A Pregnant Woman at Risk of Heart Failure Couldnt Get Urgent Treatment. She Died Waiting for an Abortion.
When Ciji Graham visited a cardiologist on Nov. 14, 2023, her heart was pounding at 192 beats per minute, a rate healthy people her age usually reach during the peak of a sprint. She was having another episode of atrial fibrillation, a rapid, irregular heartbeat. The 34-year-old Greensboro, North Carolina, police officer was at risk of a stroke or heart failure.In the past, doctors had always been able to shock Grahams heart back into rhythm with a procedure called a cardioversion. But this time, the treatment was just out of reach. After a pregnancy test came back positive, the cardiologist didnt offer to shock her. Graham texted her friend from the appointment: Said she cant cardiovert being pregnant.The doctor told Graham to consult three other specialists and her primary care provider before returning in a week, according to medical records. Then she sent Graham home as her heart kept hammering.Like hundreds of thousands of women each year who enter pregnancy with chronic conditions, Graham was left to navigate care in a country where medical options have significantly narrowed.As ProPublica has reported, doctors in states that ban abortion have repeatedly denied standard care to high-risk pregnant patients. The expert consensus is that cardioversion is safe during pregnancy, and ProPublica spoke with more than a dozen specialists who said they would have immediately admitted Graham to a hospital to get her heart rhythm under control. They found fault, too, with a second cardiologist she saw the following day, who did not perform an electrocardiogram and also sent her home. Although Grahams family gave the doctors permission to speak with ProPublica, neither replied to ProPublicas questions.Graham came to believe that the best way to protect her health was to end her unexpected pregnancy. But because of new abortion restrictions in North Carolina and nearby states, finding a doctor who could quickly perform a procedure would prove difficult. Many physicians and hospitals now hesitate to discuss abortion, even when women ask about it. And abortion clinics are not set up to treat certain medically complicated cases. As a result, sick pregnant women like Graham are often on their own.I cant feel like this for 9mo, Graham wrote her friend. I just cant.She wouldnt. In a region that had legislated its commitment to life, she would spend her final days struggling to find anyone to save hers.Carolyn Graham holds a portrait of her daughter Ciji, who was a police officer. Andrea Ellen Reed for ProPublicaGraham hated feeling out of breath; her life demanded all her energy. Widely admired for her skills behind the wheel, she was often called upon to train fellow officers at the Greensboro Police Department. At home, she needed to chase her 2-year-old son, SJ, around the apartment. She was a natural with kids shed helped her single mom raise her nine younger siblings.She thought her surprise pregnancy had caused the atrial fibrillation, also called A-fib. In addition to heart disease, she had a thyroid disorder; pregnancy could send the gland into overdrive, prompting dangerous heart rhythms.When Graham saw the first cardiologist, Dr. Sabina Custovic, the 192 heart rate recorded on an EKG should have been a clear cause for alarm. I cant think of any situation where I would feel comfortable sending anyone home with a heart rate of 192, said Dr. Jenna Skowronski, a cardiologist at the University of North Carolina. A dozen cardiologists and maternal-fetal medicine specialists who reviewed Grahams case for ProPublica agreed. The risk of death was low, but the fact that she was also reporting symptoms severe palpitations, trouble breathing meant the health dangers were significant.All the experts said they would have tried to treat Graham with IV medication in the hospital and, if that failed, an electrical shock. Cardioversion wouldnt necessarily be simple likely requiring an invasive ultrasound to check for blood clots beforehand but it was crucial to slow down her heart. A leading global organization for arrhythmia professionals, the Heart Rhythm Society, has issued clear guidance that cardioversion is safe and effective in pregnancy.Even if the procedure posed a small risk to the pregnancy, the risk of not treating Graham was far greater, said Rhode Island cardiologist Dr. Daniel Levine: No mother, no baby.Custovic did not answer ProPublicas questions about why the pregnancy made her hold off on the treatment or whether abortion restrictions affect her decision-making.The next day as her heart continued to thump Graham saw a second cardiologist, Dr. Will Camnitz, at Cone Health, one of the regions largest health care systems.According to medical records, Grahams pulse registered as normal when taken at Camnitzs office, as it had at her appointment the previous day. Camnitz noted that the EKG from the day before showed she was in A-fib and prescribed a blood thinner to prepare for a cardioversion in three weeks if by then she hadnt returned to a regular heart rhythm on her own.Some of the experts who reviewed Grahams care said that this was a reasonable plan if her pulse was, indeed, normal. But Camnitz, who specializes in the electrical activity of the heart, did not order another EKG to confirm that her heart rate had come down from 192, according to medical records. Hes an electrophysiologist and he didnt do that, which is insane, said Dr. Kayle Shapero, a cardio-obstetrics specialist at Brown University. According to experts, a pulse measurement can underestimate the true heart rate of a patient in A-fib. Every cardiologist who reviewed Grahams care for ProPublica said that a repeat EKG would be best practice. If Grahams rate was still as high as it was the previous day, her heart could eventually stop delivering enough blood to major organs. Camnitz did not answer ProPublicas questions about why he didnt administer this test.Three weeks was a long time to wait with a heart that Graham kept saying was practically leaping out of her chest.Ciji Grahams business card from the Greensboro Police Department hangs on the fridge in Shawn Scotts home above a baby picture of their son, SJ. Graham used to leave love notes on the fridge for Scott before she left for work. Andrea Ellen Reed for ProPublicaCamnitz knew about Grahams pregnancy but did not discuss whether she wanted to continue it or advise her on her options, according to medical records. That same day, though, Graham reached out to A Womans Choice, the sole abortion clinic in Greensboro.North Carolina bans abortion after 12 weeks; Graham was only about six weeks pregnant. Still, there was a long line ahead of her. Women were flooding the state from Tennessee, Georgia and South Carolina, where new abortion bans were even stricter. On top of that, a recent change in North Carolina law required an in-person consent visit three days before a termination. The same number of patients were now filling twice as many appointment slots.Graham would need to wait nearly two weeks for an abortion.Its unclear if she explained her symptoms to the clinic; A Womans Choice spokesperson said it routinely discards appointment forms and no longer had a copy of Grahams. But the spokesperson told ProPublica that a procedure at the clinic would not have been right for Graham; because of her high heart rate, she would have needed a hospital with more resources.Dr. Jessica Tarleton, an abortion provider who spent the past few years working in the Carolinas, said she frequently encountered pregnant women with chronic conditions who faced this kind of catch-22: Their risks were too high to be treated in a clinic, and it would be safest to get care at a hospital, but it could be very hard to find one willing to terminate a pregnancy.In states where abortions have been criminalized, many hospitals have shied away from sharing information about their policies on abortion. Cone Health, where Graham typically went for care, would not tell ProPublica whether its doctors perform abortions and under what circumstances; it said, Cone Health provides personalized and individualized care to each patient based on their medical needs while complying with state and federal laws.Graham never learned that she would need an abortion at a hospital rather than a clinic. Physicians at Duke University and the University of North Carolina, the premier academic medical centers in the state, said that she would have been able to get one at their hospitals but that would have required a doctor to connect her or for Graham to have somehow known to show up.Had Graham lived in another country, she may not have faced this maze alone.In the United Kingdom, for example, a doctor trained in caring for pregnant women with risky medical conditions would have been assigned to oversee all of Grahams care, ensuring it was appropriate, said Dr. Marian Knight, who leads the U.K.s maternal mortality review program. Hospitals in the U.K. also must abide by standardized national protocols or face regulatory consequences. Researchers point to these factors, as well as a national review system, as key to the countrys success in lowering its rate of maternal death. The maternal mortality rate in the U.S. is more than double that of the U.K. and last on the list of wealthy countries.Grahams friend Shameka Jackson could tell that something was wrong. Graham didnt seem like her usual perky and silly self, Jackson said. On the phone, she sounded weak, her voice barely louder than a whisper.When Jackson offered to come over, Graham said it would be a waste of time. Theres nothing you can do but sit with me, Jackson said she replied. The doctors aint doing nothing.Graham no longer cooked or played with her son after work, said her boyfriend, Shawn Scott. She stopped hoisting SJ up to let him dunk on the hoop on the closet door. Now, she headed straight for the couch and barely spoke, except to say that no one would shock her heart.I hate feeling like this, she texted Jackson. Aint slept, chest hurts.All I can do is wait until the 28th, Graham said, the date of her scheduled abortion.Scott sits on a bed in the apartment complex where he once lived with Graham. Andrea Ellen Reed for ProPublicaOn the morning of Nov. 19, Scott awoke to a rap on the front door of the apartment he and Graham shared. Hed been asleep on the couch after a night out with friends and thought that Graham had left for work.A police officer introduced himself and explained that Graham hadnt shown up and wasnt answering her phone. He knew she hadnt been feeling well and wanted to check in.Most mornings, Graham was up around 5 a.m. to prepare for the day. With Scott, she would brush SJs teeth, braid his hair and dress him in stylish outfits, complete with Jordans or Chelsea boots.When Scott walked into their bedroom, Graham was face down in bed, her body cold when he touched her. The two men pulled her down to the floor to start CPR, but it was too late. SJ stood in his crib, silently watching as they realized.The medical examiner would list Grahams cause of death as cardiac arrhythmia due to atrial fibrillation in the setting of recent pregnancy. There was no autopsy, which could have identified the specific complication that led to her death.Scott shows a collage of photos from his relationship with Graham. Andrea Ellen Reed for ProPublicaHigh-risk pregnancy specialists and cardiologists who reviewed Grahams case were taken aback by Custovics failure to act urgently. Many said her decisions reminded them of behaviors theyve seen from other cardiologists when treating pregnant patients; they attribute this kind of hesitation to gaps in education. Although cardiovascular disease is the leading cause of death in pregnant women, a recent survey developed with the American College of Cardiology found that less than 30% of cardiologists reported formal training in managing heart conditions in pregnancy. A large proportion of the cardiology workforce feels uncomfortable providing care to these patients, the authors concluded in the Journal of the American Heart Association. The legal threats attached to abortion bans, many doctors have told ProPublica, have made some cardiologists even more conservative.Custovic did not answer ProPublicas questions about whether she felt she had adequate training. A spokesperson for Cone Health, where Camnitz works, said, Cone Healths treatment for pregnant women with underlying cardiac disease is consistent with accepted standards of care in our region. Although Grahams family gave the hospital permission to discuss Grahams care with ProPublica, the hospital did not comment on specifics.Three doctors who have served on state maternal mortality review committees, which study the deaths of pregnant women, told ProPublica that Grahams death was preventable. There were so many points where they could have intervened, said Dr. Amelia Huntsberger, a former member of Idahos panel.Shawn SJ Scott Jr. at his aunts house in Kannapolis, North Carolina Andrea Ellen Reed for ProPublicaGrahams is the seventh case ProPublica has investigated in which a pregnant woman in a state that significantly restricted abortion died after she was unable to access standard care.The week after she died, Grahams family held a candlelight ceremony outside of her high school, which drew friends and cops in uniform, and also Greensboro residents whose lives she had touched. One woman approached Grahams sisters and explained Graham had interrupted her suicide attempt five years earlier and reassured her that her life had value; she had recently texted Graham, If it wasnt for you, I wouldnt be here today, expecting my first child.As for Grahams own son, no one explained to SJ that his mother had died. They didnt know how to describe death to a toddler. Instead, his dad and grandmother and aunts and uncles told him that his mom had left Earth and gone to the moon. SJ now calls it the Mommy moon.For the past two years, every night before bed, he asks to go outside, even on the coldest winter evenings. He points to the moon in the dark sky and tells his mother that he loves her.The post A Pregnant Woman at Risk of Heart Failure Couldnt Get Urgent Treatment. She Died Waiting for an Abortion. appeared first on ProPublica.
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