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 Graham’s 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 didn’t offer to shock her. Graham texted her friend from the appointment: “Said she can’t 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 Graham’s family gave the doctors permission to speak with ProPublica, neither replied 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 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 can’t feel like this for 9mo,” Graham wrote 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 anyone to save hers.
Graham 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 — she’d 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 can’t 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 Graham’s 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 wouldn’t 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 ProPublica’s 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 region’s largest health care systems.
According to medical records, Graham’s pulse registered as normal when taken at Camnitz’s 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 hadn’t returned to a regular heart rhythm on her own.
Some of the experts who reviewed Graham’s 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. “He’s an electrophysiologist and he didn’t 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 Graham’s care for ProPublica said that a repeat EKG would be best practice. If Graham’s 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 ProPublica’s questions about why he didn’t 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.
Camnitz knew about 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, though, Graham reached out to A Woman’s 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.
It’s unclear if she explained her symptoms to the clinic; A Woman’s Choice spokesperson said it routinely discards 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 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 Graham’s 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 country’s 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.
Graham’s friend Shameka Jackson could tell that something was wrong. Graham didn’t 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. “There’s nothing you can do but sit with me,” Jackson said she replied. “The doctors ain’t 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. “Ain’t slept, chest hurts.”
“All I can do is wait until the 28th,” Graham said, the date of her scheduled abortion.
On the morning of Nov. 19, Scott awoke to a rap on the front door of the apartment he and Graham shared. He’d 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 hadn’t shown up and wasn’t answering her phone. He knew she hadn’t 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 SJ’s 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 Graham’s 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.
High-risk pregnancy specialists and cardiologists who reviewed Graham’s case were taken aback by Custovic’s failure to act urgently. Many said her decisions reminded them of behaviors they’ve 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 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 cardiac 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 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 Graham’s death was preventable. “There were so many points where they could have intervened,” said Dr. Amelia Huntsberger, a former member of Idaho’s panel.
Graham’s 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, Graham’s 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 Graham’s 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 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 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.
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