Texas State HB 2-New Abortion Standards in the State of Texas

Being that I live in Texas I thought I would link to the actual TX HB2 that was passed this week.  It can be found here

I’ve also decided to cut and paste some of the bill, hopefully for some clarity.   Please feel free to read the entire bill and offer your opinions.

Some interesting points and my thoughts:

Section (4) restricts “elective abortions at or later than 20 weeks post-fertilization”.  I could see where some might use this language to “back date” a pregnancy by several weeks.   Pregnancy due dates are determined by adding 40 weeks (280 days) to the approximate first date of your last menstrual period or 266 days to the end of ovulation.    So what we might think of as a 20 week pregnancy (calculated from date of first missed period) would arguably be called 22 weeks, assuming fertilization occurs 2 weeks prior to the missed period.   One could technically say that section 4 actually restricts abortion to pregnancies that are 18 weeks by conventional dating versus 20 weeks post fertilization.

Later in the bill  (Section 171.042(1)) the statement reads ‘”Post-fertilization age” means the age of the unborn child as calculated from the fusion of a human spermatozoon with a human ovum.”  The benefit to this definition would be found when calculating gestational age of in vitro babies, when the exact date of fertilization is known.

Section (4) (B) states:  “this Act does not apply to abortions that are necessary to avert the death or substantial and irreversible physical impairment of a major bodily function of the pregnant woman or abortions that are performed on unborn children with severe fetal abnormalities.”   So much for those who claim the State of Texas is trying to stop all abortions after 20 weeks.

Sec. 171.0031:  REQUIREMENTS OF PHYSICIAN…(a) A physician performing or inducing an abortion: (1) must, on the date the abortion is performed or induced, have active admitting privileges at a hospital that: (A) is located no further than 30 miles from the location at which the abortion is performed or induced; and (B) provides obstetrical and gynecological health care services…”  This requires an OB-GYN to perform the abortion, not, for example, a family practitioner.  This also ensures that in the remote case that there is a complication a woman is no more than 30 miles from adequate emergency medical attention.  

Physicians will also be required to “…provide the pregnant woman with: (A) a telephone number by which the pregnant woman may reach the physician, or other health care personnel employed by the physician or by the facility at which the abortion was performed or induced with access to the woman’s relevant medical records, 24 hours a day to request assistance for any complications that arise from the performance or induction of the abortion or ask health-related questions regarding the abortion; and (B) the name and telephone number of the nearest hospital to the home of the pregnant woman at which an emergency arising from the abortion would be treated.”   You know, this seems reasonable to me.  When I have elective day surgery of any kind, I’m provided with information on who to contact if I have a complication, there is always a physician on call.   Even when I go to the dentist and have dental surgery, I have someone I can call if there is a complication.

Section (171.043) requires the physician to “…mak[e] a determination of the probable post-fertilization age of the unborn child…” or “…possessing and relying on a determination of the probable post-fertilization age of the unborn child  made by another physician…”  So, either the physician dates the pregnancy with a sonogram, or relies on the woman providing the date of her last menstrual period, or that information is provided by her regular OB-GYN who has determined the gestational age of the fetus, say in the case of referral for fetal anomaly or medical condition of the mother necessitating the abortion.

In Section 171.045.  METHOD OF ABORTION “…if the pregnancy is greater than 20 weeks…” (or 18 weeks depending on the discussion earlier) “…(b) …a physician performing an abortion under subsection (a) shall terminate the pregnancy in the manner that, in the physician’s reasonable medical judgment, provides the best opportunity for the unborn child to survive.”   In this setting, if a women had a pregnancy greater than 20 weeks and her physical health was compromised by the pregnancy in such a way that it necessitated termination, the physician could, if it was in his own ”reasonable medical judgment” elect to induce labor or schedule a cesarean section to afford a chance at a live birth rather than abort the pregnancy using other means.

While I can’t see of any circumstance where, if I were pregnant past 20 weeks and had a medical condition that necessitated an abortion I would prefer an abortion to a potential live birth, I can see problems with determining who would assume the cost of a NICU stay in the event of an “unwanted” child greater than 20 weeks gestational age being delivered alive.   In Texas this child would qualify for Medicaid if the parents did not have private insurance.   The mother could then give up an unwanted child for adoption at this point.

Sec. 171.048 (c)  states that “A state executive or administrative official may not decline to enforce this subchapter…based on the official’s own beliefs about what the state or federal constitution requires, unless the official is enjoined by a state or federal court…”    If I’m interpreting this correctly, this would negate the situation going on in Pennsylvania and what went on in California with State Attorneys General refusing to uphold state law (with respect to DOMA).

Sec 171.06 describes the regulation of abortion-inducing drugs, including the off-label use of drugs.  Exempted are drugs used to treat ectopic pregnancies, situations involving fetal demise, or drugs used to treat a medical condition of the mother, for example, chemotherapy drugs.   This section also defines “ gestational age” as the “amount of time that has elapsed since the first day of the woman’s last menstrual period.”    Since this is different from the definition at the beginning of the bill, I can see confusion regarding this section.   This section also defines a physician as either an MD or a DO.   This section also requires a physician to administer an abortion-inducing drug (meaning they couldn’t be prescribed by an MD and then dispensed by a pharmacist, or prescribed and dispensed by a nurse practitioner or physician assistant).  The physician (or his/her agents) is also required to make a 14 day follow up appointment to assess that pregnancy termination has taken place and the woman is in good health.

Section 4.  Section 245.010(a) of the Health and Safety code is amended to require abortion facilities to be equivalent to the minimum standards (italics mine) adopted for ambulatory surgical centers.

This section requires that the abortion facility provide a written report (like a dictated or written operative report or discharge summary) that would include “…the patient’s year of birth, race, marital status, and state and country of residence…the type of abortion procedure…the date the abortion was performed…whether the patient survived the abortion and if not…cause of death…the probable post-fertilization age of the child based on the best medical judgment of the attending physician at the time of the procedure…the date, if known, of the patient’s last menstrual period…number of previous live births…number of previous induced abortions.”   I don’t see problems with this.   Complete medical records provide valuable epidemiological information and would allow us to see the actual prevalence of abortion and at what stage of pregnancy they are performed.  OB-GYNs routinely document the number of pregnancies, live births, still births, and spontaneous and induced abortions their patients undergo.   This is considered appropriate documentation of a patient’s medical history.

Section 6.  Section 164.052(a) Occupations Code prohibits a physician from performing an abortion in the third trimester unless it is necessary to “prevent the death of the woman: (B) the viable unborn child has a severe, irreversible brain impairment; or (C) the woman is diagnosed with a significant likelihood of suffering imminent severe, irreversible brain damage or imminent severe, irreversible paralysis; (19) performs an abortion on an unemancipated minor without the written consent of the child’s parent or… a court order.”

Since there has been much discussion about the minimum standards of ambulatory surgical centers, I’ve linked the entire document here:

The minimum standards:  

§ 243.010. MINIMUM STANDARDS.  (a) The rules must contain minimum standards applicable to an ambulatory surgical center and for

(1)  the construction and design, including plumbing, heating, lighting, ventilation, and other design standards necessary to ensure the health and safety of patients;

(2)  the qualifications of the professional staff and other personnel;

(3)  the equipment essential to the health and welfare of the patients;

(4)  the sanitary and hygienic conditions within the center and its surroundings;  and

(5)  a quality assurance program for patient care.

(b)  Standards set under this section may not exceed the minimum standards for certification of ambulatory surgical centers under Title XVIII of the Social Security Act (42 U.S.C. Section 1395 (et seq.).

(c)  This section does not authorize the board to:   (1)  establish the qualifications of a licensed practitioner;  or  (2)  permit a person to provide health care services who is not authorized to provide those services under another state law.

I then looked up the minimum standards set under Title XVIII of the Social Security Act, which can be found here:

This states in part that “[t]he department may inspect an ambulatory surgical center at reasonable times as necessary to assure compliance with this chapter.”  Otherwise, this document appears nearly identical to the Texas State minimum standards with no real definition of what those minimum standards are.

So I poked around the internet and found this.

CMS (the Centers for Medicaid and Medicare Services) requires a separate waiting room, not to be shared with another entity.  Document found here

The State of Texas does require plans for ambulatory surgical centers to be submitted for approval, here.

I was unable (okay, I was too lazy) to locate the actual requirements for plumbing and electrical specifications.

It does appear that the State regulates the size of rooms, what constitutes a room (must have an exterior window) and requires that 10% of rooms must be handicapped accessible.

Now we can have a discussion about what the HB 2 does and doesn’t say, as opposed to just shouting catch phrases at each other.   In my next post, I’ll look at the number of facilities in the State of Texas that provide abortions versus actual health care for women (i.e, Pap smears, referrals to mammograms).

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