Each month, Dr. Andrea Palmer delivers about 20 babies, easily the best of part of her job. But some days, she has to deliver difficult news.
"The conversations are just — they're gut wrenching every time," she said.
Palmer is an OB-GYN in Fort Worth, Texas. She recently had to tell a woman that her fetus had a condition called anencephaly, "where, essentially, the baby doesn't have a brain." It's always fatal — often during the pregnancy, or else soon after birth — and patients are typically given the option to terminate.
"I've had some moms who choose to continue the pregnancy because this is the only time they're gonna have with their baby," she said. "Which is just heartbreaking to me."
Texas doctors like Palmer say S.B. 8, an unusual new state law banning most abortions, is complicating other types of medical decisions. They're hoping for more clarity soon, as legal challenges continue, including a federal challenge from the Biden administration.
Continuing a pregnancy after a diagnosis like anencephaly comes with additional health risks, and for some patients, additional emotional trauma, Palmer said.
"I have other patients who just, imagining the sorrow that each prenatal visit would bring, knowing that's never gonna result in a baby they could take home – that is just too much to bear," she said.
Before S.B. 8, Palmer would have offered to end the pregnancy by inducing labor. But the new law, which the U.S. Supreme Court allowed to take effect Sept. 1, prohibits abortions after cardiac activity is detectable, except for medical emergencies.
At more than 16 weeks, Palmer said her patient opted to go out of state for an abortion — something she said many of her patients could never afford.
Some doctors say the law also is complicating medical decisions when women come in for help while experiencing a miscarriage.
"For example, patient comes in, 17 weeks, with her water broken. That's a nonviable pregnancy. The biggest risk to the patient is that she could become infected," said Dr. Theresa Patton, an OB-GYN in Dallas.
In such cases, Patton said she'd normally offer medication to expedite the miscarriage and reduce the risk of infection, which can trigger a severe condition called sepsis. But she and other doctors say it's not clear under the law what constitutes a "medical emergency."
"We don't want a patient to get sick for a pregnancy that is not going to progress, it's not going to continue," Patton said. "Now, am I going to be in legal trouble for offering that termination now? Do I need to wait until she's septic and imminently in danger herself before I offer that termination? These are all of the things that we have been struggling with what we should do."
Dr. Jennifer Villavicencio, with the American College of Obstetricians and Gynecologists, said laws like S.B. 8 often fail to account for the "liminal" spaces and complexities surrounding pregnancy.
"What do you want your doctor thinking about when you or your family member is in a life-threatening situation?" she asked. "Do you want them thinking about the best possible treatment...or do you want them weighing whether or not they're willing to risk their personal livelihood, safety, and decades of training in order to treat your family member who has their life at risk?"
John Seago, of the anti-abortion rights group Texas Right to Life, defends the law.
"I mean the euphemism of 'managing' a miscarriage or 'expediting' a miscarriage, that's a euphemism for causing the death of an unborn child," Seago said. "And that's what's clearly being opposed by the legislature."
But Seago acknowledges that it removes some options for healthcare providers.
"We understand that our ethics and our commitment to human life does limit medicine...from being as efficient as it wants to be," he said. "However, this is protecting innocent human life, and seeking to protect these values."
Some doctors tell NPR they worry about advising patients about going outside Texas for procedures, because the law allows civil lawsuits with penalties for violation starting at $10,000, targeting anyone who "aids or abets" an illegal abortion.
Seago said he believes the fear of frivolous lawsuits is being overblown, and noted that the law only applies to abortions performed in Texas.
But Dr. Andrea Palmer, in Fort Worth, doesn't find much reassurance there, and notes the law authorizes to anyone who believes an illegal abortion has taken place to sue anyone they believe was involved.
"We're scared for our patients. I am gonna continue to provide the counseling that I think is appropriate for my patient, regardless of what the law says I can or cannot say in my exam room, frankly," she said. "But it's definitely a weird and scary time to be an obstetrician in the state of Texas."