BOISE, Idaho — About once a year, in recent years, Dr. Becky Uranga has found herself in the same high-stakes situation: The Meridian OB-GYN sees a patient whose water has broken around 20 weeks into her pregnancy.

At that stage, the chances of the fetus surviving are low, “but not zero,” Uranga said. In a best-case scenario, she and her team can get the mother on antibiotics and keep her and the fetus in a “holding pattern” for a few more weeks, increasing the likelihood that the baby could survive with time in the neonatal intensive care unit.

But it’s a high-risk proposition: Once the mother’s water has broken, the risk of infection or other complications dramatically increases. If those occur, doctors must induce labor to protect the mother.

Inducing labor around 20 or 21 weeks, when the fetus is periviable — an “in-betweenie time,” Uranga called it — could kill the fetus. If doctors induce and the baby dies, that induction could be viewed as an abortion.

“Those are the scary ones,” the cases that risk running afoul of Idaho’s strict abortion ban, Uranga told the Idaho Statesman. “Those are the ones that are going on airplanes” to receive care out of state.

Idaho’s abortion ban includes some carve-outs to allow for pregnancy terminations when medically necessary, including the removal of a “dead unborn child” and the removal of an ectopic pregnancy.

But Idaho physicians told The Idaho Statesman that those exceptions often do not exist in practice — in large part because legal language is ill-suited to capture the complexities of medical care.

It’s one reason why advocates have worked this election cycle to rewrite the state’s abortion laws, putting forward Proposition 1, a ballot measure to expand abortion access in the state. If passed, the initiative “would restore commonsense, lifesaving exceptions to Idaho’s abortion ban,” organizers wrote.

Miscarriage, complex cases are rarely ‘certain’

The lack of exceptions in Idaho’s current law has been a major concern in providing miscarriage care, doctors said.

On paper, miscarriage management shouldn’t be an issue, as Idaho law does not consider the removal of a “dead unborn child” to be abortion. (Though undefined, “dead” is generally understood to mean that there is no cardiac activity in the embryo or fetus, according to the Abortion Defense Network.)

But miscarriage cases are rarely so cut-and-dry, doctors said.

In some cases, doctors may not be completely certain whether a woman is miscarrying — perhaps she has miscarried before there is a visible fetus, or the levels of pregnancy-related hormones in her body are dropping, said Dr. Loren Colson, a family doctor who provides obstetric care, including miscarriage management. Or, a miscarriage may be “inevitable” if the mother is bleeding and naturally evacuating the contents of the uterus — but for the moment, the fetus still has a heartbeat.

“It’s unlikely to be a certain thing,” Colson said.

Miscarriage “is a medical diagnosis, not a legal diagnosis,” said Dr. Caitlin Gustafson, a family medicine obstetrician in McCall. “We’re trying to apply a legal definition to a scope of care in which there’s nuance.”

Idaho’s laws have had a “chilling effect,” Gustafson said, on providing any treatment that could be “misconstrued as an induced abortion.” In response, many physicians are encouraging patients to delay, to wait and see whether there is a certain miscarriage, she said.

That can be the right approach in some cases. But in others, it poses serious risks, Gustafson said.

“There’s story after story of women who had dreadful experiences of bleeding … and even life-threatening complications,” Gustafson said.

Doctors told the Statesman they faced similar dilemmas in a wide range of situations. Colson recounted the story of one of his patients, who was pregnant but still had an intra-uterine device in place.

The doctor in his practice who noticed the IUD “was afraid” to remove it, Colson said, because they worried doing so could cause a miscarriage, which could be viewed as an abortion. Data shows that it’s much higher-risk to the pregnancy to leave an IUD in place than to remove it, so Colson did ultimately decide to take it out. Fortunately, he said, the pregnancy continued.

But he had to “wrestle with” the decision for 24 hours beforehand, he recalled. In case the removal killed the fetus, he wondered, “could I argue in court that I was giving the fetus the best chance of survival?”

‘There’s a level of fear’ in providing care

The stakes for doctors in these complex situations are high. They could go to jail for up to five years if a court finds they performed an abortion — and they risk being sued by a patient’s family member who misunderstood the care they were providing.

In a case of managing a miscarriage, for example, “someone else standing in the room, down the line, could say to you, ‘There was a heartbeat’ when you know there wasn’t,” Gustafson said.

The risk of a civil lawsuit has made communicating with patients and their families all the more fraught, she said. It’s led doctors to order extra scans and exams beyond what is medically necessary.

“There’s a level of fear” now in providing this kind of care, Gustafson said.

She’s one of nearly 400 Idaho doctors who signed an open letter urging Idahoans to vote for Proposition 1.

Idaho’s abortion ban “is one of the strictest bans in the nation,” the letter reads. “It ties our hands when a patient is clinically deteriorating and threatens physicians with prison for exercising the medical judgment we were trained and licensed to use.”

Nearly 100 Idaho doctors, in response, signed an open letter opposing Prop 1. Dr. Kim Cox, an OB-GYN in Pocatello, was one of those signatories. Prop 1, he told the Statesman, goes “too far” in expanding abortion access.

But even he has concerns about the state’s current laws.

“I support the laws as they stand, with the following modifications: We need some more protection and clarity for physicians who are managing complicated high-risk pregnancies in which termination may be indicated,” he said. “And number two, we need a provision for lethal fetal anomalies, which we do not currently have.”

Idaho’s abortion ban took effect in 2022. Between then and 2024, the state lost 35% of its doctors who practiced in obstetrics, according to a 2025 study by a division of the Journal of the American Medical Association.

The OB-GYN at Gustafson’s hospital, the St. Luke’s McCall Medical Center, left because of Idaho’s abortion ban, and the hospital hasn’t been able to replace her, Gustafson said. The hospital also has no maternal fetal medicine specialist.

The result is that Gustafson works with Treasure Valley-based providers — already spread thin with their own caseloads — to remotely consult on complex cases. As a family doctor, she can provide some, but not all, of the care her patients need.

Her rural hospital is equipped to medically manage an ectopic pregnancy before it ruptures a tube, for example. But no one in the hospital has the surgical skills to manage a rupture if it does happen, she said.

There are similar gaps at rural hospitals around the state. Increasingly, for patients, “your care depends on your ZIP code,” Gustafson said.

The loss of providers has had cascading effects into care that has nothing to do with pregnancy, said Dr. Jessica Evans-Wall, an emergency medicine physician. In the Boise area, she increasingly sees patients come to the ER with severe vaginal bleeding — often advanced cases of conditions that ordinarily would have been seen in an OB-GYN outpatient clinic.

But those clinics are stretched thin, with minimal availability for ad hoc appointments. The loss of doctors since the abortion ban isn’t the only reason, Evans-Wall said, but it’s a key driver.

“Patients just don’t have access,” Evans-Wall said. And so “they wait until it is a true emergency, and then they come in to see us.”

One such patient, it turned out, had cervical cancer. She only found this out when she came to Evans-Wall’s department with severe vaginal bleeding. Ordinarily, it’s a condition that would have been detected early with a Pap smear.

The delays in care lead to complications, doctors said — and sometimes, to death. Gustafson highlighted September reporting by ProPublica that found deaths from ectopic pregnancies had nearly doubled nationwide between 2020 and 2025, compared with the previous six years. The spike has been much steeper, the outlet found, in states with abortion bans.

“The ProPublica data was glaring and hit home hard, especially for those of us in rural areas, where our patient is a helicopter away from emptying their belly of that blood, saving their organs, potentially,” Gustafson said. Or “potentially saving their life, because if the hemorrhage goes unchecked, they’ll go into shock and die.”

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