by Kavitha Surana, Lizzie Presser and Andrea Suozzo

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Nearly four years ago in Texas, the state’s new abortion law started getting in the way of basic miscarriage care: As women waited in hospitals cramping, fluid running down their legs, doctors told them they couldn’t empty their uterus to guard against deadly complications.

The state banned most abortions, even in pregnancies that were no longer viable; then, it added criminal penalties, threatening to imprison doctors for life and punish hospitals. The law had one exception, for a life-threatening emergency.

Heeding the advice of hospital lawyers, many doctors withheld treatment until they could document patients were in peril. They sent tests to labs, praying for signs of infection, and watched as women lost so much blood that they needed transfusions.“You would see the pain in peoples’ eyes,” one doctor said of her patients.

Not every hospital tolerated this new normal, ProPublica found. A seismic split emerged in how medical institutions in the state’s two largest metro areas treated miscarrying patients — and in how these women fared.

Leaders of influential hospitals in Dallas empowered doctors to intervene before patients’ conditions worsened, allowing them to induce deliveries or perform procedures to empty the uterus.

In Houston, most did not.

The result, according to a first-of-its-kind ProPublica analysis of state hospital discharge data, is that while the rates of dangerous infections spiked across Texas after it banned abortion in 2021, women in Houston were far more likely to get gravely ill than those in Dallas.

As ProPublica reported earlier this year, the statewide rate of sepsis — a life-threatening reaction to infection — shot up more than 50% for women hospitalized when they lost a second-trimester pregnancy.

A new analysis zooms in: In the region surrounding Dallas-Fort Worth, it rose 29%. In the Houston area, it surged 63%.

ProPublica has documented widespread differences in how hospitals across the country have translated abortion bans into policy. Some have supported doctors in treating active miscarriages and high-risk cases with procedures technically considered abortions; others have forbidden physicians from doing so, or left them on their own to decide, with no legal backing in case of arrest.

This marks the first analysis in the wake of abortion bans that connects disparities in hospital policies to patient outcomes. It shows that when a state law is unclear and punitive, how an institution interprets it can make all the difference for patients.

Yet the public has no way to know which hospitals or doctors will offer options during miscarriages. Hospitals in states where abortion is banned have been largely unwilling to disclose their protocols for handling common complications. When ProPublica asked, most in Texas declined to say.

ProPublica’s Texas reporting is based on interviews with 22 doctors in both the Houston and Dallas-Fort Worth metro areas who had insight into policies at 10 institutions covering more than 75% of the births and pregnancy-loss hospitalizations in those areas.

The findings come as evidence of the fatal consequences of abortion bans continue to mount, with a new report just last month showing that the risk of maternal mortality is nearly twice as high for women living in states that ban abortion. Last year, ProPublica documented five preventable maternal deaths, including three in Texas.

One second-trimester pregnancy complication that threatens patients’ lives is previable premature rupture of membranes, called PPROM, when a woman’s water breaks before the fetus can live on its own. Without amniotic fluid, the likelihood of the fetus surviving is low. But with every passing hour that a patient waits for treatment or for labor to start, the risk of sepsis increases.

The Texas Supreme Court has said that

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