Texas nurses worry about women’s health care in a post-Roe era

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AURORA, COLORADO — Texas nurses Jessica Phillips and Keshia McDonald stared at each other in disbelief when they heard the news that abortions would soon be outlawed in the state.

The two were among hundreds of caregivers who learned that the U.S. Supreme Court had overturned Roe vs Wade as a national conference for nurses who specialize in women’s health was starting in Aurora, Colorado, last week.

“My first reaction was devastation,” said McDonald, who was at a workshop with Phillips and other nurses Saturday. “I never would’ve expected this in 2022, and I’m really just uncertain about the future of women’s health.”

The Supreme Court decided in a 6-3 vote to undo a nearly half-century precedent that had affirmed access to abortion as a constitutional right. It will now be up to each state to determine their own abortion laws, and half of them are poised to ban or severely limit the procedure. Through a “trigger law” that goes into effect 30 days after the Supreme Court releases a formal judgment, Texas will soon ban all abortions from the moment of fertilization with narrow exceptions only to save the life of a pregnant patient or prevent “substantial impairment of major bodily function.”

Many nurses and other health care providers have raised the alarm that banning abortion will have wide-sweeping effects, affecting lifesaving medical procedures beyond elective abortions. Medical professionals now worry about having to deal with complex legal questions about what they can and can’t do, sometimes in the middle of care in which every second matters.

No easy answers

The difficult questions started after Senate Bill 8 was passed in Texas. Phillips said after that statute was enacted, effectively banning abortions after about six weeks of gestation, she was shocked to hear physicians grapple with what they legally were allowed to do. And it’ll only get worse now that Roe was overturned.

“The law isn’t specific in what scenarios abortions are allowed — but it also shouldn’t be. Physicians should be the ones making that call,” said Phillips, who was a labor and delivery nurse for 17 years and now uses her expertise working for a health nonprofit. “A patient’s health should be between her and those providing care to her.”

Throughout the first days of the Association of Women’s Health, Obstetric and Neonatal Nurses conference, which started Saturday, medical professionals have gone over what the myriad abortion laws in their home states allow them to do now that Roe’s protections are gone. Texas’ trigger law banning abortions is expected to go into effect in about two months.

Phillips said these situations might be hypothetical, but they all stem from real-world experiences that are impacted by the Supreme Court’s ruling.

One example discussed was what to do if someone’s water breaks very early into the pregnancy. This could cause an infection, and the fetus is unlikely to survive, Phillips said.

Before Roe was repealed, doctors would typically perform an abortion and other treatments to keep the patient healthy. But under the Texas trigger law, physicians would be faced with a conundrum, she said. When is the patient sick enough to warrant lifesaving care? Is it right away, since doctors know that the patient will get an infection that could complicate other care or put her safety at risk? Or does the doctor first have to let the patient reach that point to avoid legal liability?

There are more and more questions like these every day, Phillips said.

“When is it considered grave enough to her health? Is it immediately because you know the outcome or do you have to wait for her to get sicker and sicker? Because you also have to consider that, if you wait for her to get sicker, delivering her is more complicated because sometimes they end up hemorrhaging or they’re already in organ failure or all sorts of things,” Phillips said.

Doctors will have to second-guess decisions not based on medical best practices but on abortion laws, she said. She fears it will lead to patients dying or not receiving the care they need.

“To hear physicians who’ve been doing this forever even consider having to let someone get sick blows my mind,” she added. “It’s not something I’ve in my 17-year career ever heard of.”

There are also times when doctors perform abortions because they know a pregnancy will not be successful and the baby would die after being delivered, Phillips said. But under Texas’ laws allowed after Roe was repealed, pregnant people would be forced to deliver.

“That’s a very emotionally devastating experience,” Phillips said. “And we know Texas does not have adequate mental health services.”

Jonathan Webb, CEO of the Association of Women’s Health, Obstetric and Neonatal Nurses, which has more than 2,000 members in Texas, said the organization has started conversations with prosecutors to help educate its members about what medical procedures might now be deemed criminal in their states.

Webb knows from experience the tough decisions parents sometimes must make: His wife was once diagnosed with an ectopic pregnancy, in which an embryo implants outside the uterus. Proceeding with the pregnancy would have been fatal to his wife.

“We had to make a difficult decision over prioritizing her life over the life of our unborn child,” Webb said.

He can’t imagine being unable to make that decision on their own because of state law roadblocks.

The impact on people of color and the profession

AWHONN board member Suzanne Baird was working at Texas Children’s Pavilion for Women in Houston when the state’s so-called sonogram law went into effect in 2012.

The law required women who wanted an abortion to first get a sonogram 24 hours before the procedure and have the doctor make the fetal heartbeat audible to the patient.

Baird said she saw firsthand as women, who were told they had a nonviable pregnancy and that the fetus would not survive, were made to see their unborn child one more time.

“It was just cruel,” Baird said, who was assistant director of nursing clinic program development at the hospital.

She was also in Texas in 2013 when the Legislature passed a law requiring doctors who perform abortions to have admitting privileges at hospitals within 30 miles of an abortion clinic — a move that she said resulted in many clinics closing.

But back then, even as those restrictions went into effect, Baird said she couldn’t imagine that one day Roe v. Wade would be overturned — and the huge impact the decision would have on patients in Texas.

Baird was one of roughly 2,200 people attending the AWHONN conference just outside Denver. She was sitting in a board meeting Friday morning when the Supreme Court announced its decision to overturn the law. With Roe’s end, nurses anticipate an even more difficult world for their patients who face high-risk pregnancies in which the mother or fetus’ survival is in danger. Doctors and nurses will face even more difficult decisions about when to intervene and recommend terminating a high-risk pregnancy for fear of criminalization. Birth rates will likely go up and Baird fears maternal mortality rates will follow, she said.

The United States has the highest maternal mortality rate of all developed countries, with significant racial and ethnic disparities. Texas has among the highest pregnancy-related deaths in the nation.

And unsafe abortions will increase because of the ban, said Sandra K. Cesario, AWHONN board president and the doctorate program director at Texas Woman’s University in Houston.

Abortion opponents have presented adoption as the solution for unwanted pregnancies, but abortion stops pregnancy, while adoption requires pregnant people to give birth, which comes with a host of potential complications that disproportionately affect people of color and low-income people.

“People of color often don’t have adequate access to health care anyway — and now will have their options completely eliminated,” McDonald said.

With Roe revoked, inequities about who can and can’t control their reproductive health care will only increase, Baird said. Tennessee, where she now works, has a trigger ban in effect that will make abortion illegal in the state within a minimum of 30 days after Roe is overturned. She anticipates surrounding states will pursue more abortion restrictions, which means patients may have to travel across at least two states to get abortion care if they so choose.

“Not all women will be able to do that,” she said. “The wealthy will be able to do that.”

Cesario reflected back on some of the actions she’s taken as a nurse that helped end a patient’s pregnancy to save their life — and that would now be criminalized.

“I guess I could be put in jail for things I did,” Cesario said.

McDonald, who is a nurse manager at an outpatient setting in Central Texas, said the end of Roe has complicated a lot, including her plans for her career.

Both McDonald and Phillips fear that the repercussions of the Supreme Court’s ruling could exacerbate the ongoing shortage of nursing staff. Many nurses have been deeply affected by burnout from the COVID-19 pandemic, and the pair believes Texas’ looming abortion ban will send further doubts into practicing and would-be caregivers.

“This makes the future so scary. We don’t know what the decisions will be,” McDonald said. “We don’t want to withhold care from people.”

While discussing the future of women’s and maternal health care, AWHONN members found some solace in each other this weekend. Phillips and McDonald said it was emotionally draining and difficult to learn about the Supreme Court’s decision, but it did help to be surrounded by a community of health workers — all of whom just want what’s best for their patients’ health.

“I can’t imagine having to learn about it with anyone else,” Phillips said.

Uncertainty for the future of health care hovered over the planned programming for the nurse’s conference. Attendees were soon asking if there was anything they could do. Hours after the Supreme Court announcement, those who arrived to the conference a day early began looking for any protests they could attend in nearby Denver.

Baird said she knew what her sign would say: “I can’t believe we still have to march for this.”

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