Texas Senate Bill 4

ACOG Responds to Texas SB 4

On December 2, 2021, Texas Senate Bill 4 (SB 4) went into effect. This law imposes scientifically unsupported restrictions on medication abortion and requires reporting requirements for false "abortion complications." In a statement, ACOG President J. Martin Tucker, MD, FACOG, and ACOG District XI (Texas) Secretary R. Todd Ivey, MD, FACOG, stated, "By continuing to severely limit access to essential reproductive medical care, Texas lawmakers are materially interfering with the patient–clinician relationship and paving the way for others who may wish to mimic these dangerous laws across the country."

ACOG is committed to advocating at all levels for our members' ability to provide quality patient care and medical counsel, free from interference or threat of punishment or retribution. This page provides information about ACOG’s advocacy and clinical resources and reproduces some, but not all, relevant provisions of SB 4. We will continue to update this page as ACOG generates additional information and member resources.

Please note: This site is for informational purposes only and should not be construed as legal advice on any subject matter. You should not act or refrain from acting on the basis of any content included in this site without seeking legal or other professional advice.

ACOG Position

• ACOG clinical guidance affirms the safety and efficacy of medication abortion through 70 days gestation and specifies that there is no justification for on-site dispensing of mifepristone or mandatory in-person exams prior to and following a medication abortion.
• ACOG has opposed complication reporting requirements in the past and opposes this one too. Such laws presume a causal relationship between abortion and dozens of medical conditions where none exists, thereby fomenting a false impression that abortion is unsafe. These requirements also compel physicians to make reports counter to their medical judgment.

Evidence-Based Resources

ACOG routinely creates and updates evidence-based resources for members related to access to, provision of, and advocacy for reproductive health care.

Several starting points include:

• ACOG Spontaneous and Induced Abortion Resource Center: A member portal for questions about spontaneous or induced abortion, such as reimbursement issues, patient materials, and clinical questions. ACOG members can receive an expert response free of charge by submitting your questions online.
• Information for Patients Seeking Abortion Care Resource Digest: A guide compiled by the ACOG Implementing Progress in Abortion Care and Training (IMPACT) Program to help clinicians identify resources available for patients subject to the limitations of applicable law.
• Policy Priorities page: A clearinghouse for ACOG advocacy resources, policies, and clinical guidance related to abortion access.
• ACOG State Government Affairs Department: To find ways to plug into advocacy efforts in your state, contact ACOG’s State Government Affairs team at [email protected].

Make Your Voice Heard

• Share your story: To help us highlight the voices of obstetrician-gynecologists across the country, we encourage you to share a personal perspective demonstrating the urgent need to protect access to care and cease political interference in the patient-physician relationship, including by making medication abortion more available.
• Call on Congress to pass the Women's Health Protection Act, which would establish federal protections safeguarding clinicians and patients from state restrictions on medically appropriate care. Read more about WHPA.
• Spread the word: Follow @ACOGAction on Twitter and @acog_org on Instagram for additional updates on ACOG’s advocacy and join the conversation on social media.
• Keep up-to-speed on developments by reading ACOG Rounds: in your inbox every Friday. Not getting Rounds? Check your email preferences in the MyACOG section of the ACOG website.

Information for Texas Members

ACOG encourages Texas members to read the full text of the law. Some relevant provisions are reproduced below. ACOG provides this information for your reference. Please note that by reproducing this information, ACOG is not endorsing any of the terminology used by SB 4.

SB 4 amends Section 171.063, Health and Safety Code, to expand the definition of medication abortion to explicitly include misoprostol, methotrexate, and any "off-label" use of other medications. SB 4 also imposes additional requirements for the provision of medication abortion, including limiting it to 49 days gestation and banning provision by courier, delivery, or mail.

Definitions

• Expands definition of "abortion-inducing drug" to include misoprostol and methotrexate as "off-label use of drugs, medicines, or other substances known to have abortion-inducing properties."
• Expands definition of “medication abortion:” In addition to "mifepristone regimen," SB 4 adds to the definition of medication abortion, "off-label use of drugs, medicines, or other substances known to have abortion-inducing properties that are prescribed, dispensed, or administered with the intent of causing an abortion, misoprostol (Cytotec), and methotrexate"
• Creates definition of “provide” in regards to a medication abortion: as "any act of giving, selling, dispensing, administering, transferring possession, or otherwise providing or prescribing an abortion-inducing drug," and replaces "give, sell, dispense, administer, or prescribe" with "provide" throughout the law.

Exceptions

• The definition of "abortion-inducing" drugs excepts circumstances where medications were "prescribed, dispensed, or administered for other medical reasons."

Additional requirements for "providing" an "abortion-inducing drug"

• Bans "a manufacturer, supplier, physician, or any other person" from providing a patient "any abortion-inducing drug by courier, delivery, or mail service."
• Bans provision of medication abortion beyond 49 days gestational age
• Before providing an "abortion-inducing drug," a physician must conduct an in-person examination, "Independently verify that a pregnancy exists," document the intrauterine location of the pregnancy "to determine whether an ectopic pregnancy exists;" and determine the patient’s blood type.
• For patients who are Rh negative, "as diagnosed by the most accurate standard of medical care," the physician must "offer to administer Rh immunoglobulin (RhoGAM) at the time the abortion-inducing drug is administered or used or the abortion is performed or induced to prevent Rh incompatibility, complications, or miscarriage in future pregnancies;" and document whether the patient "received treatment for Rh negativity, as diagnosed by the most accurate standard of medical care"

Penalties: A person who "intentionally, knowingly, or recklessly" violates this subchapter commits a state jail felony. The Texas Medical Board is charged with enforcement.

SB 4 also amends Section 171.006, Health and Safety Code, regarding abortion complications reporting by adding 14 examples of "abortion complications" that must be reported, and applying reporting requirements to all physicians and health care facilities. There is no time frame specified between the abortion and complication. SB 4 also requires the state to publish an annual aggregate report of reported complications. The Texas Department of Health and Human Services has posted the required reporting form and contact information for questions and “assistance completing the online forms, for technical support, and to provide feedback on the user experience” on its website.

Changes to abortion complications reporting statute

• Defines "abortion complication or adverse event" as a "harmful event or adverse outcome with respect to a patient related to an abortion that is performed or induced on the patient and that is diagnosed or treated by a health care practitioner or at a health care facility."
• Adds 14 examples of "abortion complications" that must be reported, including cardiac arrest, adverse reactions to anesthesia or other drugs, and preterm delivery in subsequent pregnancies. The full list is below.
• Broadens current law to apply complications reporting requirements to a physician at any "health care facility that is a hospital, abortion facility, freestanding emergency medical care facility, or health care facility that provides emergency medical care"—not just physicians at the clinic where the abortion was performed—who "diagnoses or treats" an abortion complication.
• Does not specify a time frame between the patient’s abortion and the advent of complications.
• Adds the following "abortion complications" requiring reporting: blood clots resulting in pulmonary embolism or deep vein thrombosis; failure to actually terminate the pregnancy; pelvic inflammatory disease; endometritis; missed ectopic pregnancy; cardiac arrest; respiratory arrest; renal failure; metabolic disorder; embolism; coma; placenta previa in subsequent pregnancies; preterm delivery in subsequent pregnancies; fluid accumulation in the abdomen; hemolytic reaction resulting from the administration of ABO-incompatible blood or blood products; adverse reactions to anesthesia or other drugs; or any other adverse event as defined by the United States Food and Drug Administration ’s criteria provided by the MedWatch Reporting System.

Reporting process

• A physician must submit a report within three business days after a complication is diagnosed or treated.
• Each health care facility must submit a report on each abortion complication diagnosed or treated at the facility within 30 days.

Complications data

• An annual report that aggregates on a statewide basis each abortion complication will be published.

Penalties

• Each violation is subject to a civil penalty of $500 for each day of a continuing violation. Violations are reported to the Texas medical board, and three "offenses" result in loss of license.

Definitions

• Adds "induced" to all references to abortions performed (i.e. "a performed or induced abortion").