Madeline Fening
A nurse holds a sign in support of abortion access at a Planned Parenthood rally in Downtown Cincinnati on May 15, 2022.
While staring at the ceiling of an Ohio emergency room, Ellen Groh realized she’d experienced this pain four years before.
In February 2020, at nearly 18 weeks pregnant, she experienced a miscarriage.
“I was feeling great and then all of a sudden I had to poop,” Groh says over a Zoom call. Some identifying details, like her legal last name, have been changed to protect her identity. “And so I ran to the bathroom, and I didn’t poop. I delivered into the toilet. My 18-week fetus, pregnancy… I’m going to call them pregnancies, I think. I don’t really know what to call them.”
Weeks before, this pregnancy came as a surprise to Groh and her then-boyfriend, now husband. Nervously embracing the prospect of parenthood, everything was new to the young couple, including the symptoms of labor that had started three days before she ended up delivering in her toilet. Despite both Groh and her husband working in the medical field, they felt lost at that moment.
“We kind of froze,” she says. “We’re like, ‘What the hell do we do?’”
Groh told her husband to call their doctor, who instructed her to go to the hospital right away. There, she delivered her placenta, received antibiotics and started to navigate ricocheting feelings.
“It’s all different emotions, like relief, guilt, obviously sadness,” she says. “But like, we were okay. Cried a lot.”
Fast forward to October of 2023. Groh and her husband found out they were pregnant for the second time. Still a surprise, but a welcome one. They were excited to be parents.
“I want to say it was planned, because it was kind of like, if it’s going to happen, it’s going to happen,” she says. “Who’s ever ready?”
Like her first pregnancy, Groh’s developing embryo was healthy, but she and her husband took extra precautions to try and prevent another miscarriage, like genetic testing. Everything from her anatomy scan in February 2024 looked great.
Less than 10 days later at 20 weeks gestation, Groh and her husband were having sex – which is widely considered safe for pregnant individuals – when she began bleeding.
“I just kept bleeding and I was like, ‘Well, this is not normal,’” Groh says. “I had one big cramp and I was like, wow, that’s weird.”
Groh’s doctor told her to go right to the hospital. She thought they’d be coming home that same day.
“We didn’t even pack any bags,” she says. “It’s like, alright, we’ll be back soon.”
Groh’s cervix was nearly four centimeters dilated with telescoping membranes, meaning it was likely her body would try to deliver the pregnancy. Doctors presented the idea of cerclage, which is where doctors stitch a patient’s cervix shut to stave off labor, but Groh was told she may be too far dilated.
“After you’re dilated a certain amount, it becomes a risk of rupturing the membranes, and then [you’re at risk of] infection,” Groh says.
Next came the subject of viability – a conversation Groh knew was coming.
Fetal viability, which is the gestational age at which a fetus can survive outside the womb, is generally considered to be around 23 to 24 weeks with intensive medical care. Pregnancies delivered between 21 and 22 weeks rarely survive, with only 3% of babies surviving four hours after delivery, according to the National Institutes of Health.
“At this point […] I don’t think anybody has told me specifically that I’m miscarrying yet because, like, they’re trying, you know? We’re trying to get hope,” Groh says. “But I just want the facts. Give me the facts because I understand what’s happening with my body. With the limited medical knowledge that I have of this area, I can understand.”
Groh made it clear to her care team that she is a pediatric nurse. She knows the size of the tubes that can be used to keep a premature baby alive, and that a baby delivered at 20 weeks is too small for even the smallest tools needed to give them hope. She’s also intimately aware of what life would look like if she were to deliver a baby that’s not ready to enter the world – if her pregnancy would survive at all.
“There are substantial effects that this pregnancy, that this child could have down the road. Because I see this daily at work,” she says. “At this point, with the knowledge that I have and my history, in my brain, I think I know what’s gonna happen.”
Contractions were ramping up and becoming increasingly painful. Doctors confirmed Groh’s instincts from her experience in 2020: this wasn’t labor, this was a miscarriage. The pregnancy’s chances of survival were extremely low and the threat of infection and complications were rising, putting her own health at risk. Her care team grew with more specialists, more doctors who presented her with options, of which she knew there was only one. She decided to call it.
“It was almost like, kind of relieving,” she says. “I have all these thoughts in my brain, but now we’re going down a solid path. This is the path that we’re going down.”
The path included a handful of options for ending Groh’s physical and emotional suffering, but only two stuck out in the moment and in her memory: delivering the miscarried fetus naturally or getting a dilation and evacuation, known as a D&E.
“At the end of the day, this is what I wanted. I wanted a D&E,” Groh says. “I wanted to be done having contractions because I knew this fetus, or this pregnancy, was not going to survive. I had already been through it once, so I knew that this is what this fetus is going to look like.”
In addition to being used in miscarriage cases like Groh’s, a D&E is a method of abortion care used by doctors. Often referred to as a surgical abortion, the procedure uses suction and medical tools to empty the uterus. Some patients may also use misoprostol to remove a miscarriage during early pregnancy loss. Misoprostol is one pill from the often two-step medication abortion method, which is available to patients who are less than 11 weeks along in their pregnancy.
Patients who want or need to terminate a pregnancy can do so with a D&E until 21 weeks and six days gestation – that’s when Ohio law prohibits abortions of any kind moving forward, unless the patient’s life is at risk.
In Groh’s case, there was no way to know how long it would take to deliver her miscarried fetus naturally. All they knew was she was bleeding and the pregnancy was still giving off tones that indicate cardiac activity, and that matters. Doctors could have proceeded with the D&E if Groh’s fetus was no longer giving off heart tones, but Ohio law requires that doctors and their patients wait at least 24 hours before starting an abortion if fetal or embryonic cardiac activity is detected. The medical community generally considers cardiac activity to begin in utero around six weeks gestation, which is usually before most patients know they are pregnant. The concept of being able to hear a true fetal heartbeat at six weeks is also contested by some physicians.
According to Dr. Nisha Verma, an OB/GYN from the American College of Obstetricians and Gynecologists, cardiac valves don’t even exist at six weeks of gestation.
“The flickering that we’re seeing on the ultrasound that early in the development of the pregnancy is actually electrical activity, and the sound that you ‘hear’ is actually manufactured by the ultrasound machine,” Verma told NPR for a story about “heartbeat bills.”
Anatomy of the 24-hour rule
Identifying the presence of fetal heart tones is part of Ohio’s mandatory “informed consent” requirement for abortion patients, and it’s wrapped up in the 24-hour rule under that same umbrella.
The Ohio Legislature first imposed a mandatory information requirement for abortion in a law that took effect in 1992. Originally, that law allowed the information to be conveyed 24 hours before the abortion, “verbally or by other non-written means of communication” – meaning it did not require an initial in-person visit to the clinic. The information could be given by phone or even fax. This law was challenged in state court in Preterm Cleveland v. Voinovich, but the 10th District Court of Appeals upheld it as constitutional, and the Ohio Supreme Court declined to hear the case.
Then, in 1998, the legislature amended the law to require that the communication must occur in person.
Ever since, a physician must give the patient written confirmation that a cardiac activity is present and provide the patient with information about the statistical probability of carrying that pregnancy to term. The patient must sign and acknowledge receipt of this information, fulfilling the state’s informed consent requirement for abortion care.
Ohio is one of 33 states that requires such counseling before an abortion is performed; one of 29 states that details what information abortion providers must give these patients; one of 28 states that requires patients to wait a specific amount of time for their abortion after counseling; and one of just 16 states that requires this counseling take place in person, according to the Guttmacher Institute.
After jumping through the hoops of a consultation appointment and putting pen to paper, that’s when the clock starts. And while the waiting period rule may only span 24 hours, abortion providers report there are domino effects that can last weeks.
Why abortion providers oppose the 24-hour rule
Vanessa Hinsdale is the administrative director of surgery for Planned Parenthood of Southwest Ohio. She says the 24-hour waiting period clogs the entire scheduling system, impacting all patients.
“With the waiting periods for us because of the volume of patients that we see, it takes right now about 20 days to get in just for your first appointment,” Hinsdale says. “That clock is ticking and, say they really want a medication abortion, you know, they get in and they’re nine weeks and it’s 10 weeks in a day – it is literally 70 days, so if you come back after that 24-hour period and you are 71 days, we can’t. Without a waiting period, they would have more of a choice.”
The U.S. Supreme Court’s overturning of Roe v. Wade in June of 2022 created a cascading effect on abortion rights across the nation. States that once had abortion access quickly enacted “trigger bans” that drastically scaled back abortion access, sometimes outlawing it altogether. Ohio’s own “heartbeat bill” was enacted after the fall of Roe, effectively banning abortions after six weeks, but the ban was put on pause four months later when a Hamilton County judge granted a motion for preliminary injunction. In November of 2023, Ohio voters passed a citizen-led state constitutional amendment to enshrine the right to reproductive freedom, protecting abortion access. Issue 1 passed with wide margins – 56.8% of the vote. Ohio was the first red state to restore abortion rights after the Supreme Court returned the decision to the states.
Because Ohio abortion law currently allows patients to access an abortion up until 21 weeks and six days gestation, Ohio has become the only option for many out-of-state patients seeking an abortion. These patients are commonly coming from states with total abortion bans, like Indiana, Kentucky, Tennessee and West Virginia. But even states that have enacted and maintained narrow abortion windows, like Florida and South Carolina, are seeing citizens flee to Ohio for care. Hinsdale says Ohio’s waiting period law is making it difficult to meet the needs of both in-state and out-of-state patients.
“I will tell you, because of the 24-hour period and the amount of distance that patients are traveling here, we see around 51% of our patients are not in the state of Ohio,” Hinsdale says. “They’re coming from Lexington, Louisville, Tennessee, Indiana, Georgia, Florida, Louisiana.”
Ohio currently has nine abortion clinics in operation, including six surgical centers and three medication-only clinics. Depending on a patient’s location and gestational timeline, even in-state patients may need to travel hours and stay overnight to meet the 24-hour waiting period requirements. For out-of-state patients, this further extends the time spent away from work, family and loved ones, many of whom may not know their loved one is seeking an abortion.
“Not everybody has that comfort level, that ability, those people,” Hinsdale says.
There is no medical rationale for the 24-hour waiting period, says Hinsdale – it’s simply a matter of the state requiring the patient to have time to think about their decision. In Preterm Cleveland v. Voinovich, the case that upheld the 24-hour waiting period rule, Judge Petree wrote in his partial concurrence (he disagreed with others on the three-judge panel on providing patients with state-mandated information) that a 24-hour waiting period “would foster reflection” in patients.
“Clearly a waiting period, with ample provision for emergency situations, would foster reflection about important medical decisions,” the ruling reads. “Though we are unaware of similar waiting periods for other types of medical procedures, this is not fatal. No doubt there are many situations where medical providers perform questionable and perhaps unnecessary surgeries, such as hysterectomies, where a waiting period might serve to quell unthinking acceptance of a doctor’s conclusion. This is not too far afield of the common insurance company practice of requiring second opinions before invasive procedures are undertaken.”
But Hinsdale says sterilization procedures, like hysterectomies, aren’t held to the same standard as abortion care for “reflection” about your decision.
“If you are getting a vasectomy and you’re using certain types of insurance, or any kind of sterilization, there is a waiting period, and that is a very small subset of the population,” Hinsdale says. “There is nothing else that’s comparative to being like, you have to jump all through these hoops and wait and do all these things in order to have basic healthcare.”
The 24-hour waiting period law is different for those who are experiencing a medical emergency and want or need an abortion as a result, but doctors are often dealing with extremely narrow definitions about what constitutes “life of the mother” exceptions. Even if a patient is pregnant for less than 21 weeks and six days – the cut-off time for an elective abortion in Ohio – it’s against the law for a doctor to provide an abortion within the 24-hour waiting period window when there’s fetal cardiac activity. That is, unless the patient is at risk of losing their life or a major bodily function. In Ohio, a doctor who is found to have violated that 24-hour rule can be charged with a misdemeanor and potentially lose their license. Since the fall of Roe, there have been highly publicized cases of doctors, including in Ohio, who are declining to perform abortions for medically-emergent patients for fear of breaking the law.
“If you make standard medical care a crime when folks in all kinds of difficult medical situations present, especially in emergency situations, we are always going to see some type of delay,” Caitlin Gustafson, an OB-GYN in Idaho, told Politico in April. “Because it’s criminalized care, physicians are going to naturally hesitate.”
Whether a doctor will take on that risk on behalf of a patient experiencing a medical emergency can vary from hospital to hospital – sometimes transfers have to happen.
“You do have a section of patients that have a pregnancy that might have been a very desired, very sought after, sometimes a fertility-based pregnancy and that there might be parts of the pregnancy that are not sustainable but are not risk of life to the mother,” Hinsdale says. “If a patient doesn’t want to [deliver the pregnancy], they want to be able to just have a procedure, they either have to, in some cases, follow the 24-hour law or they have to go out of state to where there’s not a waiting period. It’s just more undue stress on a very stressful situation.”
Photo: Mary LeBus
A sign from an abortion rally
The clock starts for Groh
In Groh’s case, the start of her 24-hour waiting period on that February evening was when she started to feel less like a stoic pediatric nurse and more like a scared patient.
“I was terrified – oh my god, I’m going to start crying,” Groh says, pausing the interview for a moment. “Jesus Christ, I haven’t cried like this in a while.”
Her body was still bleeding. The unknown was catching up to her anxieties, and she still had 24 hours to go.
“I was bleeding and nobody knew if there was an abruption,” she says. “I was like, I’m gonna bleed out, and nobody’s gonna be able to do anything.”
Groh signed her informed consent form around 9 p.m. that night, meaning doctors had to wait until 9 p.m. the following day to begin her D&E. Her care team promised to monitor her heavily over the 24 hours, tracking her bleeding, the fetal heart tones. She wasn’t sure if they would be able to move up the D&E time if the fetus’ cardiac activity stopped, but she was in too much pain to think about specifics at this point.
“[I had to] sit here in this agony of these contractions that are terrible,” she says. “I’ve never felt pain like this before.”
Doctors gave Groh an epidural to help with her painful contractions. She declined one at first, feeling strange about getting care that resembled what was supposed to be a happy experience for fully-developed pregnancies.
“I’m like, I’m miscarrying a baby, I’m not truly in childbirth,” she says. “I’m like, I don’t need an epidural. Like, I will look weak if I get an epidural, basically. But no, I got one, and that thing was life-changing.”
Groh’s anxieties dulled slightly with her pain. Her husband, mom and cousin made sure she wouldn’t be alone for a second of her 24-hour waiting period. Under the hum of hospital fluorescents and steady beeps, Groh and her family tried to make the hardest 24 hours of her life feel somewhat normal.
“I was trying not to think about it,” she says. “We are very sarcastic people in my family, and we joke a lot with each other about things. It was kind of just like, we’re just getting through this. We’re here and we’re getting through it. We’re gonna joke about stuff, we’re going to cry about stuff, we’re gonna do it all. We just have to get through these freaking 24 hours.”
Snacking on vending machine sustenance in a line of chairs in front of Groh, her husband joked that he felt like they were at the movies, with Groh as the leading lady. She laughs at the comment still, thankful she had her family there to wait with her as the clock ticked.
“I have these people here to support me, which other people do not,” she says, tearing up again at the thought. “I could not imagine being told that I have to wait 24 hours and not having anybody with me. So this is why I’m doing this [interview], because it’s jacked up that there are people out there that have to do this by themselves.”
To Groh’s surprise and dismay, she felt the sudden urge to push around 3 a.m., just six hours into her 24-hour mandatory waiting period. Her husband hurried to call for the nurse, but her pregnancy arrived first. It was breathing.
“It’s obviously traumatic,” Groh says. “I deliver a breathing, 20-week pregnancy, taking breaths, but still not viable. This is not the road I wanted to go down. I wanted the D&E so that I did not have to deliver, see this pregnancy breathing, knowing that it’s going to die. That was probably one of the hardest things, because I chose to have a D&E, but because of [the 24-hour rule], I did not make it to that time. I had to go down the path that I did not choose.”
Reflecting on those moments makes Groh sad, but really she’s angry. She knows there are patients out there who are forced to navigate the same experience alone, patients who aren’t mentally equipped the same way she was thanks to her own medical training.
“That’s why I’m angry,” she says. “I think of, once again, all the people who don’t have the support system that I have, and […] there are people that suffer from mental health issues, I think we all do in some sort of aspect, but there are people that can’t handle it.”
The memory of delivering a dying pregnancy, the baby she was looking forward to meeting later under radically different circumstances, has cemented itself indelibly in Groh’s mind. The memory of her miscarriage at home now coupled with another fatal birth in the hospital. It was never supposed to be this way.
“It was traumatic the first time, and now I’m doing it a second time. It’s even more traumatic,” she says. “I could have had a D&E. I could have been asleep, like I wanted to be. I could have not had a recollection of delivery.”
Her choices whittled down by fate and the state, Groh used what little election she had left to do something that she still can’t explain to this day – she chose to hold her dying baby. Asked why, after everything she went through, she held her arms out.
Groh pauses.
“I don’t know. I have no idea. Because, I mean, it’s your baby,” Groh says. “I didn’t have to hold the pregnancy. That was also my choice.”
Taking the 24-hour rule to court
In April of 2024, the American Civil Liberties Union, the ACLU of Ohio and Planned Parenthood Federation of America filed a lawsuit on behalf of Ohio abortion providers to challenge Ohio’s laws that force abortion patients to wait 24 hours to begin abortion care.
According to the ACLU, the laws violate a part of the Issue 1 constitutional amendment that prohibits the state from “burdening, prohibiting, penalizing and interfering with access to abortion, and discriminating against abortion patients and providers.”
“These laws violate Ohio’s constitutional right to reproductive freedom passed on November 7, 2023,” reads a press release from the ACLU. “The challenged abortion restrictions unnecessarily require the overwhelming majority of patients to make two trips to a health center and, in practice, often force patients to wait much longer than 24 hours to receive an abortion. This delays – and in some cases, completely prevents – patients from receiving an abortion.”
“The singling out of abortion for differential and unfavorable treatment perpetuates the discriminatory view that patients do not think carefully about their decisions and do not understand the nature of the procedure,” adds Bethany Lewis, executive director of Cleveland’s Preterm abortion clinic. “This is a patronizing stereotype that has no place in our laws.”
Jessie Hill is the lead attorney with the ACLU taking on the state’s 24-hour rule. She says their lawsuit goes after more aspects of the informed consent process for abortions in Ohio, but the 24-hour waiting requirement is the focus of this case.
“The Reproductive Freedom Amendment that Ohioans adopted in November has much stronger and clearer language that makes it clear the state cannot restrict reproductive decisions, including abortion, unless they are doing so to advance patient health and in accordance with medical standards,” Hill says. “That is clearly not what this [24-hour waiting period] law does. And that’s really the linchpin of our case.”
The lawsuit is set to go to trial in April 2025, but the ACLU has a hearing scheduled for their motion on a preliminary injunction to stop the 24-hour rule on Aug. 16 in a Franklin County Common Pleas court. Ohio Attorney General Dave Yost, a Republican, filed an opposition to this request, saying in court documents that it’s the state’s duty to “respect the will of the people” who passed Issue 1, but that it’s also the state’s duty to defend “statutory provisions that the amendment does not invalidate against meritless attack.”
What makes the lawsuit “meritless” to Yost is that the newly-passed constitutional amendment keeps the state from burdening, penalizing, prohibiting, interfering with or discriminating against patients seeking an abortion or those assisting with an abortion. To Yost, clinics themselves are not protected by this amendment, so a lawsuit filed by those representing clinics can’t legitimately argue that the 24-hour rule is impeding on patients’ individual rights.
Yost goes on to address the argument made by the plaintiff that laws creating delays in care, like the domino effect of a mandatory waiting period, are not even the state’s business.
“But the fact that patients often wait longer than 24 hours is not because of the law, but rather is attributable to several factors outside of the state’s control,” Yost’s filing stated.
Ohio Republican Governor Mike DeWine, who opposed the passage of Issue 1, told WSYX that the 24-hour requirement should stay in place.
“Those guardrails are still in effect. They worked well before. So I don’t see any reason to change them,” DeWine told reporters in May.
Former Dayton mayor and Democratic candidate for Ohio Governor Nan Whaley, who was named the newest CEO for Planned Parenthood Southwest Ohio in June, said the law has not “worked well” like DeWine believes.
“The 24-hour waiting period is a real challenge for people coming from long distances that, unfortunately, have to come in from long distances to access abortion care,” Whaley says. “We’re becoming a safe-haven state – and we see this in the Cincinnati clinic, particularly – the rule is holding up the ability for us to serve more patients.”
Asked if she thinks the 24-hour rule “worked well” for her, as DeWine would suggest, she scoffed.
“Not at all, no. I feel like it discredited my knowledge, my decision making abilities,” Groh says. “It comes down to the fact that this was my choice. Your choice would have been totally different, which is fine, your choice is your choice. But I want to make the choices that are best for me and for my family. So that’s at the end of the day what it boils down to, and I want to make them when I want to make them.”
A version of this article originally appeared in City Beat.
