Women die when they can’t access legal abortions and timely medical care in their state.
By Kavitha Surana
Reporter
ProPublica
In her final hours, Amber Nicole Thurman suffered from a grave infection that her suburban Atlanta hospital was well-equipped to treat.
She’d taken abortion pills and encountered a rare complication; she had not expelled all of the fetal tissue from her body. She showed up at Piedmont Henry Hospital in need of a routine procedure to clear it from her uterus, called a dilation and curettage, or D&C.
But just that summer, her state had made performing the procedure a felony, with few exceptions. Any doctor who violated the new Georgia law could be prosecuted and face up to a decade in prison.
Thurman waited in pain in a hospital bed, worried about what would happen to her 6-year-old son, as doctors monitored her infection spreading, her blood pressure sinking and her organs beginning to fail.
It took 20 hours for doctors to finally operate. By then, it was too late.
The otherwise healthy 28-year-old medical assistant, who had her sights set on nursing school, should not have died, an official state committee recently concluded.
Tasked with examining pregnancy-related deaths to improve maternal health, the experts, including 10 doctors, deemed hers “preventable” and said the hospital’s delay in performing the critical procedure had a “large” impact on her fatal outcome.
Their reviews of individual patient cases are not made public. But ProPublica obtained reports that confirm that at least two women have already died after they couldn’t access legal abortions and timely medical care in their state.
There are almost certainly others.
Committees like the one in Georgia, set up in each state, often operate with a two-year lag behind the cases they examine, meaning that experts are only now beginning to delve into deaths that took place after the Supreme Court overturned the federal right to abortion.
Thurman’s case marks the first time an abortion-related death, officially deemed “preventable,” is coming to public light. ProPublica will share the story of the second in the coming days. We are also exploring other deaths that have not yet been reviewed but appear to be connected to abortion bans.
Doctors warned state legislators women would die if medical procedures sometimes needed to save lives became illegal.
Though Republican lawmakers who voted for state bans on abortion say the laws have exceptions to protect the “life of the mother,” medical experts cautioned that the language is not rooted in science and ignores the fast-moving realities of medicine.
The most restrictive state laws, experts predicted, would pit doctors’ fears of prosecution against their patients’ health needs, requiring providers to make sure their patient was inarguably on the brink of death or facing “irreversible” harm when they intervened with procedures like a D&C.
“They would feel the need to wait for a higher blood pressure, wait for a higher fever — really got to justify this one — bleed a little bit more,” Dr. Melissa Kottke, an OB-GYN at Emory, warned lawmakers in 2019 during one of the hearings over Georgia’s ban.
Doctors and a nurse involved in Thurman’s care declined to explain their thinking and did not respond to questions from ProPublica. Communications staff from the hospital did not respond to multiple requests for comment. Georgia’s Department of Public Health, which oversees the state maternal mortality review committee, said it cannot comment on ProPublica’s reporting because the committee’s cases are confidential and protected by federal law.
The availability of D&Cs for both abortions and routine miscarriage care helped save lives after the 1973 Supreme Court ruling in Roe v. Wade, studies show, reducing the rate of maternal deaths for women of color by up to 40% the first year after abortion became legal.
But since abortion was banned or restricted in 22 states over the past two years, women in serious danger have been turned away from emergency rooms and told that they needed to be in more peril before doctors could help. Some have been forced to continue high-risk pregnancies that threatened their lives. Those whose pregnancies weren’t even viable have been told they could return when they were “crashing.”
Such stories have been at the center of the upcoming presidential election, during which the right to abortion is on the ballot in 10 states.
But Republican legislators have rejected small efforts to expand and clarify health exceptions — even in Georgia, which has one of the nation’s highest rates of maternal mortality and where Black women are three times more likely to die from pregnancy-related complications than white women.
When its law went into effect in July 2022, Gov. Brian Kemp said he was “overjoyed” and believed the state had found an approach that would keep women “safe, healthy and informed.”
After advocates tried to block the ban in court, arguing the law put women in danger, attorneys for the state of Georgia accused them of “hyperbolic fear mongering.”
Two weeks later, Thurman was dead.
Thurman, who carried the full load of a single parent, loved being a mother. Every chance she got, she took her son to petting zoos, to pop-up museums and on planned trips, like one to a Florida beach. “The talks I have with my son are everything,” she posted on social media.
But when she learned she was pregnant with twins in the summer of 2022, she quickly decided she needed to preserve her newfound stability, her best friend, Ricaria Baker, told ProPublica. Thurman and her son had recently moved out of her family’s home and into a gated apartment complex with a pool, and she was planning to enroll in nursing school.
The timing could not have been worse. On July 20, the day Georgia’s law banning abortion at six weeks went into effect, her pregnancy had just passed that mark, according to records her family shared with ProPublica.
Thurman wanted a surgical abortion close to home and held out hope as advocates tried to get the ban paused in court, Baker said. But as her pregnancy progressed to its ninth week, she couldn’t wait any longer. She scheduled a D&C in North Carolina, where abortion at that stage was still legal, and on Aug. 13 woke up at 4 a.m. to make the journey with her best friend.
On their drive, they hit standstill traffic, Baker said. The clinic couldn’t hold Thurman’s spot longer than 15 minutes — it was inundated with women from other states where bans had taken effect. Instead, a clinic employee offered Thurman a two-pill abortion regimen approved by the U.S. Food and Drug Administration, mifepristone and misoprostol. Her pregnancy was well within the standard of care for that treatment.
Getting to the clinic had required scheduling a day off from work, finding a babysitter, making up an excuse to borrow a relative’s car and walking through a crowd of anti-abortion protesters. Thurman didn’t want to reschedule, Baker said.
At the clinic, Thurman sat through a counseling session in which she was told how to safely take the pills and instructed to go to the emergency room if complications developed. She signed a release saying she understood. She took the first pill there and insisted on driving home before any symptoms started, Baker said. She took the second pill the next day, as directed.
Deaths due to complications from abortion pills are extremely rare. Out of nearly 6 million women who’ve taken mifepristone in the U.S. since 2000, 32 deaths were reported to the FDA through 2022, regardless of whether the drug played a role. Of those, 11 patients developed sepsis. Most of the remaining cases involved intentional and accidental drug overdoses, suicide, homicide and ruptured ectopic pregnancies.
Baker and Thurman spoke every day that week. At first, there was only cramping, which Thurman expected. But days after she took the second pill, the pain increased and blood was soaking through more than one pad per hour. If she had lived nearby, the clinic in North Carolina would have performed a D&C for free as soon as she followed up, the executive director told ProPublica. But Thurman was four hours away.
On the evening of Aug. 18, Thurman vomited blood and passed out at home, according to 911 call logs. Her boyfriend called for an ambulance. Thurman arrived at Piedmont Henry Hospital in Stockbridge at 6:51 p.m.
ProPublica obtained the summary narrative of Thurman’s hospital stay provided to the maternal mortality review committee, as well as the group’s findings. The narrative is based on Thurman’s medical records, with identifying information removed. The committee does not interview doctors involved with the case or ask hospitals to respond to its findings. ProPublica also consulted with medical experts, including members of the committee, about the timeline of events.
Within Thurman’s first hours at the hospital, which says it is staffed at all hours with an OB who specializes in hospital care, it should have been clear that she was in danger, medical experts told ProPublica.
Her lower abdomen was tender, according to the summary. Her white blood cell count was critically high and her blood pressure perilously low — at one point, as Thurman got up to go to the bathroom, she fainted again and hit her head. Doctors noted a foul odor during a pelvic exam, and an ultrasound showed possible tissue in her uterus.
The standard treatment of sepsis is to start antibiotics and immediately seek and remove the source of the infection. For a septic abortion, that would include removing any remaining tissue from the uterus. One of the hospital network’s own practices describes a D&C as a “fairly common, minor surgical procedure” to be used after a miscarriage to remove fetal tissue.
After assessing her at 9:38 p.m., doctors started Thurman on antibiotics and an IV drip, the summary said. The OB-GYN noted the possibility of doing a D&C the next day.
But that didn’t happen the following morning, even when an OB diagnosed “acute severe sepsis.” By 5:14 a.m., Thurman was breathing rapidly and at risk of bleeding out, according to her vital signs. Even five liters of IV fluid had not moved her blood pressure out of the danger zone. Doctors escalated the antibiotics.
Instead of performing the newly criminalized procedure, they continued to gather information and dispense medicine, the summary shows.
Doctors had Thurman tested for sexually transmitted diseases and pneumonia.
They placed her on Levophed, a powerful blood pressure support that could do nothing to treat the infection and posed a new threat: The medication can constrict blood flow so much that patients could need an amputation once stabilized.
At 6:45 a.m., Thurman’s blood pressure continued to dip, and she was taken to the intensive care unit.
At 7:14 a.m., doctors discussed initiating a D&C. But it still didn’t happen. Two hours later, lab work indicated her organs were failing, according to experts who read her vital signs.
At 12:05 p.m., more than 17 hours after Thurman had arrived, a doctor who specializes in intensive care notified the OB-GYN that her condition was deteriorating.
Thurman was finally taken to an operating room at 2 p.m.
By then, the situation was so dire that doctors started with open abdominal surgery. They found that her bowel needed to be removed, but it was too risky to operate because not enough blood was flowing to the area — a possible complication from the blood pressure medication, an expert explained to ProPublica. The OB performed the D&C but immediately continued with a hysterectomy.
During surgery, Thurman’s heart stopped.
Her mother was praying in the waiting room when one of the doctors approached. “Come walk with me,” she said.
Until she got the call from the hospital, her mother had no idea Thurman had been pregnant. She recalled her daughter’s last words before she was wheeled into surgery — they had made no sense coming from a vibrant young woman who seemed to have her whole life ahead of her:
“Promise me you’ll take care of my son.”
There is a “good chance” providing a D&C earlier could have prevented Amber Thurman’s death, the maternal mortality review committee concluded.
Every state has a committee of experts who meet regularly to examine deaths that occurred during or within a year after a pregnancy. Their goal is to collect accurate data and identify the root causes of America’s increasing maternal mortality rate, then translate those lessons into policy changes. Their findings and recommendations are sent to the Centers for Disease Control and Prevention, and their states publish an annual report, but their reviews of individual cases are never public.
Georgia’s committee has 32 regular members from a variety of backgrounds, including OB-GYNs, cardiologists, mental health care providers, a medical examiner, health policy experts, community advocates and others. This summer, the committee reviewed deaths through Fall 2022, but most states have not gotten that far.
After reviewing Thurman’s case, the committee highlighted Piedmont’s “lack of policies/procedures in place to evacuate uterus immediately” and recommended all hospitals implement policies “to treat a septic abortion on an ongoing basis.”
It is not clear from the records available why doctors waited to provide a D&C to Thurman, though the summary report shows they discussed the procedure at least twice in the hours before they finally did.
Piedmont did not have a policy to guide doctors on how to interpret the state abortion ban when Thurman arrived for care, according to two people with knowledge of internal conversations who were not authorized to speak publicly. In the months after she died, an internal task force of providers there created policies to educate staff on how to navigate the law, though they are not able to give legal advice, the sources said.
In interviews with more than three dozen OB-GYNs in states that outlawed abortion, ProPublica learned how difficult it is to interpret the vague and conflicting language in bans’ medical exceptions — especially, the doctors said, when their judgment could be called into question under the threat of prison time.
Take the language in Georgia’s supposed lifesaving exceptions.
It prohibits doctors from using any instrument “with the purpose of terminating a pregnancy.” While removing fetal tissue is not terminating a pregnancy, medically speaking, the law only specifies it’s not considered an abortion to remove “a dead unborn child” that resulted from a “spontaneous abortion” defined as “naturally occurring” from a miscarriage or a stillbirth.
Thurman had told doctors her miscarriage was not spontaneous — it was the result of taking pills to terminate her pregnancy.
There is also an exception, included in most bans, to allow abortions “necessary in order to prevent the death of the pregnant woman or the substantial and irreversible physical impairment of a major bodily function.” There is no standard protocol for how providers should interpret such language, doctors said. How can they be sure a jury with no medical experience would agree that intervening was “necessary”?
ProPublica asked the governor’s office on Friday to respond to cases of denied care, including the two abortion-related deaths, and whether its exceptions were adequate. Spokesperson Garrison Douglas said they were clear and gave doctors the power to act in medical emergencies. He returned to the state’s previous argument, describing ProPublica’s reporting as a “fear-mongering campaign.”
Republican officials across the country have largely rejected calls to provide guidance.
When legislators have tried, anti-abortion groups have blocked them.
In 2023, a group of Tennessee Republicans was unable to push through a small change to the state’s abortion ban, intended to give doctors greater leeway when intervening for patients facing health complications.
“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 Rep. Esther Helton-Haynes, a nurse who sponsored the bill.
The state’s main anti-abortion lobbyist, Will Brewer, vigorously opposed the change. Some pregnancy complications “work themselves out,” he told a panel of lawmakers. Doctors should be required to “pause and wait this out and see how it goes.”
At some hospitals, doctors are doing just that. Doctors told ProPublica they have seen colleagues disregard the standard of care when their patients are at risk of infection and wait to see if a miscarriage completes naturally before offering a D&C.
Although no doctor has been prosecuted for violating abortion bans, the possibility looms over every case, they said, particularly outside of well-funded academic institutions that have lawyers promising criminal defense.
Doctors in public hospitals and those outside of major metro areas told ProPublica that they are often left scrambling to figure out on a case-by-case basis when they are allowed to provide D&Cs and other abortion procedures. Many fear they are taking on all of the risk alone and would not be backed up by their hospitals if a prosecutor charged them with a crime. At Catholic hospitals, they typically have to transfer patients elsewhere for care.
When they do try to provide care, it can be a challenge to find other medical staff to participate. A D&C requires an anesthesiologist, nurses, attending physicians and others. Doctors said peers have refused to participate because of their personal views or their fear of being exposed to criminal charges. Georgia law allows medical staff to refuse to participate in abortions.
Thurman’s family members may never learn the exact variables that went into doctors’ calculations. The hospital has not fulfilled their request for her full medical record. There was no autopsy.
For years, all Thurman’s family had was a death certificate that said she died of “septic shock” and “retained products of conception” — a rare description that had previously only appeared once in Georgia death records over the last 15 years, ProPublica found. The family learned Thurman’s case had been reviewed and deemed preventable from ProPublica’s reporting.
The sting of Thurman’s death remains extremely raw to her loved ones, who feel her absence most deeply as they watch her son grow taller and lose teeth and start school years without her.
They focus on surrounding him with love but know nothing can replace his mother.
On Monday, she would have turned 31.
Originally published by ProPublica, 09.16.2024, under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 United States license.
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