Two friends were denied care after Florida banned abortion. One almost died.

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.

After so many miscarriages, Anya and Derick had finally decided to try in vitro fertilization. Now they had eight embryos, frozen in liquid nitrogen.

One of them was Bunny.

Anya wanted a baby more than anything. The miscarriages only made her more determined. She bought pregnancy tests in bulk on Amazon — the cheap, off-brand kind so she could use three or four a day.

“This is everything to me,” she said she told friends and family members who asked, after several miscarriages, if she might consider adoption. “I deserve to have my own biological child.”

By the time she started IVF last spring, Cook was developing a reputation as a mentor for other women in the Fort Lauderdale area struggling with fertility. She would spend hours answering questions on a local Facebook support group — consulting on the pros and cons of estrogen patches, and the most opportune days to have sex.

Cook met Smith-Cunningham in the summer of 2021, when Smith-Cunningham posted a question about a fertility drug she’d been considering. They messaged back and forth, slipping into an easy blend of English and Patois once they realized they were both from Jamaica.

When they got pregnant around the same time — Smith-Cunningham first, then Cook three weeks later — they started texting every day. They exchanged links for cribs they liked and debated the best color for a nursery. Cook put Smith-Cunningham’s doctors appointments on her calendar so she would always remember to check in.

“2nd trimester!!!!!!!” Cook texted her friend at 4:03 a.m. on the day Smith-Cunningham entered her 13th week of pregnancy.

“I hope its good to me lol,” Smith-Cunningham responded later that morning.

“I hope so too,” Cook said.

Smith-Cunningham had moved to the United States from Jamaica to be with her husband in 2019. A plane ride away from her mother and all her friends, her husband working long hours, Smith-Cunningham had already experienced one miscarriage and was scared to go through another pregnancy alone.

“I don’t have a sister,” she said. “Anya was my safe place.”

After so much disappointment, Cook and Smith-Cunningham agreed that they would help each other keep their expectations in check, pledging not to buy anything baby-related until they were both safely past the 20-week mark.

But then, one Sunday morning in mid-December, Derick suggested he and Anya check out Pottery Barn Kids — and Anya decided she didn’t want to wait anymore.

In rhinestone sandals and biker shorts that showed off her bump, she strolled up and down the aisles with Derick on her arm, feeling the gaze of other women in the store. They went to Target next for a maternity swimsuit. Then to Yard House for a celebratory steak.

“I felt finally that I belonged,” Anya said. “I felt like my body was no longer broken.”

Anya’s water broke the following Wednesday, just after 10 p.m., as she was walking out of a TGI Friday’s.

She felt a rush of warm liquid on her legs, whipping around to see if someone had doused her with a glass of water. Then she put her hand in her underwear.

“Derick, look,” she remembers saying, holding out her wet fingers. “Something’s not right.”

Anya spent an hour in the waiting room of the Broward Health hospital in Coral Springs, amniotic fluid dripping onto the floor, she and Derick recalled. When the doctor finally saw her, he delivered the distressing news, they said: Anya was experiencing PPROM — and because of the state’s abortion law, he could not induce labor. She could not stay at the hospital, either, she said she was told.

Because she was so early in her pregnancy, she recalled the doctor saying, there was no chance her baby would survive.

Cook wanted to scream. There must be some kind of protocol for this situation, she thought — she couldn’t possibly be the first woman in Florida to have this condition since Roe v. Wade was overturned. Was there a supervisor she could talk with? Anyone else who could help?

“You’re not telling me anything,” Anya recalled saying. “So, basically, I have no options.”

The doctor at Broward told her to go home and “return immediately” if her symptoms worsened, according to medical records. A nurse offered some antibiotics to minimize the chance of infection, Anya recalled, then promised to pray for her.

Medical records from the visit, which Cook provided to The Post, show that Cook was “gushing amniotic fluid” when she arrived at the hospital, with no fluid present around the fetus. The records say that the fetus was showing cardiac activity, with a heart rate of 131 beats per minute.

The Post, with Cook’s consent, read relevant portions of the records to four physicians, all of whom agreed that Cook had a clear case of pre-viability PPROM, making her high-risk for infection and hemorrhage.

A spokeswoman for Broward Health, Jennifer Smith, did not directly address PPROM, and declined to make the doctor who treated Cook available for an interview. But she said in an interview that Cook was “not at risk” when she left the hospital after her water broke.

“There was no indication she needed any interventional care,” said Smith, the hospital’s vice president for corporate communications and marketing.

Broward’s policy on pregnancy termination, obtained through a public records request to the public hospital, mirrors the language in Florida’s abortion law.

Cook “did not necessitate an abortion in the emergency department,” Smith wrote in a statement. “Had her condition failed to improve or worsened to result in a threat to her life or irreversible physical impairment of a major bodily function, Ms. Cook would have been admitted for further care and treatment.”

Cook had no idea how many women experienced PPROM until she got home from the hospital the night she was turned away. Lying in bed, she spent hours scrolling through a PPROM message board on Facebook. She allowed herself the smallest glimmer of hope, because a few of the women said their babies had survived.

She texted Smith-Cunningham a rundown of her situation just after 1 a.m. — only to delete the messages a few hours later.

She didn’t want to scare her friend.

At the salon the next morning — while the stylist was still curling her hair — Cook got a message from Smith-Cunningham.

“Woke up this morning and feel my panty wet... My water break... my life feel like it end,” wrote Smith-Cunningham, then about 19 weeks along, at least three weeks before a fetus can survive on its own.

“Me too,” Cook texted from the salon chair at 11:01 a.m.

“What you mean... U too,” Smith-Cunningham asked.

“My water broke,” Cook wrote. “I was at the er last night.”

Less than an hour later, Cook shut herself inside the bathroom.

When Smith-Cunningham’s water broke, she was in St. Ann, Jamaica, visiting her mother for a few weeks before the baby came.

The nurse on call at the hospital that day explained that she was experiencing PPROM, Smith-Cunningham said, the same diagnosis her friend had received 600 miles away the night before. The baby was not going to make it.

As soon as possible, Smith-Cunningham said she was told, the doctors wanted to induce her.

Abortion is illegal in Jamaica, but the law includes exceptions to preserve a woman’s physical and mental health.

Smith-Cunningham called her husband in Florida, worried about the level of medical care she might receive in Jamaica. For a procedure this important, they agreed, she should be at an American hospital they trusted, with her regular OB/GYN.

While they knew there was a chance she could deliver on the flight home, they decided it was worth the risk. Her husband flew to Jamaica, and together they booked the first flight back to the United States.

As Smith-Cunningham was preparing to fly home to Fort Lauderdale, unaware of the new abortion law that would prevent doctors from ending her pregnancy, Cook was in the operating room at Memorial Regional Hospital in Hollywood, Fla., where she had been rushed from the hair salon after passing the fetus in the bathroom.

Moustafa, the OB/GYN on call, said he quickly realized that Cook was losing too much blood.

Out in the waiting room, Moustafa laid out the situation for Derick, Cook’s husband: The surest way to save Cook’s life, he said, was to perform a hysterectomy, a procedure that removes the uterus, rendering a patient infertile.

Derick explained how hard they’d been trying for a baby.

“Please,” he said, according to the two men. “Please try to save my wife and her uterus.”

The last few hours had been some of the most difficult of Derick’s life. When he got to the bathroom, Anya asked him to sever the umbilical cord dangling between her legs, Anya and Derick recalled. Derick thought he remembered seeing a doctor on TV cutting the cord with scissors. He didn’t have scissors, so he pulled.

The cord broke apart, and his wife kept bleeding.

Back in the waiting room, Derick found a quiet corner, opened a Bible, and got down on his knees. His body went into a trance, he said. He pleaded with God loud enough that other people could hear him, offering up his job, his soul, even his life — anything.

By the time Cook’s mother arrived 45 minutes later, the Bible was wet with Derick’s tears.

Doctors can’t say for sure what caused Cook’s bleeding, according to medical records. Any pre-viability PPROM patient has a high risk of severe hemorrhage, said several doctors. Moustafa said he feels confident that Cook experienced placenta accreta, a separate condition where the placenta becomes embedded in the uterine wall and won’t detach with the fetus.

Cook would have had placenta accreta even if she’d been induced at the hospital when she was diagnosed with PPROM, said several doctors familiar with the case, but her experience probably would have been considerably less traumatic. When the bleeding started, she would have already been surrounded by doctors ready to begin treatment.

“Once you start losing that much blood that quickly it becomes absolutely life-threatening,” said Moustafa. “Every minute counts.”

Cook was sedated for more than 12 hours, according to records, finally waking up the next morning. The doctors were able to preserve her uterus, Cook learned. However, the damage from the procedure that stopped the bleeding may have permanently affected the arteries that carry blood to the uterus, several doctors said, further reducing her chances of carrying a healthy pregnancy.

If Cook had placenta accreta, she most likely would have had to undergo the same procedure even if she had delivered the fetus at a hospital when she was diagnosed with PPROM, said several OB/GYNs.

As soon as she felt well enough to talk on the phone, Cook called Smith-Cunningham, eager to check in on her friend.

Smith-Cunningham was back in the United States and still pregnant — bedridden and waiting, after HCA Florida Northwest Hospital had sent her home after two visits.

The second time, Smith-Cunningham recalled, the doctor explicitly mentioned Roe v. Wade. The doctor held her hand, she said, and apologized that she couldn’t do anything to help.

HCA Florida Northwest provides abortions in cases where a physician believes “a medical emergency exists or the fetus exhibits a fatal anomaly,” Jennifer Guerrieri, the hospital’s vice president of strategic communications, said in a statement.

“Our focus is on providing the best possible care for our patients. Our hospital policies and procedures align with state and federal regulatory requirements.”

Smith-Cunningham told Cook she was terrified of bleeding out and getting infected.

“You need to keep going back to the hospital,” said Cook, who stayed in the hospital for six days. “I don’t want the same thing to happen to you.”

Smith-Cunningham switched out her sanitary pad for the 10th time that day, hoping a fresh layer in her underwear would minimize her chance of infection.

Her best shot at avoiding complications, she thought, was to do as her friend had suggested. She tried Memorial Regional Hospital — this time with her cervix dilated four centimeters — pleading with the doctor to at least have her admitted.

To stay at the hospital, Smith-Cunningham said she was told, she had to be more dilated or actively miscarrying. Memorial Regional declined a request for comment.

“If no one induces me, I’m going to die,” she said to her husband, thinking of her friend hemorrhaging in the ER.

Ivonne Reynolds, Smith-Cunningham’s regular OB/GYN, suggested that she leave Florida. Reynolds tried to find a doctor that would treat her in New York, where Smith-Cunningham has family.

“We were trying to find a location where she could get a termination done without all this back-and-forth before she gets infected,” Reynolds said in an interview.

Waiting to hear back from Reynolds, Smith-Cunningham spent Christmas Day in bed. She kept searching the same questions online: How do you know when a premature baby is coming? How can you tell when you’re getting an infection? Can you have sepsis with a normal white blood count?

At 2 a.m., she sat on the toilet with a mirror pointed up at her vagina. She saw a dark spot she hadn’t noticed before.

“I think it might be the baby,” Smith-Cunningham told her husband.

By the time she got to the hospital, she was fully dilated. She delivered the fetus eight hours later.

Smith-Cunningham and Cook scheduled follow-up appointments with their fertility specialist for the same morning in early February. They both wanted an answer to the question that had been weighing on their minds since December.

After everything they’d been through, would either of them ever be able to have a baby?

They’d each talked with Daniel Christie, their fertility and IVF doctor, soon after their water broke, filling him in on how the new abortion law had affected their care.

At the February appointment, Cook went in first.

“You have gotten beaten up, young lady,” Christie said as he pushed a saline solution through a catheter and into her uterus, studying the image on the ultrasound screen.

Cook knew this was the moment she would finally get the verdict, lying flat on the examination table, her eyes shut tight. Christie usually talked her through every little thing he saw on the screen, as he was looking, cheerfully reporting on the status of her uterus.

This time, he said nothing.

Once he removed the metal speculum, Christie informed Cook that she would have to undergo surgery to remove the remaining pieces of placenta — a procedure that he said could further reduce her chances of carrying to term.

“I’m not thrilled about it,” he told her. “But we don’t have a choice.”

Cook stayed behind in the room to support Smith-Cunningham, holding her friend’s hand as Christie delivered similar news: Smith-Cunningham — who also had retained pieces of placenta, a common outcome in PPROM pregnancies — would require the same surgery.

The surgery worked for Smith-Cunningham, but not for Cook.

On March 29, Christie informed Cook that she would require yet another operation to remove additional pregnancy tissue that remained in her uterus; the procedure could further limit her future fertility.

“I feel her sometimes still inside of me,” Cook said through tears, back on the examination table for the third time in a month.

“It’s just so much, Dr. Christie. It’s just so much.”

The next day in Tallahassee, a lawmaker Cook and Smith-Cunningham had never met shared their story on the Senate floor, as the six-week abortion ban moved closer to final passage.

“I have two constituents in my district who are living with the very real consequences of the bill that we passed not a year ago,” said Florida state Sen. Lauren Book (D).

Although Book didn’t know their names, she had heard about Cook and Smith-Cunningham from Christie a few months before.

“The woman is not at imminent risk ... and so women are being sent home in the state of Florida,” said Book, pressing the bill’s sponsor, Republican Sen. Erin Grall, on how doctors should respond under the law. “Is that the intention of the policy?”

Grall argued that these situations are covered by the bill’s medical exception.

“If the mother is going to develop something in which will threaten her life because of the pregnancy, then they would be able to take the child,” Grall said.

Grall added that doctors are playing "games and politics” in these situations, willfully misinterpreting Florida’s abortion ban when it clearly allows them to perform an abortion.

Nikki Zite, an OB/GYN at the University of Tennessee and an ACOG spokeswoman, said the idea that physicians would put patients at risk for political gain is “upsetting and offensive.”

“If lawmakers want pre-viable PPROM to be a situation where it is not controversial for physicians to act without fear of criminalization, then they need to clarify that,” said Zite.

Florida’s six-week abortion ban passed the Senate with a vote of 26 to 13, without a specific exception for PPROM.

In South Florida, Cook and Smith-Cunningham both plan to start trying to get pregnant again.

They worry the same thing will happen again — this time, with an even stricter abortion law in place.

“Getting pregnant now feels like a death sentence,” said Cook.

“They are playing with people’s lives with this law,” said Smith-Cunningham.

At least, the friends agreed, they would go through it together.

Story editing by Peter Wallsten. Photo editing by Natalia Jiménez-Stuard. Copy editing by Gilbert Dunkley.