‘I cried with her’: the diary of a doctor navigating a total abortion ban

Dr Leilah Zahedi-Spung always knew providing abortion care in Tennessee was going to be hard, but she probably never could have imagined how hard. On 25 August 2022, 18 months after Zahedi-Spung landed a dream job as a maternal fetal medicine specialist, the state enacted one of the strictest abortion bans in the country, one that does not even make explicit exceptions to save the life of the pregnant person.

Tennessee's ban makes performing or attempting to perform an abortion a Class C felony - meaning Zahedi-Spung could have faced a 15-year-prison sentence for providing life-saving care. So, in January 2023, she decided to leave for work in Colorado, where abortion is still legal in all stages of pregnancy.

At the end of 2022, she started writing a diary for the Guardian, detailing her last days in a busy doctor's office where she sometimes saw more than 40 patients a day, many begging her for help she could not give. The diary has been supplemented with interviews, to try and capture what life is like for a doctor whose work is severely restricted due to a total abortion ban.

This patient knew around 15 weeks that her pregnancy was going to be unviable, but in the confusion that followed the overturning of Roe v Wade last June, she struggled to make a decision about whether to leave the state for care or to wait it out. "It was such utter and complete chaos that she just couldn't figure out what to do," says Zahedi-Spung. As her doctor, Zahedi-Spung worried the longer the pregnancy went on, the harder it would be for her patient to let go. Eventually, they made plans to go ahead with the birth in Tennessee, through cesarian section.

Zahedi-Spung and I discuss what happened with that patient in a phone call. "She carried to term and got delivered on Friday [9 December], and her baby died within a couple of minutes after delivery. But she got some time with her and that's what she wanted," says Zahedi-Spung.

Another patient came to see Zahedi-Spung alone on 30 November, having carried a pregnancy she had long warned was at high risk of being unsuccessful. The patient had been hopeful, although she was aware of a fetal anomaly. At 36 weeks, Zahedi-Spung diagnosed a stillbirth.

"I had to tell her that her baby's dead. I mean, it's just it's awful every time. But it's really awful when they're alone," says Zahedi-Spung, reflecting on the case.

Under these circumstances, Zahedi-Spung was allowed to intervene with a dilation and evacuation procedure, without having to send this patient out of state.

"If it doesn't have a heartbeat, it's not considered an abortion," explains Zahedi-Spung.

With this patient, Zahedi-Spung saw someone whose pregnancy had implanted in the scar of her uterus, a life threatening condition that can lead to a catastrophic uterine rupture. In other cases, it may result in the placenta eating through the wall of the uterus, the bladder and sometimes the bowel. Still, the Tennessee ban does not permit an abortion for such cases.

Zahedi-Spung sent the couple to Georgia, where abortion laws are stringent, but include exceptions for maternal life and ectopic pregnancies.

"I sent her to one of my mentors, so I knew she was going to get exactly the care she needed," Zahedi-Spung says.

Up until this point, everything had been developing normally for the patient Zahedi-Spung saw on 8 December, as is often the case: most anomalies are not picked up before 16 weeks. The patient was happy and excited about their pregnancy. When they heard the pregnancy was nonviable, they were devastated.

Their options were limited. In terms of states nearby they could travel to, many were blocked off: Georgia had a six-week ban in operation, and nearby Alabama, Arkansas and Mississippi all had total bans. North Carolina was the closest state the couple would be able to receive abortion care at this stage of pregnancy.

While writing this diary, Zahedi-Spung was in the process of moving for a new job in Colorado. We caught up by phone in the middle of the day on a Friday, after she had just put her child down for nap time. She was quite sleepy herself, noticeable from her tone - she sounded relaxed but depleted."I'm exhausted by everything. I feel a little bit like a shell of myself at times," says Zahedi-Spung. To cope with the stress, she says: "I tend to retreat inward. I describe myself as having a box [in my mind] that I put all this bad stuff in. And I shut it in very tight and I stick it on a shelf."

This patient came in around 16 weeks pregnant, having felt a gush of fluid from what's called a preterm premature rupture of membranes. Her water had broken early. She was with her partner and her mom, having had a totally normal pregnancy up until that point. She was in an incredible amount of pain, contracting every five minutes and crying. The amount of pain indicated she may go into labor soon, too early for the pregnancy to be viable. A heartbeat was still detectable on the ultrasound.

"I figured she'd deliver at some point. But I didn't know when - and she was certainly not able to be discharged home given the amount of pain she was in. She was not infected; she certainly wasn't bleeding enough for me to justify doing anything. So we just had to wait, and I made her as comfortable as I could - we gave her an epidural," says Zahedi-Spung.

If there wasn't a total ban in place, Zahedi-Spung would have induced labor, or taken the patient to the operating room to perform a surgical abortion. But the rules said she couldn't.

The patient delivered around 12 hours later, after Zahedi-Spung had gone home.

"Technically we didn't break any standards of care, but the evidence-based guidelines are that if someone's water breaks prior to 22 weeks, you end the pregnancy. So I wasn't doing all that I could have done to protect the patient. Thankfully, she didn't get sick and she didn't bleed to death. But why do I have to wait for [that] to take care of people?" asks Zahedi-Spung.

The case made Zahedi-Spung angry. "I have the ability to provide life-saving care. And I'm being told I'm not allowed to do that because it offends people. It's so ridiculous. None of these lawmakers even understand the grief that these patients are suffering," she said.

Zahedi-Spung saw this patient and her partner over four days around Christmas. The couple had just learned about a heart defect from their family doctor.

"They were a very knowledgeable couple. This was an unexpected pregnancy, but a wanted one. And then this very unexpected and terrible finding of a heart defect showed up," says Zahedi-Spung. Babies with this heart defect have a very small chance of surviving the first year of their life. "They were very thoughtful, as all of my families are, about what that would mean for their life and for their kiddo's life," says Zahedi-Spung. They decided to end the pregnancy out of state.

The heartbeat bears are a memento Zahedi-Spung offers to patients when a pregnancy won't be successful. A company sends a stuffed teddy and a recording device, and Zahedi-Spung records the heartbeat and puts the device inside bear. The families can squeeze it and hear the fetal heartbeat. "It can be very important to families," says Zahedi-Spung. She learned about the practice during her residency training.

This was Zahedi-Spung's last day. She was getting ready to leave at the end of her shift to go to the airport with her family when she was told about an emergency patient who was seizing and pregnant, around 23 or 24 weeks. The patient was unable to breathe on her own and had to be intubated. Neither the patient, nor her partner or family, seemed to know she was pregnant. They were shocked when Zahedi-Spung informed them.

"That was really difficult because it meant we couldn't have a conversation about what it [would mean for the patient's health] to be delivered at this time, what it means for the baby, or anything like that," says Zahedi-Spung.

Zahedi-Spung delivered the baby alive, but is unsure whether it survived after she left. "It was very much on the edge," says Zahedi-Spung. "And she just woke up and found out about a baby she hadn't known about when she came in.

"If there was no ban, I would have given her the option to have an abortion. She was so sick, the kid was going to be sick. She was going to be impacted for the rest of her life by the surgery I had to give her. I don't know if she would have said yes to that, but I would have liked to have given her the option. Her hands were tied," says Zahedi-Spung.

Zahedi-Spung's last day at work in Tennessee was 1 January. To mark the occasion, a colleague took her out for dinner at a farm-to-table restaurant in Northshore, Chattanooga. They split the chicken, and drank martinis. "She was very sad that I was leaving. I was too. It's been bittersweet," says Zahedi-Spung. "I never wanted to leave. I loved my job. It had just become impossible for me."

Her new job started on 17 January. Before she began, she still felt conflicted over starting out again, in a state where abortion is legal.

"I've only ever known how to take care of patients in a place where it's hard," she says. Being one of the only doctors that provided the care she did in Tennessee created a unique relationship. "All of the patients I have taken care of over the last year and a half have my cell phone number. And that creates a different kind of bond with people."

As she left Tennessee, she felt a nagging guilt."Part of me felt like I was selling out by coming here," she said. "That's part of medicine. They teach us that we're not worthy, unless it is so hard. But I shouldn't have to sacrifice so much of myself for it."