GYNs said the state’s abortion ban was to blame.
In response, the Texas Legislature passed the Life of the Mother Act last year. The law updated the abortion ban’s medical exceptions, added to the legal burden needed for prosecutors to criminally charge a doctor and required the medical board to create guidance for doctors by Jan. 1, something no other state with an abortion ban has done.
The new medical training, which ProPublica obtained under a public records request, assures doctors they can now legally provide abortions, even when a patient’s life isn’t imminently in danger, and goes over nine example scenarios, including a patient’s water breaking before term and complications from an incomplete abortion.
Some of the scenarios make clear how doctors can intervene in circumstances similar to cases ProPublica has investigated. For example, in 2021, Josseli Barnica was diagnosed with an “inevitable” miscarriage, leaving her at high risk of dangerous infection, and she died after doctors would not empty her uterus while there was still a fetal heartbeat. The new training includes an example that indicates an abortion would be legal in similar cases.
But medical and legal experts who reviewed the training for ProPublica said the case studies represent only the most straightforward situations doctors encounter. The complications that women face in pregnancy are varied, complex and impossible to capture in a brief presentation, many cautioned. One attorney called the training “the bare minimum.”
“I could probably list 100 different situations that would cause people to pause and say, ‘Wow, does that fit into the law?’” said Dr. Tony Ogburn, an OB-GYN practicing in Texas. “They’re taking years and years of medical training and experience on how to manage these cases and summarizing it in 43 slides.”
Notably absent from the training is guidance on how doctors should care for patients with chronic conditions, a gray area that has come up again and again in ProPublica’s reporting. Last year, ProPublica investigated the death of Tierra Walker, a San Antonio woman with diabetes and high blood pressure who endured repeated hospitalizations and escalating symptoms before she died. Doctors dismissed her requests for an abortion to protect her health, her family said. Doctors and hospitals involved in Walker’s care did not respond to ProPublica’s requests for comment.
And no amount of training can solve what many doctors see as the main problem: the law’s steep criminal penalties. If found guilty of performing an illegal abortion, doctors face up to 99 years in prison, $100,000 in fines and the loss of their medical license. Even the possibility of a lengthy and public court battle can be a powerful deterrent, many physicians told ProPublica.
The Texas Medical Board writes in its training that “the legal risk of prosecution is extremely low” if doctors practice “evidence-based medicine,” follow “standard emergency protocols” and document cases appropriately. The training also emphasizes multiple times that the burden now falls on the state to prove that “no reasonable doctor” would have performed the abortion. Before the Life of the Mother Act, prosecutors could accuse a physician of performing an illegal abortion with little evidence.
That assurance rings hollow to some doctors, who point to the actions of Texas Attorney General Ken Paxton since the state’s abortion ban took effect.
Dr. Damla Karsan, an OB-GYN based in Houston, said she appreciates that the training tells physicians they can use their expertise to make judgment calls during emergency situations. “But having to defend your decision is still scary,” Karsan said.
In 2023, Paxton overruled Karsan’s medical judgement when her patient Kate Cox sought an abortion at 20 weeks after learning the fetus had a fatal genetic anomaly. Texas bans abortions for all fetal anomalies unless the pregnant woman is facing a medical emergency. Karsan argued that Cox qualified: She had previously had two C-sections, increasing her risk of hemorrhage, infection and future infertility. A Texas lower court permitted the abortion, but Paxton appealed the ruling to the Texas Supreme Court, which ultimately overturned the decision, arguing Karsan hadn’t done enough to prove Cox’s life was at risk.
Paxton’s office did not respond to repeated requests for comment about the Cox case and the medical board’s assertion that the risk of legal action for doctors who follow its guidance is extremely low.
Texas Medical Board President Dr. Sherif Zaafran told ProPublica that the training was reviewed by Paxton, as well as Gov. Greg Abbott and state Sen. Bryan Hughes, the abortion ban’s author. The board, which has 19 members appointed by the governor, including 12 licensed physicians but no OB-GYNs, also consulted with the Texas Hospital Association and the Texas Medical Association.
Any doctors who practice obstetric care, including all emergency room and urgent care physicians, will need to complete the self-administered online course before 2027 in order to obtain or renew their license.
Multiple doctors told ProPublica decisions about abortion care are also shaped by hospital lawyers. The Life of the Mother Act required the State Bar of Texas to create its own training for attorneys, which ProPublica reviewed. That presentation also explains that prosecutors looking to file a criminal charge now need to demonstrate that no other doctor would provide an abortion if faced with the same scenario.
Blake Rocap, a longtime reproductive rights attorney, said the state guidance should give doctors and hospitals more protections to help patients access care. “It will save lives,” he said.
After Texas’ six-week abortion ban took effect in 2021, doctors, hospitals and reproductive rights advocates repeatedly urged the Texas Medical Board to provide guidance on how medical professionals could comply with it. In particular, they sought clarity around the law’s vague exception for a “life-threatening emergency.”
For years, the board declined, saying it lacked the authority.
In the absence of guidance, confusion reigned across the state. The standard of care for miscarrying patients in the second trimester, for example, is to offer to empty the uterus, which can lower the risk of infection and sepsis, according to leading medical organizations. While some Texas doctors told ProPublica last year they regularly offer to empty the uterus in these cases, others said their hospitals didn’t allow them to do so until the fetal heartbeat stopped or they could document a life-threatening complication, leading to delays in care like the one that Barnica experienced. Across the state, cases of sepsis in second-trimester pregnancy losses shot up more than 50% after the ban took effect, according to a data analysis by ProPublica.
In 2024, the board released limited guidance stating that providers don’t need to wait until a pregnant woman is on the brink of death to intervene. The new training goes further, offering detailed examples of when abortion would be legal.
One case study addresses patients who get an abortion out of state but retain tissue in the uterus. Because the pregnancy was already ended, the medical board advises, “ongoing treatment of any retained products is not an abortion and is not considered aiding and abetting an abortion.” ProPublica investigated the death of a woman in Georgia, Amber Thurman, who died of sepsis when doctors there delayed emptying her uterus after an incomplete abortion.
The training also makes clear that the definition of ectopic pregnancies — which are always life-threatening — includes any that implant in an abnormal location outside of the uterine cavity. Previous laws had defined an ectopic pregnancy as one outside of the uterus. While most ectopic pregnancies occur in the fallopian tubes, some can also implant inside the uterus, such as in the scar tissue from a previous pregnancy.
Still, the training doesn’t address a key issue in miscarriage management that ProPublica’s reporting has highlighted: Early pregnancy loss often can’t be conclusively diagnosed with a single ultrasound. Confirming that a pregnancy has ended can take days or weeks. In those cases, some doctors have left women bleeding and in pain instead of offering a D&C, a procedure that can prevent hemorrhage. Another Texas woman named Porsha Ngumezi bled to death in 2023 while miscarrying, according to the medical examiner, after her doctor did not provide a D&C.
The training also offers no instruction on how to care for patients whose pregnancies are high risk because of underlying medical conditions like autoimmune disorders, uncontrolled blood pressure or heart disease. Pregnancy can often exacerbate these chronic conditions, sometimes leading to a small risk of death, but doctors may not consider this “life-threatening.”
Walker, the San Antonio woman ProPublica reported on last year, had uncontrolled blood pressure and developed seizures and blood clots. More than 90 doctors were involved in Walker’s care, but not one offered her the option to end her pregnancy, according to medical records. Doctors who reviewed the new training for ProPublica said they still weren’t clear when they could intervene in cases like hers — would it be when a woman first got pregnant because she already had some risk factors that made pregnancy more dangerous? Or would they have to wait until she developed specific symptoms that showed her health was declining?
Zaafran said the training makes clear that doctors can judge whether a patient is at risk of death or irreversible damage — and that they can intervene before the patient reaches that state. “In other words, you don’t need to wait until somebody has clots or seizures or whatever it might be to make a determination that something needs to be done.”
What doctors do need to do, Zaafran repeatedly said, is document those risks in case their patients qualify for an abortion. But Karsan argues she did that in the Cox case, and Paxton fought her in court anyway.
While the medical board’s training includes two case studies related to patients with fatal fetal anomalies, neither addresses whether the updated law allows an abortion in a scenario similar to Cox’s. Karsan documented in the medical records that a third C-section would put Cox at risk of death or a hysterectomy if there was a complication, and that argument is what she shared with the courts. The training emphasizes that a fatal fetal anomaly alone is not covered by the exceptions and that “the mother must have a life-threatening physical condition.” Zaafran declined to comment on Cox’s case specifically but said that his understanding was there was not enough documentation.
Cox told ProPublica she trusted her medical team’s judgment and she did not want to risk her health by continuing her pregnancy. Grieving the unexpected loss while being denied care and seeing her doctor threatened by the top lawyer in the state, Cox said, “was incredibly scary.” She ultimately traveled out of Texas to get an abortion.
“I’m grateful for my doctors. Their hands were tied in many ways,” she said. “The problem isn’t our doctors. It’s that pregnancy is too complicated to legislate.”
ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.
