Wrapping his wife in a blanket as she mourned the loss of her pregnancy at 11 weeks, Hope Ngumezi wondered why no obstetrician was coming to see her.

Over the course of six hours on June 11, 2023, Porsha Ngumezi had bled so much in the emergency department at Houston Methodist Sugar Land that she’d needed two transfusions. She was anxious to get home to her young sons, but, according to a nurse’s notes, she was still “passing large clots the size of grapefruit.”

Hope dialed his mother, a former physician, who was unequivocal. “You need a D&C,” she told them, referring to dilation and curettage, a common procedure for first-trimester miscarriages and abortions. If a doctor could remove the remaining tissue from her uterus, the bleeding would end.

But when Dr. Andrew Ryan Davis, the obstetrician on duty, finally arrived, he said it was the hospital’s “routine” to give a drug called misoprostol to help the body pass the tissue, Hope recalled. Hope trusted the doctor. Porsha took the pills, according to records, and the bleeding continued.

Three hours later, her heart stopped.

The 35-year-old’s death was preventable, according to more than a dozen doctors who reviewed a detailed summary of her case for ProPublica. Some said it raises serious questions about how abortion bans are pressuring doctors to diverge from the standard of care and reach for less-effective options that could expose their patients to more risks. Doctors and patients described similar decisions they’ve witnessed across the state.

It was clear Porsha needed an emergency D&C, the medical experts said. She was hemorrhaging and the doctors knew she had a blood-clotting disorder, which put her at greater danger of excessive and prolonged bleeding. “Misoprostol at 11 weeks is not going to work fast enough,” said Dr. Amber Truehart, an OB-GYN at the University of New Mexico Center for Reproductive Health. “The patient will continue to bleed and have a higher risk of going into hemorrhagic shock.” The medical examiner found the cause of death to be hemorrhage.

D&Cs — a staple of maternal health care — can be lifesaving. Doctors insert a straw-like tube into the uterus and gently suction out any remaining pregnancy tissue. Once the uterus is emptied, it can close, usually stopping the bleeding.

But because D&Cs are also used to end pregnancies, the procedure has become tangled up in state legislation that restricts abortions. In Texas, any doctor who violates the strict law risks up to 99 years in prison. Porsha’s is the fifth case ProPublica has reported in which women died after they did not receive a D&C or its second-trimester equivalent, a dilation and evacuation; three of those deaths were in Texas.

Texas doctors told ProPublica the law has changed the way their colleagues see the procedure; some no longer consider it a first-line treatment, fearing legal repercussions or dissuaded by the extra legwork required to document the miscarriage and get hospital approval to carry out a D&C. This has occurred, ProPublica found, even in cases like Porsha’s where there isn’t a fetal heartbeat or the circumstances should fall under an exception in the law. Some doctors are transferring those patients to other hospitals, which delays their care, or they’re defaulting to treatments that aren’t the medical standard.

Misoprostol, the medicine given to Porsha, is an effective method to complete low-risk miscarriages but is not recommended when a patient is unstable. The drug is also part of a two-pill regimen for abortions, yet administering it may draw less scrutiny than a D&C because it requires a smaller medical team and because the drug is commonly used to induce labor and treat postpartum hemorrhage. Since 2022, some Texas women who were bleeding heavily while miscarrying have gone public about only receiving medication when they asked for D&Cs. One later passed out in a pool of her own blood.

“Stigma and fear are there for D&Cs in a way that they are not for misoprostol,” said Dr. Alison Goulding, an OB-GYN in Houston. “Doctors assume that a D&C is not standard in Texas anymore, even in cases where it should be recommended. People are afraid: They see D&C as abortion and abortion as illegal.”

Doctors and nurses involved in Porsha’s care did not respond to multiple requests for comment.

Several physicians who reviewed the summary of her case pointed out that Davis’ post-mortem notes did not reflect nurses’ documented concerns about Porsha’s “heavy bleeding.” After Porsha died, Davis wrote instead that the nurses and other providers described the bleeding as “minimal,” though no nurses wrote this in the records. ProPublica tried to ask Davis about this discrepancy. He did not respond to emails, texts or calls.

Houston Methodist officials declined to answer a detailed list of questions about Porsha’s treatment. They did not comment when asked whether Davis’ approach was the hospital’s “routine.” A spokesperson said that “each patient’s care is unique to that individual.”

“All Houston Methodist hospitals follow all state laws,” the spokesperson added, “including the abortion law in place in Texas.”

“We Need to See the Doctor”

Hope marveled at the energy Porsha had for their two sons, ages 5 and 3. Whenever she wasn’t working, she was chasing them through the house or dancing with them in the living room. As a finance manager at a charter school system, she was in charge of the household budget. As an engineer for an airline, Hope took them on flights around the world — to Chile, Bali, Guam, Singapore, Argentina.

The two had met at Lamar University in Beaumont, Texas. “When Porsha and I began dating,” Hope said, “I already knew I was going to love her.” She was magnetic and driven, going on to earn an MBA, but she was also gentle with him, always protecting his feelings. Both were raised in big families and they wanted to build one of their own.

When he learned Porsha was pregnant again in the spring of 2023, Hope wished for a girl. Porsha found a new OB-GYN who said she could see her after 11 weeks. Ten weeks in, though, Porsha noticed she was spotting. Over the phone, the obstetrician told her to go to the emergency room if it got worse.

To celebrate the end of the school year, Porsha and Hope took their boys to a water park in Austin, and as they headed back, on June 11, Porsha told Hope that the bleeding was heavier. They decided Hope would stay with the boys at home until a relative could take over; Porsha would drive to the emergency room at Houston Methodist Sugar Land, one of seven community hospitals that are part of the Houston Methodist system.

At 6:30 p.m, three hours after Porsha arrived at the hospital, she saw huge clots in the toilet. “Significant bleeding,” the emergency physician wrote. “I’m starting to feel a lot of pain,” Porsha texted Hope. Around 7:30 p.m., she wrote: “She said I might need surgery if I don’t stop bleeding,” referring to the nurse. At 7:50 p.m., after a nurse changed her second diaper in an hour: “Come now.”

Still, the doctor didn’t mention a D&C at this point, records show. Medical experts told ProPublica that this wait-and-see approach has become more common under abortion bans. Unless there is “overt information indicating that the patient is at significant risk,” hospital administrators have told physicians to simply monitor them, said Dr. Robert Carpenter, a maternal-fetal medicine specialist who works in several hospital systems in Houston. Methodist declined to share its miscarriage protocols with ProPublica or explain how it is guiding doctors under the abortion ban.

As Porsha waited for Hope, a radiologist completed an ultrasound and noted that she had “a pregnancy of unknown location.” The scan detected a “sac-like structure” but no fetus or cardiac activity. This report, combined with her symptoms, indicated she was miscarrying.

But the ultrasound record alone was less definitive from a legal perspective, several doctors explained to ProPublica. Since Porsha had not had a prenatal visit, there was no documentation to prove she was 11 weeks along. On paper, this “pregnancy of unknown location” diagnosis could also suggest that she was only a few weeks into a normally developing pregnancy, when cardiac activity wouldn’t be detected. Texas outlaws abortion from the moment of fertilization; a record showing there is no cardiac activity isn’t enough to give physicians cover to intervene, experts said.

Dr. Gabrielle Taper, who recently worked as an OB-GYN resident in Austin, said that she regularly witnessed delays after ultrasound reports like these. “If it’s a pregnancy of unknown location, if we do something to manage it, is that considered an abortion or not?” she said, adding that this was one of the key problems she encountered. After the abortion ban went into effect, she said, “there was much more hesitation about: When can we intervene, do we have enough evidence to say this is a miscarriage, how long are we going to wait, what will we use to feel definitive?”

At Methodist, the emergency room doctor reached Davis, the on-call OB-GYN, to discuss the ultrasound, according to records. They agreed on a plan of “observation in the hospital to monitor bleeding.”

Around 8:30 p.m., just after Hope arrived, Porsha passed out. Terrified, he took her head in his hands and tried to bring her back to consciousness. “Babe, look at me,” he told her. “Focus.” Her blood pressure was dipping dangerously low. She had held off on accepting a blood transfusion until he got there. Now, as she came to, she agreed to receive one and then another.

By this point, it was clear that she needed a D&C, more than a dozen OB-GYNs who reviewed her case told ProPublica. She was hemorrhaging, and the standard of care is to vacuum out the residual tissue so the uterus can clamp down, physicians told ProPublica.

“Complete the miscarriage and the bleeding will stop,” said Dr. Lauren Thaxton, an OB-GYN who recently left Texas.

“At every point, it’s kind of shocking,” said Dr. Daniel Grossman, a professor of obstetrics and gynecology at the University of California, San Francisco who reviewed Porsha’s case. “She is having significant blood loss and the physician didn’t move toward aspiration.”

All Porsha talked about was her devastation of losing the pregnancy. She was cold, crying and in extreme pain. She wanted to be at home with her boys. Unsure what to say, Hope leaned his chest over the cot, passing his body heat to her.

At 9:45 p.m., Esmeralda Acosta, a nurse, wrote that Porsha was “continuing to pass large clots the size of grapefruit.” Fifteen minutes later, when the nurse learned Davis planned to send Porsha to a floor with fewer nurses, she “voiced concern” that he wanted to take her out of the emergency room, given her condition, according to medical records.

At 10:20 p.m., seven hours after Porsha arrived, Davis came to see her. Hope remembered what his mother had told him on the phone earlier that night: “She needs a D&C.” The doctor seemed confident about a different approach: misoprostol. If that didn’t work, Hope remembers him saying, they would move on to the procedure.

A pill sounded good to Porsha because the idea of surgery scared her. Davis did not explain that a D&C involved no incisions, just suction, according to Hope, or tell them that it would stop the bleeding faster. The Ngumezis followed his recommendation without question. “I’m thinking, ‘He’s the OB, he’s probably seen this a thousand times, he probably knows what’s right,’” Hope said.

But more than a dozen doctors who reviewed Porsha’s case were concerned by this recommendation. Many said it was dangerous to give misoprostol to a woman who’s bleeding heavily, especially one with a blood clotting disorder. “That’s not what you do,” said Dr. Elliott Main, the former medical director for the California Maternal Quality Care Collaborative and an expert in hemorrhage, after reviewing the case. “She needed to go to the operating room.” Main and others said doctors are obliged to counsel patients on the risks and benefits of all their options, including a D&C.

Performing a D&C, though, attracts more attention from colleagues, creating a higher barrier in a state where abortion is illegal, explained Goulding, the OB-GYN in Houston. Staff are familiar with misoprostol because it’s used for labor, and it only requires a doctor and a nurse to administer it. To do a procedure, on the other hand, a doctor would need to find an operating room, an anesthesiologist and a nursing team. “You have to convince everyone that it is legal and won’t put them at risk,” said Goulding. “Many people may be afraid and misinformed and refuse to participate — even if it’s for a miscarriage.”

Davis moved Porsha to a less-intensive unit, according to records. Hope wondered why they were leaving the emergency room if the nurse seemed so worried. But instead of pushing back, he rubbed Porsha’s arms, trying to comfort her. The hospital was reputable. “Since we were at Methodist, I felt I could trust the doctors.”

On their way to the other ward, Porsha complained of chest pain. She kept remarking on it when they got to the new room. From this point forward, there are no nurse’s notes recording how much she continued to bleed. “My wife says she doesn’t feel right, and last time she said that, she passed out,” Hope told a nurse. Furious, he tried to hold it together so as not to alarm Porsha. “We need to see the doctor,” he insisted.

Her vital signs looked fine. But many physicians told ProPublica that when healthy pregnant patients are hemorrhaging, their bodies can compensate for a long time, until they crash. Any sign of distress, such as chest pain, could be a red flag; the symptom warranted investigation with tests, like an electrocardiogram or X-ray, experts said. To them, Porsha’s case underscored how important it is that doctors be able to intervene before there are signs of a life-threatening emergency.

But Davis didn’t order any tests, according to records.

Around 1:30 a.m., Hope was sitting by Porsha’s bed, his hands on her chest, telling her, “We are going to figure this out.” They were talking about what she might like for breakfast when she began gasping for air.

“Help, I need help!” he shouted to the nurses through the intercom. “She can’t breathe.”

“All She Needed”

Hours later, Hope returned home in a daze. “Is mommy still at the hospital?” one of his sons asked. Hope nodded; he couldn’t find the words to tell the boys they’d lost their mother. He dressed them and drove them to school, like the previous day had been a bad dream. He reached for his phone to call Porsha, as he did every morning that he dropped the kids off. But then he remembered that he couldn’t.

Friends kept reaching out. Most of his family’s network worked in medicine, and after they said how sorry they were, one after another repeated the same message. All she needed was a D&C, said one. They shouldn’t have given her that medication, said another. It’s a simple procedure, the callers continued. We do this all the time in Nigeria.

Since Porsha died, several families in Texas have spoken publicly about similar circumstances. This May, when Ryan Hamilton’s wife was bleeding while miscarrying at 13 weeks, the first doctor they saw at Surepoint Emergency Center Stephenville noted no fetal cardiac activity and ordered misoprostol, according to medical records. When they returned because the bleeding got worse, an emergency doctor on call, Kyle Demler, said he couldn’t do anything considering “the current stance” in Texas, according to Hamilton, who recorded his recollection of the conversation shortly after speaking with Demler. (Neither Surepoint Emergency Center Stephenville nor Demler responded to several requests for comment.)

They drove an hour to another hospital asking for a D&C to stop the bleeding, but there, too, the physician would only prescribe misoprostol, medical records indicate. Back home, Hamilton’s wife continued bleeding until he found her passed out on the bathroom floor. “You don’t think it can really happen like that,” said Hamilton. “It feels like you’re living in some sort of movie, it’s so unbelievable.”

Across Texas, physicians say they blame the law for interfering with medical care. After ProPublica reported last month on two women who diedafter delays in miscarriage care, 111 OB-GYNs sent a letter to Texas policymakers, saying that “the law does not allow Texas women to get the lifesaving care they need.”

Dr. Austin Dennard, an OB-GYN in Dallas, told ProPublica that if one person on a medical team doubts the doctor’s choice to proceed with a D&C, the physician might back down. “You constantly feel like you have someone looking over your shoulder in a punitive, vigilante type of way.”

The criminal penalties are so chilling that even women with diagnoses included in the law’s exceptions are facing delays and denials. Last year, for example, legislators added an update to the ban for patients diagnosed with previable premature rupture of membranes, in which a patient’s water breaks before a fetus can survive. Doctors can still face prosecution for providing abortions in those cases, but they are offered the chance to justify themselves with what’s called an “affirmative defense,” not unlike a murder suspect arguing self defense. This modest change has not stopped some doctors from transferring those patients instead of treating them; Dr. Allison Gilbert, an OB-GYN in Dallas, said doctors send them to her from other hospitals. “They didn’t feel like other staff members would be comfortable proceeding with the abortion,” she said. “It’s frustrating that places still feel like they can’t act on some of these cases that are clearly emergencies.” Women denied treatment for ectopic pregnancies, another exception in the law, have filed federal complaints.

In response to ProPublica’s questions about Houston Methodist’s guidance on miscarriage management, a spokesperson, Gale Smith, said that the hospital has an ethics committee, which can usually respond within hours to help physicians and patients make “appropriate decisions” in compliance with state laws.

After Porsha died, Davis described in the medical record a patient who looked stable: He was tracking her vital signs, her bleeding was “mild” and she was “said not to be in distress.” He ordered bloodwork “to ensure patient wasn’t having concerning bleeding.” Medical experts who reviewed Porsha’s case couldn’t understand why Davis noted that a nurse and other providers reported “decreasing bleeding” in the emergency department when the record indicated otherwise. “He doesn’t document the heavy bleeding that the nurse clearly documented, including the significant bleeding that prompted the blood transfusion, which is surprising,” Grossman, the UCSF professor, said.

Patients who are miscarrying still don’t know what to expect from Houston Methodist.

This past May, Marlena Stell, a patient with symptoms nearly identical to Porsha’s, arrived at another hospital in the system, Houston Methodist The Woodlands. According to medical records, she, too, was 11 weeks along and bleeding heavily. An ultrasound confirmed there was no fetal heartbeat and indicated the miscarriage wasn’t complete. “I assumed they would do whatever to get the bleeding to stop,” Stell said.

Instead, she bled for hours at the hospital. She wanted a D&C to clear out the rest of the tissue, but the doctor gave her methergine, a medication that’s typically used after childbirth to stop bleeding but that isn’t standard care in the middle of a miscarriage, doctors told ProPublica. "She had heavy bleeding, and she had an ultrasound that's consistent with retained products of conception." said Dr. Jodi Abbott, an associate professor of obstetrics and gynecology at Boston University School of Medicine, who reviewed the records. "The standard of care would be a D&C."

Stell says that instead, she was sent home and told to “let the miscarriage take its course.” She completed her miscarriage later that night, but doctors who reviewed her case, so similar to Porsha’s, said it showed how much of a gamble physicians take when they don’t follow the standard of care. “She got lucky — she could have died,” Abbott said. (Houston Methodist did not respond to a request for comment on Stell’s care.)

It hadn’t occurred to Hope that the laws governing abortion could have any effect on his wife’s miscarriage. Now it’s the only explanation that makes sense to him. “We all know pregnancies can come out beautifully or horribly,” Hope told ProPublica. “Instead of putting laws in place to make pregnancies safer, we created laws that put them back in danger.”

For months, Hope’s youngest son didn’t understand that his mom was gone. Porsha’s long hair had been braided, and anytime the toddler saw a woman with braids from afar, he would take off after her, shouting, “That’s mommy!”

A couple weeks ago, Hope flew to Amsterdam to quiet his mind. It was his first trip without Porsha, but as he walked the city, he didn’t know how to experience it without her. He kept thinking about how she would love the Christmas lights and want to try all the pastries. How she would have teased him when he fell asleep on a boat tour of the canals. “I thought getting away would help,” he wrote in his journal. “But all I’ve done is imagine her beside me.”

Josseli Barnica grieved the news as she lay in a Houston hospital bed on Sept. 3, 2021: The sibling she’d dreamt of giving her daughter would not survive this pregnancy.

The fetus was on the verge of coming out, its head pressed against her dilated cervix; she was 17 weeks pregnant and a miscarriage was “in progress,” doctors noted in hospital records. At that point, they should have offered to speed up the delivery or empty her uterus to stave off a deadly infection, more than a dozen medical experts told ProPublica.

But when Barnica’s husband rushed to her side from his job on a construction site, she relayed what she said the medical team had told her: “They had to wait until there was no heartbeat,” he told ProPublica in Spanish. “It would be a crime to give her an abortion.”

For 40 hours, the anguished 28-year-old mother prayed for doctors to help her get home to her daughter; all the while, her uterus remained exposed to bacteria.

Three days after she delivered, Barnica died of an infection.

Barnica is one of at least two Texas women who ProPublica found lost their lives after doctors delayed treating miscarriages, which fall into a gray area under the state’s strict abortion laws that prohibit doctors from ending the heartbeat of a fetus.

Neither had wanted an abortion, but that didn’t matter. Though proponents insist that the laws protect both the life of the fetus and the person carrying it, in practice, doctors have hesitated to provide care under threat of prosecution, prison time and professional ruin.

ProPublica is telling these women’s stories this week, starting with Barnica’s. Her death was “preventable,” according to more than a dozen medical experts who reviewed a summary of her hospital and autopsy records at ProPublica’s request; they called her case “horrific,” “astounding” and “egregious.”

The doctors involved in Barnica’s care at HCA Houston Healthcare Northwest did not respond to multiple requests for comment on her case. In a statement, HCA Healthcare said “our responsibility is to be in compliance with applicable state and federal laws and regulations” and said that physicians exercise their independent judgment. The company did not respond to a detailed list of questions about Barnica’s care.

Like all states, Texas has a committee of maternal health experts who review such deaths to recommend ways to prevent them, but the committee’s reports on individual cases are not public and members said they have not finished examining cases from 2021, the year Barnica died.

ProPublica is working to fill gaps in knowledge about the consequences of abortion bans. Reporters scoured death data, flagging Barnica’s case for its concerning cause of death: “sepsis” involving “products of conception.” We tracked down her family, obtained autopsy and hospital records and enlisted a range of experts to review a summary of her care that ProPublica created in consultation with two doctors.

Among those experts were more than a dozen OB-GYNs and maternal-fetal medicine specialists from across the country, including researchers at prestigious institutions, doctors who regularly handle miscarriages and experts who have served on state maternal mortality review committees or held posts at national professional medical organizations.

After reviewing the four-page summary, which included the timeline of care noted in hospital records, all agreed that requiring Barnica to wait to deliver until after there was no detectable fetal heartbeat violated professional medical standards because it could allow time for an aggressive infection to take hold. They said there was a good chance she would have survived if she was offered an intervention earlier.

“If this was Massachusetts or Ohio, she would have had that delivery within a couple hours,” said Dr. Susan Mann, a national patient safety expert in obstetric care who teaches at Harvard University.

Many noted a striking similarity to the case of Savita Halappavanar, a 31-year-old woman who died of septic shock in 2012 after providers in Ireland refused to empty her uterus while she was miscarrying at 17 weeks. When she begged for care, a midwife told her, “This is a Catholic country.” The resulting investigation and public outcry galvanized the country to change its strict ban on abortion.

But in the wake of deaths related to abortion access in the United States, leaders who support restricting the right have not called for any reforms.

Last month, ProPublica told the stories of two Georgia women, Amber Thurman and Candi Miller, whose deaths were deemed “preventable” by the state’s maternal mortality review committee after they were unable to access legal abortions and timely medical care amid an abortion ban.

Georgia Gov. Brian Kemp called the reporting “fear mongering.” Former President Donald Trump has not weighed in — except to joke that his Fox News town hall on women’s issues would get “better ratings” than a press call where Thurman’s family spoke about their pain.

Leaders in Texas, which has the nation’s oldest abortion ban, have witnessed the consequences of such restrictions longer than those in any other state.

In lawsuits, court petitions and news stories, dozens of women have said they faced dangers when they were denied abortions starting in 2021. One suffered sepsis like Barnica, but survived after three days in intensive care. She lost part of her fallopian tube. Lawmakers have made small concessions to clarify two exceptions for medical emergencies, but even in those cases, doctors risk up to 99 years in prison and fines of $100,000; they can argue in court that their actions were not a crime, much like defendants can claim self-defense after being charged with murder.

Amid the deluge of evidence of the harm, including research suggesting Texas’ legislation has increased infant and maternal deaths, some of the ban’s most prominent supporters have muted their public enthusiasm for it. U.S. Sen. Ted Cruz, who once championed the fall of Roe v. Wade and said, “Pregnancy is not a life-threatening illness,” is now avoiding the topic amid a battle to keep his seat. And Gov. Greg Abbott, who said early last year that “we promised we would protect the life of every child with a heartbeat, and we did,” has not made similar statements since.

Both declined to comment to ProPublica, as did state Attorney General Ken Paxton, whose commitment to the ban remains steadfast as he fights for access to the out-of-state medical records of women who travel for abortions. Earlier this month, as the nation grappled with the first reported, preventable deaths related to abortion access, Paxton celebrated a decision by the U.S. Supreme Court that allowed Texas to ignore federal guidance requiring doctors to provide abortions that are needed to stabilize emergency patients.

“This is a major victory,” Paxton said.

“They Had to Wait Until There Was No Heartbeat”

To Barnica, an immigrant from Honduras, the American dream seemed within reach in her corner of Houston, a neighborhood filled with restaurants selling El Salvadoran pupusas and bakeries specializing in Mexican conchas. She found work installing drywall, saved money to support her mother back home and met her husband in 2019 at a community soccer game.

A year later, they welcomed a big-eyed baby girl whose every milestone they celebrated. “God bless my family,” Barnica wrote on social media, alongside a photo of the trio in matching red-and-black plaid. “Our first Christmas with our Princess. I love them.”

Barnica longed for a large family and was thrilled when she conceived again in 2021.

Trouble struck in the second trimester.

On Sept. 2, 2021, at 17 weeks and four days pregnant, she went to the hospital with cramps, according to her records. The next day, when the bleeding worsened, she returned. Within two hours of her arrival on Sept. 3, an ultrasound confirmed “bulging membranes in the vagina with the fetal head in the open cervix,” dilated at 8.9 cm, and that she had low amniotic fluid. The miscarriage was “in progress,” the radiologist wrote.

When Barnica’s husband arrived, she told him doctors couldn’t intervene until there was no heartbeat.

The next day, Dr. Shirley Lima, an OB on duty, diagnosed an “inevitable” miscarriage.

In Barnica’s chart, she noted that the fetal heartbeat was detected and wrote that she was providing Barnica with pain medication and “emotional support.”

In a state that hadn’t banned abortion, Barnica could have immediately been offered the options that major medical organizations, including international ones, say is the standard of evidence-based care: speeding up labor with medication or a dilation and evacuation procedure to empty the uterus.

“We know that the sooner you intervene in these situations, the better outcomes are,” said Dr. Steven Porter, an OB-GYN in Cleveland.

But Texas’ new abortion ban had just gone into effect. It required physicians to confirm the absence of a fetal heartbeat before intervening unless there was a “medical emergency,” which the law did not define. It required doctors to make written notes on the patient’s condition and the reason abortion was necessary.

The law did not account for the possibility of a future emergency, one that could develop in hours or days without intervention, doctors told ProPublica.

Barnica was technically still stable. But lying in the hospital with her cervix open wider than a baseball left her uterus exposed to bacteria and placed her at high risk of developing sepsis, experts told ProPublica. Infections can move fast and be hard to control once they take hold.

The scenario felt all too familiar for Dr. Leilah Zahedi-Spung, a maternal-fetal medicine specialist who used to work in Tennessee and reviewed a summary of Barnica’s records at ProPublica’s request.

Abortion bans put doctors in an impossible position, she said, forcing them to decide whether to risk malpractice or a felony charge. After her state enacted one of the strictest bans in the country, she also waited to offer interventions in cases like Barnica’s until the fetal heartbeat stopped or patients showed signs of infection, praying every time that nothing would go wrong. It’s why she ultimately moved to Colorado.

The doctors treating Barnica “absolutely didn’t do the right thing,” she said. But she understood why they would have felt “totally stuck,” especially if they worked at a hospital that hadn’t promised to defend them.

Even three years after Barnica’s death, HCA Healthcare, the hospital chain that treated Barnica, will not disclose whether it has a policy on how to treat miscarriages.

Some HCA shareholders have asked the company to prepare a report on the risks to the company related to the bans in states that restrict abortion, so patients would understand what services they could expect and doctors would know under what circumstances they would be protected. But the board of directors opposed the proposal, partly because it would create an “unnecessary expense and burdens with limited benefits to our stockholders.” The proposal was supported by 8% of shareholders who voted.

The company’s decision to abstain has repercussions far beyond Texas; the nation’s largest for-profit hospital chain has said it delivers more babies than any other health care provider in America, and 70% of its hospitals are in states where abortion is restricted.

As the hours passed in the Houston hospital, Barnica couldn’t find relief. On the phone with her aunt Rosa Elda Calix Barnica, she complained that doctors kept performing ultrasounds to check the fetal heartbeat but were not helping her end the miscarriage.

Around 4 a.m. on Sept. 5, 40 hours after Barnica had arrived, doctors could no longer detect any heart activity. Soon after, Lima delivered Barnica’s fetus, giving her medication to help speed up the labor.

Dr. Joel Ross, the OB-GYN who oversaw her care, discharged her after about eight more hours.

The bleeding continued, but when Barnica called the hospital, she was told that was expected. Her aunt grew alarmed two days later when the bleeding grew heavier.

Go back, she told her niece.

On the evening of Sept. 7, Barnica’s husband rushed her to the hospital as soon as he got off from work. But COVID-19 protocols meant only one visitor could be in the room with her, and they didn’t have a babysitter for their 1-year-old daughter.

So he left and tried to get some sleep.

“I fully expected her to come home,” he said.

But she never did. Her family planned two funerals, one in Houston and another in Honduras.

Nine days after her death, Barnica’s husband was processing his shock, learning how to be a single dad and struggling to raise funds to bury his wife and the son he had hoped to raise.

Meanwhile, Lima was pulling up Barnica’s medical chart to make an addition to her records.

The notes she added made one point abundantly clear: “When I was called for delivery,” she wrote, “the fetus no longer had detectable heart tones.”

“They Should Vote With Their Feet”

Texas has been on the forefront of fighting abortion access.

At the time of Barnica’s miscarriage in 2021, the Supreme Court had not yet overturned the constitutional right to terminate a pregnancy. But Texas lawmakers, intent on being the first to enact a ban with teeth, had already passed a harsh civil law using a novel legal strategy that circumvented Roe v. Wade: It prohibited doctors from performing an abortion after six weeks by giving members of the public incentives to sue doctors for $10,000 judgments. The bounty also applied to anyone who “aided and abetted” an abortion.

A year later, after the Dobbs v. Jackson ruling was handed down, an even stricter criminal law went into effect, threatening doctors with up to 99 years in prison and $100,000 in fines.

Soon after the ruling, the Biden administration issued federal guidance reminding doctors in hospital emergency rooms they have a duty to treat pregnant patients who need to be stabilized, including by providing abortions for miscarriages.

Texas Attorney General Ken Paxton fought against that, arguing that following the guidance would force doctors to “commit crimes” under state law and make every hospital a “walk-in abortion clinic.” When a Dallas woman asked a court for approval to end her pregnancy because her fetus was not viable and she faced health risks if she carried it to term, Paxton fought to keep her pregnant. He argued her doctor hadn’t proved it was an emergency and threatened to prosecute anyone who helped her. “Nothing can restore the unborn child’s life that will be lost as a result,” he wrote to the court.

No doctor in Texas, or the 20 other states that criminalize abortion, has been prosecuted for violating a state ban. But the possibility looms over their every decision, dozens of doctors in those states told ProPublica, forcing them to consider their own legal risks as they navigate their patient’s health emergencies. The lack of clarity has resulted in many patients being denied care.

In 2023, Texas lawmakers made a small concession to the outcry over the uncertainty the ban was creating in hospitals. They created a new exception for ectopic pregnancies, a potentially fatal condition where the embryo attaches outside the uterine cavity, and for cases where a patient’s membranes rupture prematurely before viability, which introduces a high risk of infection. Doctors can still face prosecution, but are allowed to make the case to a judge or jury that their actions were protected, not unlike self-defense arguments after homicides. Barnica’s condition would not have clearly fit this exception.

This year, after being directed to do so by the state Supreme Court, the Texas Medical Board released new guidance telling doctors that an emergency didn’t need to be “imminent” in order to intervene and advising them to provide extra documentation regarding risks.

But in a recent interview, the board’s president, Dr. Sherif Zaafran, acknowledged that these efforts only go so far and the group has no power over criminal law: “There’s nothing we can do to stop a prosecutor from filing charges against the physicians.”

Asked what he would tell Texas patients who are miscarrying and unable to get treatment, he said they should get a second opinion: “They should vote with their feet and go and seek guidance from somebody else.”

An immigrant from El Salvador who works 12-hour shifts, Barnica’s husband doesn’t follow American politics or the news. He had no inkling of the contentious national debate over how abortion bans are affecting maternal health care when ProPublica contacted him.

Now he is raising a 4-year-old daughter with the help of Barnica’s younger brother; every weekend, they take her to see her grandmother, who knows how to braid her hair in pigtails.

All around their home, he keeps photos of Barnica so that the little girl grows up knowing how much her mother loved her. He sees flashes of his wife when his daughter dances. She radiates the same delight.

When asked about Barnica, he can’t get out many words; his leg is restless, his eyes fixed on the floor. Barnica’s family calls him a model father.

He says he’s just doing his best.

Sitting at her computer one day in late December, Dr. Sarah Osmundson mustered her best argument to approve an abortion for a suffering patient.

The woman was 14 weeks pregnant when she learned her fetus was developing without a skull. This increased the likelihood of a severe buildup of amniotic fluid, which could cause her uterus to rupture and possibly kill her. Osmundson, a maternal-fetal specialist at Vanderbilt University Medical Center who helps patients navigate high-risk pregnancies, knew that outcome was uncommon, but she had seen it happen.

She drafted an email to her colleagues on the Nashville hospital’s abortion committee, arguing that the risk was significant enough to meet the slim exception to Tennessee’s strict abortion ban, which allows termination only when “necessary to prevent the death of the pregnant woman or to prevent serious risk of substantial and irreversible impairment of a major bodily function.” She pleaded with her fellow doctors to spare this woman the gamble when her baby wasn’t even viable.

Then came the replies.

One doctor wasn’t “brave enough.”

Another urged her to consider the optics — approving an abortion in this case could be seen as “cavalier” and trying to circumvent the law. “I’m saying this because I care about you and your personal liberties,” the doctor said.

To Osmundson, the responses reflected just how much abortion bans had warped doctors’ decision-making and forced them to violate the ethics of their profession, which require acting in the best interests of their patients.

Most medical exceptions in abortion bans only allow the procedure to “save the life of the mother.” But there is a wide spectrum of health risks patients can face during pregnancy, and even those that are potentially fatal could fall outside of the exceptions, depending on how the law is interpreted and enforced. Without clarification from legislators and prosecutors on how to handle the real-life nuances that have emerged in hospitals across America, doctors in abortion ban states say they are unable to provide care to high-risk pregnant patients that meets medical standards.

Under threat of prison time and professional ruin, they are finding their personal interests pitted against their patients’ and are overriding their expert training for factors that have nothing to do with medicine, like political perceptions and laws they aren’t qualified to interpret. As a result, some patients are forced to endure significant risks or must travel out of state if they want to end a pregnancy. Sometimes, their doctors aren’t even giving them adequate information about the dangers they face.

Osmundson and 30 other doctors across nine states in which abortion is banned or restricted described to ProPublica the impossible landscape they must navigate in the nearly two years since the Supreme Court struck down Roe v. Wade.

It is one in which fetuses — some with no chance of survival — are being prioritized over their at-risk mothers and oncologists are hesitating to give chemotherapy to cancer patients for fear of legal consequences if it disrupts the pregnancies.

Doctors described the position they’ve been put in — denying abortions to high-risk patients who are begging for them — as “distressing,” “untenable” and “insane.” Speaking out about the broken system felt like the only way to not be complicit, Osmundson said. “It’s going to take physicians coming together and saying: ‘We’re not going to participate in this. We’re going to do what we think is right for patients.’”

Osmundson, who has worked at Vanderbilt for the past eight years, decided to share with ProPublica the inner workings of the hospital’s abortion committee to give the public a rare glimpse into the tortured decisions she and her colleagues are being forced to make. It shows how maternal health care could be dramatically altered across America if Republicans gain control of Congress this fall and succeed in passing the nationwide ban that influential anti-abortion activists have long sought.

In a series of interviews, Osmundson detailed the deliberations in a wide variety of cases and described conversations and emails among doctors. She did not disclose the identities of patients or their individual files. ProPublica was able to confirm details with one patient and three colleagues familiar with the committee, some of whom were not willing to speak publicly for fear of professional repercussions. Vanderbilt declined to comment.

What she shared shows how the strictly written bans fail to account for a broad range of dangerous maternal health risks, leaving doctors to deny abortion requests for medical reasons like warning signs of preeclampsia, a potentially fatal blood pressure condition; complications related to Type 1 diabetes, which can cause vision loss, kidney disease and death; and conditions requiring patients to have their uteruses “cracked open” in order to give birth.

She’s come to believe it’s time to take abortion decisions out of doctors’ hands and shift the final say to hospital lawyers and administrators. In her view, that’s the only way to protect the independent judgment of the medical experts, who could make strong arguments in their patients’ interests using research and data.

“I understand pragmatism,” Osmundson told ProPublica. “I also don’t want to have a patient die and be responsible for it.”

She also thinks hospitals should require doctors to obtain informed consent from patients facing dangerous pregnancy complications, so that providers can’t make decisions on their behalf without counseling them about their risk and getting their response. “In this climate, we’ve really diminished women’s autonomy,” she said. “If a patient says, ‘I don’t want to take on that risk,’ we need to honor that.”

A few months ago, she was on call caring for a patient who had developed severe high blood pressure near 24 weeks, a warning sign for preeclampsia, which can rapidly deteriorate and lead to organ damage or death. With her pregnancy at the edge of viability, the patient requested to have a cesarean section, Osmundson said, even though there was a significant chance the baby might not survive.

Osmundson said she scheduled the surgery. This was not considered an abortion, because the intent was still to deliver a live baby. But after her shift ended, Osmundson recalled, a colleague overrode her and kept the patient pregnant.

Osmundson and her colleagues launched the committee in fall 2022 to address a crisis they were seeing unfold in abortion ban states across the country and at Vanderbilt: Patients facing severe and urgent pregnancy complications were being denied care by hospitals where doctors were terrified about the new legal personal and professional risks.

With strength in numbers, the committee members would back one another up and aim to serve the most patients possible while staying within the law.

Since then, the committee has helped Vanderbilt doctors respond to the most severe emergencies. Abortion requests can hit the committee’s inbox at any hour — at least two a month, but sometimes four in a week. When complications are urgently life-threatening — cardiac failure, Stage 3 kidney disease — doctors often coordinate through a few text messages and sign off that an abortion is medically indicated.

The committee has also developed critical protocols. If a patient’s water breaks before a fetus is viable, the administration considers it a medical emergency because the patient has a high chance of developing sepsis, which can lead to death. In those cases, it’s a blanket policy that doctors can offer abortion care, Osmundson said.

Other cases fall outside of the committee’s power. Osmundson said she has seen some doctors avoid the issue entirely, never informing their patients about the option to terminate their risky pregnancies; those cases never make it to the committee’s attention. The law also makes no exception for sexual assault or fetal anomaly cases, even when the pregnancy is not viable. Doctors direct these and other patients who want abortions to leave the state, if they can. In 2023, Osmundson counted 27 cases of nonviable pregnancies that were referred out of state.

It is those cases in the middle — potentially perilous, but not urgently deadly — that can feel like bombs hitting their inboxes, blasting shrapnel into the rest of their days as they turn over the particulars and try to come to a consensus.

The six doctors, five of whom are women, sometimes call one another up to hash it out. Other times, the discussion unfolds over email and can involve specialists from other departments. They respect one another and know they share the same goals, but the conversations can be heated and emotionally draining.

Last October, a challenging case came before the abortion committee, showcasing the murky limits of Tennessee’s exception.

The patient was seven weeks pregnant and stable, but with a medical history that would make delivery very high risk. Surgeons would need to make a vertical incision on her abdomen — a procedure Osmundson described as “fileting” the uterus — that could lead to permanent bladder or bowel damage due to the patient’s existing complications.

When Osmundson read the file, her mind ticked through worst-case scenarios if things didn’t go well: The patient might need to use an ostomy bag attached to her abdomen to dispel waste. She could suffer severe blood loss or develop sepsis. She could die. The patient already had children and, in a letter to her doctors, requested an abortion.

The challenge for the doctors: The patient had no immediate complications; the potential emergency would not occur until the baby was at full term and doctors were performing surgery. Was it enough to predict that a patient might suffer “substantial and irreversible impairment” or death, based on past case studies? Or did the emergency need to have actually begun?

The law doesn’t say. Nor does it give guidance on how doctors should interpret the spectrum of risk. Was a 50% chance of death or “substantial and irreversible impairment” enough to meet the standard of the law? Twenty percent? Ten? The law says only that an abortion must be “necessary” in a doctor’s “reasonable” medical judgment.

Committee members could see how a zealous prosecutor might challenge that judgment. Doctors like Osmundson often help manage risk for patients who choose to go forward with dangerous pregnancies; some make it through with few long-term issues. It wasn’t hard to imagine a scenario in which a prosecutor held up cases of women who had survived similar complications and pointed to one patient’s abortion as a crime. The penalties for violating the ban include up to 10 years in prison and a $15,000 fine. Doctors can also lose their medical licenses if they are criminally charged. Many have expressed that they would not trust jurors without medical training to evaluate their cases and decide their fate.

In that October case, one doctor argued that the patient’s condition did not fit the definition of a medical emergency because continuing the pregnancy itself would not cause direct harm to an organ — all of the risk would emerge at the time of delivery.

“Who are we to say what is too much or not enough risk?” another wrote. “Where is the line and why do we have to decide that?” But the doctor pointed out that if they offered the abortion, “nurses and other staff will be upset.”

A third wrote: “I unfortunately don't think this meets the criteria for the law and my interpretation even though it is the ethical right thing to do.”

A fourth: “If one of our purposes is to protect the physicians involved in the care of these patients, I think this case is too risky.”

Osmundson bit her lips as she read the responses. After work, as she cooked dinner for her family and played with her kids, she couldn’t stop thinking about the patient. It was one thing to choose to continue a high-risk pregnancy — another to be forced to. As a doctor who spent her career working with the most difficult cases, she knew better than anyone that even healthy pregnancies could suddenly turn life-threatening.

“I just watched a woman die from liver failure this weekend after a normal uncomplicated pregnancy,” Osmundson told them. “I’m finding it morally repugnant to force anyone to continue a pregnancy for a potential life when the pregnancy poses a real threat to her life.”

If the patient the committee was considering died, Osmundson felt they would all have blood on their hands.

“I cannot deny abortion care to a patient concerned about their medical safety,” she wrote.

The group punted the decision until the university’s ethics committee could weigh in.

The patient was left waiting on a faceless abortion committee to deliver its verdict as the clock ticked.

Soon after, Osmundson learned, the woman was no longer pregnant. Perhaps it was a miscarriage. Or perhaps, Osmundson thought, she had gotten fed up and taken measures into her own hands.

It saved the committee from making a difficult decision. This time.

The predicament is far worse at many other hospitals.

Plenty of doctors ProPublica interviewed don’t work at a well-resourced institution or have an administration that has promised criminal defense if they are prosecuted. And some hospitals rely on state funding, leaving them subject to the demands of lawmakers who could request their emails and protocols, which are public record. Many doctors requested anonymity to speak about sensitive internal matters, fearful they could land on the radar of state officials looking to target abortion providers.

There were wide variations in how their hospitals have navigated the post-Roe reality. Some had abortion committees, but many relied on informal networks among colleagues to make decisions. A few had developed protocols like Vanderbilt’s, but others still require signs of infection or bleeding in order to act, even in cases when a patient’s water breaks before viability. “We are trying to push the idea that the harm does not have to be immediate,” said Dr. Nisha Verma, an OB-GYN and abortion provider in Georgia. “But institutions want to protect themselves.”

Doctors recounted nurses saying they weren’t allowed to treat patients who needed urgent abortions to survive. One was bleeding out. Another was septic. “That’s part of our risk,” one doctor said. “You don’t know who you are working with, who will decide you need to run this by the district attorney.”

Doctors felt similar hesitation from their specialist colleagues, some of whom have balked at having to sign off on any abortion-related paperwork. One OB-GYN described trying to get a cardiologist to evaluate a pregnant patient with heart failure. “We got a ‘Look, we know what you guys are doing and we don’t agree with abortion, so we aren’t going to say she can have an abortion,’” the doctor said.

In other cases, specialists have been afraid to treat patients for fear of accidentally causing harm to a fetus. One OB-GYN said an oncologist at their hospital was reluctant to provide cancer treatment for a patient who wanted to continue their pregnancy, in case chemotherapy were to be misconstrued as an abortion.

Some doctors feel that instead of offering backup, their hospitals have siloed all responsibility to a few providers who would take the fall if an abortion case were challenged. “Care was dependent on each case and who saw the patient and what their risk tolerance was and their views about abortion,” said Dr. Jessica Tarleton, an OB-GYN and abortion provider in South Carolina who left her institution due to its handling of the ban. “It was like chaos all the time.”

Doctors have no clarity on whether they could face repercussions for offering abortions for life-threatening health risks that aren’t active emergencies.

Lawmakers and prosecutors don’t want to offer it.

In Tennessee, legislators sided with an anti-abortion group last year to defeat an effort to include clear exceptions for fatal fetal anomalies and broader health risks. A lobbyist for the group opposed language that would allow doctors to provide abortions to “prevent” emergencies because, he said, “that would mean that the emergency hasn’t even occurred yet.” And Attorney General Jonathan Skrmetti is fighting a legal effort aimed at getting a judge to clarify the ban’s exception; he argues that the state can’t be held liable for doctors “overcomplying” for fear of violating the law. The case is ongoing.

Anti-abortion groups that support the bans have advocated for the narrowest possible interpretation of exceptions. “We would want a stricter standard,” Blaine Conzatti, the president of Idaho Family Policy Center, told ProPublica in November. “The only appropriate reason for abortion would be treating the mother and the unintended consequence is the death of the preborn child.”

Meanwhile, officials have doubled down on their warnings about the consequences if doctors go too far.

Texas Attorney General Ken Paxton fought back against the Biden administration’s federal guidance to offer abortion care for patients with medical complications and threatened doctors with prosecution if they complied with a court’s order to offer emergency abortion care. And in Indiana, the Attorney General Todd Rokita investigated a doctor for sharing with the media that a 10-year-old rape victim had to go out of state to get an abortion.

“There aren’t many people who want to risk or just rely on the goodwill of the legislature and the attorney general or any politician in our state,” one doctor said. Penalties vary by state — in Texas a doctor could face 99 years behind bars.

No doctor has been prosecuted under their state’s abortion ban. But the few public glimpses into judges’ thinking hasn’t provided reassurance. Recently, a Texas court denied a doctor’s request to serve a woman who wanted an abortion because her fetus had a fatal anomaly. The doctor argued the woman shouldn’t be subject to the risks of carrying to term a baby that would not survive. The court said the doctor hadn’t proved her life was in danger.

Will a judge decide the same if a doctor is charged with a felony? Would a jury, or an appellate court, or ultimately the Supreme Court? “The bottom line,” said Dr. Emily Patel, a maternal-fetal medicine specialist in Nebraska, “we don’t know what [the exception] means and won’t know until it’s tested in a court of law.”

No doctor wants to be the first to stand trial. “I don’t know how you can overinterpret the law when you are looking at jail time,” said Dr. Dawn Bingham, an OB-GYN in South Carolina. “A prudent person would hear that and go, ‘Well I guess I will interpret that to be as safe as possible.’”

A year ago, Osmundson said, she could never have imagined arguing to strip her committee of its decision-making power and turning it into an advisory board. But now she believes it’s the only way to shield doctors from the ethical conflict of denying patients evidence-based care. “I feel like these committees are kind of making physicians become complicit in an unethical and unjust system,” she said.

Dr. Mack Goldberg, her committee colleague, knows the position perhaps better than anyone else. Unlike most of his colleagues, including Osmundson, he actually performs abortions; since clinics shuttered in the wake of the ban, he’s one of the only people in the state with the expertise and institutional support to do so for medical complications.

He knows the hospital submits paperwork to the state after each one. And while he recognizes that his colleagues are putting their names on the decisions, he feels more exposed. He often can’t shake the feeling of being constantly on call, his livelihood perpetually on the line, a burning question in the back of his mind: “When push comes to shove, if I ever got trudged through a court case, how many people will truly have my back?”

Despite all of the anguish it causes him to turn away some patients, Goldberg disagrees with Osmundson. He believes it’s important for doctors to continue walking the tightrope: Do as much as possible with the support of colleagues and their institution, while being honest with patients about their risks and options. He feels the committee has made it possible for him to save some lives by acting quickly, and he doesn’t want to leave the call to hospital administrators and lawyers, who may be even more risk averse.

”We are on the front lines,” he said. “At the end of the day, the patients are staring right in our faces.”

Late last year, he sighed heavily as he counseled the woman whose baby was developing without a skull and gently told her what he tells all of his patients in her position: that he had the training to help her, but because of Tennessee’s laws, he might face prosecution and jail time if he did. He had a baby at home and couldn’t take that risk, he explained. Instead he would refer her to options outside the state.

The patient, Charlotte Miller, told ProPublica she understood and appreciated his thorough counseling. But she was stricken to realize it would have been different had they been in her home state of Colorado.

When the 22-year-old sat across from Goldberg in his office, all she knew was that she didn’t want to spend the next six months putting her body through the hardships of pregnancy to give birth to a baby that would never survive.

Her first pregnancy had been challenging. She struggled with worsened asthma and endometriosis, a painful condition in which tissue grows outside of the uterus. The toll on her mental health alone would be enormous, she believed, and she didn’t want to risk any unexpected complications that could make getting pregnant again more difficult. She desperately desired another child, but in this case, the best option, she was certain, would be to deliver her baby as soon as possible — to have the chance to hold him and say goodbye.

Instead, her family would have to scrape together more than $1,200, a week of her partner’s paycheck as a waiter, so she could travel to a clinic in Illinois. There, her only choice would be a dilation and evacuation procedure while unconscious, not a delivery in which her baby could emerge intact and she could hold him in his last moments. Before it came to that, she lost the pregnancy naturally.

She’d been unaware of the committee’s debate about her health risks. When she learned of it, it only affirmed what she’d come to believe: “It’s just so disheartening to me that doctors can want to provide me care and not be able to because of what a law says, for fear that they would have repercussions.”

State Rep. Taylor Rehfeldt was speaking on the floor of the South Dakota Capitol, four months pregnant with her third child, begging her Republican colleagues to care about her life.

“With the current law in place, I will tell you, I wake up fearful of my pregnancy and what it would mean for my children, my husband and my parents if something happened to me and the doctor cannot perform lifesaving measures,” she told her fellow lawmakers last February, her voice faltering as tears threatened.

Rehfeldt was a stroke survivor and her pregnancy put her at high risk for blood clots and heart issues that could kill her. The state’s ban made abortion a felony unless it was “necessary to preserve the life of the pregnant female.” If Rehfeldt developed complications, doctors told her, the law didn’t make clear how close to death she needed to be before they could act.

“When can a doctor intervene? Do I need to have my brain so oxygen-deprived to the point that I am nonfunctional?” she asked the room.

Rehfeldt is an ambitious rising Republican: She has a strong anti-abortion voting record and is serving as the House assistant majority leader. She also was a nurse. But her background and credentials failed to rally her colleagues to support a narrow clarification to the ban that would allow a doctor to end a pregnancy if “the female is at serious risk of death or of a substantial and irreversible physical impairment of one or more major bodily functions.”

“I would never have possibly imagined that a bill protecting a woman’s life could be so contentious,” Rehfeldt said on the floor of the House, announcing she was withdrawing her bill before even bringing it to a vote.

The language she and two other Republicans had landed on was still so slim, most national medical organizations and abortion-access advocates wouldn’t support it.

But even that had no chance. South Dakota Right to Life — a local affiliate of the major anti-abortion organization National Right to Life, which can rally voters to sway Republican primary elections — had told her it opposed any changes. (South Dakota Right to Life declined to comment.)

When the Supreme Court struck down the constitutional right to abortion last year, strict abortion bans in more than a dozen states snapped into effect. Known as “trigger laws,” many of the bans were passed years earlier, with little public scrutiny of the potential consequences, because few expected Roe v. Wade to be overturned.

Most of the trigger laws included language allowing abortion when “necessary” to prevent a pregnant person’s death or “substantial and irreversible” impairment to a major bodily function. Three allowed it for fatal fetal anomalies and two permitted it for rape victims who filed a police report. But those exceptions have been nearly inaccessible in all but the most extreme cases.

Many of the laws specify that mental health reasons can’t qualify as a medical emergency, even if a doctor diagnoses that a patient might harm herself or die if she continues a pregnancy. The laws also carry steep felony penalties — in Texas, a doctor could face life in prison for performing an abortion.

The overturn of Roe has intensified the struggle between those who don’t want strict abortion bans to trump the life and health of the pregnant person and absolutists who see preservation of a fetus as the singular goal, even over the objections of the majority of voters. In the states where near-total abortion bans went into effect after Roe’s protections evaporated, the absolutists have largely been winning.

And the human toll has become clear.

On the floors of state legislatures over the past year, doctors detailed the risks their pregnant patients have faced when forced to wait to terminate until their health deteriorated. Women shared their trauma. Some Republican lawmakers even promised to support clarifications.

But so far, few efforts to add exceptions to the laws have succeeded.

A review by ProPublica of 12 of the nation’s strictest abortion bans passed before Roe was overturned found that over the course of the 2023 legislative session, only four states made changes. Those changes were limited and steered by religious organizations. None allowed doctors to provide abortions to patients who want to terminate their pregnancies because of health risks.

ProPublica spoke with more than 30 doctors across the country about their experiences trying to provide care for patients in abortion-ban states and also reviewed news articles, medical journal studies and lawsuits. In at least 70 public cases across 12 states, women with pregnancy complications faced severe health risks and were denied abortion care or had treatment delayed due to abortion bans. Some nearly died or lost their fertility as a result. The doctors say the true number is much higher.

Early signs indicated Republicans might compromise, as voters in red states showed strong popular support for protecting abortion access and polls revealed the majority of American voters do not support total abortion bans. That opposition has only hardened since then, as reproductive rights drove a wave of Democratic electoral victories in Kentucky, Virginia and Pennsylvania in November. In Ohio, voters approved an amendment to the state’s constitution guaranteeing the right to an abortion.

But in the most conservative states, Republicans ultimately fell in line with highly organized Christian groups. Those activists fought to keep the most restrictive abortion bans in place by threatening to pull funding and support primary challenges to lawmakers that didn’t stand strong.

Their fervor to protect the laws reflects a bedrock philosophy within the American anti-abortion movement: that all abortion exceptions — even those that protect the pregnant person’s life or health — should be considered the same as sanctioning murder.

Facing Political Threats, Lawmakers Cave

By the time the 2023 legislative sessions began, the consequences of total abortion bans written years earlier by legal strategists with no medical expertise had become clear.

Across the nation, women described the harm they experienced when care was delayed or denied for high-risk complications or fatal fetal anomalies.

Amanda Zurawksi, a Texas woman who almost died after she was made to wait for an abortion until she developed a serious infection, testified before the U.S. Senate Judiciary Committee: “The preventable harm inflicted on me has already, medically, made it harder than it already was for me to get pregnant again.”

Jaci Statton, an Oklahoma woman who had a dangerous pregnancy that is never viable and can become cancerous, sued after being told that doctors “couldn’t touch me until I was crashing and that we should wait in the parking lot until I was about to die,” she told the Tulsa World.

Nancy Davis, a Louisiana woman who traveled out of state for an abortion after she learned her fetus was developing without a skull, said doctors told her, “I had to carry my baby to bury my baby.”

Mylissa Farmer, a Missouri woman who described being denied abortion care at three separate emergency room visits after her water broke before viability, sparked a federal investigation of the hospitals. The experience was “dehumanizing,” she told The Associated Press. “It was horrible not to get the care to save your life.”

Polls show that the majority of Americans reject laws that don’t allow patients to make health care decisions about their own bodies. When voters have been asked directly, as they were in ballot measures in Kansas, Kentucky, Montana and Ohio, they have chosen to protect abortion access. And in the 2022 midterms, congressional Republican candidates in some swing districts lost over their abortion stances.

Sensing backlash, some Republicans signaled a willingness to revisit their states’ abortion bans.

“I think there’s enough support for a compromised solution that matches up with most voters,” Republican Kentucky state Sen. Whitney Westerfield told Louisville Public Media in November 2022.

“We need to make clear what the trigger law meant,” Tennessee state Sen. Becky Duncan Massey said to WBIR Channel 10 in August 2022. “Doctors should be concerned about saving the life of a mom.”

In 10 of the 12 states with laws that ProPublica reviewed, lawmakers made efforts to add new exceptions or clarify language in 2023. In eight of them, Republicans were part of the effort.

But over time, calls from some Republicans for compromise were overwhelmed by strong opposition from anti-abortion lobbyists. In Idaho, Louisiana, North Dakota, Oklahoma, South Dakota, Tennessee and Texas, Republican lawmakers voted down or killed exceptions that would give doctors broader discretion to address health risks.

In Arkansas, Idaho, Kentucky, North Dakota, Tennessee and Texas, they quashed bills that would let doctors offer abortion when it was clear the fetus would never survive. Bills proposing rape and incest exceptions failed in eight of the states. In Arkansas, lawmakers voted against rape and incest exceptions that were narrowed to apply only to children.

The rejections came after women and families came to statehouses to share their own heartbreaking experiences.

“We found out that my baby had a giant hole in her chest and her intestines were strangling her heart,” Chelsea Stovall said in testimony to the Arkansas State Legislature, crying as she shared her experience terminating a nonviable pregnancy earlier that year. “I had to travel out of state to a doctor who didn’t know me and didn’t know potential complications.”

Stovall told ProPublica she did have complications — she bled for more than a month after the abortion and had to have a second procedure.

State Rep. Delisha Boyd, a Democrat who put forward a rape and incest exception bill in Louisiana, shared that she was conceived when her mother was raped at 15 by an older man.

“I know that my mother never recovered from that and she was dead before she was 28 years old,” Boyd said. “If we are pro-life, we have to be concerned with more than just the baby in utero. No one looked out for my mother. No one looked out for me once I was born.” Boyd said she noticed Republican lawmakers leaving the room as she and other women shared their personal stories.

In Arkansas, when state Rep. Ashley Hudson, a Democrat, proposed a rape and incest exception that was limited to children under 16 — because “we are talking about a situation where a 10-year-old child is being forced to carry a pregnancy that may kill her” — her Republican colleagues swiftly voted against it.

Republican Rep. Cindy Crawford countered with her experience operating a shelter for girls, where she said she had supported many 12-year-olds who gave birth.

“Just because a young girl is pregnant and — at 12 or whatever — you think she should have an abortion, would you not agree that two wrongs don’t make a right? That her mental health would be worse after she experienced an abortion?” she asked Hudson.

“I disagree and I would disagree that it’s up to me at all,” Hudson replied.

All of those efforts failed.

Four states made minor changes to their total abortion bans, in close alignment with anti-abortion organizations.

In Idaho and Tennessee, doctors who first pushed for changes were cut out of the process after local anti-abortion organizations pressured lawmakers.

In North Dakota, the state repealed its abortion ban because of constitutional challenges. Then the representatives of local Catholic dioceses worked with the hospital association to pass a new bill that was nearly as strict as the original.

In Texas, a narrow bill quietly passed. It was put forward by Democrats, then changed by Republicans and specifically addresses court challenges.

In the four states, the new laws created exceptions for immediately life-threatening situations, such as ectopic pregnancies, where the fetus implants outside the uterine cavity, and molar pregnancies, where no embryo forms. The Texas law still allows doctors to be charged for providing abortion care for an ectopic pregnancy or if a patient’s water breaks before viability, but it codifies those conditions as a legitimate defense in court. The North Dakota law made some small concessions: A “serious health risk” is now defined as one that poses only “substantial physical impairment to a major bodily function,” not substantial and irreversible, for example.

Doctors said the new changes did little to help patients facing health risks or whose fetuses have severe anomalies. They said the exceptions are mainly limited to people who are already facing an emergency.

This was by design, according to some lawmakers, including Idaho state Sen. Todd Lakey, whose exceptions bill intentionally focused only on situations where a pregnant patient is facing death. “That was our decision, was to focus on the life versus more of a health-type exception,” he said. He said earlier that a woman’s health “weighs less, yes, than the life of the child.”

Also in Idaho, Democratic state Sen. Melissa Wintrow asked David Ripley, the leader of Idaho Chooses Life, why the law’s new language couldn’t include a broader exception for the health of the mother.

“It sounds pretty easy to me to say, ‘Hey, protect the health of the mother.’ I’m at a loss as to why you can’t put that language in the bill,” she said during a hearing.

“In the real world, we’re talking about a spectrum,” Ripley responded. “We’re talking about death, and we’re talking about a headache.” Idaho Chooses Life did not respond to a request for comment.

During the session, a state senator tried to remove Idaho’s exception for rape or incest. He failed, but the exception was limited to the first 12 weeks of pregnancy.

The exception, as with most abortion bans that have a rape or incest clause, requires a woman to produce a police report. Current law doesn’t explicitly guarantee that rape or incest victims can get copies of their own reports when an investigation is open, said Wintrow.

When Tennessee Republicans introduced a bill to give doctors more protection to offer terminations when a pregnant patient faced a condition that could become life-threatening, Will Brewer, the lead lobbyist for Tennessee Right to Life, testified against it, arguing the patient’s condition needed to deteriorate before a doctor could intervene.

“There are issues with pregnancy that could be considered an emergency — or at least could possibly be considered an anomaly or medically futile — that work themselves out,” Brewer, who has no medical training, testified on the House floor. “I’m not talking about an eleventh hour, you know, a patient comes into the ER bleeding out, and what do we do? I’m talking about (a situation when) there is a condition here that some doctors would say constitutes an emergency worthy of a termination and other doctors would say, ‘Let’s pause and wait this out and see how it goes.’ I wouldn’t want the former to terminate when the latter says there’s room to see how it goes before this is urgent enough.”

He also opposed language that would allow doctors to “prevent” medical emergencies instead of treating active emergencies.

“That ‘prevent’ language has me concerned because that would mean that the emergency hasn’t even occurred yet,” he said. Brewer did not respond to a request for comment.

Doctors say that real-life pregnancy complications are rarely so cut and dried. In many cases, patients can go from stable to requiring life support in a matter of minutes.

“It is not always so clear, and things don’t always just work themselves out,” said Dr. Kim Fortner, a Tennessee maternal-fetal medicine specialist with 20 years of experience, testifying at the same hearing.

And doctors point out that health risks that are not immediately life-threatening can still have severe consequences.

Conditions like hypertension or blood clots within the veins that are not life-threatening in the first trimester could cause death as the pregnancy progresses, said Dr. Carrie Cwiak, an OB-GYN in Georgia. In those cases, it should be the patient’s decision whether to continue their pregnancy — not their doctor’s or their legislator’s decision, she said.

Anti-Abortion Groups Turn Up the Pressure

Tennessee Right to Life is part of a network of Christian special-interest groups that represents a minority of voters but wields outsized influence in Republican-majority legislatures. They use score cards to rate lawmakers on their fealty to anti-abortion causes and fund primary campaigns against Republicans who do not toe the line.

In February in Tennessee, for example, seven Republicans at a House subcommittee hearing expressed strong support for a bill written with input from doctors that would create exceptions for abortion care to prevent medical emergencies and for severe fetal anomalies.

“No one wants to tell their spouse, child or loved one that their life is not important in a medical emergency as you watch them die when they could have been saved,” said Republican state Rep. Esther Helton-Haynes, a nurse and one of the bill’s sponsors.

But Brewer, the Right to Life lobbyist, threatened during his testimony before the legislature that the group’s political action committee would issue negative score cards to any lawmaker who voted for a health exception.

His comments drew a strong rebuke from the Republican speaker of the House that day. Afterward, Tennessee Right to Life sent out emails to their network of voters, urging them to contact lawmakers who supported the bill.

Tennessee state Sen. Richard Briggs, a physician, planned to introduce the same bill in the Senate because polling showed about 80% of Tennesseeans believe abortion should be either completely legal or legal under some conditions. But he told ProPublica the pressure was too much. He couldn’t get the bill heard in any Senate committees after Right to Life came out against it.

Weeks later, Tennessee Right to Life supported a separate “clarification” bill that did not address the majority of the doctors’ concerns. No doctors were given the opportunity to speak in the legislature and the bill was quickly passed.

“This is just pure power politics,” said Briggs. “We’re going to have to address that we’re not listening to the voting public. And you know, we could lose. I mean, our people will start losing elections.”

But in Louisiana, Mary DuBuisson, a Republican state representative who proposed a change to clarify that abortions are legal for people having miscarriages, lost her next election after the group ran attack ads against her.

In North Dakota, two Republican lawmakers considering an amendment to allow abortions after the six-week limit in cases of child rape said they would not vote for if it did not have the support of the North Dakota Catholic Conference, a group that acts on behalf of the state’s two Catholic dioceses. The amendment quickly failed.

In Idaho, an effort by doctors and the Idaho Medical Association to lobby a small health exception was stopped in its tracks when the chair of the Idaho Republican Party, Dorothy Moon, issued a letter accusing the medical association of being a “progressive trade association” that represents “doctors educated in some of the farthest Left academic institutions in our country.” Soon after, Republicans introduced a separate bill that cut out the doctors and was written with the input of Idaho Chooses Life.

In the four states that did pass bills, the changes were limited and designed to respond to court challenges.

For example, in Idaho, a state district judge found that their no-exception abortion ban violated a federal law that requires emergency departments to treat pregnant patients facing an emergency. The clarification bill, supported by Idaho Chooses Life, made a small exception for life-threatening emergencies, ectopic pregnancies and molar pregnancies, targeted to deflect the judge’s argument.

Idaho and Tennessee “wanted to keep their law intact,” said Ingrid Duran, the legislative director for National Right to Life. Her organization didn’t want to see changes to the bans, but, she said, “I understand why they needed to do that, just to remove the wind from the sails of the opposition.”

The law has continued to make practicing maternal care in Idaho untenable for some doctors. They say the law is still unclear about the level of risk a patient must be facing for a doctor to offer abortion.

“Idaho still has no exceptions for mom unless we know 100% they’re dying,” said Dr. Lauren Miller, a maternal-fetal medicine specialist who has since left the state, part of an exodus of OB-GYNs who have moved due to the abortion ban.

Blaine Conzatti, the president of Idaho Family Policy Center, a group that helped pass the original version of the no-exception abortion law, said his organization did not want to see the law clarified.

“We would want a stricter standard than what this law allows,” he said. In his group’s view, abortion is almost never ethical.

“The only appropriate reason for abortion would be treating the mother and the unintended consequence is the death of the preborn child,” he said. “If the mother got cancer and you began treating her with chemo and radiation and the unintended consequence is that the baby dies, that’s ethically appropriate. But performing an abortion procedure to terminate the pregnancy is not ethically appropriate.”

A Core Philosophy

For the anti-abortion movement, the goal has always been total abortion bans with no exceptions and constitutional recognition that a fetus has the same rights as a person, said Mary Ziegler, a leading historian of the U.S. abortion debate.

This unyielding position was influenced by thinkers like Charles E. Rice, a law professor at the University of Notre Dame whose 1990 book “No Exception: A Pro-Life Imperative,” argues that the anti-abortion movement should not support any exceptions — even for the life of the pregnant person.

“If two people are on a one-man raft in the middle of the ocean, the law does not permit one to throw the other overboard even to save his own life,” he wrote.

The Catholic Church and the anti-abortion movement also have a history of celebrating the stories of women who were willing to sacrifice their lives to continue their pregnancies.

One of the most well-known stories is about Chiara Corbella Petrillo, a young Italian woman who refused chemotherapy in 2011 for cancer on her tongue because she was pregnant. As the cancer progressed, it became difficult for her to speak and see. A year after giving birth to a healthy baby boy, she died.

Live Action, a major anti-abortion advocacy group, included Petrillo on a list of “7 Brave Mothers Who Risked Their Lives to Save Their Preborn Babies.”

“In a culture where women are bombarded with the message that convenience and worldly achievement are tantamount — even overriding their children’s right to life — it is refreshing to see women who have defied the norm,” an editor for the organization wrote.

In anti-abortion circles, Petrillo has been described as a “heroine for the 21st century” and a “modern day saint.”

Her story was turned into a book, which appeared on a 2016 Mother’s Day gift list in the magazine Catholic Digest. The Catholic Church has opened an inquiry to consider whether Petrillo should be elevated to sainthood.

For decades, major anti-abortion groups did not see a no-exceptions approach as politically possible. Groups including National Right to Life and Susan B. Anthony Pro-Life America instead made gains by pressuring lawmakers to chip away at abortion protections via targeted restrictions that strangled access but wouldn’t curtail the basic right enshrined in Roe v. Wade. Between 2011 and 2017, 50 abortion clinics in the South closed due to the new laws.

But after Donald Trump was elected and began filling the Supreme Court with judges handpicked by the Federalist Society, a network of conservative and libertarian lawyers, some influential anti-abortion activists saw an opening for more radical action.

Paul Benjamin Linton was one of them. A longtime Catholic legal activist, he had argued against Rice’s commitment to a no-exceptions position that had no chance in the Supreme Court — not because he disagreed with it morally, but because he believed an incremental strategy would result in more babies being born. (Linton did not respond to emails and voicemails.)

After Trump’s election, he shifted to supporting banning abortion completely. Linton began drafting legislation that did not include explicit exceptions for the life or health of the pregnant person. Starting in 2019, he promoted some of the country’s strictest abortion bans in Tennessee, Idaho, and Texas. Those trigger laws, unenforceable at the time they were passed, became a stark reality for millions of people of childbearing age when Roe was overturned. Though slightly modified in 2023, they continue to sharply limit the ability of doctors to provide abortions to patients facing health risks.

Bleak Path Forward

To many doctors in the most restrictive abortion-ban states who participated in the 2023 legislative session, the path forward offers few signs of hope. Some see little appetite from lawmakers and lobbyists to continue pushing for new exceptions unless the political calculus changes significantly.

Nikki Zite, a doctor involved in the effort to add exceptions to Tennessee’s abortion law, said she and her colleagues across the state have been asking lobbyists what the strategy is for a renewed push in the next session. “I was hopeful that these issues would be revisited and we might have more success,” Zite said. “But I’m hearing the excuse, ‘It’s an election year and there’s a supermajority of Republicans’ and that it’s very unlikely to go anywhere.”

Briggs, the Tennessee state senator, said he is considering sponsoring another bill that would cover health complications and severe fetal anomalies in 2024. But he is mindful that it’s an election year and many of his moderate Republican colleagues will be facing Right to Life-backed challengers.

“I’m not optimistic about the bill passing, not at all,” he said. “And I don’t want to hurt any of our moderates enough to get a radical elected.”

Westerfield, the Kentucky state senator who last year spoke about a possible compromise on the abortion ban “that matches up with most voters,” told ProPublica he still believes most Kentuckians support allowing abortions in some cases. But he said he didn’t think it was something he could vote for — and he didn’t know whether his Republican colleagues might consider it either.

“I wouldn’t put a wager on any of it,” he said.

Some doctors in abortion-ban states that have made small changes to their laws told ProPublica they now feel cautiously comfortable treating obviously life-threatening conditions, like ectopic pregnancies, without calling legal counsel or an ethics committee. But they regularly turn away women requesting abortions in the vast gray zone related to health.

Some spoke of having to tell patients dealing with multiple medical complications, like diabetes and lupus, that pregnancy is likely to worsen their condition — but they can’t help with an abortion. They have cared for patients with serious heart complications who have continued dangerous pregnancies against their will. In some cases, doctors have had to rush patients facing extreme complications exacerbated by pregnancy, like kidney failure, to hospitals out of state.

Doctors like Sarah Osmundson, a maternal-fetal-medicine specialist in Tennessee, continue to ask themselves: How close to death does a patient have to be before I can intervene?

“We are keeping patients pregnant entirely for fetal benefit — not for maternal benefit, Osmundson said. “If a patient says, ‘I don’t want to take on that risk,’ we need to honor that.”