When Ciji Graham saw a cardiologist on November 14, 2023, her heart was beating at 192 beats per minute, a rate that healthy people her age usually reach at the height of a sprint. She had another episode of atrial fibrillation, a fast, 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 get Graham’s heart back into rhythm through a procedure called cardioversion. But this time, treatment was simply out of reach. After a pregnancy test came back positive, the cardiologist didn’t offer her a shock. Graham texted her friend from the date: “She said she couldn’t cardiovert while pregnant. »
The doctor told Graham to see three other specialists and his primary care provider before returning in a week, medical records show. Then she sent Graham home as her heart kept racing.
Like hundreds of thousands of women each year who begin pregnancy with chronic illnesses, Graham has had to deal with care in a country where medical options have drastically reduced.
As ProPublica reporteddoctors in states that ban abortion have repeatedly denied standard care to high-risk pregnant patients. The expert consensus is that cardioversion is safe during pregnancyand ProPublica spoke with more than a dozen specialists who said they would have immediately admitted Graham to the hospital to check his heart rhythm. They also criticized a second cardiologist she saw the next day who did not perform an EKG and also sent her home. Although Graham’s family gave the doctors permission to speak with ProPublica, none of them responded to ProPublica’s questions.
Graham came to believe that the best way to protect her health was to end her unexpected pregnancy. But because of new restrictions on abortion in North Carolina and neighboring states, finding a doctor who can quickly perform a procedure would prove difficult. Many doctors and hospitals are now reluctant to discuss abortion, even when women ask for it. And abortion clinics are not designed to handle certain medically complicated cases. As a result, sick pregnant women like Graham often find themselves alone.
“I can’t feel this way for 9 months,” Graham wrote to her friend. “I just can’t.”
She wouldn’t. In a region that had legislated its commitment to life, she would spend her final days struggling to find someone to save her people.
Graham hated feeling out of breath; his life demanded all his energy. Widely admired for her driving skills, she was often called upon to train her colleagues in the Greensboro Police Department. At home, she had to chase her 2-year-old son, SJ, around the apartment. She was good with children: she had helped her single mother raise her nine younger siblings.
She thought her surprise pregnancy had caused atrial fibrillation, also known as A-fib. In addition to heart disease, she suffered from a thyroid disorder; Pregnancy could send the gland into overdrive, causing dangerous heart rhythms.
When Graham saw the first cardiologist, Dr. Sabina Custovic, the heart rate of 192 recorded on an ECG should have been a clear cause for alarm. “I can’t think of any situation where I would feel comfortable sending someone 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 Graham’s case for ProPublica agreed. The risk of death was low, but the fact that she also reported symptoms – severe palpitations, difficulty breathing – meant the health dangers were significant.
All the experts said they would have tried to treat Graham with intravenous drugs in hospital and, if that failed, with an electric shock. Cardioversion wouldn’t necessarily be simple – likely requiring an invasive ultrasound to check for blood clots first – but it was crucial to slow his heart. A leading global organization for arrhythmia professionals, the Heart Rhythm Society, has published clear guidelines that “cardioversion is safe and effective during pregnancy.”
Although the procedure posed a low risk to pregnancy, the risk of not treating Graham was much greater, said Rhode Island cardiologist Dr. Daniel Levine: “No mother, no baby.” »
Custovic did not respond to ProPublica’s questions about why the pregnancy prevented her from undergoing treatment or whether abortion restrictions affected her decision-making.
The next day, as his heart continued to beat, Graham saw a second cardiologist, Dr. Will Camnitz, at Cone Health, one of the area’s largest health systems.
According to medical records, Graham’s pulse was normal when it was taken at Camnitz’s office, as it was during his appointment the day before. Camnitz noted that the EKG from the day before showed that she was in A-fibrillation and prescribed an anticoagulant to prepare for cardioversion in three weeks – if by then she had not returned to a regular heartbeat on her own.
Some of the experts who reviewed Graham’s care said it was a reasonable plan if his 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 dropped from 192, medical records show. “He’s an electrophysiologist and he didn’t do this, which is insane,” said Dr. Kayle Shapero, a cardio-obstetrics specialist at Brown University. According to experts, a pulse measurement may underestimate an A-fib patient’s true heart rate. All the cardiologists who reviewed Graham’s care for ProPublica said a new EKG would be best practice. If Graham’s heart rate was still as high as the day before, his heart could eventually stop supplying enough blood to major organs. Camnitz did not respond to ProPublica’s questions about why he did not administer this test.
Three weeks was a long wait with a heart that Graham said was practically coming out of his chest.
Camnitz was aware of Graham’s pregnancy but did not discuss whether she wanted to continue it or advise her on her options, according to medical records. That same day, however, Graham contacted A Woman’s Choice, Greensboro’s only abortion clinic.
North Carolina bans abortion after 12 weeks; Graham was only about six weeks pregnant. However, there was a long queue in front of her. Women flocked to the state of 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 now occupied twice as many appointment slots.
Graham would have to wait almost two weeks to have an abortion.
It is unclear whether she explained her symptoms to the clinic; A spokesperson for Woman’s Choice said it regularly rejected appointment forms and no longer had a copy of Graham’s. But the spokesperson told ProPublica that a procedure at the clinic would not have been appropriate for Graham; due to her high heart rate, she would have needed a hospital with more resources.
Dr. Jessica Tarleton, an abortion provider who has spent recent years working in the Carolinas, said she frequently encounters pregnant women with chronic illnesses facing this kind of bind: Their risks are too high to be treated in a clinic, and it would be safer to get care in a hospital, but it might be very difficult to find one willing to terminate a pregnancy.
In states where abortion has been criminalized, many hospitals have been reluctant to share information about their abortion policies. Cone Health, where Graham usually went for treatment, would not tell ProPublica whether its doctors performed abortions and under what circumstances; he said, “Cone Health provides personalized, individualized care to each patient based on their medical needs while complying with state and federal laws. »
Graham was never told that she would need to have an abortion in a hospital rather than a clinic. Doctors at Duke University and the University of North Carolina, the state’s main academic medical centers, said she could have gotten one at their hospitals — but that would have required a doctor to connect her or Graham having somehow known it was coming.
If Graham had lived in another country, she might not have faced this maze alone.
In the United Kingdom, for example, a doctor trained in caring for pregnant women with at-risk medical conditions would have been responsible for overseeing all of Graham’s care, ensuring it was appropriate, said Dr. Marian Knight, who leads the U.K. Maternal Mortality Review Program. UK hospitals must also follow standardized national protocols or face regulatory consequences. Researchers highlight these factorsas well as a national testing system, as key to the country’s success in reducing its maternal mortality rate. The maternal mortality rate in the United States is more than double that of the United Kingdom and is last on the list of rich countries.
Graham’s friend, Shameka Jackson, could tell something was wrong. Graham didn’t seem like her usual self, “playful and silly,” Jackson said. On the phone, she sounded weak, her voice barely above a whisper.
When Jackson offered to come, Graham said it would be a waste of time. “There’s nothing you can do but sit with me,” Jackson replied. “The doctors don’t do anything.”
Graham no longer cooked or played with her son after work, said her boyfriend, Shawn Scott. She stopped lifting SJ to let him dive onto the hoop of 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 this,” she texted Jackson. “I haven’t slept, my chest hurts.”
“All I can do is wait until the 28th,” Graham said, the date of her scheduled abortion.
On the morning of November 19, Scott woke up to a knock on the front door of the apartment he shared with Graham. He had fallen asleep on the couch after a night out with friends and thought Graham had gone to work.
A police officer showed up and explained that Graham had not shown up and was not answering his phone. He knew she wasn’t feeling well and wanted to check in.
Most days, Graham got up around 5 a.m. to get ready for the day. With Scott, she brushed SJ’s teeth, braided her hair and dressed her in elegant outfits, with Jordans or Chelsea boots.
When Scott entered their bedroom, Graham was face down in the bed, his body cold when he touched her. The two men pulled her to the ground to begin CPR, but it was too late. SJ stood in his crib, silently watching them as they realized.
The medical examiner would list Graham’s cause of death as “cardiac arrhythmia due to atrial fibrillation in the setting of a recent pregnancy.” No autopsy would have identified the specific complication that led to his death.
High-risk pregnancy specialists and cardiologists who reviewed Graham’s case were surprised by Custovic’s failure to act urgently. Many said his decisions reminded them of behaviors they had observed in other cardiologists when treating pregnant patients; they attribute this kind of hesitation to educational gaps. Although cardiovascular disease is the leading cause of death among pregnant women, a recent survey done in conjunction with the American College of Cardiology found that fewer than 30 percent of cardiologists reported having formal training in the management of heart disease during pregnancy. “A large proportion of cardiology staff feel uncomfortable providing care to these patients,” authors concluded in the Journal of the American Heart Association. The legal threats attached to the abortion ban, many doctors told ProPublica, have made some cardiologists even more conservative.
Custovic did not respond to ProPublica’s questions about whether she felt she had adequate training. A spokesperson for Cone Health, where Camnitz works, said: “Cone Health’s treatment for pregnant women with underlying heart disease is consistent with accepted standards of care in our region. » Although Graham’s family gave the hospital permission to discuss Graham’s care with ProPublica, the hospital would not comment on the details.
Three doctors who have served on national maternal mortality review panels, which study deaths of pregnant women, told ProPublica that Graham’s death was preventable. “There were so many things they could have intervened on,” said Dr. Amelia Huntsberger, a former member of the Idaho panel.
Graham’s is the seventh case ProPublica has investigated in which a pregnant woman in a state that severely restricted abortion has died after she was unable to access standard care.
The week after her death, Graham’s family held a candlelight ceremony outside her high school, attended by friends and uniformed police officers, as well as Greensboro residents whose lives she had touched. A woman approached Graham’s sisters and explained that Graham had interrupted her suicide attempt five years earlier and had reassured her that her life had value; she had recently texted Graham: “If it wasn’t for you, I wouldn’t be here today, expecting my first child.” »
As for Graham’s own son, no one explained to SJ that his mother had died. They didn’t know how to describe the death of a toddler. Instead, his father, grandmother, aunts, and uncles told him that his mother had left Earth and gone to the Moon. SJ now calls her “Mommy Moon”.
For two years, every evening before going to bed, he has asked to go out, even on the coldest winter evenings. He points to the moon in the dark sky and tells his mother that he loves her.
