Cook tried to tune out the easy chatter outside, happy women with working wombs catching up with their hairdresser. At 36, she’d already experienced a long line of miscarriages, but none of the pregnancies had been more than five weeks along. Now she had to deliver a nearly 16-week fetus — a daughter she’d planned to call Bunny.
She took a deep breath and closed her eyes.
As soon as the fetus hit the water, blood started flowing between her thighs. Blood splattered on the white toilet seat and across the floor. She panicked, her hands shaking as she picked up her phone to call her husband, Derick.
“Baby,” she said, “I need you to come to the bathroom.”
Over the course of the day, according to medical records, Cook would lose roughly half the blood in her body.
She had intended to deliver the fetus in a hospital, a doctor by her side. When her water broke the night before — at least six weeks ahead of when a fetus could survive on its own — she drove straight to the emergency room, where she said the doctor explained that she was experiencing pre-viability preterm prelabor rupture of the membranes (PPROM), which occurs in less than 1 percent of pregnancies. The condition can cause significant complications, including infection and hemorrhage, that can threaten the health or life of the mother, according to multiple studies.
At the hospital in Coral Springs, Fla., Cook received antibiotics, records show. Then she was sent home to wait.
Cook’s experience reflects a new reality playing out in hospitals in antiabortion states across the country — where because of newly enacted abortion bans, people with potentially life-threatening pregnancy complications are being denied care that was readily available before the Supreme Court overturned Roe v. Wade in June.
When abortion was legal across the country, doctors in all states would typically offer to induce or perform a surgical procedure to end the pregnancy when faced with a pre-viability PPROM case — which is the standard of care, according to the American College of Obstetricians and Gynecologists (ACOG), and an option that many women choose. Especially before the 20-week mark, a fetus is extremely unlikely to survive without any amniotic fluid.
But in the 18 states where abortion is now banned before fetal viability, many hospitals have been turning away pre-viability PPROM patients as doctors and administrators fear the legal risk that could come with terminating even a pregnancy that could jeopardize the mother’s well-being, according to 12 physicians practicing in antiabortion states.
The medical exceptions to protect the life of the mother that are included in abortion bans are often described in vague language that does not appear to cover pre-viability PPROM, doctors said. That’s because the risks of the condition are often less clear-cut than other medical emergencies, such as an ectopic pregnancy, in which a fertilized egg grows outside of the uterus, dooming the fetus and posing an immediate danger to the mother’s life.
A 2022 study on the impact of Texas’s six-week abortion ban found that 57 percent of pre-viability PPROM patients in Texas who were not given the option to end their pregnancies experienced “a serious maternal morbidity,” such as infection or hemorrhage, compared with 33 percent of PPROM patients who chose to terminate in states without abortion bans. According to 2018 ACOG guidance, “isolated maternal deaths due to infection” have been reported in early PPROM cases.
Florida’s abortion law, enacted last year, bans the procedure after 15 weeks of pregnancy except when an abortion would either “save the pregnant woman’s life” or “avert a serious risk of substantial and irreversible physical impairment of a major bodily function.” The law includes another exception for a “fatal fetal anomaly,” which generally would not apply in a pre-viability PPROM case, according to several doctors, because there is no fetal anomaly but a lack of amniotic fluid, which limits the fetus’s chances of survival.
The state’s Republican-led legislature is swiftly moving toward passing a far stricter law banning abortion after six weeks of pregnancy. The new measure — which passed the Florida Senate last week and is awaiting final passage in the House — adds exceptions for rape and incest but does not address PPROM.
One of the sponsors of Florida’s 15-week abortion ban defended the current law as written, saying the existing exception should be sufficient to cover cases with serious health risks. An explicit exception for PPROM is not necessary, she added.
“The bottom line is we value life, and we would like to protect life,” said former Florida state senator Kelli Stargel (R). “We don’t want to give a gaping exception that anyone can claim.”
Of all the pregnancy complications affected by abortion bans, pre-viability PPROM is one of the most widespread, according to doctors interviewed for this story. The condition is common enough that one day after Cook was turned away from the hospital, the same thing happened to one of her closest friends. Shanae Smith-Cunningham, 32, was 19 weeks into her pregnancy when her water broke.
This story of what happened to the two friends is based on over 200 pages of medical records provided by the patients and on internal hospital documents, as well as text messages, videos and social media posts. In addition to Cook and Smith-Cunningham, The Washington Post interviewed friends and family members who witnessed the events, and several of the doctors involved in the women’s care.
About 15 minutes after Anya delivered the fetus, paramedics charged through the hair salon doors with a stretcher, she and her husband, Derick Cook, recalled. Paramedics slipped the fetal remains inside a red biohazard bag and rushed Anya to a nearby hospital.
When Hany Moustafa, the OB/GYN on call that day, started the procedure to clear remaining pregnancy tissue out of Anya’s uterus, she was still bleeding profusely, he said, describing Anya’s condition with her consent. She was “critically ill” and “mechanically ventilated,” according to medical records.
The doctor stepped out into the waiting room to talk to Derick, who had followed his wife to the ER.
Moustafa told Derick that his wife could die in the operating room, both men recalled.
“I will do my very best,” the doctor said. “But the rest is up to God.”
Four months earlier, on a sweltering afternoon in mid-August, Anya told her husband to meet her at the park. She waited under her favorite tree, close enough to the playground that she could hear children laughing, with eight pink and blue balloons.
“How many do you see?” she asked as Derick walked toward her, while she filmed him on her phone.
“Four and four?”
“We have four boys and four girls,” she said.