Kate Cox is one of hundreds in Texas denied abortions despite serious health risks, data show

A Texas woman’s unsuccessful legal fight for an abortion on medical emergency grounds drew nationwide headlines in recent days, but her plight is hardly a rare occurrence amid vague and highly restrictive state laws in the post-Roe era. Kate Cox is likely one of hundreds, if not thousands, of Texans who’ve faced a similar struggle this year to get an abortion for medical reasons, according to a STAT review of studies and abortion data from other states.

Over the first six months of this year, there were 34 legal abortions recorded in Texas, all of which were categorized as both “medical emergencies” and to “preserve the health of the woman,” in a state where abortions are only permitted under such circumstances. That figure, said physicians and researchers, is far below the number of patients who would typically need abortions to protect the health of the mother, suggesting many women have been forced to continue pregnancies despite the risks, or to travel out of state for abortions.

Just next door, the state of Oklahoma provides a benchmark: State data show 324 abortions were performed there because the physical health of the mother was at risk in 2021, the year before Oklahoma enacted its own abortion ban. The line between risk and crisis is blurred in the official statistics, but 59 abortions that year were necessary to avert the death of the mother, which is the narrowest possible interpretation of an emergency. Applying that rate to Texas, with a population more than seven times larger, the number of women facing death who needed abortions would exceed 400 a year, while close to 2,400 would likely face physical health risks.

Risks don’t always become imminently life-threatening, but strict definitions that separate the two are not easily applicable in health care. “Medicine is not black and white, there’s a lot of gray,” said Daniel Grossman, director of Advancing New Standards in Reproductive Health (ANSIRH), a research group at the University of California, San Francisco. “Pregnancy itself is very dangerous and medical conditions can progress quickly during pregnancy in a way that’s very different from a non-pregnant state. There isn’t a moment necessarily where it’s clear the patient’s risk of dying is so high, it’s much more of a subjective assessment.”

Meanwhile, some 394 abortions in Oklahoma in 2021 were due to a possible problem with the health of the fetus, a concern shared by Cox, whose fetus carried a genetic disorder, trisomy 18, with an extremely low chance of survival.

Another indicator of the need for medically necessary abortions is a 2013 study of 954 abortions at 30 U.S. abortion facilities, which found some 6% were performed out of concern for the patient’s own health. In Texas, where 32,988 abortions were performed in the first six months of 2018 (before the state adopted a “heartbeat” law in 2019 that effectively banned abortion after six weeks of pregnancy), that would be equivalent to nearly 4,000 abortions a year.

“We can logically assume there are hundreds, if not thousands, of cases [of pregnancies that need to be terminated for health emergencies] in a state like Texas every year,” said Gretchen Ely, professor of social work at the University of Tennessee who studies reproductive health and health disparities.

The state, though, only started tracking reasons for abortions in September 2021, coinciding with its adoption of laws that permit abortion only in vaguely defined medical emergencies.

Erinma Ukoha, a maternal fetal medicine fellow at a New York hospital and a fellow with the advocacy group Physicians for Reproductive Health who specializes in high-risk pregnancies, said she discusses abortion as a possible treatment option with patients who have pregnancy-related health issues on a daily basis. “Pregnancy emergencies arise all the time,” she said.

The 34 Texas abortions in the first half of 2023, she said, don’t reflect the true number of pregnancies that needed to be terminated for medical reasons. Instead, she added, Texas has created a legal prohibition that often overrides physicians’ interpretation of emergency, as demonstrated by Cox’s recent lawsuit.

Continuing her pregnancy was potentially life-threatening, according to the suit, and risked making Cox permanently infertile, which Cox and her physician argued met the Texas definition of allowing abortion in cases where pregnancy will create “substantial impairment of a major bodily function.” While a lower court sided with her initially, the Texas Supreme Court refused to allow her to have an abortion, though it was deemed necessary by her doctor. She ended up traveling out of state to end the pregnancy.

“Even in cases where a physician believes there’s a medical indication, as we’ve seen in the case of Kate Cox, there’s so much uncertainty around what will retrospectively be perceived by the medical system as necessary,” said Deepshikha Ashana, medical professor at Duke University specializing in critical care.

Grossman recently published a report on reproductive care after the U.S. Supreme Court’s Dobbs decision that overturned Roe v. Wade. He highlighted several cases of patients who faced immense medical risk but couldn’t get appropriate care in states with abortion restrictions.

Those who develop preterm premature rupture of membranes (PPROM) in the second trimester, which happens in 0.4% to 0.7% of pregnancies, would have been offered abortions pre-Dobbs, because the fetus is unlikely to survive and the patient is at risk of infection. Now in these states, Grossman highlighted instances where physicians sent patients home, waiting for them to develop an infection which, in several cases, became severe and required ICU treatment.

In addition to PPROM, pregnancy also comes with risks including hemorrhaging, pre-eclampsia, and liver dysfunction, all of which can rapidly go from distressing to a life-or-death emergency.

Waiting for the threat of death to worsen is precarious for both doctors and patients, and emergency care typically works to prevent crises, said Hayley Gershengorn, an intensivist and health services researcher at the University of Miami. “If we’re waiting for people to be on the foothold of death, our ability is lessened.” Rather than wait for care, others with PPROM noted in Grossman’s report had to drive for several hours to receive treatment out of state. Such journeys are becoming increasingly common. Around half of abortions performed in Oklahoma in 2022 were for Texas residents, while others travel further.

Gershengorn said the journey significantly increases risk. ”To say they can just go somewhere else — it is not the case,” she said. “Forget financial resources and the logistics, which is a whole other story. To travel 500 miles when you’re on the verge of critical illness is risky, and people don’t always tolerate that.”

Both the need for travel and delays accessing care significantly exacerbate risks, said Andréa Becker, a postdoctoral research fellow at the ANSIRH research group, who’s published research showing maternal mortality is significantly worse in states with abortion restrictions and exacerbated for Black patients.

The lack of certainty around what constitutes enough risk to perform an abortion is, she said, a way to further deter abortions. “There’s a lot of ambiguity in the laws that were passed post-Dobbs and within this ambiguity doctors aren’t able to provide the standard of care,” she said. “There’s a chilling effect.”

This story is part of ongoing coverage of reproductive health care supported by a grant from the Commonwealth Fund.