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After the Supreme Court overturned Roe v. Wade, ending nearly 50 years of federal protection for abortion, some states began enforcing strict abortion bans while others became new havens for the procedure. ProPublica is investigating how sweeping changes to reproductive health care access in America are affecting people, institutions and governments.

State Rep. Taylor Rehfeldt was speaking on the floor of the South Dakota Capitol, four months pregnant with her third child, begging her Republican colleagues to care about her life.

“With the current law in place, I will tell you, I wake up fearful of my pregnancy and what it would mean for my children, my husband and my parents if something happened to me and the doctor cannot perform lifesaving measures,” she told her fellow lawmakers last February, her voice faltering as tears threatened.

Rehfeldt was a stroke survivor and her pregnancy put her at high risk for blood clots and heart issues that could kill her. The state’s ban made abortion a felony unless it was “necessary to preserve the life of the pregnant female.” If Rehfeldt developed complications, doctors told her, the law didn’t make clear how close to death she needed to be before they could act.

“When can a doctor intervene? Do I need to have my brain so oxygen-deprived to the point that I am nonfunctional?” she asked the room.

Rehfeldt is an ambitious rising Republican: She has a strong anti-abortion voting record and is serving as the House assistant majority leader. She also was a nurse. But her background and credentials failed to rally her colleagues to support a narrow clarification to the ban that would allow a doctor to end a pregnancy if “the female is at serious risk of death or of a substantial and irreversible physical impairment of one or more major bodily functions.”

“I would never have possibly imagined that a bill protecting a woman’s life could be so contentious,” Rehfeldt said on the floor of the House, announcing she was withdrawing her bill before even bringing it to a vote.

The language she and two other Republicans had landed on was still so slim, most national medical organizations and abortion-access advocates wouldn’t support it.

But even that had no chance. South Dakota Right to Life — a local affiliate of the major anti-abortion organization National Right to Life, which can rally voters to sway Republican primary elections — had told her it opposed any changes. (South Dakota Right to Life declined to comment.)

When the Supreme Court struck down the constitutional right to abortion last year, strict abortion bans in more than a dozen states snapped into effect. Known as “trigger laws,” many of the bans were passed years earlier, with little public scrutiny of the potential consequences, because few expected Roe v. Wade to be overturned.

Most of the trigger laws included language allowing abortion when “necessary” to prevent a pregnant person’s death or “substantial and irreversible” impairment to a major bodily function. Three allowed it for fatal fetal anomalies and two permitted it for rape victims who filed a police report. But those exceptions have been nearly inaccessible in all but the most extreme cases.

Many of the laws specify that mental health reasons can’t qualify as a medical emergency, even if a doctor diagnoses that a patient might harm herself or die if she continues a pregnancy. The laws also carry steep felony penalties — in Texas, a doctor could face life in prison for performing an abortion.

The overturn of Roe has intensified the struggle between those who don’t want strict abortion bans to trump the life and health of the pregnant person and absolutists who see preservation of a fetus as the singular goal, even over the objections of the majority of voters. In the states where near-total abortion bans went into effect after Roe’s protections evaporated, the absolutists have largely been winning.

And the human toll has become clear.

On the floors of state legislatures over the past year, doctors detailed the risks their pregnant patients have faced when forced to wait to terminate until their health deteriorated. Women shared their trauma. Some Republican lawmakers even promised to support clarifications.

But so far, few efforts to add exceptions to the laws have succeeded.

A review by ProPublica of 12 of the nation’s strictest abortion bans passed before Roe was overturned found that over the course of the 2023 legislative session, only four states made changes. Those changes were limited and steered by religious organizations. None allowed doctors to provide abortions to patients who want to terminate their pregnancies because of health risks.

ProPublica spoke with more than 30 doctors across the country about their experiences trying to provide care for patients in abortion-ban states and also reviewed news articles, medical journal studies and lawsuits. In at least 70 public cases across 12 states, women with pregnancy complications faced severe health risks and were denied abortion care or had treatment delayed due to abortion bans. Some nearly died or lost their fertility as a result. The doctors say the true number is much higher.

Early signs indicated Republicans might compromise, as voters in red states showed strong popular support for protecting abortion access and polls revealed the majority of American voters do not support total abortion bans. That opposition has only hardened since then, as reproductive rights drove a wave of Democratic electoral victories in Kentucky, Virginia and Pennsylvania in November. In Ohio, voters approved an amendment to the state’s constitution guaranteeing the right to an abortion.

But in the most conservative states, Republicans ultimately fell in line with highly organized Christian groups. Those activists fought to keep the most restrictive abortion bans in place by threatening to pull funding and support primary challenges to lawmakers that didn’t stand strong.

Their fervor to protect the laws reflects a bedrock philosophy within the American anti-abortion movement: that all abortion exceptions — even those that protect the pregnant person’s life or health — should be considered the same as sanctioning murder.

Facing Political Threats, Lawmakers Cave

By the time the 2023 legislative sessions began, the consequences of total abortion bans written years earlier by legal strategists with no medical expertise had become clear.

Across the nation, women described the harm they experienced when care was delayed or denied for high-risk complications or fatal fetal anomalies.

Amanda Zurawksi, a Texas woman who almost died after she was made to wait for an abortion until she developed a serious infection, testified before the U.S. Senate Judiciary Committee: “The preventable harm inflicted on me has already, medically, made it harder than it already was for me to get pregnant again.”

Jaci Statton, an Oklahoma woman who had a dangerous pregnancy that is never viable and can become cancerous, sued........

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