The patient pregnant with twins was having complications likely to lead to the death of both fetuses. As Dr. Isabel Bryan scrubbed in for her shift, she reviewed the task ahead: she would abort one of them.
At the prospective mother’s request, Bryan was going to perform an incredibly rare “selective reduction” procedure of one of the fetuses, thereby raising the odds that the other would live.
The operation took place at Mount Sinai Hospital in New York City last week. The OB-GYN, a native Texan, was familiar with what’s called “twin-to-twin transfusion syndrome” because of the medical training she received in Philadelphia.
In this rare condition, twins share one placenta and the network of blood vessels that supply oxygen and nutrients essential for development in the womb. These were being delivered in unequal measure. It’s not supposed to work that way, and carrying twins is already a high-risk pregnancy.
Bryan (not her real name) was also familiar with the selective reduction procedure in which a doctor inserts a scope or needle into the uterus, finds the connecting vessels on the placenta or the affected twin’s cord, and uses laser or heat energy to stop blood flow to one fetus.
It’s a procedure that never would have happened in Texas, where not only is abortion illegal but medical students aren’t trained in it.
“She was at risk of losing both twins so she decided to terminate one of them,” Bryan said. “In Texas, that’s not an option. You just have to wait until you lose both twins. All the data shows that because we were able to terminate one twin, this family has a higher chance of having a live birth. I feel so grateful to be able to offer these services, because [in Texas] we would just monitor them until one of them is dead or they’re both dead.”
Situations such as this have prompted Texas medical students to leave the state for OB-GYN training. It’s also created a harrowing scenario for Texas women with pregnancy complications who can’t be sure that their physician knows how to save a life.
Consequences
Bryan was born and raised in Austin and got a bachelor’s degree in neuroscience at the University of Texas. Once she got to medical school at Houston’s Baylor College of Medicine, she began dreaming of a career in obstetrics and gynecology, helping pregnant women, whether it be delivering babies or advising them on options for safely terminating a pregnancy.
Since September 2021, it has been a crime punishable by up to life in prison to perform an abortion in Texas. A new “bounty hunter law” enacted this month allows private citizens to sue out-of-state abortion pill prescribers, manufacturers and distributors for more than $100,000 per violation.
While OB-GYN training slots remain nearly full, the number of applicants to residencies in abortion-ban states dropped by 6.7 percent in 2024 compared to the prior year, contrasting with a slight 0.4 percent increase in states where abortion is legal, according to a September 2025 report from Manatt Health Consulting.
“In Texas, we would just monitor them until one of them is dead or they’re both dead.”
Dr. Isabel Bryan
Bryan said she knew what was coming when lawmakers began deliberating the Texas Heartbeat Act (Senate Bill 8) while she was still in school. After graduating with her MD, she left Texas and moved to Pennsylvania for her residency, which she completed earlier this year, and began a three-year fellowship in New York in July.
“I absolutely loved my experience at Baylor,” she said. “I feel like the reproductive justice advocates in Texas are the best I’ve met in my career. That being said, the state’s anti-abortion laws were 100 percent a huge factor in my decision to leave.”
As soon as she “matched” with the residency program at Penn Medicine, “everything got bad” with the Texas abortion ban, she said. The maternal mortality rate in Texas rose 56 percent after the abortion ban became law, according to the Gender Equity Policy Institute. Infant deaths rose 13 percent.
The maternal morbidity rate, which measures the frequency of unexpected severe health problems like severe bleeding and organ failure, is extremely high in small rural hospitals in Texas, where OB-GYNs are afraid of consequences for doing what was once their job and is now illegal, Bryan said.
Some doctors are even uncomfortable telling a patient about available resources and options they can pursue in other states because that might be considered “aiding and abetting,” she said.
“A tiny hospital can’t afford to be sued or lose its one OB-GYN in [a 200-mile radius],” she said. “Nor should an OB-GYN have to risk their license. It’s more than just a personal liability; it’s a liability to the community. There’s a lot of opportunity for advocacy in Texas, and I really thought about coming back. I haven’t had to deal with this everyday fight to take care of people and not be able to offer them evidence-based medicine.”
Bryan, 31, remains close to her parents, who live in Austin. Her father is an MD with a family medical practice. Bryan isn’t married and doesn’t have any children, and she had the freedom to pursue her residency elsewhere, an option she acknowledged isn’t available to all OB-GYN students.
As a young medical student, Bryan served on the immigration steering committee for Doctors for America and completed a youth advocacy program at Planned Parenthood. She knew the needs were great in reproductive healthcare and says she believed she wouldn’t be of maximum service unless she left the Lone Star State.
Texas is one of 13 states that banned abortion in recent years, making no exceptions for rape or incest. Women can legally travel to a non-restrictive state for the procedure, but it’s expensive and they have a small window in which to do it safely, often while their health is rapidly declining.
The Texas ban came about nine months before the U.S. Supreme Court overturned Roe v. Wade in 2022.
State law prohibits doctors from performing an abortion in Texas if a heartbeat is detected. A “narrow exception” exists by which an abortion can be performed to save the life of a pregnant patient, but many say the law is unclear and they’re being forced into a position where they have to choose between risking their medical licenses and a possible prison sentence to protect a patient.
Almost one-third of OB-GYNs in Texas do not have a clear understanding of the law and how it relates to their medical practice, and 60 percent are fearful of legal repercussions, according to a 2024 survey by Manatt Health. About 450 Texas-based practicing doctors and 47 medical residents who are members of the professional association American College of Obstetricians and Gynecologists were surveyed for the report.
According to the survey, one in five has considered leaving Texas and 13 percent are planning to retire early because of the state’s restrictions.
The situation has created a public health crisis, said Nick Kabat, an attorney for the Center for Reproductive Rights in New York.
The crisis is multi-pronged: pregnant women aren’t getting comprehensive reproductive healthcare in Texas, medical students aren’t getting the training they need to save a mother’s life and doctors who have received proper training can’t use discretion when providing care because they might go to prison, Kabat said.
In addition to legal consequences, public education institutions like Baylor College of Medicine could potentially lose state funding for pushing back against state laws.
“You can’t hear these stories and not care,” Kabat said. “You want to see people be able to plan their families and have healthy pregnancies. I know that at the end of the day, there are risks, and people are going to die. I so deeply don’t want that to happen. I know that nationwide, we have a maternal health crisis and our maternal mortality rates are abysmal compared to our peer countries around the world. I know we can do a better job and that most of these deaths are preventable.”
Zurawski v. Texas
Austin resident Amanda Zurawski contacted the Center for Reproductive Rights in 2022 to share a tragic experience that became the subject of a lawsuit filed by the Center, and a documentary, Zurawski v. Texas, produced by Chelsea and Hillary Clinton.
Zurawski testified before the U.S. Senate Judiciary Committee in April 2023 that she and her husband were thrilled when their daughter Willow was conceived after 18 months of grueling fertility treatments. But then her pregnancy took a turn.
“I dilated early due to a condition known as cervical insufficiency,” Zurawski said in public testimony. “Soon after, my membranes ruptured and we were told by multiple doctors that the loss of our daughter was inevitable. My healthcare team was anguished as they explained there was nothing they could do because of Texas’ anti-abortion laws. I was locked in this bizarre and avoidable hell. Would Willow’s heart stop or would I deteriorate to the brink of death?”
Zurawski was taken to the hospital where she and her husband learned she was in septic shock. She was hospitalized for three days while medical professionals battled to save her life, according to her testimony.
“What I needed was an abortion, a standard medical procedure,” she said. “As a result of what happened to me, I may have been robbed of the opportunity to have children in the future. Being pregnant is difficult and complicated enough. We do not need you to make it even more terrifying and frankly, downright dangerous, to create life in this country.”
“This has gone on long enough and it’s time now for you to do your job, your duty, and protect us,” she added.
Zurawski’s lawsuit marked the first time a formerly pregnant woman took legal action against an abortion ban since the Supreme Court overturned Roe v. Wade in the Dobbs v. Jackson Women’s Health Organization ruling. By the time the Zurawski suit was decided, 22 plaintiffs had signed on, including two Houston-based gynecologists.
The Texas Supreme Court ruled in May 2024, rejecting the plaintiffs’ plea to clarify emergency exceptions in abortion bans and finding no constitutional right to abortion.
Kabat said the Texas Legislature “attempted to provide” more clarity around ectopic and molar pregnancies and a condition known as P-PROM, or Preterm Prelabor Rupture of Membranes. They also attempted to advise on the legal standard that would apply if a doctor is prosecuted, he said.
“This law says that the doctor has to exercise reasonable medical judgment,” Kabat said. “It seems to be giving doctors some objective standard that, as long as the state of Texas can put up some expert who will say the doctor was not acting reasonably, then that is enough to meet the burden of prosecution.”
“It’s similar to the standard in medical malpractice,” he added. “That’s really chilling. Med mal is lower because what’s at stake in medical malpractice is money, not the doctor’s liberty and livelihood. Applying the same standard is incredibly chilling because doctors know they can be found liable even when they are acting in good faith.”
“The end result is that doctors are terrified that they’re going to be prosecuted for helping their patients.”
The court further dismissed claims that bans violate patient rights and upheld the state’s abortion ban, leaving doctors afraid to provide care even in severe emergencies and prompting OB-GYN students to seek training in states that offer more comprehensive reproductive care, said Dr. Judy Levison.
Levison, a professor emeritus with Baylor College of Medicine, left Houston in 2023 and moved to Denver to be closer to her children and grandchildren, but the Texas abortion ban played a role, she said. She doesn’t see patients anymore but she still helps pregnant women in need of healthcare, even, or perhaps, especially, if they live in Texas. Levison was one of the plaintiffs in the Zurawski lawsuit.
The OB-GYN said she didn’t want to just be a spectator when so many women were being put in harm’s way.
“The standard of care used to be that you would offer abortion when you had early ruptured membranes prior to viability, and that is no longer being offered if there is still a heartbeat,” Levison said. “It’s terrifying.”
All the plaintiffs in the Zurawski case had “wanted pregnancies,” meaning they weren’t just hoping to terminate because their birth control didn’t work.
One of the plaintiffs, Samantha Casiano, learned at her 20-week scan that her baby had anencephaly and would not survive.
“She didn’t have the funds or the means to get an abortion out of state and she had kids to take care of and a job that she would lose if she left for several days to go for an abortion,” Levison said. “There were so many barriers, so she was forced to carry and she describes how awful it was watching her baby, over four hours, suffocate.”
Such situations are traumatic for patients but also morally distressing for physicians, Levison said. That’s why many young people fled after the Dobbs ruling and continue to reconsider their career paths.
Levison says she felt guilty leaving “the cause and campaign” in Texas but she channeled that energy into the Colorado Doula Project, which provides support for women who are having abortions. At least 30 percent of the women seeking abortions in Colorado are from Texas, she said.
The loss in the Zurawski lawsuit was troubling, but not unexpected, and it raised public awareness, the doctor added.
“What we were talking about in every one of these cases was a medical complication,” she said. “I even had a physician colleague, when I was explaining it, say, ‘That’s an abortion? I thought an abortion was just when a woman decided she didn’t want to be pregnant.’ Abortion is a whole spectrum of treatment and management of pregnancy. I don’t think anyone makes this decision lightly. I think that’s often misunderstood.”
Bryan said her interest in gynecology was inspired by working under the tutelage of Levison and Dr. Anitra Beasley at Baylor, but when Donald Trump was elected president for the first time during Bryan’s senior year of college, she said she became aware of disparities that were occurring in public health.
“The most courageous people are the ones who are staying and still fighting,” she said. “If I had stayed at Baylor, it would be easy to say I’m going into maternal family medicine so I don’t need to learn how to do a [dilation and evacuation].”
But what’s safe for the doctor isn’t always what’s best for the patient, she said.
“I’m always thinking about the people in Texas who are either privileged enough to know that [abortion is] an option and go out of state and those who just don’t even realize they have another option.”
Legislative Barriers
Several of the reproductive care experts who spoke to the Houston Press last week said Texas laws are among the most restrictive and the Republican-majority legislature isn’t likely to flip any decisions in the near future.
The Center for Reproductive Rights filed the lawsuit for Zurawski and served as the legal team for the plaintiffs. They knew what they were up against, Kabat said.
Texas Attorney General Ken Paxton proved he intends to enforce anti-abortion laws by going after a Waller midwife earlier this year. The case of Maria Rojas is still playing out in court, and the midwife has appealed. Paxton responded by charging more people linked to Rojas’ clinics in Waller and Montgomery counties, where she provided healthcare for pregnant women, many of whom do not speak English or have health insurance.
Paxton is running for U.S. Senate and his replacement as attorney general is likely to be a Republican with a similar anti-abortion stance. State Sen. Joan Huffman, Sen. Mayes Middleton, U.S. Rep. Chip Roy and former Assistant U.S. Attorney Aaron Reitz are among the candidates in the March primary for AG.
In the documentary Zurawski v. Texas, Center for Reproductive Rights senior attorney Molly Duane referred to Paxton as “exceptionally cruel.”
“People are going to die, and the question is, does anyone in the state of Texas, in a position of power, actually care?” Duane says in the documentary.
Is the Lone Star State’s appetite to reject abortion at all costs about politics? Money? Or an ingrained religious belief? Kabat says it may vary among lawmakers but everyday people do not want states to restrict access to abortion.
“The anti-abortion movement that has lobbied for and promoted these laws has made clear that pregnant people are not their No. 1 concern,” he said.
Pamela Merritt became the executive director of Medical Students for Choice in 2021, months before Roe v. Wade was overturned. A problem already existed in medical education, she said.
“Prior to the Dobbs ruling that struck down Roe, getting adequate and modern reproductive health education in medical school was already hit or miss,” she said. “That goes back to the reality that it was a male-dominated field for so many decades. Men make up the majority of senior faculty or administration of a medical school.”
Merritt’s organization serves 10,000 students in 26 countries and provides financial support for students to receive clinical training in abortion-legal states.
Merritt, who is based in Chicago, lived in Dallas for seven years and said she has great affection for Texas but is aware that the state is particularly vulnerable to “legislative shenanigans” and doesn’t have a good public health record, particularly with pregnancy outcomes in marginalized communities.
“You also have some of the most amazing national and international med school programs in Texas, so we had a lot to lose, and we lost it,” she said.
Merritt said that medical school programs have to manage “steering clear of retribution from the state legislature,” and Paxton, who has set up a punitive environment for OB-GYNs and basically said, “Let [the mothers] die.”
“Keep in mind the state government controls the budget for all state-funded entities,” she said. “The program itself might see the value of training but they don’t want to piss off Ken Paxton. A lot of the decision-making has got to be heartbreaking, but the reality is, we still haven’t figured out how to navigate that in several states, and Texas is the worst, because Ken Paxton is unhinged.”
“There’s not a single employer who isn’t aware that the odds are that residents coming out of Texas haven’t received adequate training, so it devalues that residency for OB-GYN,” she added. “A resident can’t practice in Colorado as an OB-GYN if they don’t know how to save the life of a patient, so they’re going to have to do that training.”
Merritt added that she can’t imagine why an international student would risk studying in Texas “with [Immigration and Customs Enforcement] behaving the way that it is.”
“It breaks my heart because I know real people who want to raise their families in Texas,” she said. “It’s going to be 2026 in a couple of weeks. Nobody should be considering whether they can survive pregnancy to the degree that they are in Texas.”
Fight or Flight
Although there doesn’t appear to be an official report on how many Texan OB-GYN students have left to do their residencies out of state, it’s clear that Bryan is among many who opted to pursue their careers elsewhere. Others are still contemplating whether it’s worth leaving behind roots and family.
Dani Mathisen, a plaintiff in the Zurawski case, was an OB-GYN student at UT Southwestern Medical School when the state’s abortion ban was signed into law. She was pregnant and received a lethal fetal diagnosis but was denied an abortion in Texas, an experience that prompted her to do her residency in Hawaii, Kabat said.
According to Kabat, Mathisen’s family member who was providing her obstetric care wouldn’t recommend an out-of-state doctor for fear of being prosecuted under SB 8.
“We’ve been contacted by a lot of other medical students just like Dr. Mathisen,” Kabat said. “Dr. Mathisen left the state to do her residency and she didn’t want to stay in Texas even though her family is there, just because of these laws.”
“Medical students are at a time in their lives when they are making decisions about their family and having children. Doing that in a state like Texas can be scary. That’s the Dr. Mathisen story,” he added.
“The other aspect of it, long-term, is these doctors were used to getting training in abortion care at a clinic in the area where they were getting their medical training,” he continued. “In Texas, before these bans, you were able to go to the abortion clinic in your city and watch maybe 100 abortions be performed, and that’s important because that’s how you get trained in very basic procedures. Now that training doesn’t exist. They’re not trained in providing miscarriage management.”
A patient could be denied care in the case of a miscarriage not because it’s against the law but because doctors don’t know how to manage it, Kabat said.
Bryan pointed out that there are OB-GYN students who don’t want to perform abortions for religious reasons or because they want to focus on a different area of expertise. For her, though, she says it was a matter of having as much education as possible so she’d be able to do what was necessary to save a life if ever in that situation.
“I knew that if I stayed at Baylor, regardless of whether I was going to do a fellowship in family planning and regardless of whether Senate Bill 8 passed, there were already such strict restrictions that I was not going to leave residency confident in doing a second-trimester [abortion],” she said.
“Even if I’d thought I was ending up back in Texas, I wanted to be one of those people who could do the [dilation and evacuation] in the second trimester. I don’t think most OB-GYNs in Texas know how to do a D&E in the second trimester because they aren’t being taught how to do it,” she added.
Exchange programs with out-of-state residencies are available for Texas OB-GYN students, but they’re disruptive and expensive and can drive students deeper into debt, Levison said. When her students at Baylor asked whether they should leave Texas, Levison said she would suggest some things to consider.
“If you’re taking care of high-risk pregnancies as a maternal-fetal medicine specialist, you’re going to encounter this regularly,” she said. “If you know that you want to do gynecologic oncology, which is cancer treatment, in the long run, [abortion is] probably not something you’re not going to encounter a lot. I think what’s happening now is residents are not being trained that when they detect early signs of infection, it’s not being drummed into them that they can offer a choice because a woman’s life is at risk.”
“Right now, in Texas, the fetus’ health is put above the mother’s health in some situations. Is that what you want to do?” she added.
A huge concern, Bryan said, is that there will eventually not be enough OB-GYNs in Texas, particularly in rural areas.
“To be an OB-GYN in rural Texas must be so scary, because even if you want to do the right thing, you’re in a conservative area, so you’re more likely to be sued, and you don’t have resources and you have no precedent to make these decisions or to have people back you up,” she said. “Working at an academic center, if you’re sued, unless you did something grossly negligent, you have the whole hospital backing you up.”
Merritt said she tells people who are evaluating medical school in Texas to think long and hard about the amount of time they’re investing and the probability of sinking into at least $300,000 worth of debt.
“You didn’t do that so you can get a 1950s education in reproductive healthcare,” she said.
Bryan said she doesn’t expect any abortion laws to be overturned by the state legislature in the near future, but it’s possible that a precedent could be set by a higher court.
She said she wants to have a family one day and would consider giving birth in Texas, but she’s quick to point out that her privilege would protect her from being impacted by state laws.
“If I have complications, I know that this is a situation where some people would terminate,” she said. “I don’t need a doctor to tell me that. And I would also be able to fly to Colorado or New Mexico to do it.”
“The rhetoric in the ivory tower, but probably all over the Northeast and the West Coast, is like, ‘Forget Texas. They did this to themselves.’ But that completely diminishes all the incredible people and patient population and families and diversity that exists in the state. I’m still proud to be a Texan and would love to come back and work with that patient population. I just didn’t want it to impact my training.”
This article appears in Jan 1 – Dec 31, 2025.