Do no harm

Outside the Texas capitol on March 7, a 35-year-old blonde stood in the grass in a white dress and heels. She stepped up to a podium bristling with microphones and sighed. Her face was tight-lipped, and she had bags under her eyes. “Hello,” she said to the gathered reporters. “My name is Amanda Zurawski, and I’m here to tell you a little bit about my experience with the Texas abortion bans.”

Zurawski is one of the five women who, along with two doctors, sued the state of Texas over laws protecting babies from abortion. (Eight more women joined the lawsuit two months later.) Behind Zurawski that day under the cloudy sky stood three of her fellow plaintiffs, along with lawyers from the pro-abortion Center for Reproductive Rights. The lawsuit claims the state’s pro-life laws prevented the five women from receiving—and the two doctors from providing—“necessary and potentially life-saving obstetrical care.” It asks the court to order the state of Texas to clarify the medical exceptions in the laws so doctors can treat women without the threat of lawsuits.

That afternoon outside the Texas Capitol, Zurawski told an abbreviated version of the story her lawyers outlined in detail in the complaint filed a day earlier with the Travis County District Court. In August 2022, Zurawski’s cervix started dilating during her 17th week of pregnancy. Soon after, her water broke, putting her at risk of developing an infection. But doctors told her they couldn’t do anything to help, citing state laws that only allow for abortion in a “medical emergency,” or when the woman faces a “life-threatening physical condition.” They told her they had to wait until either her baby died or Zurawski showed signs of infection.

“I cannot adequately put into words the trauma and despair that comes with waiting to either lose your own life, your child’s life, or both,” Zurawski said into the microphones. “For days, I was locked in this bizarre and avoidable hell.” In the end, the baby died, and Zurawski developed an infection that nearly killed her, too. 

The Meteor and People magazine broke Zurawski’s story in mid-October. By the end of the month, she and her husband, Josh, appeared in a political ad endorsing gubernatorial candidate Beto O’Rourke, Gov. Greg Abbott’s ultimately unsuccessful Democratic challenger. In the ad, they blasted Abbott for signing into law the state’s protections for unborn babies. Other news outlets picked up the story and in February the couple appeared as the first lady’s guests at President Joe Biden’s 2023 State of the Union address. The month after she sued the state of Texas, Zurawski testified at a U.S. Senate Judiciary Committee hearing on abortion. She had become the perfect illustration for the abortion industry’s claims that women would die without legal abortion.

But her case—and the care doctors gave her—is not as black and white as the legal filings suggest.

Amanda Zurawski Tom Williams/CQ Roll Call via AP

The Center for Reproductive Rights did not respond to my requests for interviews with Zurawski. But, all along, she and her husband have publicly blamed pro-life Texas lawmakers—not their doctors—for Zurawski’s close shave with death, even though many pro-life organizations argue her doctors could have legally performed an abortion or induced labor when she first went to the hospital. Meanwhile pro-life physicians, and even the recommendations from pro-abortion medical organizations, make it clear those aren’t the only options for women facing such complications. Zurawski’s story, and the anecdotes of women with similar pregnancy experiences, illustrates one side effect from four decades of legalized abortion: Doctors faced with a complicated case too often prefer to end the baby’s life rather than fight to save both mother and child.

ZURAWSKI AND HER HUSBAND spent 18 months going through what she called “grueling” fertility treatments before finally getting a positive pregnancy test. In July 2022, they announced their pregnancy on Instagram with a photo of them wearing “MAMA” and “DAD” hats, holding ultrasound images of their baby. Zurawski had just ­finished the invite list for her baby shower, about five weeks into her second trimester, when doctors diagnosed her with an incompetent cervix, which meant she was dilating prematurely. Doctors can sometimes save the pregnancy in these situations by stitching the cervix shut, a procedure known as a cerclage. But because the amniotic membranes were already protruding through Amanda’s ­cervix, they said that wasn’t an option. Telling her the baby would not survive, doctors sent her home.

That night, a Tuesday, Zurawski’s water broke. She went to the emergency room, where medical staff diagnosed her with preterm prelabor rupture of membranes (PPROM). Sometimes, women in this condition soon go into labor naturally. But not Zurawski.

This is where the new Texas state laws come in. In 2021, legislation went into effect protecting babies from abortion once they have a detectable heartbeat. On top of that, another law took effect the same week Zurawski’s water broke. It protects babies beginning at conception. The countdown to that law’s effective date started in June when the Supreme Court’s Dobbs v. Jackson Women’s Health Organization ruling overturned Roe v. Wade.

The new law allowed abortions when the pregnancy causes a “life-threatening physical condition” that puts the woman at risk of death or “substantial impairment of a major bodily function.” The heartbeat law gives an exception for a “medical emergency,” which Texas statute defines in the same way. Zurawski’s baby still had a heartbeat, and she wasn’t yet showing signs of infection. So hospital staffers determined her case didn’t fall under the exceptions. They sent her home again on Wednesday with instructions to monitor herself for infection. The Zurawskis considered traveling to New Mexico for an abortion but feared she could develop an infection while on the road.

At an OB appointment two days later, her vitals were still stable. But within a matter of hours, Zurawski was in the emergency room again—this time with a fever of 102 degrees. She was septic. The doctors put her on antibiotics and induced labor. Her baby girl died. During the three days Zurawski spent in the ICU fighting the infection, family members flew into town, expecting the worst.

Zurawski survived, but the ordeal left her with severe scar tissue that could make it even harder for her to conceive again.

Still, despite the claims outlined in Zurawski’s lawsuit, many pro-life groups argue her doctors could have aborted Amanda’s baby legally or induced labor once they diagnosed her with PPROM because of how quickly infection can develop. Even setting state law aside, some doctors say medical workers could have done more to help both Zurawski and her baby.

In its response to the lawsuit, the state of Texas argued Zurawski and the other women suffered because of their doctors’ decisions, adding they had no evidence of state officials threatening to enforce the law against the women or their doctors.

Dr. Jeffrey Barrows, senior vice president of ­bioethics and public policy for the Christian Medical & Dental Associations and a former practicing OB-GYN, read the description of her case in the original complaint.

“I am limited by just the details that this case gives. But there’s enough for me to kind of raise some questions,” he said. “And the first is, why didn’t they put the patient in … steep Trendelenburg?” Patients in this position rest at an incline, head down, on a table that supports them at the shoulders. The position allows gravity to pull back the prolapsing membranes, potentially giving the physician a chance to perform a cerclage. In Amanda’s case, Barrows said, “I can’t think of a reason that I would not at least try” this approach. Other doctors I spoke with agreed that although it’s not guaranteed to work, they’ve seen this technique successfully get babies to the point of viability.

“And the fact that [Zurawski] was sent home? I mean, if a patient is so far along that you can’t do a cerclage … you wouldn’t send the patient home,” Barrows added.

Once a woman’s water breaks, he said, infection commonly shows up within a day or two. “And so you just put them in the hospital, observe them. You keep them at bed rest, and you start an IV, and if there’s any sign of any fever, then you give them IV antibiotics. And then you induce labor.”

Barrows said a fever with PPROM is a sign of chorioamnionitis, a life-threatening infection inside the uterus. “You have one job as the attending physician, and that is, induce labor and get the baby out … so that the body can fight the infection, because it can’t fight infection as well with the baby in there.”

But without sign of infection, “I think the best thing for the baby is to just observe,” Barrows said.

At such an early point in pregnancy, Barrows admits, the chances of the baby surviving are low. One study conducted in the first few months after the Texas heartbeat law took effect followed 28 pregnant women in Texas who experienced complications, including PPROM, early in pregnancy. Doctors would have normally treated these cases by ending the pregnancies but relied on what the study called “state-mandated expectant management” instead. Of the eight babies born alive, seven died within 24 hours. Only one baby remained alive—although still hospitalized—at the end of the study period.

Babies who do survive these conditions can sometimes have underdeveloped lungs or skeletal deformities. But Barrows has seen women in similar situations continue long enough to pass the point of viability, where the baby is likely to survive outside the womb. Even the practice bulletin on “Prelabor Rupture of Membranes” put out by the pro-abortion American College of Obstetricians and Gynecologists (ACOG) shows there’s a chance of survival. According to the bulletin, babies whose amniotic sac ruptured before 22 weeks gestation survive 14.4 percent of the time when doctors wait and observe instead of immediately inducing labor or performing an abortion. If their water broke after 22 weeks but still before viability, they survive 57.7 percent of the time. (ACOG notes most studies of these cases are retrospective and include only the cases where doctors did not act to separate mom and baby earlier, which means they “likely overestimate survival rates because of selection bias.”)

For the mom, waiting does mean more risk. In the study of the 28 Texas women, none died, but doctors had to induce labor for 10 of them because they developed chorioamnionitis. One woman required a hysterectomy. Five had blood transfusions. But according to ACOG, mothers develop sepsis in only 1 percent to 5 percent of cases in which doctors wait and observe when the water breaks before the baby is viable. Reports of “maternal deaths due to infection,” it says, are “isolated.”

“Not that a pro-life doctor is going to put the mother at undue risk,” Barrows said. “But in my care of women through the years … they didn’t want to just jump in and kill the baby. … They didn’t mind a little bit of risk.”

Rachel Guy, shortly after she was born. Handout

SUZANNE GUY was one of those pregnant mothers who, like the women Barrows cared for, was willing to accept some risk.

At Guy’s home in Marietta, Ga., a cluttered ­bulletin board hangs above a shelf on the blue wall behind her. From it hangs a black sign with big white letters, “PRAY TO END ABORTION,” and under it the logo “40 DAYS FOR LIFE.” Guy, wearing a teal T-shirt also bearing the blue 40 Days for Life angel wings, waves her hands as she talks about how she and her now 25-year-old daughter started co-leading their local 40 Days campaign, praying outside Planned Parenthood and counseling families that come for appointments.

But pro-life work hasn’t always been such a ­passion for Guy. “It really wasn’t until everything happened with my daughter that I realized I was not engaged,” she said.

Suzanne and Peter Guy with Rachel as an infant. Handout

That “everything” happened in 1997, when Guy and her husband, Peter, finally saw two lines on a drugstore pregnancy test after seven years of infertility. They were elated and eagerly accepted a ­referral to a highly recommended OB-GYN practice.

Guy remembers lying on the table at the 22-­week ultrasound with gel on her stomach, looking at the image of her baby on the ultrasound screen. Then suddenly, the tech rushed off to get a doctor. She returned with dire news: Half your amniotic fluid is gone. You need to have an abortion. There’s no way your baby will live. You could die. But Guy said no.

The doctor reminded her that her baby’s growth would be retarded and the lungs underdeveloped. Guy still said no.

Suzanne and Rachel. Robin Rayne/Genesis

The Guys came back two weeks later to the same scenario, except this time the amniotic fluid was completely gone. The baby’s heart was still beating, but they faced the same warnings. Sitting across from the couple in his office, another doctor calmly encouraged them to abort and said they would be able to have other children. But the Guys said no again and again as the doctor laid out his hopeless diagnosis.

When they asked what else he could do for them, he told them that in all his years of practice, everyone else in this position had aborted. He sent them home to wait for the baby to die. “All I could think of is all those precious, scared, vulnerable ­parents, trusting the person with all the medical fancy degrees and initials behind their name to tell them what to do,” Guy recalled.

With the help of a friend at church, Guy transferred to a different practice. The doctors admitted her to the hospital and put her on bed rest. They began monitoring Guy’s vitals and the baby’s vitals, preparing to fight for both patients. Guy remembers even the way they talked was different than the other doctors. They were honest about the possibility of the baby dying, or being born too weak even to cry. But Guy said they talked about the case with a sense of hope and spoke of the baby as a valuable human being. At the beginning of week 26, the doctors performed an emergency C-section. Rachel Guy came into the world—alive and “squawking.”

During her experience with the first set of OB-GYNs, Guy wondered how she’d ended up with doctors who seemed to her to have no interest in saving her baby’s life. But she’s since learned her experience is not uncommon.

Rachel Guy visits an orphanage in Uganda in 2017. Handout

ACCORDING TO ACOG, rupture of the membranes before viability happens in less than 1 percent of pregnancies. Women in this condition, it says, should be given two options: expectant management or immediate delivery. As described by the bulletin, immediate delivery can look like induction of labor or a dilation and evacuation (D&E or dismemberment) abortion procedure, but it’s not the only option. Expectant management—the close monitoring that Dr. Barrows described and Suzanne Guy experienced—could give the baby a fighting chance. And, as early as 20 weeks, the bulletin says, doctors can consider putting the woman on antibiotics to fight off a possible infection.

But when Amanda Zurawski’s water broke, doctors told her they would normally offer an abortion in these circumstances and that “there was no other medical care the hospital could provide,” due to the state’s pro-life laws. That’s the language from the original complaint filed in Zurawski v. Texas.

Another Texas woman named as a plaintiff in the case, Anna Zargarian, received the same diagnosis—at 19½ weeks. Emergency room doctors told her “for patients in her situation, they would usually recommend termination of the pregnancy” and that a D&E was the safest treatment for her. But again, because her baby was still alive, they said they couldn’t legally perform an abortion or even induce labor, even though she was at risk of hemorrhaging or developing sepsis. The only option they could provide was expectant management, which the complaint describes as “where she would wait either to go into labor naturally, or for her health to deteriorate sufficiently for the hospital to be able to intervene.”

Anna Zargarian (left) at the Texas State Capitol in Austin after speaking as part of the announcement of the filing of the case Zurawski v. State of Texas. Sara Diggins/Austin American-Statesman via AP

The complaint doesn’t name the doctors or the hospitals that handled Zurawski’s and Zargarian’s cases. But two OB-GYNs also joined the lawsuit. The ­document says one of the OB-GYNs, Houston Dr. Damla Karsan, would normally treat patients who have emergent medical conditions by offering them “abortion care.” Now, it says, “Dr. Karsan instead has had to give them information about where to seek abortion care out of state”—as if she simply has no other options.

Meanwhile, Barrows and three other pro-life physicians I talked to described expectant management as their standard approach to these PPROM cases. They would induce labor immediately upon the first sign of an infection. Otherwise, they would try to give the baby as much time as possible. Some said they would also provide steroid injections to help accelerate the development of the baby’s lungs.

While they acknowledged the babies often did not make it, they also spoke of women remaining stable for weeks until the baby reached a point where he or she could survive outside the womb. They would have never known which baby could make it that far, though, if they had immediately performed an abortion or induced labor.

One of the doctors I spoke with was Pensacola, Fla., OB-GYN William Lile. When I talked with him over Zoom, he was still in his blue scrubs. He had just come from his hospital’s labor and delivery unit, where a mom gave birth to a healthy baby two weeks after her water broke at 32 weeks. Another recent patient had been 22 weeks pregnant with an incompetent cervix. She was showing early signs of infection and was ineligible for a cerclage. But the doctors admitted her to the hospital, put her on bed rest, started IV antibiotics, and waited to see how far they could get her. “I saw her this morning. She’s 24 weeks and three days,” said Lile. Three months later, he said the mother carried the baby until 30 weeks before going into active labor. The baby, he said, “is doing extremely well in the NICU.”

In his mind, every pregnancy carries risk. But he’s heard of too many physicians in his profession encountering risk and encouraging abortion or immediate induction of labor.

“We have a lot of physicians out there who just want to take the easy way. The goal of medicine should be to take the best way,” he said. In Lile’s view, the whole purpose of recent developments in maternal-fetal medicine is to find treatment options that are in the best interest of both mom and baby. “Even though it’s going to take more time, it’s going to be more effort, more visits—take the best way, not just the easy way.”