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33 Illinois counties, including Madison, Calhoun and Clinton, voted to leave the state because some voters said state laws favor Chicago residents.

FEMA has opened a new Disaster Recovery Center in Clayton to assist tornado victims seeking help with disaster assistance applications, insurance claims, and replacement of essential personal property.

A jury ruled Thursday in favor of 13 employees who had largely sought religious exemptions from SLPS’s vaccine mandate in 2021.

The owners who purchased Urban Chestnut Brewing Co. amid bankruptcy announced plans Monday to revive another beleaguered beer brand.

EDWARDSVILLE - The EHS Tiger Talk Podcast Network will receive a $1,320 grant from the Illinois Farm Bureau and the Illinois Press Foundation. The award is part of the Illinois High School Journalism Grants Program offered by the Illinois Press Foundation and financially sponsored for a third consecutive year by Illinois Farm Bureau. EHS was one of 19 recipients across the state and will use the grant money to purchase two microphones, mic stand, digital voice recorder, stream deck, capture card, webcam, green screen backdrop, and Ring light kit. The EHS Tiger Talk Podcast Network concluded a successful first season during the 2022-23 school year in which students produced two weekly podcasts, including The Jungle, the official EHS sports podcast, and Tiger Spotlight, a podcast that highlights the Tiger community. The two podcasts produced a total of 54 episodes with 1,409 plays. “With this grant, we look forward to expanding this initiative as we move into

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by Spencer Norris, New York Focus, and Joel Jacobs, ProPublica, graphics by Lucas Waldron, ProPublica

This article was produced for ProPublica’s Local Reporting Network in partnership with New York Focus, an investigative news outlet reporting on New York. Sign up for Dispatches to get our stories in your inbox every week, and sign up for New York Focus’ newsletter here.

Hotels have long been considered a last resort for sheltering people who’ve lost their housing. But over the past few years, they’ve become New York’s predominant response to homelessness outside New York City, a recent investigation by New York Focus and ProPublica found.

Social services agencies across the state now place nearly half of all individuals and families seeking shelter in hotels. Yet those placed in hotels often go without services that they’re supposed to receive in shelters, such as meals, help finding housing and sometimes child care so they can look for work.

The growing reliance on hotels has been driven by soaring rent, shelter closures and a spike in evictions that followed a moratorium during the COVID-19 pandemic.

The state Office of Temporary and Disability Assistance has known about the problem for years and even put rules to address the issue on its regulatory agenda. But the agency has failed to formally propose the rules or come up with a way to ensure people receive services they need.

Here are five charts to explain our investigation.

Statewide Spending on Hotels More Than Tripled From 2018 to 2024 Data source: Analysis of Office of Temporary and Disability Assistance data on emergency shelter payments. Years are fiscal years. (Lucas Waldron/ProPublica)

The number of families and individuals placed in hotels doubled in the two years following the end of New York’s eviction moratorium in 2022. As the population in hotels shot up, so did the bill. Over that period, spending on hotels outside of New York City more than tripled to $110 million.

OTDA oversees the state’s county-run social services districts. The agency’s commissioner, Barbara Guinn, said that it prefers that counties use shelters, but that there aren’t enough beds for everyone who needs one. She said that the agency hadn’t studied the growth in hotel use.

Required Services in Shelters vs. Hotels Note: Requirements are for hotels outside of New York City. New York regulations state that hotels can be considered shelters, and thus mandated to provide services. But there aren’t any that are currently required to do so, Office of Temporary and Disability Assistance spokesperson Anthony Farmer said. Source: New York Codes, Rules and Regulations.

Despite the growth in spending, families placed in hotels aren’t promised the same services as people in shelters. New York requires family shelters to provide services like child care, assistance finding housing and three meals a day. But the regulations generally exempt hotels.

There’s an exception: A hotel is supposed to be considered a shelter if it “primarily” serves temporary housing recipients. OTDA spokesperson Anthony Farmer said that the agency interprets “primarily” to mean “exclusively, or almost exclusively,” and that no hotels currently meet that standard. An analysis of the agency’s data by New York Focus and ProPublica found that welfare recipients made up over half of the capacity for at least 16 hotels during fiscal year 2024.

Guinn said that social services offices have to work within the confines of what hotel owners will allow, and that counties try to provide services off-site.

The Number of Individuals and Families Housed in Hotels for More Than Six Months Nearly Tripled From 2022 to 2024 Data Source: Analysis of Office of Temporary and Disability Assistance data on emergency shelter payments. Years are fiscal years. Stays may not be continuous. (Lucas Waldron/ProPublica)

Not only are more people being placed in the hotels, but they are staying for much longer periods. The number of families and individuals spending at least six months out of the year in hotels nearly tripled from 2022 to 2024.

The lack of services leads to people getting stuck in the system, creating a snowball effect, said Steve Berg, chief policy officer for the National Alliance to End Homelessness.

“It’s this expanding problem,” he said. “A good shelter should be housing-focused. If they don’t have a pretty substantial effort to move people quickly back into housing and provide the services that are necessary to do that, the shelters quickly fill up, and then they just need more shelters.”

Farmer said via email that a lack of affordable housing contributes to the longer stays, and that counties can use other funding to help people move back into permanent housing.

New York Social Services Agencies Frequently Paid Hotels Over Fair Market Rent for a Two-Bedroom Apartment

Nearly half of all payments to hotels were for more than twice the counties’ FMR.

Data Source: Analysis of Office of Temporary and Disability Assistance data on emergency shelter payments; U.S. Department of Housing and Urban Development fair market rent data for two-bedroom apartments in each county for federal fiscal year 2024. (Lucas Waldron/ProPublica)

Many hotels are charging rates higher than rent for permanent housing.

The news organizations found that the overwhelming majority of hotel payments exceeded fair market rent for a two-bedroom apartment in the same county. (Fair market rent is defined by the U.S. Department of Housing and Urban Development as the 40th percentile of rent plus utilities in the local housing market.) The rates charged were often more than twice that.

“We’re forced to rent hotel rooms across the state, and the operators of these places understand that,” said state Sen. Roxanne Persaud, a Democrat and chair of the chamber’s Social Services Committee. “The municipalities’ backs are against the wall. And so they must place the unhoused person or persons somewhere. And so that’s why you see the cost is skyrocketing, because people understand that it’s an easy way to make money off the government.”

More Than a Third of Hotels Used to Shelter Homeless People Were Out of Date on Social Services Inspections as of October 2024 Data Source: Analysis of Office of Temporary and Disability Assistance data on inspections of hotels and motels used for emergency shelter. (Lucas Waldron/ProPublica)

New York Focus and ProPublica found numerous examples of families with children living in sordid and dangerous conditions. Roaches, mold, broken windows and filthy linens were common. Some hotels were subject to over a hundred emergency calls a year for assaults, robberies, mental health crises, overdoses and other incidents.

Hotels sheltering homeless families are supposed to be inspected every six months by their county’s social services office. Yet data obtained from OTDA shows that many wind up behind schedule. As of October, about 40% of hotels were either out of date on their inspection or didn’t have one listed.

Farmer, the OTDA spokesperson, said that nearly all hotels were inspected within a year, and that some had stopped accepting welfare recipients.

Guinn, the commissioner, said that OTDA will formally propose rules this year clarifying that people in hotels must receive the same services as they would receive in shelters. She also said her agency will increase oversight of how social services offices are delivering those services.

U.S. Rep. Mike Bost, citing lost mail and delays, wants the Post Service’s inspector general to audit the St. Louis Processing and Distribution Center in Hazelwood.

As a professional in the disability field for more than 40 years, I know firsthand how much of a lifeline Medicaid is for people with disabilities and those who care for them. At Easterseals Midwest, we support people with disabilities to live independently, find meaningful employment, get support in their everyday lives, and more. The […]

China is a major buyer of U-S agricultural specialty products. Some producers worry the on-and-off tariffs with the country could hurt America's reputation as a reliable seller.

ST. LOUIS - As a cold front exits the Bi-State, you can already feel the less humid air settling into the region behind it. The last of any rain or storms will exit before sunrise Tuesday morning and skies will gradually clear from northwest to southeast. The day will be sunny with highs in the [...]

Celebrations are in order as Blondie's iconic frontwoman Debbie Harry is turning 80 on Tuesday.Harry co-founded Blondie with guitarist Chris Stein in New York in the ‘70s. The band hit it big in 1979…

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by Jessica Lussenhop, and photography by Sarahbeth Maney

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In court, Dr. Nancy Harper comes across as professional and authoritative. Often she begins her testimony by explaining her subspeciality: child abuse pediatrics, which focuses on the diagnosis and documentation of signs of child abuse. Her role, she often reminds judges and juries, is solely medical. Whether or not to remove a child from their home, terminate the parent’s rights or, in the most serious cases, charge a caregiver criminally is not up to her.

According to Harper’s testimony, she and her team at the Otto Bremer Trust Center for Safe and Healthy Children in Minneapolis handle about 700 cases of suspected abuse each year. She has testified that 10% to 20% of those wind up confirmed for physical abuse, although it is difficult to determine if these figures are accurate since child protection cases are not public.

When Harper, the center’s director, and her team diagnose abuse, parents and caregivers often struggle to challenge those opinions. By Harper’s own estimation, she’s never been wrong.

“I don’t think I’ve ever had a case where I thought it was abusive head trauma and the other specialist didn’t,” Harper testified in 2023, in the case of a day care provider charged with the death of a child in her care.

The defense attorney in the case pressed her: “Have you ever incorrectly diagnosed a child with abusive head trauma?”

“Not currently to my recollection,” she answered.

But in a handful of cases, judges and juries have found day care providers and parents not guilty of crimes after Harper has testified that abuse occurred, though a verdict cannot necessarily be interpreted as a repudiation of Harper or any other expert witness’ determinations or credibility.

Additionally, two federal lawsuits filed recently accuse Harper of ignoring or even concealing alternative explanations for children’s injuries. And, more broadly, medical and legal experts are increasingly questioning a leading child abuse diagnosis, shaken baby syndrome, which is also known as abusive head trauma.

Harper did not respond to requests for comment. She has yet to respond to either lawsuit. In past court testimony, Harper has said that both shaken baby syndrome and abusive head trauma are considered scientifically valid diagnoses by the mainstream medical community. Any controversy, she has said, exists primarily in the legal world rather than the medical one.

Kathleen Pakes, a former prosecutor who now specializes in the forensics of child abuse cases for the Office of the Wisconsin State Public Defender, said Harper’s claim of never making an incorrect diagnosis strains credulity.

“There is no other specialty in medicine that has zero error rate. None,” she said.

Below are four cases in which Harper concluded there was abuse but courts or juries determined otherwise.

On July 12, 2017, an 11-month-old boy named Gabriel Cooper collapsed in his high chair at the day care that Sylwia Pawlak-Reynolds operated in South Minneapolis. Paramedics took him to Hennepin County Medical Center, where he was declared brain dead a day later.

Harper reviewed Cooper’s medical records and wrote that “in the absence of a well-documented consistent severe accidental injury, non-accidental trauma or abusive head trauma remains the primary diagnostic consideration.” The child, she wrote, was essentially shaken to death. Before any criminal charges were filed, Pawlak-Reynolds boarded a plane for her native Poland to care for her ailing father, according to her attorney. In February 2018, prosecutors charged Pawlak-Reynolds with two counts of second-degree murder, citing Harper’s diagnosis.

According to her husband, Will Reynolds, they did not realize Pawlak-Reynolds was pregnant when she boarded her flight to Poland. She remained there to give birth to their third child, who is now 6, while Reynolds remained in Minnesota with their two older children, who are now 13 and 16. Reynolds said he and his wife have no confidence that she will get a fair trial, and that she fears she will lose custody of their youngest child if she reenters the country. The family has now been separated for eight years.

Sylwia Pawlak-Reynolds’ husband, Will Reynolds, remains in Minnesota with their two older children.

Early in the case, Pawlak-Reynolds’ attorneys obtained the same copy of Cooper’s hospital records that had been provided to Minneapolis police, which included the paramedics’ report. The document had been printed out at a significantly reduced scale, shrinking the text to the point that some fields were illegible. Two years later, they obtained a second copy, printed at normal size, which revealed a possible alternate explanation for the injuries: “Mom recalls [patient] did fall 2 days ago, striking the back of his head.”

“That was the sort of proverbial silver-bullet evidence that we’re always looking for in every case and usually never find,” said Brock Hunter, Pawlak-Reynolds’ lawyer.

Polish courts, including an appeals court, have denied extradition requests from the U.S. three times, and the country’s minister of justice has affirmed the rulings. The denials are particularly critical of Harper’s assessment. Polish forensic experts evaluated the case records and took note of a finding by a neurology expert hired by Pawlak-Reynolds, who wrote that Cooper carried a gene tied to a blood clotting disorder.

The ambulance report, the Polish judges wrote, “was concealed from the defense.”

“Then, after the fact was made public, it did not affect the actions of the American authorities in any way,” a Polish district court judge wrote in 2022.

Hennepin Country Medical Center

The Hennepin County Medical Examiner’s Office certified Cooper’s manner of death as “undetermined” and the date and place of injury “unknown,” a tacit disagreement with Harper’s opinion that Cooper would have collapsed “shortly after infliction of the trauma.”

The Hennepin County Medical Examiner’s Office declined to comment.

Then in 2023, Hennepin County Attorney Mary Moriarty wrote to Pawlak-Reynolds’ attorneys after meeting with them: “We agree that to resolve the current impasse regarding Ms. Pawlak-Reynolds, the best course for all involved is to dismiss the pending charges without prejudice, and for her to return to the United States.”

But months later, Moriarty changed her mind.

In a statement to ProPublica, a spokesperson for the Hennepin County Attorney’s Office wrote that the office is completing a “final, thorough review” of the case that will include an evaluation of “concerns regarding the medical conclusions and the overall strength of the case.”

Gabriel’s parents, Joseph and Samantha Cooper, did not respond to requests for comment. In a television interview in June, they denied that Cooper struck the back of his head two days before his collapse. They said that they want justice for their son.

Pawlak-Reynolds declined to comment through her attorney. In late February, her husband filed a federal lawsuit against Harper that claims she “knowingly and intentionally falsified, modified and erased exculpatory information” from her evaluation of Cooper, and she diagnosed abusive head trauma to “promote her own personal, academic, reputational and financial needs.”

Harper has yet to respond to the lawsuit. A spokesperson for Hennepin Healthcare, which operates Hennepin County Medical Center, declined to comment on the case or the lawsuit.

“There is no oversight,” Reynolds said. “It’s the thing they’re most resistant against and the thing that is most necessary to stop this legacy of brutality, that results in kids being taken away from innocent caregivers and innocent caregivers going to prison.”

An old photograph shows Pawlak-Reynolds and one of her children

In August 2017, Kathryn Campbell called 911 after a 4-month-old girl at her day care seemed lethargic and was “breathing wrong.” First responders did not take the baby to the hospital, but her mother eventually did. At the hospital, MRI scans showed fluid in the baby’s brain and doctors noted small bruises.

Dr. Barbara Knox, a child abuse pediatrician then with the University of Wisconsin, told police it was “obvious child abuse.” The Dane County district attorney charged Campbell with physical abuse of a child. Campbell pleaded not guilty.

But before the 2021 trial, Knox left the University of Wisconsin after she was placed on leave for “unprofessional acts that may constitute retaliation” and intimidation of her own staff. A Wisconsin Watch investigation cast doubt on Knox’s judgment in several cases of alleged abuse.

Knox did not respond to the Wisconsin Watch series or to ProPublica’s requests for comment. After two families in Alaska sued her in 2022, alleging she had wrongly concluded their children had been abused, Knox wrote in an affidavit that she has no control over whether police and child protection services workers take children away from parents, that she did not “conspire” with police or anyone else on custody issues, and that she did not personally evaluate one of the children. The lawsuit was dismissed in 2024 after the families agreed to drop the matter.

Knox moved on to a job at the University of Florida. According to a spokesperson for the university, Knox resigned as a pediatrician with the Child Protective Team in late June, effective Aug. 15. He declined to comment on the circumstances.

At Campbell’s trial, Knox’s name was never mentioned. Instead, Harper stepped in as an expert witness. When Campbell heard Knox had been replaced, she was initially hopeful.

“I’m like, oh, great, new eyes,” Campbell said. “They’re going to look at it and go, ‘This is nuts, I don’t agree with this.’ And I definitely was wrong.”

Harper’s assessment affirmed Knox’s diagnosis of abuse. She told the jury that the bruises were likely caused by squeezing by an adult’s hand. A medical expert hired by Campbell’s defense argued that the child’s bleeding could not be precisely dated and that a preexisting medical condition could have caused it.

After just two hours of deliberation, the jury returned a not guilty verdict. Campbell said she is grateful to have the case concluded, though she said she is still haunted by the accusations against her.

“That was the hardest thing too, going home after this case was done, and being like, ‘Am I allowed to be alone with my children now?’” she said. “It’s all because of the quote-unquote experts not doing their due diligence and looking further into underlying issues that these kids could have.”

In a statement to ProPublica, Dane County District Attorney Ismael Ozanne expressed confidence in both Harper and Knox, saying “their testimony had been consistent with many different medical professionals and experts in their own areas of practice.”

“It is important to note that a not guilty verdict by lay jurors hardly invalidates the widespread acceptance of abusive head trauma as a diagnosis in the medical community nor would it cause us to have concerns about Dr. Harper’s qualifications or knowledge in the field,” he added. “Jurors are not bound to accept any expert testimony as accurate.”

In the winter of 2022, a 4-month-old boy began breathing abnormally at his day care in Mineral Point, Wisconsin. His parents took him to a hospital, where he died days later. A police investigation determined that his day care provider, Joanna Ford, left him and several other children alone in her home for over an hour while she went to a tattoo and piercing parlor.

Prosecutors used Harper as an expert witness in the case. After evaluating the child’s medical records, she concluded that his injuries were “clinically diagnostic of abusive head trauma,” or, put another way, Ford shook the baby violently. She was charged with first-degree reckless homicide. Ford pleaded not guilty.

Ford’s defense lawyers successfully petitioned the judge in the case for a hearing to determine whether Harper’s expert witness testimony would be scientifically valid and admissible at trial. In response to questions, Harper explained why the child’s symptoms — brain swelling, blood under his skull, damage to his eyes — pointed to abuse, and why, despite the controversy surrounding it, the diagnosis of abusive head trauma was scientifically sound. She also explained that, because the baby was not walking or crawling, the fact that none of his caregivers could explain his injuries indicated abuse.

“People should know what happened,” she testified.

On cross examination by Ford’s lawyers, Harper said she couldn’t say for certain what time the abuse would have occurred, exactly how Ford had injured the baby and that there are no “great biomechanical models” for shaken baby syndrome.

A little over a month later, Judge Lisa McDougal delivered a highly critical ruling that barred Harper from telling the jury that the child died as the result of “abusive head trauma, non-accidental injury, child abuse or murder.” She also took issue with the idea that a lack of explanation for injuries is indicative of abuse, calling it a “leap in logic.”

“Offering a conclusive opinion as to how an injury may have occurred crosses a line and does not fit within the dictionary definition of what diagnosis is,” McDougal said. The judge also said that Harper views herself as an advocate, and that that casts doubt on her “fidelity to the scientific validation of abusive head trauma diagnoses, especially when it is a close call.”

The murder charge was dismissed. For leaving the children alone, Ford pleaded guilty to the lesser charge of neglect of a child where the consequence is death. She is serving a 10-year prison sentence. Ford, through her attorney, declined a request for an interview. The Iowa County district attorney also declined to comment.

On Feb. 4, 2022, Paul and Sarah Marshall hosted a dinner for her parents and a family friend at their home in Hudson, Wisconsin. Afterward, their 7-week-old son, Fox, became fussy. Paul Marshall carried him into the mother-in-law unit on the lower level of the house, which was cool and dark, to try to calm him. He emerged minutes later in a panic, yelling that the baby spit up and stopped breathing.

Paramedics rushed Fox to Children’s Minnesota, a hospital about 25 minutes across the state border in St. Paul. Doctors ran tests, and a scan showed Fox had a skull fracture with fluid pooling on both sides of his brain. He died days later.

Harper examined Fox, as well as his twin sister, Liana, and found “skull fractures, likely rib fractures, metaphyseal fractures.”

“This constellation of findings in a nonambulatory infant is clinically diagnostic of inflicted injury or child physical abuse likely occurring on more than one occasion,” she wrote.

But the Marshalls said that wasn’t true. They told Harper that Sarah Marshall had experienced a difficult pregnancy with gestational diabetes and severe anemia, and that Liana had a vacuum-assisted delivery. Both twins had been to their regular pediatrician over health concerns. While Liana’s health improved, Fox’s had not.

A spokesperson for Children’s Minnesota declined to comment on the case.

Because he was the last person alone with Fox before he stopped breathing, Paul Marshall was charged with first-degree reckless homicide. He was also charged with physical abuse of a child for hurting Liana. Sarah Marshall said there was no evidence that her soft-spoken husband had hurt their children.

“The state wanted to cast me as a naive idiot,” she said. “I chose not to believe it because of the logic and facts in my face. I had no reason to believe the accusation.”

At Paul Marshall’s 2023 trial, his defense lawyer, Aaron Nelson, cross-examined the other doctors who treated or evaluated Fox and Liana, and was able to highlight points of medical disagreement. A doctor who tested Liana for genetic disorders said she could not rule out rickets as a possible cause of her bone fractures. A neuropathologist did not agree with Harper that Fox had a trauma-induced blood clotting disorder. By Harper’s own admission on cross-examination, determining the age of the skull fractures in children Fox and Liana’s age was difficult. Nelson called six of his own medical experts to suggest that the difficult birth or a vitamin deficiency could explain the twins’ injuries.

“How many people have to be wrong for Dr. Harper to be right?” Nelson said in closing arguments.

After an 11-day trial, the jury found Marshall not guilty.

In a statement to ProPublica, St. Croix County District Attorney Karl Anderson pointed out that Harper was not the only treating physician who was concerned that Fox and Liana had been abused.

“A not guilty verdict does not mean that the jury concluded that the children were not abused,” Anderson said. “Rather, it means that they did not conclude that the State proved that Paul Marshall caused the death, beyond a reasonable doubt.”

Paul and Sarah Marshall with their children at home, which is decorated with memories of their son, Fox

Six weeks after the trial, the family moved three hours away into a century-old farmhouse that is far from the community that they felt wrongfully villainized by.

One of the cruelest impacts of the abuse diagnosis, they said, came after it was clear that Fox would die and the hospital staff began making preparations for his organs to be donated. Sarah Marshall said she had hoped to someday hear her son’s heart beating in another child’s chest. Instead, a court order put a halt to the procedure.

“They were already treating him as evidence,” she said.

The experience of going from a grieving parent to an accused murderer, her husband said, has given the couple post-traumatic stress. Paul Marshall said he is grateful to be with his wife and children, but what he calls a “broken system” has left them unsure whether or not to have another baby or even be left alone with one of their daughters.

“You get pregnant. You go to all of your appointments. You voice all of your concerns. You do everything you’re supposed to do as a parent and your child still dies. And the state tells you it’s your fault,” Sarah Marshall said. “I don’t understand why I live in a world like that.”

Mariam Elba contributed research.

The city is creating a demolition plan, first focusing on buildings that were vacant and condemned before the tornado and then, with consent, homes beyond repair.

As Republicans in Congress rip up the safety net, the quest for wages that keep pace with the high cost of living intensifies.

The besieged agency cannot even handle its current workload. After last week’s Supreme Court ruling, workers expect millions more people seeking help.

Treasury Secretary Scott Bessent is gay and married. Hello?

by Kavitha Surana, Lizzie Presser and Andrea Suozzo

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Before states banned abortion, one of the gravest outcomes of early miscarriage could easily be avoided: Doctors could offer a dilation and curettage procedure, which quickly empties the uterus and allows it to close, protecting against a life-threatening hemorrhage.

But because the procedures, known as D&Cs, are also used to end pregnancies, they have gotten tangled up in state legislation that restricts abortion. Reports now abound of doctors hesitating to provide them and women who are bleeding heavily being discharged from emergency rooms without care, only to return in such dire condition that they need blood transfusions to survive. As ProPublica reported last year, one woman died of hemorrhage after 10 hours in a Houston hospital that didn’t perform the procedure.

Now, a new ProPublica data analysis adds empirical weight to the mounting evidence that abortion bans have made the common experience of miscarriage — which occurs in up to 30% of pregnancies — far more dangerous. It is based on hospital discharge data from Texas, the largest state to ban abortion, and captures emergency department visits from 2017 to 2023, the most recent year available.

After Texas made performing abortions a felony in August 2022, ProPublica found, the number of blood transfusions during emergency room visits for first-trimester miscarriage shot up by 54%.

The number of emergency room visits for early miscarriage also rose, by 25%, compared with the three years before the COVID-19 pandemic — a sign that women who didn’t receive D&Cs initially may be returning to hospitals in worse condition, more than a dozen experts told ProPublica.

While that phenomenon can’t be confirmed by the discharge data, which tracks visits rather than individuals, doctors and researchers who reviewed ProPublica’s findings say these spikes, along with the stories patients have shared, paint a troubling picture of the harm that results from unnecessary delays in care.

“This is striking,” said Dr. Elliott Main, a hemorrhage expert and former medical director for the California Maternal Quality Care Collaborative. “The trend is very clear.”

Blood Transfusions in First-trimester Pregnancy Loss ER Visits Spiked After Texas Banned Abortion

After the state’s first abortion ban went into effect in September 2021, blood transfusions increased. After abortion became a felony in August 2022, they increased more.

Note: For emergency department visits involving a pregnancy loss at less than 13 weeks gestation, or with an unknown gestational week.

The data mirrors a sharp rise in cases of sepsis — a life-threatening reaction to infection — ProPublica previously identified during second-trimester miscarriage in Texas.

Blood loss is expected during early miscarriage, which usually ends without complication. Some cases, however, can turn deadly very quickly. Main said ProPublica’s analysis suggested to him that “physicians are sitting on nonviable pregnancies longer and longer before they’re doing a D&C — until patients are really bleeding.”

That’s what happened to Sarah De Pablos Velez in Austin last summer. As she was miscarrying and bleeding profusely, she said physicians didn’t explain that she had options for care. Sent home from the emergency room without a D&C two times, she ultimately needed blood transfusions so that she wouldn’t die, according to medical records. “What happened to me was just so wrong,” she told ProPublica. "Doctors need to be providing care to pregnant women — that needs to be a baseline.”

Sarah De Pablos Velez was sent home from an emergency room while bleeding profusely during a miscarriage last year; she ultimately needed blood transfusions to save her life. (Ilana Panich-Linsman for ProPublica)

After ProPublica exposed preventable deaths following delays in care, the Texas Legislature passed a bill this year to clarify that doctors can provide abortions when a patient is facing a life-threatening emergency, even if it is not imminent.

But many Texas doctors say the reform does not address the difficulty of treating women experiencing early miscarriages, which almost always involve blood loss; they say it’s hard to know when the expected bleeding might evolve into a life-threatening emergency — one that could have been prevented with a D&C. Women can bleed and remain stable for a long time, until they crash.

Texas forbids abortion at all stages of pregnancy — even before there is cardiac activity or a visible embryo. And while the law allows doctors to “remove a dead, unborn child,” it can be difficult to determine what that means during early miscarriage, when an array of factors can signal that a pregnancy is not progressing.

An embryo might fail to develop. Cardiac activity may not emerge when it should. Hormone levels might dip or bleeding might increase. Even if a doctor strongly suspects a miscarriage is underway, it can take weeks to conclusively document that a pregnancy has ended, and all the while, a patient might be losing blood.

Some OB-GYNs and emergency room physicians have long been advising patients to complete their miscarriage at home, especially at Catholic hospitals, even if that is not the standard of care. But now, physicians across the state are faced with a law that threatens up to 99 years in prison, and more are making a new calculus around whether to intervene or even tell patients they are likely miscarrying, said Dr. Anitra Beasley, an OB-GYN in Houston. “What ends up happening is patients have to present multiple times before a diagnosis can be made,” she added, and some of those patients wind up needing blood transfusions.

While they can be lifesaving, transfusions do not stop the bleeding, experts told ProPublica, and they can introduce complications, such as severe allergic reactions, autoimmune disorders or, in rare events, blood cancer. The dangers of hemorrhage are far greater, from organ failure to kidney damage to loss of sensation in the fingers and toes. “There’s a finite amount of blood,” said Dr. Sarah Prager, a professor of obstetrics and gynecology at the University of Washington. “And when it all comes out, you’re dead.”

ProPublica’s findings about the rise in blood transfusions make clear that women who experience early miscarriages in abortion ban states are living in a more dangerous medical climate than many believe, said Amanda Nagle, a doctoral student investigating the same blood transfusion data for a forthcoming paper in the American Journal of Public Health.

“If people are seeking care at an emergency department,” Nagle said, “there are serious health risks to delaying that care.”

Waiting for Certainty

In some clinics and hospitals across Texas, the pressure to definitively diagnose a miscarriage has led to delays in offering D&Cs.

Considering the chance of criminal prosecution, some doctors now default to what many pregnancy loss experts view as an overly cautious method for diagnosing miscarriage: ultrasound images alone, using criteria from the Society of Radiologists in Ultrasound. Relying only on images to diagnose — and discounting other factors, like lab results or clinical symptoms — can take days or even weeks.

Dr. Gabrielle Taper was a resident at a Catholic hospital in Austin when the ban was enacted, and a culture of fear took hold among her colleagues, she told ProPublica. “We started asking, ‘Are we certain that we can document that we’ve met the radiology guidelines?’ as opposed to just treating the patient in front of us,” she said.

If they couldn’t show that the likely miscarriage met the criteria, they often felt they had to discharge patients without offering a D&C. “People are already in distress, and you are giving them confusion, a false sense of hope,” she told ProPublica. “Having to send a patient home knowing they may bleed so much they would need a blood transfusion — when I know there are procedures I could do or medicine I could offer — is just excruciating.”

The hospital where she worked did not respond to ProPublica’s request for comment.

The American College of Obstetricians and Gynecologists does not recommend this approach, advising doctors instead to review the ultrasound as one piece of information among many and counsel patients on all their options.

The Society of Radiologists in Ultrasound said that the guidelines “are not meant to apply in the setting of a life-threatening situation, such as heavy bleeding,” but did not respond to a question about whether it agreed with ACOG that doctors should use a combination of ultrasound images and clinical judgment to assess a pregnancy loss.

Dr. Courtney A. Schreiber, an obstetrics and gynecology professor and expert in early pregnancy care, said that even if a patient wants to let a likely miscarriage complete at home, the medical team should still explain different management options, including medication to speed up the process or a D&C, should symptoms like bleeding get worse.

“It’s our obligation to share information, help manage expectations and keep women safe,” she said.

What happened to Porsha Ngumezi shows how dangerous it can be to delay care, according to more than a dozen doctors who previously reviewed a detailed summary of her case for ProPublica.

When the mother of two showed up bleeding at Houston Methodist Sugar Land in June 2023, at 11 weeks pregnant, her sonogram suggested an “ongoing miscarriage” was “likely,” her doctor noted. She had no previous ultrasounds to compare it with, and the radiologist did not locate an embryo or fetus — which Ngumezi said she thought she had passed in a toilet; her doctors did not make a definitive diagnosis, calling it a pregnancy of “unknown location.” After hours bleeding, passing “clots the size of grapefruit,” according to a nurse’s notes, she received two blood transfusions — a short-term remedy. But she did not get a procedure to empty her uterus, which medical experts agree is the most effective way to stop the bleeding. Hours later, she died of hemorrhage, leaving behind her husband and young sons.

Hope Ngumezi holds a photograph of him and his late wife, Porsha, who died in a Houston hospital during a miscarriage in June 2023. (Danielle Villasana for ProPublica)

Doctors and nurses involved in Ngumezi’s care did not respond to multiple requests for comment for ProPublica’s story last fall, and the hospital did not answer questions about her care when asked about it again for this story. A spokesperson from Methodist Hospital said its OB-GYNs follow ACOG’s miscarriage diagnosis guidelines, which recommend considering clinical factors in addition to ultrasounds.

Visit After Visit

Even in circumstances in which the abortion ban allows a doctor to intervene — to treat a life-threatening emergency, for example, or to “remove a dead, unborn baby” — there’s plenty of evidence, detailed in lawsuits and federal investigations, that doctors in Texas still aren’t offering procedures.

As soon as Sarah De Pablos Velez, a 30-year-old media director, learned she was pregnant last summer, she began attending regular checkups at St. David’s Women’s Care, in Austin. During her third appointment at about nine weeks, a resident, Dr. Carla Vilardo, and her supervisor, Dr. Cynthia Mingea, reviewed the ultrasound, according to medical records, which indicated her pregnancy wasn’t viable. Instead of being offered treatment for a miscarriage, De Pablos Velez says she was advised to hold out hope and come back for the next checkup.

Five maternal health experts and practicing OB-GYNs who reviewed the records for ProPublica said by that ultrasound visit, doctors would have had enough information to determine that the pregnancy wasn’t viable, even under the most conservative guidelines. If they wanted to be extra sure, they could have done blood work or one more ultrasound during that visit.

Instead, De Pablos Velez was told to come back in two weeks, according to medical records. During a visit when she should have been nearly 11 weeks pregnant, Mingea wrote in her chart she was “not optimistic” about the pregnancy's viability. Still, De Pablos Velez was advised to return in another week to be sure.

Within a few days, when the cramping got so bad she could barely walk, De Pablos Velez went to the emergency room at St. David’s Medical Center, unaware that a D&C could stop the pain and the bleeding. “I’ve never researched what it looks like for women who have a miscarriage,” she told ProPublica. “I always thought you go to the bathroom and have a little bit of blood.”

Over two visits to the emergency room, doctors told her that she could complete the miscarriage at home, even as she reported filling up three toilet bowls with blood and a nurse remarked that they needed a janitor to clean the floor, De Pablos Velez and her husband recalled. No obstetrician ever came to assess her condition, according to medical records, and while her hospital chart says “all management options have been discussed with the patient and her husband,” De Pablos Velez and her husband both told ProPublica no one offered her a D&C.

She was told to follow up with her OB at her next appointment in three days. Six hours after discharge, though, she was trying to ride out the pain at home when her husband heard her muttering “lightheaded” in the bathroom and ran to her in time to catch her as she collapsed. “She was pale as a ghost, sweating, convulsing,” said her husband, Sergio De Pablos Velez. “There was blood on the toilet, the trash can — like a scene out of a horror movie.”

An ambulance rushed her to the hospital, where doctors realized she no longer had enough blood flowing to her organs. She received two blood transfusions. Without them, several doctors who reviewed her records told ProPublica, she would have soon lost her life.

De Pablos Velez and her husband, Sergio, at home in Austin (Ilana Panich-Linsman for ProPublica)

Vilardo and the doctors who saw De Pablos Velez in the emergency room did not respond to requests to speak with ProPublica or declined to be interviewed. St. David’s Medical Center, which is owned by HCA, the largest for-profit hospital chain in America, said it could not discuss her case unless she signed privacy waivers. The hospital did not respond to ProPublica’s questions even after she submitted them. The De Pablos Velezes say that a hospital patient liaison told them after the ordeal that the hospital would conduct an internal investigation, educate the emergency department on best practices and share the results. It never shared anything. When ProPublica asked about the status of the investigation, neither the liaison nor the hospital responded.

Mingea, who supervised Vilardo’s care during checkups, reviewed the clinic’s records with ProPublica and agreed that De Pablos Velez should have been counseled about miscarriage management options at the clinic, weeks before she ended up in the ER. She said she did not know why she wasn’t but pointed ProPublica to the Society of Radiologists in Ultrasound criteria, which is hanging on the clinic’s wall and is used to teach residents.

She was adamant that her clinic, which she described as “very pro-choice — about as much as we can be in Texas,” regularly provides D&Cs for miscarrying patients. “I feel badly that Sarah had this experience, I really do,” she said. “Everybody deserves to be counseled about all their options.”

Doctors had five opportunities to counsel De Pablos Velez about her options and offer her a D&C, said Dr. Jodi Abbott, an associate professor of obstetrics and gynecology at Boston University School of Medicine, who reviewed case records. If they had, the life-or-death risks could have been avoided.

De Pablos Velez “basically received the same care Porsha Ngumezi did, only Porsha died and she survived,” said Abbott. “She was lucky.”

Sophie Chou contributed data reporting, and Mariam Elba contributed research.

by Andrea Suozzo, Kavitha Surana and Lizzie Presser

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Even though about a million women a year experience a miscarriage, there is little research on complications related to pregnancy loss in the first trimester, when most miscarriages happen. The need to explore this phase is urgent, experts told ProPublica, given the way state abortion bans have disrupted maternal health care.

Although most early miscarriages resolve without complications, patients with heavy bleeding can hemorrhage if they don’t get appropriate treatment — which includes a procedure called dilation and curettage, or D&C, that is now tangled up in legislation that bans abortion. As women recounted being left to lose dangerous amounts of blood, and ProPublica told the story of a mother who died in a Houston hospital while seeking miscarriage care, reporters searched for a way to gain a broader understanding of what was happening in the state.

We consulted dozens of researchers and clinicians to develop our methodology and understand how to look at early miscarriage outcomes in the emergency department.

Our latest analysis, of hospital discharge data from Texas, found that after the state made performing abortions a felony in August 2022, the number of blood transfusions during emergency room visits for first-trimester miscarriage shot up by 54%.

The number of emergency room visits during first-trimester miscarriage also rose by 25%, a sign that women may be returning to hospitals in worse condition after being sent home, more than a dozen experts told ProPublica.

Experts say the spike is a troubling indicator of delays in care.

The most effective way to prevent severe blood loss during miscarriages, experts said, is a D&C, which uses suction to remove remaining tissue, allowing the uterus to close. The procedure is also used to terminate pregnancies.

Dr. Elliott Main, an expert on maternal hemorrhage and the former medical director for the California Maternal Quality Care Collaborative, said the increase in transfusions suggested to him that doctors working under abortion bans are now delaying those interventions for miscarrying patients for longer — “until they’re really bleeding.”

These findings add to ProPublica’s growing body of reporting revealing that maternal outcomes have gotten worse after the state’s abortion bans. In February, we published an analysis of second-trimester pregnancy loss hospitalizations, which found that the rate of sepsis climbed by more than 50% after the state banned abortion. That study focused only on inpatient stays in Texas hospitals. However, many of the clinicians and researchers we spoke with told us that that focus would limit what we could say about miscarriage care earlier in pregnancy; most people experiencing first-trimester pregnancy complications would likely be seen in a shorter emergency department visit, rather than an inpatient stay.

This methodology lays out the steps we took to examine early miscarriage outcomes in the emergency department, to help experts and interested readers understand our approach and its limitations.

Identifying First-Trimester Emergency Visits

We purchased seven years of discharge records for inpatient and outpatient encounters at hospitals and ambulatory surgery centers from the Texas Department of State Health Services. These records contain deidentified data for visits, with information about the encounter, including diagnoses recorded and procedures performed, as well as some patient demographic information and billing data.

We limited our analysis to visits with a diagnosed pregnancy loss across both the inpatient and outpatient datasets. We followed a methodology that maternal health researchers have used for many years to identify “abortive outcomes” — instances of pregnancy loss at less than 20 weeks, which includes diagnoses like ectopic pregnancy and miscarriage. Researchers have typically identified these cases in order to exclude them from metrics assessing complications in childbirth. In contrast, we focused our analysis only on those encounters with a pregnancy loss diagnosis. Medical experts suggested that it's possible more women are self-managing abortions at home; since a self-managed medication abortion would present like a spontaneous miscarriage, however, we can’t differentiate those patients in our data.

We also limited our analysis to either emergency department visits or inpatient stays that began in the emergency department. The state’s outpatient data also includes encounters for outpatient procedures and data for ambulatory surgery centers, which we excluded to focus on emergent hospital care. Ultimately, our analysis focused on 35,500 first-trimester visits per year that came into hospitals through the emergency department, excluding a small number (about 1,400 per year) of inpatient stays that did not begin in the emergency room.

To limit our analysis to pregnancy loss in the first trimester, we looked for a diagnosis code indicating gestational weeks. In cases where a long hospitalization had multiple gestational week codes recorded over the course of the stay, we took the latest one. We excluded any row that had a gestational week code of 13 weeks or more, which marks the start of the second trimester. The vast majority — 78% — of emergency department visits for pregnancy loss had a code indicating unknown gestational week or no gestational week diagnosis code at all. We included those visits in the first-trimester category. Clinicians told us that a pregnant patient coming to the emergency department in her first trimester is less likely to have had a doctor’s appointment establishing gestational age. Since pregnancy loss in the second or third trimester is more serious, and because it is easier to establish gestational age in a pregnancy that is further along, an emergency department doctor would likely be able to establish a gestational age over the course of treatment in those cases.

We then filtered our list of visits to ones where the patient was female and between the ages of 10 and 54, to exclude rows with potential errors. This removed 2,692 visits, or 1.1% of all visits we’d identified.

The number of emergency department first-trimester hospitalizations were relatively stable prior to COVID-19. In 2022, the first full year after the state passed its six-week abortion ban, the number of encounters jumped by 11%. And in 2023, the year after the state criminalized abortion, they rose again, increasing by 25% from pre-COVID levels.

While we could identify an increase in visits, we could not identify patients across visits, which means we can’t say how many of these visits represent the same person returning to the emergency department multiple times for the same pregnancy loss. Texas has seen an increase in live births since the state banned abortion — about 2.7% in 2022, compared with the pre-COVID average, and declining slightly in 2023. But this increase in births — and, by extension, pregnancies — does not explain the rate of change in emergency visits, which far surpasses it.

Clinicians also told us that the threshold for diagnosing pregnancy loss increased after the state banned abortion. To assess how many relevant visits our analysis might be leaving out, and whether we were missing more visits after hospital policy changes, we looked for visits without a pregnancy loss code but with a diagnosis of “threatened abortion” or “early pregnancy hemorrhage,” indicating uterine cramping or bleeding in early pregnancy. Since clinicians told us that these diagnoses might range from light spotting to significant bleeding, and since bleeding in pregnancy is common and does not always indicate a miscarriage in progress, we did not include these visits in our main analysis. However, we also identified a 23% increase in visits with those codes — from an annual average of 70,936 prior to COVID to 87,431 in 2023.

Identifying Transfusions

Next, we identified pregnancy loss visits with a transfusion, which typically indicates that there has been a dangerous loss of blood.

For our inpatient dataset, where procedures performed during a hospitalization were recorded as ICD-10-PCS codes, we identified visits with a blood transfusion using a list of codes defined by the Centers for Disease Control and Prevention. The outpatient dataset, which uses Current Procedural Terminology codes, has just one code — 36430 — for blood transfusions.

Prior to COVID-19, there were 840 first-trimester pregnancy loss emergency department visits each year, on average, with a blood transfusion. In 2022, the first full year after the state passed its first abortion ban, transfusions climbed to 1,076 — an increase of 28% from pre-COVID years. By 2023, the first full year after abortion was criminalized, that number climbed to 1,290 — an increase of 54% compared to pre-COVID. That’s 450 more visits with a blood transfusion in 2023 than the pre-COVID average.

Blood Transfusions in First-trimester Pregnancy Loss ER Visits Spiked After Texas Banned Abortion

After the state’s first abortion ban went into effect in September 2021, blood transfusions increased. After abortion became a felony in August 2022, they increased more.

Note: For emergency department visits involving a pregnancy loss at less than 13 weeks gestation, or with an unknown gestational week.

Even as the number of visits to the emergency department increased, the proportion of those visits with a transfusion also went up, from 2.5% in pre-COVID years to 2.8% in 2022 and 3% in 2023 — suggesting that the increase in transfusions may not be explained by an increase in encounters alone.

Experts who reviewed ProPublica’s data wondered if the increase in transfusions might be driven by more women experiencing complications of ectopic or molar pregnancies, rare nonviable pregnancies in which the likelihood of a blood transfusion is much higher than for a spontaneous miscarriage. The data did not bear this out. When we excluded visits with ectopic and molar pregnancy diagnoses, the increase in the number of pregnancy loss transfusions was even higher — it rose by 61% by 2023.

To understand whether there were increases in the numbers of transfusions in other maternal visits over the same time period, we also looked at blood transfusions in delivery events, using the federal methodology to identify birth complications. In hospital births, the number of transfusions increased by 6.7% in 2022 and 9.9% in 2023 compared with the pre-COVID average — an increase, but smaller in magnitude than the increase in first-trimester pregnancy loss hospitalizations.

Sophie Chou contributed data reporting.

In 1888 a stray dog roamed into a post office in Albany, New York. Perhaps initially attracted to the scent or texture of the canvas mailbags, the free-spirited Owney—a nickname for Owen—started accompanying them onto mail wagons and Railway Mail Service train cars. As Owney traveled throughout the country, Railway Mail Service clerks proudly placed …

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