Did an Abortion Ban Cost a Young Texas Woman Her Life? (original) (raw)

L_EGAL NAME OF DECEASED_

Yeniifer Alvarez-Estrada Glick

DATE OF DEATH—ACTUAL OR PRESUMED
July 10, 2022

MARITAL STATUS AT TIME OF DEATH
☑ Married

IF DEATH OCCURRED IN A HOSPITAL
☑ ER/Outpatient

IF FEMALE
☑ Pregnant at time of death

LOCATION (CITY/TOWN AND STATE)
Luling, TX

MANNER OF DEATH
☑ Pending Investigation

Yeniifer Alvarez arrived in central Texas from San Luis Potosí, Mexico, in 1998. At three, she was just old enough to have a sense of a world left behind: the fire that warmed the house in the evening, the meat hung to dry outside the door, and la bisabuela, her adored great-grandmother, who had died shortly before Yeni and her mom went north. In Luling, Yeni, her parents, aunts, and grandmother settled into a cramped house with a tin roof that was down the street from her great-uncles, the first members of the family to discover the town’s decent jobs, in the oil fields.

Black gold had been gushing there since the nineteen-twenties, and a sulfurous odor hung in the air. To this day, when the smell drifts fifty miles north, people in Austin call it “the Luling effect.” Yeni’s father worked in oil, too, but it wasn’t long before he was deported. Yeni’s mother, Leticia, stayed and got a job in the kitchen of a local Mexican restaurant, where the pay was modest but no one was asking about papers. Every morning, Yeni and her little brother Michael rode to a red brick schoolhouse in a car overstuffed with other kids. At the wheel was a neighbor who, for a dollar a day, took care of children whose parents’ workdays started well before class did.

Leticia divorced, remarried, and took a second job, at a poultry plant. She had two more sons, and she relied on Yeni to help raise them. Pedro, born when Yeni was ten, received a diagnosis of autism; he was so sensitive to sound that raindrops on the roof could make him spiral, and on the rare occasion when he spoke Yeni understood that he’d given each word serious thought. Francisco, who arrived when she was thirteen, was vulnerable, too—bullied in elementary school, he retreated to studying online.

Yeni’s mother, Leticia, relied on her daughter to help care for the rest of the family.

By the time Yeni went to high school, she’d become the nerve center of her extended-family operation. She was the one who fretted over a mortgage payment; followed up on the applications for disability that she filed for her cousin, who’d had a stroke at sixteen; warned family members when politicians were stoking rage against the undocumented; and made the delicate decision about whether to call the police when Pedro, alarmed by something he couldn’t articulate, ran away. Only at school did the pressure ease up.

Whereas other teen-age girls in Luling dreamed of being crowned Watermelon Thump Queen at the annual farmers’ festival, Yeni’s hope was to become a scientist. One day, she imagined, she’d have a college degree—chemistry or biology, she hadn’t decided—and buy a home in Wimberley, a pretty Hill Country town forty miles west of Luling. She could almost see the ranch house, nestled in the woods, with extra bedrooms for Leticia and the boys. She could still almost see the place years later, her mother said, after scholarships had been turned down for lack of a Social Security number and she was a certified nursing aide cutting toenails at Hillcrest Manor, a nursing home near one where her brother Michael worked as a janitor.

“Life is too short for tears and hate,” she always said, and comfort could be found in blasting Queen Bey in the car on the way home from work, in laughing with friends at an over-the-top burlesque cabaret, and in her boyfriend, an Army Reserve specialist named Andrew Glick. He wasn’t as liberal as she was, but they shared a skewed sense of humor and a longing for experiences more vibrant than those afforded by rural Texas. Andrew loved anime, wanted to go to Tokyo, and didn’t balk when Yeni made it clear that, should the two of them stay together and leave Luling, her younger siblings would be coming along. She called them her _niños_—the children she’d had without getting pregnant.

The wedding was in November, 2021, and on the preceding evenings Andrew received a crash course in ranchera. The mariachis were driving six hours for a single night—there could be no disappointments on the dance floor. After the ceremony, in a barn flanked by oak trees, Yeni, twenty-six, swayed in a tulle ball gown, a silver tiara, and the longest veil she could find. The following month, Yeni announced with joy that she was pregnant. The only downside, she told her mom, was that she and Andrew, who had moved in with the family, would be deferring their plan to leave Luling. Where else but in this stinker of a town would there be so many aunts and cousins excited to meet a newborn, and to help?

Luling’s sole general hospital, Ascension Seton Edgar B. Davis, is named for the God-fearing shoemaker who discovered that the town was sitting on oil. The hospital’s helipad has a canary-yellow signal that reads “Low Flying Aircraft.” In Caldwell County, where Luling is situated, more than a quarter of the people under sixty-five are uninsured, according to a recent census estimate; for some of them, delaying medical care until it becomes urgent is a way of life. Critically ill people, including women who are pregnant, often arrive at the hospital only to be rushed to better-equipped facilities somewhere else.

The hospital’s labor-and-delivery unit closed years ago, and there is no ob-gyn on site. The women in Yeni’s family, like most women in Luling, were used to travelling to Kyle, thirty miles northwest, or to Austin, for routine care. But sometimes a pregnancy-related crisis is too urgent to allow for travel time, and the Luling emergency room—with four beds and one doctor—is the only place to go.

By 2022, two hospital employees told me, the number of women giving birth in the Luling E.R. was surging. They recalled seeing only five or six births in the previous decade. Now it felt like “uncontrolled chaos,” one of them said. Babies were being delivered in the waiting room, or crowning on a stretcher in the hallway, the four beds being occupied.

The two employees were accustomed to seeing early miscarriages or the swift delivery of someone’s fourth child. But lately women were coming in with more varied and complex conditions, and at times the E.R. felt like a neonatal intensive-care unit—but one lacking the equipment to properly handle sick babies. The hospital’s single baby-warming crib was discovered, during a birth, to be missing a wheel; a nurse had to prop it up with her feet to prevent the newborn from falling out while the doctor received obstetrics counsel over the phone from a specialist in Austin.

“Anything that fails in society, anything that’s broken, ends up being the emergency room’s problem,” one of the employees told me. Both of them suspected that the surge was being driven by diminished access to abortions, following the enactment, in 2021, of a state law known as S.B. 8, which banned the procedure after the sixth week of pregnancy in nearly all cases. A Johns Hopkins Bloomberg School of Public Health study recently showed that, in a nine-month period following the passage of S.B. 8, nearly ten thousand additional babies were born in Texas.

What conservative lawmakers hailed as the saving of infant lives, medical professionals I interviewed in rural Texas saw as a beleaguering challenge. According to state data, even before S.B. 8 half the counties in Texas were unequipped to treat pregnant women, lacking a single specialist in women’s health, such as an ob-gyn or a certified midwife. Multiple doctors told me that the overturning of Roe v. Wade, in June of 2022, exacerbated the crisis, as practitioners retired early or moved to states where they’d have more liberty to make medical judgments. So who, exactly, was supposed to handle the extra deliveries in women’s-health deserts such as Caldwell County? What would become of women in remote locales who experienced a hemorrhage or a ruptured fallopian tube?

Although it was illegal for the E.R. to turn away patients who needed urgent care, hospital workers in Luling couldn’t hide their reservations. “This is not the place you want to be,” one of them told pregnant patients. “It could end up tragic.” There wouldn’t be an anesthesiologist on hand to numb the pain with an epidural, much less an expert in maternal-fetal medicine. Not every patient was in a position to travel elsewhere, however. If a pregnant woman visited the Luling E.R. three times in a row, staff came to assume that she’d end up delivering there, whether they were prepared or not.

Yeni was among the uninsured, and when her teeth hurt or drug-store creams weren’t curing a rash, she turned to the Luling E.R. Over time, the staff came to know her and her ailments. In her mid-twenties, she learned that she had hypertension, or high blood pressure, and diabetes. Both conditions ran in her family; Yeni began storing her insulin next to her mother’s in the fridge.

After _Covid_-19 peaked in Luling, Yeni fell ill, and she was hospitalized with pulmonary edema, a condition, in which the lungs fill with fluid, that strains the heart and can be fatal. Another long-term complication was her weight, which rarely dipped below two hundred and sixty pounds. For all these reasons, when Yeni became pregnant she was a high-risk patient.

Seven weeks into her pregnancy, in late January, 2022, Yeni messaged Andrew: “Slight breathing problems.” A few days later, she woke up bleeding. Her first instinct was to call her mother. ‘Does it hurt?,’ Leticia asked. It didn’t, but Yeni was too scared to trust her mother’s theory that miscarriages were accompanied by pain. She raced to the E.R., where her case was termed a “threatened miscarriage.” An ultrasound showed normal fetal growth; her blood pressure, however, had spiked to a worrisome 185/98.

“It would be worth ten times that with legs.”

Cartoon by Mike Twohy

Although some women with the same conditions as Yeni—hypertension, diabetes, a history of pulmonary edema, severe obesity—end up safely delivering healthy babies, others become so unwell that a difficult question arises: Is this a pregnancy that the patient can safely continue? Some studies show that cardiovascular diseases account for more than a third of pregnancy-related deaths in the U.S. “When a pregnant patient comes to you with a history of pulmonary edema, the question is: What is the cause, and can it be managed or reversed?,” Uri Elkayam, the director of the maternal-cardiology program at the University of Southern California, told me. “Pregnancy increases blood volume, and with limited cardiac reserves the pressure from the heart may be reflected into the lungs, causing pulmonary edema and heart failure.” His rule of thumb is that, if a patient is fairly sick early on, “one needs to assume that as pregnancy progresses things only will get worse.” In those cases, he said, termination lowers the risk of death.

According to Yeni’s medical records, doctors didn’t raise the possibility of a therapeutic termination with her. Ascension Seton, a network of Catholic hospitals whose mission is “rooted in the loving ministry of Jesus,” is averse to abortions. But, as some medical professionals familiar with Yeni’s care told me, the hospitals can make an exception when a woman’s life is at risk. The field of obstetrics is replete with gray areas, and in the past a physician with a borderline case could direct the patient to another facility, with fewer restrictions on abortion. But that option effectively disappeared in the months before Yeni got pregnant.

When S.B. 8 banned abortions past the six-week limit, it included an exception in cases of “medical emergency.” At the same time, the law made it tricky for health-care workers to raise the emergency flag, by enabling citizens to initiate lawsuits against people who “aid or abet” banned abortions, incentivizing them with the possibility of a ten-thousand-dollar reward. A person involved with Yeni’s medical case told me, “One of the things that S.B. 8 does is undermine a sense of common mission and trust, even within a care-giving team—you know, who’s going to go behind your back and sue you because they watched you do your care?”

After the bleeding episode, Yeni left the E.R. with a referral to Jessica Mueller, an ob-gyn who is part of the Ascension Seton network in Kyle. After making the appointment, Yeni had to find someone to cover her shift at a home-care job that she’d recently started: attending to a man with quadriplegia, whose ability to eat, drink, and bathe depended on her. Once she made it to Kyle, Mueller informed her that her hypertension remained severe, and she needed to be admitted to the hospital.

This was news that Yeni could not afford to hear. As it was, she could barely keep up with her medical expenses—this visit alone was costing her two hundred and fifty dollars, out of pocket. Undocumented pregnant women can be eligible for government-funded health coverage, and Yeni had applied for it but hadn’t received a response. “I don’t know what to do,” she’d texted Andrew shortly before the appointment with Mueller. “I just dropped 500 plus my car payment to get it out of the way so I’m left with 200 that’s not even enough to cover cost and I’m just done I don’t know what to do. They won’t help me unless I get insurance but I can’t get insurance.”

Mueller could not convince Yeni, now ten weeks pregnant, to be hospitalized, but she did her best to warn her patient about the dangers of skipping doses of blood-pressure medication, which Yeni sometimes did because the drugs could make her nauseated or sleepy, inhibiting her ability to do her job. If she did not get her blood pressure and glucose under control, Mueller said, she would be at risk of having a heart attack, a stroke, or a miscarriage. Medical records do not suggest any discussion of the fact that an abortion could have alleviated the additional strain that the pregnancy placed on her heart. (Mueller did not respond to requests for comment.)

Deciding whether to end a much wanted pregnancy because of serious health risks is an excruciating process for many women, and it is also difficult terrain for doctors. Informed consent is a fundamental principle of medicine—a patient can basically do what she chooses with her body, and can take or leave medical advice, but doctors are ethically bound to give the patient enough information to grasp the possible costs and benefits of her choices. In states with abortion bans, which emphasize the rights of the unborn and tend to have the poorest maternal-health outcomes, a doctor’s advice to a pregnant woman can be especially fraught.

Two weeks before Yeni saw Mueller, Lorie Harper, the director of maternal-fetal medicine at the University of Texas at Austin, who practices at Ascension Seton, had told colleagues at a conference how S.B. 8 was affecting her work: “Some women just cannot take the stress of pregnancy, so they may basically die or develop a life-threatening condition. In those cases, I have to recommend an abortion in order to prevent a maternal death. And that is getting much harder.” She added, “Physicians are having to choose between their own personal well-being and, at times, a patient’s well-being.”

Another doctor in the Ascension Seton system told me, “One of the great challenges and rewarding features of obstetrics is that you have two patients. They sometimes have competing interests, and one is dependent on the other. Your job is to get both through the pregnancy safely, but that’s not always possible. And it’s very frustrating to have your hands tied because the patient who you need to save is not the one that’s protected by law.”

Yeni’s first visit to Mueller was followed by five more. By the third visit, she was taking her medications as prescribed, but she had missed a virtual appointment with a maternal-fetal specialist because the house where her client lived had terrible cell-phone service. Mueller’s notes catalogued what doctors call social determinants of health—structural factors that shape a person’s welfare, beyond her individual choices or treatments. “Unable to get lantus rx bc was $400,” Mueller wrote, of Yeni’s prescription for long-acting insulin. “BP elevated today, was 20 min late for appt so was stressed about this.” On Yeni’s sixth visit, her blood pressure was normal. She had asked Mueller to write down her baby’s sex on a piece of paper. The unopened note was passed to a florist, who prepared a box of balloons. In mid-April, a small crowd assembled in Leticia’s back yard chanting, “Cinco, cuatro, tres, dos, uno,” at which point pink balloons rose into the sky. It was a girl, for whom Yeni and Andrew had already chosen a name: Selene.

Three weeks later, in the early hours of May 9th, Andrew Willis, a doctor at the Luling E.R., was halfway through his shift when Yeni arrived with her husband. She had woken in the middle of the night, struggling to breathe. For about a month, she had been coughing persistently and gasping for air, especially when lying down, but now she could feel her heart racing as her oxygen levels dropped. She couldn’t walk without becoming short of breath. Her blood pressure was dangerously high: 205/129. She was twenty-two weeks and six days pregnant.

Willis’s instinct was to transfer Yeni to a facility in Kyle or Austin which was credentialled to treat high-risk-pregnancy cases. But her vitals had to be stabilized first. With a nasal cannula, he brought up her oxygen levels. Her blood pressure, though, wasn’t responding to treatment: it dropped to 175/108, went back up to 219/126, then soared to 233/133. An X-ray revealed that Yeni had once again developed pulmonary edema. The longer she stayed in Luling, the greater the danger.

The hospital called a helicopter, but bad weather set in. Yeni would have to go by ambulance to a bigger hospital. An ob-gyn in Kyle advised Willis not to transfer Yeni there. Instead, she would be sent to the Ascension Seton Medical Center Austin, twenty miles farther away. In the paperwork, hypertension and pulmonary edema were listed as reasons for the transfer, along with suspected preeclampsia, a complication of pregnancy that is characterized by high blood pressure and can damage organs. Doctors often recommend that preeclamptic women deliver early.

Ever since Yeni’s death, some of the medical professionals involved in and briefed about her care have been haunted by the question of whether sins of omission were committed. They have asked themselves if responsibility for her death resided in part with the new laws that suppress free discussion—both among doctors and with patients—about therapeutic abortion.

Shortly after eight in the morning, an ambulance was whisking Yeni to the Austin hospital—el grande, as Yeni described it to her mother. The breathing difficulty was making her panic, as it had in the past—this was the third time she’d been given a diagnosis of pulmonary edema. She messaged Andrew:

“I’m alone and scared.”

“Where is my mom.”

Leticia was also terrified. That morning, she had rushed to the Luling E.R., and, as she’d watched the ambulance doors close, it had occurred to her that her daughter might die inside the vehicle—Yeni had never looked so sick. On arrival in Austin, records show, Yeni was at “high risk for clinical decompensation/death.”

Yeni’s fetus, at nearly twenty-three weeks, was on the cusp of viability. According to a 2022 study in the Journal of the American Medical Association, a baby delivered at twenty-three weeks has a less-than-fifty-per-cent chance of survival, and a significant number of the babies who do survive have severe disabilities. When considering an early delivery, a doctor must carefully weigh the benefit to the mother against the cost to the fetus. A second, more controversial approach in cases like Yeni’s is a late-term abortion. In 2021, according to data obtained by the Centers for Disease Control and Prevention, less than one per cent of abortions occurred at or after twenty-one weeks. When an abortion is performed at this stage of pregnancy, it is often to protect the life of the mother.

Yeni was so unwell on admission—“stupid sick,” in the words of one person involved in her care—that she was immediately transferred to the intensive-care unit and placed on assisted breathing. Though she was unable to speak, she could still text. “I want to live,” she told Andrew, distressed. A little later, she tried to collect herself. When Leticia asked how she was feeling she replied, “Fine,” adding a thumbs-up emoji.

Leticia recognized her daughter’s habit of downplaying fears. How many dozens of messages had she received over the years that said “I love you mom and everything will be O.K.”? So she persisted: “Gorda, tell me the truth.” Yeni let this message go unanswered.

In the following days, under the care of Celeste Sheppard, a specialist in maternal-fetal medicine, and others, Yeni’s pulmonary edema improved with blood-pressure medications. Her supplemental oxygen was dialled back, and tests showed that she most likely didn’t have preeclampsia. It was a moment of seeming stability, in which medical professionals might have started a conversation with Yeni about the progressive burden that the pregnancy placed on her already vulnerable heart and lungs, and about the risks that continuing it might pose to her life. This didn’t happen. Four days after admission, Yeni was discharged with an adjusted dose of hypertension medication and a potent diuretic. (Sheppard declined to answer questions about Yeni’s care.)

“Thirty-two? Feels more like twenty-nine to me. Yeah, I’d say twenty-nine.”

Cartoon by Emily Bernstein

When Yeni returned to Luling, exhausted, her family wondered if she would have been kept in the hospital longer had she been insured. (Some ob-gyns I spoke with also raised this question.) Leticia urged her to quit her job and stay home until Selene was born. But Yeni needed the money. How else would Selene’s needs be covered? “I’m fine,” she insisted. Leticia, though, could hear how Yeni dragged her feet when she came home from work. Was this normal for the fifth month of pregnancy? Although there were fewer than ten steps between where Yeni parked her car and the stoop, the journey left her spent. She started departing family gatherings before everyone else, including the elders. (“Where are you going, mija?”) Even employees at the local supermarket, who had come to know Yeni over the years as a lively customer, had started worrying about her pallor.

In late May, Yeni texted Tuesday Coe, the nurse who cared for her quadriplegic client at night, saying that the shortness of breath had returned. She went to see Mueller, the ob-gyn in Kyle, and was asked to return the following day with a urine sample, which would be tested for excess protein, a sign of preeclampsia. When Yeni got back from the appointment, she felt defeated. She told Coe that she knew something was wrong but the doctors didn’t seem to be getting to the bottom of it. “It was always the same thing, that they couldn’t find anything,” Coe told me. “And every time she had to go, it was so expensive, because she had no insurance, so she stopped going.” Yeni’s breathing problems continued, but records indicate that she did not visit the ob-gyn again.

Just after 5 A.M. on July 10th, Yeni’s chronic symptoms intensified. A city ambulance arrived, and paramedics found her sitting on the side of her bed, feeling weak. She told them she was anxious, and they found that her blood pressure was perilously high—213/146. Andrew said that she was taking only half the blood-pressure medication she’d been prescribed. Yeni explained that her dose was always changing.

Yeni’s oxygen levels were falling, and the paramedics concluded that she needed to go to the hospital. She took twenty minutes to get dressed, and when she finally left the house she stumbled before recovering her footing and making it to a stretcher inside the ambulance. She needed to catch her breath, she said; then her breathing turned into a cough. The paramedics put her on oxygen and started her on an I.V. You’ll be going to Kyle via helicopter, they told her—she was too far along into her pregnancy, and too hypertensive, to admit to the Luling hospital.

Acute pulmonary edema often causes patients to panic, and, before the driver could start the engine, Yeni unfastened her safety belts—she couldn’t breathe, she said. The paramedics struggled to calm her down. According to three medical professionals familiar with Yeni’s case, it is appropriate in such situations to provide a hypertension medicine, like Labetalol, immediately. Instead, the paramedics interpreted some of her symptoms as signs of anxiety.

Luling’s sole general hospital, Ascension Seton Edgar B. Davis, closed its labor-and-delivery unit years ago, and women there are used to driving elsewhere for obstetric care. But sometimes a pregnancy-related crisis is too urgent to allow for travel time: the Luling emergency room—with four beds and one doctor—is the only place to go.

Andrew Willis, the Luling E.R. doctor, recommended sedation when they called him. They gave Yeni the first of two milligrams of Ativan, medical records show, and then a hundred micrograms of fentanyl. Labetalol was among the last medications administered.

By this time, neighbors had joined a distraught Andrew outside the ambulance, and were wondering why paramedics called to rush Yeni to a hospital five minutes away had been parked for almost two hours. (The director of Luling Emergency Medical Services, Richard Slaughter, did not respond to questions about the medications Yeni received or about the delayed departure; Willis did not respond to requests for comment.)

Minutes after 7 A.M., when the paramedics finally pulled up to the E.R., the helicopter meant to transport Yeni was still en route, but Willis and a small team were waiting at one of the hospital doors. They had I.V. bags of magnesium sulfate, which helps prevent seizures in preeclamptic women, and medications that would lower Yeni’s blood pressure. When the ambulance stopped, though, the paramedics didn’t get out. The hospital workers looked at one another. Finally, one of them flung open the vehicle’s doors—Yeni had no pulse.

The paramedics had been giving her CPR. Willis took over, and with each compression a doctor trained in emergency medicine was making one of the most difficult calculations in the field of obstetrics: when to turn from working on a mother to working on her baby. The consensus among specialists is that initiating a C-section within roughly four minutes of the mother’s death improves the infant’s chances of survival; delivering the baby also improves chances of resuscitating the mother. Willis worked on Yeni past the four-minute mark, then made an incision in her abdomen. When Selene, now thirty-one weeks, came to rest on the old baby warmer, she, too, was dead.

After Andrew Glick, who had been in the waiting room, heard that Yeni and the baby were gone, he fled the E.R. Not long afterward, he left Luling for good in his wife’s old car, where he’d kept one of her last cans of soda in the cup holder. Although he declined through family members to speak to me, he decided to share, via e-mail, a single document: Yeni’s autopsy report.

C_ause of Death_

Hypertensive cardiovascular disease associated with morbid obesity

Other Contributing Factors
Pregnancy

The autopsy capped more than three thousand pages of medical records chronicling the short life of Yeniifer Alvarez-Estrada Glick. None of the records from when Yeni was alive acknowledge that, given her multiple underlying conditions, an abortion would have increased her chances of survival. Only the autopsy put it plainly. “Pregnancy creates stress on the heart and can exacerbate underlying heart disease and cause hypertensive crises,” the medical examiner wrote, in naming pregnancy as a factor in Yeni’s death.

Yeni’s passing came as a shock to her family. “We were scheduled to do her baby shower that weekend,” Andrew’s sister Lisa Bozeman told me. “But we weren’t having a baby shower. We were having a funeral.” Ever since Yeni’s death, some of the medical professionals involved in and briefed about her care have been haunted by the question of whether sins of omission were committed. They have asked themselves if responsibility for her death resided in part with the new laws that suppress free discussion—both among doctors and with patients—about therapeutic abortion. Had fear of legal repercussions trumped compassionate care?

Yeni’s death occurred two weeks after the overturning of Roe, which triggered abortion restrictions in states across the country. In Idaho, Texas, and Missouri, for instance, performing an abortion in almost all circumstances became classified as a felony for which a doctor could face years in prison and the loss of a medical license. Even before the Supreme Court ruling, the U.S. (the rare wealthy nation without universal health care) was one of the few countries where maternal deaths had increased significantly in the past two decades. A study by the University of Colorado Boulder predicted a surge in maternal deaths after Roe fell, disproportionately among women of color; analysts at The Lancet and Harvard Medical School voiced similar worries.

The task of determining whether that prediction has come to pass in Texas belongs to the state’s Maternal Mortality and Morbidity Review Committee. Texas’s maternal-death rate has more than doubled since 1999, driven by the increase in maternal-care deserts and by a lack of prenatal care, of health insurance, and of access to contraception. The review committee has, for the past decade, attempted to conduct close analyses of these deaths, drawing on medical records, police reports, and other documentation. Its reports serve both as road maps for averting future deaths (the vast majority of the examined deaths were likely preventable, the committee’s latest findings show) and as social indictments, underscoring how much a woman’s race, economic status, and location factor into her likelihood of dying while pregnant. Members of the committee told me that the review process is cumbersome, and that they won’t start assessing 2022 cases until later this year, at the earliest.

Given that procedural lag time, The New Yorker asked four outside experts to review Yeni’s medical file, which her mother obtained. All four said that Yeni’s death was preventable; that she’d been discharged prematurely from the Austin hospital; and that a therapeutic abortion, if offered and accepted, would probably have saved her life.

Joanne Stone, the chair of the ob-gyn department at the Icahn School of Medicine at Mount Sinai and the former president of the Society for Maternal-Fetal Medicine, said flatly, “If she weren’t pregnant, she likely wouldn’t be dead.” When Yeni was well enough to be moved out of the I.C.U. in Austin, Stone went on, “the discussion would be, ‘Do you want to continue this pregnancy now, knowing that, because you already had the severe-range blood pressure and pulmonary edema, your likelihood of getting really sick is super-high?’ ” In such cases, she explained, “you have a consultation, you have the neonatologists come talk to her, you have the maternal-fetal-medicine specialists come talk to her, and then sometimes the patient needs a day or two to come to a decision. But in the legal landscape of Texas you can’t even start that discussion.”

Thomas Traill, the director of the E. Cowles Andrus Cardiac Clinic, at Johns Hopkins, and an expert in pregnancies of women with cardiac conditions, agreed with Stone about the gravity of Yeni’s risk. He told me that, had Yeni had access to proper care for her serious underlying conditions, she would have been advised not to get pregnant in the first place, and that when she saw an ob-gyn ten weeks after she conceived an abortion should have been discussed. He contended that, with the law apparently stifling such a conversation, E.R. doctors and paramedics were placed in an “impossible situation” that ended in “a very preventable maternal death.”

Charles E. Brown, a maternal-fetal expert who used to work at Ascension Seton in Austin, noted that Yeni’s problems were heightened by the inconsistency with which she took her hypertension medications. However, he concurred with the other experts that the threat to her life was sufficiently high that at ten weeks along she should have been asked, “Do you want to continue this pregnancy?” Brown also said that, in Austin, Yeni should have been carefully monitored until a viable delivery was likely, instead of being discharged into a care desert. He considers her death a consequence of both S.B. 8 and a crisis long predating it: Texas’s inadequate funding of the medical needs of the poor.

One of Yeni’s closest friends, Dolores Favela, said, “She and Andrew were so young, and if given a choice they probably would have thought to themselves, We’ll have so much time together, we can have a child later on.”

To Tony Ogburn, an ob-gyn who has spent his career serving women of color in low-income communities, most recently as chair of the department of obstetrics and gynecology at the University of Texas Rio Grande Valley, “Yeni was a ticking time bomb—one that exploded.” He acknowledged that some people would say she was noncompliant—“that this is her fault.” But, he noted, if that’s the attitude Americans have, the United States will never fix its maternal-mortality problem. Among the aspects of Yeni’s case that particularly troubled him were the breaches of informed consent and shared decision-making. If Yeni had been made fully aware that she might die at twenty-seven, and had learned how an abortion might increase her chances of survival, and then had chosen to continue the pregnancy, Ogburn said, that would be O.K. Instead, she and her family had seemingly been denied crucial medical information that they had a right to know.

A spokesperson for Ascension Seton declined to answer specific questions about Yeni’s care and any role that Texas’s abortion restrictions might have played in it. (The spokesperson cited legal reasons and the right to privacy, although Yeni’s mother had signed a waiver of privacy rights in order to allow the hospital to respond to my questions.) “We are committed to providing high-quality care to all individuals,” the spokesperson said, “with special attention to the poor and vulnerable.”

On a recent morning, when I joined Leticia and her sister Elizabeth at a diner in downtown Luling, the women gestured uneasily toward the booth behind us: four paramedics in uniform eating breakfast tacos, their radios hanging off their belts. In a community of only five thousand people, it is difficult to ask questions about the choices made by institutions on which your own life might one day depend. So Yeni’s family and friends talked quietly among themselves, wondering what Yeni would have chosen had she known how imperilled she was.

One of her closest friends, Dolores Favela, said, “She and Andrew were so young, and if given a choice they probably would have thought to themselves, We’ll have so much time together, we can have a child later on.” Leticia wasn’t as sure, recalling something Yeni said in passing after her improvement in the Austin I.C.U.: that if a doctor had to choose between saving her or saving Selene, her daughter should come first. Leticia had responded, half in jest, “And who exactly is going to take care of Selene?” “Well, you, Mami!” Yeni said. “Me?” Leticia teased. “If you leave, you better take Selene with you!” Laughing, the women laid the subject to rest, never to discuss it again.

Yeni and Selene’s shared tombstone.

Now that both Yeni and Selene were gone, Leticia tried to find comfort in the idea that it had all been God’s will. But what if it hadn’t been? What if the catastrophe could have been prevented? She thought that Yeni would have pursued answers had such a thing happened to someone she loved. Leaving the diner, Leticia and Elizabeth headed to the cemetery, as they often did, to shoo the lizards from the grave, tidy the marigolds, and test the solar-powered lights that they’d draped over the tombstone to insure that Yeni and Selene would not be left in the dark. ♦

Fabrice Robinet contributed additional research for this piece.