One year later, El Paso health care providers are still reckoning with the impact of Senate Bill 8 – a law that, at the time it took effect, imposed the nation’s strictest time limit on abortions and empowered private citizens as its enforcers.

SB 8 went into effect Sept. 1, 2021, outlawing abortions as soon as cardiac activity can be detected in an embryo. That occurs as early as six weeks, when most people don’t yet know  they’re pregnant. 

The law allows private citizens to sue anyone who “aids or abets” an illegal abortion. This can range from doctors who terminate a pregnancy past six weeks to friends or family who help someone obtain an abortion – for example, buying them misoprostol, a medication used to induce contractions.

The U.S. Supreme Court later voted on June 24 to overturn Roe v. Wade, opening the path to a Texas trigger law, which makes performing an abortion a felony punishable by up to life in prison. Within hours of that decision, health clinics across the country, including Planned Parenthood in El Paso, stopped performing abortions. 

But these laws have affected health care beyond elective abortions. Doctors have to take additional steps to protect both themselves and their patients in health care procedures that might be misinterpreted as abortions, said Dr. Naima Khamsi, an OB-GYN in El Paso.

“Day to day, there are lots of moments where we are dancing around rules that are put in place not by physicians, that are purely political, purely one-sided, that don’t take into account all in the world of obstetrics,” Khamsi said. “The minute you start impeding in that patient-doctor relationship with these laws, you put people at risk.”

Anti-abortion laws in Texas can obstruct care for miscarriages

Khamsi has worked in the field of obstetrics and gynecology for 11 years. While she has never worked as an abortion provider, she’s had to make changes in her practice over the years as Texas rolled out abortion restrictions. Many of her patients aren’t aware of how anti-abortion laws affect pregnancy care until a situation arises where it directly impacts them, she said.

Some of her patients who experienced early pregnancy loss wanted to take misoprostol, a medication commonly used to complete a miscarriage. The pill causes the uterus to contract and expel its contents, and can also be used to induce an abortion.

For some, miscarrying at home feels less intrusive than dilation and curettage, or D&C, a surgical procedure that involves scraping the uterine lining to remove tissue. Misoprostol is also a less expensive procedure than D&C.

But Khamsi has run up against pharmacies in El Paso that refuse to sell misoprostol because the medication can also be used for abortion. Pharmacists, even at brand-name pharmacies, weren’t filling out prescriptions because they feared someone would accuse them of giving out abortion medication, Khamsi said.

The El Paso Pharmacy Association did not respond to a request for comment.

Khamsi said if she diagnoses a patient with pregnancy loss in a hospital, she now gives them the medication before they go home. If she diagnoses a patient in the clinic, she may steer them to a pharmacy that’s on her clinic’s list of places that will fill prescriptions.

Khamsi’s clinic has also implemented an additional step for evidence of pregnancy loss. After an ultrasound shows no fetal heartbeat, Khamsi asks a second physician to perform an ultrasound. If two doctors diagnose and document the pregnancy loss, it “doesn’t appear like I’m arbitrarily saying someone had a miscarriage,” she said.

A pregnancy loss is already a traumatic experience and Khamsi’s patients have questioned why they have to undergo a second ultrasound, she said. She had to explain to them this new policy is to protect both her and the patient from being accused of abortion care.

Texas forces some mothers to carry risky pregnancies, doctors say

Dr. Amanda Hollingsworth is an OB-GYN who has practiced for 12 years in El Paso. Soon after SB 8 passed – and even before it took effect – the law obstructed care for one of her patients, she recalled. 

The patient learned about 11 to 12 weeks into her pregnancy that her fetus had trisomy 13, a genetic disorder that can cause severe intellectual and physical disabilities. The overwhelming majority of infants with trisomy 13 do not survive to their first year, with many dying within two weeks after birth.

Her patient did not want to continue her pregnancy, but Hollingsworth struggled to schedule a D&C for her patient. One hospital turned them away. At another hospital, the anesthesiologist tried to stop the procedure from happening because the fetus had a heartbeat.

“But this baby’s not going to survive. Why are you torturing this mother?” Hollingsworth argued.

They eventually brought in another anesthesiologist.

Some fetuses can’t survive outside the womb, Khamsi said. A fetus that doesn’t develop a brain can still develop a heart and have a heartbeat. Or a fetus can have a dysfunctional heart that stops beating once the baby is born and separated from the mother.

Texas laws now ban abortions unless the mother’s life is in danger or the pregnant person risks “substantial” bodily harm. But nonviable pregnancies, in which the fetus has no chance of survival, can fall in a gray area. Hospitals now have teams with physicians and lawyers to determine whether a complicated pregnancy constitutes a medical emergency, Khamsi said.

An ectopic pregnancy is a medical emergency that’s legal under Texas abortion laws, but the confusion after SB 8 led some Texas hospitals to delay treatment. In an ectopic pregnancy, a fertilized egg grows outside the uterus and cannot survive past the first trimester. Delaying treatment can cause serious health complications for the mother, such as internal bleeding.

“There was a time before SB 8 when you could counsel your patients in their various options, and now there aren’t options to give,” Khamsi said. “It’s hard for people to understand that our hands are tied.

Texas abortion laws have ripple effect 

Hollingsworth fears that Texas’s abortion ban will create barriers to maternal health care that will lead to a rise in deaths among pregnant patients. El Pasoans have high rates of diabetes and  hypertension, conditions that can lead to higher-risk pregnancies and increase the likelihood of maternal mortality, she said. 

But in other ways, she said, El Paso’s abortion situation is slightly better than other parts of Texas because the city is on the border with Mexico, where people can obtain misoprostol without a prescription, and New Mexico, where abortion is legal.

New Mexico Gov. Michelle Lujan Grisham announced Wednesday that the state is dedicating $10 million to the development of a reproductive health care clinic in Doña Ana County. As more states move to restrict access to reproductive care, New Mexico will continue to protect access to abortion and the “full spectrum of reproductive health care,” Grisham said in a press release.

“The reality is that abortion politics at the core is about more than abortion,” said Sarah Walborn, a doula in El Paso. “It’s about bodily autonomy and the right to make decisions about your own body and health care.”

A doula is a trained birth worker who supports a person in pregnancy, labor and postpartum care. Walborn said even before SB 8, many of her clients felt like they weren’t in control of their pregnancy experience. SB 8 and Texas trigger law further undermine their choices for the sake of protecting a fetus, she said.

In response to the restrictions, some of her clients with unplanned pregnancies delayed seeking prenatal care at a health clinic. They were still undecided about whether to continue the pregnancy and didn’t want their pregnancy on the record, she said.

Texas abortion laws have a ripple effect, the extent of which is unknown, Walborn said.

The state’s laws have hindered the ability of Texas medical schools to offer the range of training most OB-GYN students want, Dr. Tony Ogburn told The Texas Tribune. Ogburn is the professor and chair of the University of Texas Rio Grande Valley’s Department of Obstetrics and Gynecology. 

Medical schools are required to offer abortion care training and residency rotations to OB-GYN students. But since the number of abortions have fallen drastically in the state, on-site training opportunities practically disappeared for medical students in residency in Texas, he said.

Texas Tech University Health Sciences Center El Paso, which operates the Paul L. Foster School of Medicine, and the University of Texas at El Paso’s College of Nursing did not respond to requests for comment about how abortion laws affect their schools.

Khamsi fears the criminalization of abortion won’t be enough for some Texas lawmakers. In July, President Joe Biden signed an executive order protecting access to contraception and other reproductive health care services. That doesn’t stop her from worrying about what could come next for her field.

“It makes me sad for my patients and it makes me scared for myself,” Khamsi said. “I wouldn’t want to do something that doesn’t allow me to practice … It’s stressful thinking about what might come down the pipeline and later affect what you practice today. It’s very much changed.”

El Paso Matters reporter Victoria Rossi contributed to this story.