Termination boards: How physicians are providing abortions within exceptions allowed by bans

(NEW YORK) — Shortly after a Tennessee trigger ban on abortion went into effect last September, a group of maternal fetal medicine specialists, family planning physicians, bioethicists, neonatologists and a lawyer gathered to form a panel tasked with determining whether the facility could provide medically necessary abortion care in line with state law.

Physicians decided it was best to evaluate and gain a consensus in situations where patients were requesting abortion care or doctors are recommending it.

“It really came about from the fact that many of us are very concerned and nervous for our own safety, and felt that some of these would be decisions that are better made in a group setting,” Dr. Sarah Osmundson, a maternal fetal medicine specialist in Tennessee, told ABC News.

“Usually these are time-sensitive issues,” Osmundson said. “So, even though we have meetings every other month, when a case arises, it usually means that we have to either ad hoc meet or talk or communicate over email and explain the patient’s situation. And then we ask for three physicians to review the chart and to weigh in on whether they think an abortion would meet the standards set by the current laws.”

Tennessee’s law only makes exceptions for cases where it is necessary to prevent death or serious and permanent bodily injury to the mother.

“We are basically looking at these cases individually and trying to guess whether we think a reasonable group of other Tennesseans would look at these individual cases and agree that an ongoing pregnancy represents a risk of death to the patient or serious medical impairment,” Osmundson said.

Physicians in several states told ABC News that facilities are using termination boards or medical ethics boards to navigate whether they can provide patients with medically necessary abortions in line with exceptions allowed in their states.

Dr. Nicole Teal, a maternal fetal medicine specialist, told ABC News that abortions past 20 weeks of pregnancy in the hospital where she works in North Carolina require two physicians to sign off in cases where the mother’s life is at risk. In most cases, both physicians are specialists. In July, North Carolina will start enforcing a ban that prohibits abortions past 12 weeks of pregnancy, with an up to 20-week exception for rape or incest and 24 weeks for fatal fetal anomalies.

If physicians feel the case is a gray area and they are unsure whether the abortion would be permitted under the ban, they get the hospital’s legal and ethics teams involved before providing care.

“Logistically speaking, what happens when someone comes in and they’re sick and it’s Saturday night? The ethics committee is not going to convene Saturday night at midnight to come up with an answer,” Teal said.

Some common pregnancy complications could be deadly if left untreated, but patients may not be showing signs of illness or an imminent threat to their life when they first show up at a hospital. This leaves doctors’ hands tied.

Teal told the story of one patient who came in who came in with “very severe preeclampsia,” a serious and sometimes fatal pregnancy complication that occurs after 20 weeks, but physicians had to wait until her health got worse before they could help her because the state’s 20-week ban was in effect.

“We knew it was happening, her blood pressure was getting higher, her labs were starting to get off. But we basically waited until her labs got bad enough that we could say, ‘It’s an imminent threat to her life.’ Basically we had to wait until her labs started crashing before we could take care of her,” Teal said.

“Preeclampsia sometimes progresses really rapidly, like in a couple days, and sometimes it takes weeks and we couldn’t say for sure it would it be one day or seven days before it was an imminent threat to her life,” Teal said.

Teal said several friends who practice medicine in southern states — like Florida, Mississippi, Georgia, Tennessee and even Texas — have been reaching out about patients whose health is in danger asking if she could provide them with abortion care. That access could no longer be available when a 12-week abortion ban goes into effect in July.

One patient with pulmonary hypertension, a serious condition that has over a 50% maternal mortality rate if the mom remains pregnant, was denied an abortion in Mississippi by an ethics committee, according to Teal. She traveled to North Carolina to receive care, Teal said.

At a leading health care facility in Houston, medically necessary abortions have to be approved by at least 75% of a panel made up of about six multidisciplinary physicians and a lawyer, according to Dr. Alireza Shamshirsaz, a maternal fetal medicine specialist who moved from Texas to Massachusetts last year.

Shamshirsaz said this usually only happens when a mother is very sick. Physicians need lab work, vital signs and sometimes cultures that show her health deteriorating.

“You can act [without getting their approval] and [retroactively] submit this data to the board, but then you need to be a very brave physician, because now you put your credentials and your career on the line,” Shamshirsaz told ABC News.

Before he left the hospital where he worked in Texas, Shamshirsaz said he had a patient pregnant with twins who went into labor early. After delivering the first of the two babies, the umbilical cord was prolapsed in the vagina, a rare medical emergency, and because the fetus still had a heartbeat, the board denied abortion care.

After staying in the hospital for several days, the patient was sent home, Shamshirsaz said. She later came back in septic shock and lost one of her kidneys. Shamshirsaz said she will likely need a transplant or dialysis in the future.

At the Boston facility where he currently works, Shamshirsaz said physicians can provide abortions up to 26 weeks and six days without needing approval. In complex late-term abortions that go past that threshold, Shamshirsaz gets other physicians at the Boston facility to sign off on the care as a safety net for himself.

Dr. Kelly Mamelson, a second-year resident who has lived in Florida almost her entire life, told ABC News the facility she currently works at requires two physicians to sign off on a medically indicated abortion — the only abortions it provides — whether that be maternal or fetal indication, before it can be performed.

“There is certainly a lot of anxiety behind [the laws’ ambiguity] and it can lead to delays in care,” Mamelson said.

For patients with pre-viable rupture of membranes — a condition fatal for fetuses if they are not at a gestational age compatible with life that can also be dangerous for mothers — if there is still a fetal heartbeat, physicians at her hospital in Florida have to wait until the mother is showing signs of an infection before they provide abortion care, Mamelson said.

“By waiting until you’re in a very dire situation, or potentially fatal situation, you’re doing a lot of harm to the patient. So, waiting for a mom to become septic, to then perform a procedure is extremely problematic. And I think it really highlights the lack of medical knowledge that seems to be pretty common among the legislators making these decisions,” Mamelson said.

Even after Tennessee lawmakers added an exception allowing abortions for ectopic pregnancies, physicians fear abortion laws when it comes to providing lifesaving care, Osmundson said.

“I think we are also balancing our ethical obligations as physicians and the oath that we took, and many of us have just decided that we’re going to do what we think is right for patients to ensure that nobody dies or has serious morbidity as a result of not performing care,” Osmundson said.

“Most of us do this at great personal risk. Unfortunately, I don’t think that we feel super protected by the current laws,” Osmundson said.

Even though the hospital where she works has told physicians it would provide criminal defense coverage if it ever comes to that, Osmundson said the risk of prosecution is still a huge burden. She also said the risk is far greater for physicians who do not work in a large medical center that would be willing to support them.

“It’s a huge mental and emotional burden to experience some of these cases along with patients and to try to care for these patients. And I would love the state of Tennessee to be witness to how challenging that is. I think it would help them empathize with what our patients go through,” Osmundson said.

“I never thought I would have to entertain what the state of Tennessee thinks is right or wrong,” Osmundson said.