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What a High-Risk Pregnancy Looks Like After Dobbs

Pregnancy can be dangerous — sometimes fatal — for both women and the fetuses they hope to give birth to. Fetal conditions, such as a non-viable twin threatening the health of its sibling, can also put the mother at risk. So are conditions such as cancer, heart disease, kidney dysfunction, diabetes, and lupus. Even something as simple as age — getting pregnant if you’re under 17 or over 35 — or carrying twins or having a history of multiple miscarriages can put women and pregnancies at risk. That’s why so many midwives consider the ability to terminate a pregnancy as essential: doctors need access to abortion procedures to provide care and save lives.

Catrina Rainey and James Packwood and their 9-year-old son at home in August, a month before her due date. In May, Catrina learned that one of the twins she was carrying had a serious brain defect that made it unlikely that she would live outside the womb for more than six months and could threaten the viability of the other fetus until birth. A reduction — the termination of an unhealthy fetus to protect a healthy sibling — occurred in May. It was one of the last such proceedings to be conducted in Ohio, after the state made them illegal, following Dobbs’ decision.

The Cleveland Clinic’s division of maternal-fetal medicine, one of the largest of its kind in the country, is set up to address high-risk pregnancies and the dangers that can accompany them. It manages more than 5,000 such pregnancies each year. In August, less than two months after the Supreme Court ruled Dobbs v. Jackson Women’s Health Organization overturned Roe v. Wade and abolished the constitutional right to abortion, photographer Stephanie Sinclair spent two weeks capturing the newly troubled world at the Cleveland Clinic. .

Everything changed on the day of the Dobbs decision, June 24. Towards the end of that Friday, a three-year-old law called a “heartbeat law” went into effect that made it a felony to terminate a pregnancy after a fetal heartbeat is detected. A heartbeat can generally be detected after about six weeks of pregnancy, before many women know they are pregnant; previously abortions were allowed, with restrictions, up to 22 weeks of gestation. Suddenly, most of the termination proceedings planned by the Cleveland Clinic a week earlier were now crimes. Only three exceptions allowed for abortions after the new cutoff: to prevent the death of the mother; to prevent a “serious risk of the substantial and irreversible impairment of an important bodily function of the pregnant woman”; and to respond to ectopic pregnancies, where a fertilized egg implants outside the uterus.

Every morning, midwives, nurses, the NICU team and pharmacists meet to discuss their patients. Increasingly restrictive abortion laws have raised fears that they will not be able to provide necessary care. We “want the best for them emotionally and medically, and the ruling affects that,” says Dr. Tristi Muir. “Healthcare decisions can be very complex and are best made between the doctor and the patient.”

The uncertainties about how to interpret and deliver care in response to those exceptions meant that Cleveland Clinic staff had to continue their work under unclear legal circumstances. How do you know if a mother’s life is in danger? How do you predict and prove that the mother will face potentially irreversible physical damage? “As doctors, we literally take an oath to care for patients,” says Dr. Stacey Ehrenberg, who specializes in high-risk pregnancies at the Cleveland Clinic. “And now we’ve tied our hands.”

Once the heartbeat law became law, routine procedures for treating miscarriage — which is how at least one in 10 pregnancies ends — could be considered abortions. The most effective drugs used in cases of miscarriage, mifepristone and misoprostol, are the same drugs used to induce abortion; the surgical evacuation of the uterus is another procedure used in miscarriages that is also an abortion method. The new law means that most patients admitted to the Cleveland Clinic’s emergency room during a miscarriage will have to wait 24 hours before being treated — treatment given earlier could be considered an illegal abortion. dr. Ashley Brant, an OB/GYN at the Cleveland Clinic, says they had a core group of physicians providing abortion care who were well versed in what the law had been. But the new law, she says, “opens the floodgates on who could provide this kind of care.” For example, an emergency room doctor who is used to treating miscarriages with certain procedures may now be breaking the law. That risk threatens to affect medical care.

dr. Maeve Hopkins with a patient, before an amniocentesis to verify previous evidence from a blood test and ultrasound that her fetus had Down syndrome. Worried about both the financial burden of caring for a child with special needs and the impact on her daughter, who is almost 2, the patient had already decided she would terminate the pregnancy if diagnosed with Down syndrome. would be confirmed, although she would have. to travel outside of Ohio to do this.

Ohio had changed the parameters of reproductive care for decades. Physicians are required to ask patients who want and qualify for an abortion to hear or see a picture of the fetus’ heartbeat; physicians and other medical providers, including pharmacists, may withhold medical care based on their moral, religious or ethical beliefs; doctors are required to send an official report to the state health service for every patient who receives a qualified abortion. And any patient who chooses to have an abortion should be given a 21-page booklet entitled “Fetal Development and Family Planning.” Those changes happened over many years. The heartbeat law went into effect so quickly that even powerful institutions like the Cleveland Clinic were caught off guard. “I’ve lived in a restrictive state for almost my entire career, experiencing legislative changes along the way that restricted access, but not to this degree,” says Dr. Justin Lappen, chief of maternal fetal medicine at Cleveland Clinic.

Lappen, Brant and a lawyer from the clinic held an emergency meeting Monday after the Supreme Court’s decision to provide medical and legal guidance to the more than 600 doctors, nurses and administrators who attended remotely. “Everyone was very emotional and upset that this actually happened,” said Dr. Amanda Kalan, a specialist in maternal fetal medicine. “The people who make the laws are not doctors and they don’t understand the implications of all these laws.”

Megan Keeton, 31, immediately after cesarean section. Complications from two previous pregnancies — one resulted in a stillbirth, the other in the birth of her daughter, Aryia, now 7, who has spastic quadriplegic cerebral palsy — led doctors to tell Jones not to get pregnant again because of the risks to her. her health. (She suffered a stroke shortly after giving birth to her daughter.) But just before making an appointment late last year to have her fallopian tubes tied, she found out she was pregnant for the third time. “I was asked if I wanted an abortion, and I said no,” Jones said.

Elizabeth Whitmarsh, the communications director for Ohio Right to Life, which lobbied for the heart rate bill, denies that the bill itself is responsible for any ill effects. “The only thing that’s not legal in Ohio right now is the murder of a child,” she says when asked about the implications of the bill. Ohio State Representative Adam Holmes, along with Congressman Steve Chabot and former Governor John Kasich, did not respond to requests for comment.

On July 11, two and a half weeks after the Dobbs decision, an Ohio representative named Gary Click introduced a two-sentence bill that would further restrict abortion. The bill aims to “protect the constitutional rights of all unborn human individuals from the moment of conception” unless the mother’s life is endangered. Right now, Lappen says, “We have some patients who can still receive abortion care after five or six weeks if no heartbeat is detected.” But if this bill becomes law, he adds, “there would really be virtually no abortion care on the table in Ohio.”

Mary Lynch, 36, with her children, at a checkup with Dr. Stacey Ehrenberg. Lynch’s previous pregnancy resulted in a baby with a fatal genetic defect. “After two days, we couldn’t let him suffer anymore, so we took him to comfort care, where they gave him a lot of morphine and I held him for hours,” Lynch says. After learning there was a 25 percent chance that the same condition would develop in future pregnancies, she and her husband opted for in vitro fertilization so the embryos could be genetically tested. But Lynch worries that if Ohio’s “personality law” is passed, it could have implications for IVF, which often requires discarding fertilized embryos; if that happens, Lynch plans to move to Illinois for future IVF treatments.

dr. Maeve Hopkins, an OB/GYN who specializes in high-risk pregnancies at the Cleveland Clinic, grew up outside of Cleveland and returned to the city after working in Pennsylvania and North Carolina. She is now doubting her move. “I don’t know of an OB/GYN in Ohio who hasn’t considered leaving,” she says. U.S. News & World Report currently ranks Cleveland Clinic’s obstetrics and gynecology care as the fourth best in the nation, but Dr. Tristi Muir, the president of the OB/GYN and Women’s Health Institute there, points out that this status — and even more importantly, the quality of women’s health care available to Ohioans — has become vulnerable: “Doctors may not come to our state to practice or train.”

Sarah Stacy at home in a daycare that she had prepared for a pregnancy that ended in an abortion. A scan during her 12th week revealed that her fetus had cystic fluid around the head and neck and birth defects of the heart and brain. If she delivered the fetus to full term, she was told, it would only survive a few hours to a few days. It is illegal in Ohio to terminate a pregnancy due to birth defects, so Stacy had to travel out of state for the procedure alone. “I found out it was a girl too,” Stacy says. “And I have two boys at home. So it’s like this was my girl. She was planned.”

Stephanie Sinclair is a Pulitzer Prize-winning photographer known for her focus on human rights issues. She founded Too Young to Wed, a charity that aims to empower girls and end child marriage worldwide. Jaime Lowe is a frequent contributor to the magazine and the author of the Breathing Fire: Female Inmate Firefighters on the Frontlines of California’s Wildfires.