Christina Zielke and her husband were excited when she got pregnant in July. It was her first pregnancy at age 33 – everything was new. But during the ultrasound at her initial prenatal appointment in Washington D.C., there was no heartbeat. Bloodwork taken a few days apart showed her pregnancy hormone levels were dropping.

A doctor from her Ob-Gyn's office called her to confirm that the pregnancy had ended in a miscarriage. They laid out her options: Take medication to make the pregnancy tissue come out faster, have a dilation and curettage or D&C procedure to remove the pregnancy tissue from her uterus, or wait for it to come out on its own.

The doctor suggested she wait, but didn't tell her how long that can take. After a few weeks with no change, she looked online and read that for some people it takes weeks before vaginal bleeding starts. "So I counted myself as one of those women – it was just taking longer for my body – and I tried to put it out of my mind," she says.

Soon after that, Zielke and her husband Greg Holeyman took the seven-hour drive from D.C. to northeast Ohio for a wedding party for her younger brother.

"On the drive to Ohio, I had some really heavy bleeding – to the point [that] we had to stop and clean out the car and change all the clothes," she says. She assumed her body had passed the pregnancy tissue and "that was really probably it."

But that wasn't it. The next night, at around 4 a.m., she started to bleed again – a lot.

She crawled into an empty bathtub at her dad and stepmom's house so the blood wouldn't make a mess. Blood soon filled the bottom of the tub. "I was passing blood clots the size of golf balls," she says. She woke up her husband and they called a nurse at her insurer's advice line who told them to go to an emergency room.

They arrived at University Hospitals TriPoint Medical Center in Painesville, Ohio, at around 6 a.m. Medical staff there did her bloodwork and an ultrasound – again, there was no heartbeat. To check how much blood she had lost, they measured her hemoglobin level – Zielke says they told her she hadn't lost enough for it to be of concern yet.

"At this point, shift changes have happened, I've seen a physician, two [or] three different nurses, an ultrasound tech – no one for more than a few minutes at a time," she says. The whole time, she kept bleeding, filling up diapers with blood.

One nurse mentioned in passing that a D&C is sometimes needed to get heavy bleeding to stop, but Zielke says she wasn't offered one, nor was she given any other treatment, not even IV fluids or pain medication.

Then, "about two and a half hours into this slew of tests, a nurse comes in and tells me that I'm being discharged," Zielke says.

The couple was confused by this. It felt to them like Zielke was still experiencing a medical emergency.

"They said they needed to prove there was no fetal development," she says. "I was told that I could come back in two days for a repeat hormone test to confirm I was miscarrying."

Zielke objected – she told them she already had that laboratory confirmation of the miscarriage weeks earlier in D.C. She tried to show them her medical records on her phone and offered her Ob-Gyn's contact information, but she says she didn't get a response.

Holeyman, Zielke's husband, says hospital staff seemed "hesitant." The two of them wondered at the ER if that was because of Ohio's new six-week abortion ban. "I wish someone had come out and said, 'Hey, this is a state law, this is what we're afraid of,' and was a little more frank," he says. Instead he says, paraphrasing what he heard: "It was, 'Well, we don't know if this [pregnancy] is viable, this could still be viable. This is the information you got in D.C., but we need to confirm it."

Zielke says she didn't want to leave the ER, but she didn't know how to protest. On discharge papers, where she had to sign, she says she wrote "I disagree."

Then she and her husband drove about twenty minutes back to her dad's house. "At this point, I'm assuming that the worst has passed me," she says. As much as she was scared to leave, she thought the bleeding would stop and she would start feeling better.

But when she pulled up to her dad's house, "I didn't make it back through the door again until there was blood running down into my shoes."

The situation: Christina Zielke was discharged from an ER in Ohio without treatment for her miscarriage even though she'd been bleeding profusely for hours.

The state law: When Zielke was in Ohio in early September, the state had a law known as a "heartbeat bill" in effect, which bans abortion after about six weeks of pregnancy. The law was passed in 2019, and went into effect the same day the Supreme Court overturned Roe v. Wade on June 24. In mid-September, a judge in Hamilton County blocked the law. Ohio's Republican attorney general has begun the appeals process, and the case is ultimately expected to go to the state supreme court.

Health care providers who violate the law face fifth-degree felony charges, up to a year in prison, loss of their medical license, and fines up to $20,000.

What's at stake: Ohio's abortion restriction doesn't explicitly restrict the treatment of miscarriages or emergency care, but it can have that effect anyway.

Health care providers use the same clinical tools to manage a miscarriage as they do to perform abortions – the medications and surgical options are identical. That can mean when someone seeks care during a miscarriage, a pharmacist or doctor who suspects a patient is seeking an abortion might deny or delay providing treatment, fearing prosecution.

A miscarriage may urgently need those medical interventions when it doesn't resolve on its own, explains Dr. Kamilah Dixon, assistant professor of obstetrics and gynecology at The Ohio State University, who was not involved in Christina Zielke's care. Heavy bleeding can occur "if the miscarriage had started and there's still pregnancy tissue inside of the uterus," she explains. That's because the tissue can interfere with the normal contractions of the uterus which help shut down small blood vessels and control bleeding.

Another risk during a miscarriage is that the retained pregnancy tissue causes an infection, which can lead to a potentially life-threatening infection in the blood called sepsis.

The way to stop heavy bleeding or to address an infection from an incomplete miscarriage is with a D&C, Dixon says. "Basically it's a procedure where we put instruments inside of the uterus to remove the pregnancy tissue," she explains.

Ohio's heartbeat law states that abortion procedures are legal "when there is a medical emergency or medical necessity" whether or not the pregnancy could still be viable. However, in the months after Roe v. Wade was overturned when this law was in effect, there were numerous reports of doctors being unsure of what qualifies for this exception, leading them to delay care.

CNN reported that Tara George was denied an abortion by a hospital lawyer even though her fetus had lethal fetal anomalies and continuing the pregnancy put her health at risk.

And in an affidavit filed in the case challenging the heartbeat bill, Dr. David Burkons said that two patients with ectopic pregnancies, which can be dangerous, were seen by ER physicians who were afraid to treat them "without being absolutely certain there was no intrauterine pregnancy." In one case, the patient's fallopian tube later ruptured.

Because of reports like this from around the country, the federal government sent every hospital a letter in July, reminding them a federal law called the Emergency Medical Treatment and Active Labor Act, or EMTALA, supercedes state abortion restrictions when there's a conflict between them.

Katie Watson, a bioethicist and lawyer and professor at Northwestern University, says some health care providers don't seem to understand that EMTALA provides solid legal cover for treating pregnant patients in medical crisis.

"We're in a moment of tremendous fear, and we're working with hospitals and doctors who are not fans of liability," she says. That has led to situations where "physicians or staff say, 'Only if I think I'm 1,000% safe will I do necessary, potentially life-saving medical care.'"

University Hospitals, which runs TriPoint Medical Center, declined a request for an interview about Zielke's care, citing patient privacy. In a statement, spokesperson George Stamatis wrote, "University Hospitals complies with Ohio laws. Our position is always that health care decisions are best made between the patient and her physician."

The impact: When she came home from the hospital, Christina Zielke was still bleeding, so she climbed back into the empty bathtub. Her family made some eggs and got her Gatorade, to try to build up her strength.

"Another hour of bleeding passes and I say, 'I don't think this is right,'" she says. "'I don't think we should have come home.'" Again, her husband helped her call an advice line, and a nurse told them right away that they needed to go back to the hospital.

By then, it was around 11 a.m. – she'd been bleeding profusely since 4 a.m. — for seven hours. "I tell my husband, 'Alright, I just need a minute or two to wash off, get myself clean enough to get out of this tub.'" She had been taking photos each time the bottom of the tub filled with blood, "just trying to prove what was happening, because I felt like I wasn't believed," she says.

Her husband came to help her get up.

"That's when I started to feel the world slip away," she says. "I looked at him and I said, 'I don't think I'm okay.'"

She'd lost so much blood, so quickly, her blood pressure had plummeted. Holeyman watched as her eyes rolled back. Her body went limp – she lost consciousness. He caught her neck so she didn't bang her head against the tub. "I thought she was a goner," he says.

He yelled to her stepmom to call 911. Then, Zielke's eyes opened again, and he reassured her that an ambulance was coming, telling her, "just keep breathing, stay calm," he recalls.

When the paramedics arrived, they used a sheet to pull her out of the bathtub onto a stretcher.

Just hours after being discharged, she says, she was back in the very same ER. She doesn't remember much from the period after she fainted, but she knows she was given IV fluids and warmed up.

Blood samples showed her hemoglobin level had dropped from 12.5 grams per deciliter that morning to 9.7 g/dL in the afternoon. "That is a fairly significant blood loss," says Dr. Nicole Veitinger of the Ohio chapter of the American College of Emergency Physicians. "The fact that she had enough [blood] loss in a short amount of time to pass out certainly would be concerning."

After a few hours in the ER, Zielke was admitted to the Ob-Gyn department of the hospital and had a D&C under general anesthesia. She was given the option to stay overnight and recover, but chose to go home that evening. "It wasn't a place I felt safe," she says.

The policy debate: Mike Gonidakis, president of the advocacy group Ohio Right to Life, which lobbied to pass the heartbeat bill, argues that what happened to Zielke — based on her account — was not a result of Ohio's law.

"This woman obviously was having a medical issue based on a miscarriage," he says. "This really has nothing to do with abortion – the baby did not have a beating heart."

Gonidakis, who serves on the state medical board, disputes the idea that the abortion law is unclear about what constitutes an emergency or that it is causing physicians to delay or deny necessary care. "There are exceptions for those types of situations in the law," he says. "What we're seeing, I fear, is doctors with an agenda saying, 'Well, I don't know what to do' when, in fact, they do." (NPR has found no evidence of this in the case of Zielke's care.)

Jessie Hill, law professor at Case Western Reserve University who serves as a volunteer attorney for the ACLU of Ohio in the case challenging the state's abortion law, calls it "appalling" to suggest that doctors would harm patients to advance a political agenda.

"It is the classic move to stigmatize providers, to push this off on to them and suggest that they should understand the law the way a lawyer does, [and] walk all the way up to the line of what may or may not be legal."

She agrees with Gonidakis that – based on Zielke's account of her experience at the ER – there's nothing explicitly in the law that would have prevented her from being treated. But, she says, when an abortion law puts doctors in the position of facing "criminal prosecution, prison time, fines, loss of your medical license – it's entirely rational for doctors to steer clear when in doubt of violating the law."

Neither the primary sponsor of the heartbeat bill, Ohio Senator Kristina Roegner nor Senate President Matt Huffman – both Republicans – agreed to NPR's request for an interview for this story. Ohio's legislature is Republican-controlled, and leaders are reportedly considering a vote on legislation to ban abortion at conception – even earlier than the six-week limit – before the end of the year.

The patient's perspective: Christina Zielke says she doesn't know for sure why she got sent home without care the first time she went to the hospital, but she thinks the requirement to have proof that it was really a miscarriage "could have cost me my life that day."

She is grateful for the care she got from the paramedics who pulled her out of the bathtub. "Before we left Ohio, we took some ice cream bars by the fire station," to thank them, she says.

She filed an internal complaint with the Ob-Gyn practice in D.C. that didn't adequately counsel her when she first learned about her miscarriage. Her doctor was very apologetic, she says, and assured her that if and when she gets pregnant again, she won't be left on her own.

She also filed a complaint with the Ohio hospital. "I had spent so much of the day fighting to feel seen and taken care of," she says. "It was such a traumatizing experience." She is also dealing with bills from two separate out-of-network ER visits, totaling more than $10,000 – and the bills keep coming. "It's taken dozens of calls and emails with multiple insurance companies and providers, and not one of them is sorted."

Physically, she's recovering slowly. For days after her hospital stay she felt weak and tired – she had painful cramps and discomfort for weeks.

She's been open with colleagues and friends about what happened. She's frustrated by how little miscarriage is talked about, and thinks that stigma is part of the reason why she felt so in the dark about what to expect and how to advocate for the care she needed.

"If me telling my story can help just one other woman or family seek advice sooner or feel more comfortable talking about it – or feel less alone," she says, "then I think it's worth sharing."

Days & Weeks is NPR's series telling personal stories of lives affected by abortion restrictions in the post-Roe era. Do you have story about how your state's abortion laws have changed your life? Share your story.

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