But unlike parents in most of the U.S., she had extra help that was once much more common: house calls.

Adele was only a few weeks old when a registered nurse showed up at Bonfield’s door on Dec. 10 to check on them and offer hands-on help and advice.

As a city resident who had recently given birth, she was eligible for up to three home visits from , a program of the city health department.

She didn’t need to feed and change the baby before packing everything up for a car trip to the pediatrician or a clinic. It was a relief; Bonfield was exhausted and was still trying to figure out how to use the infant car seat.

“Everything is so abstract before you have a baby,” Bonfield said. “You are going to have questions you never even thought about.”

Louisiana is among the worst-performing states in maternal and infant health outcomes. So New Orleans is trying to catch health issues early — and get families off to an easier start — by adding health visits during the crucial first months of life.

The hope is that health outcomes can be improved by returning to the old-fashioned medical practice of house calls.

The Family Connects model has been tried in communities . It began in Durham, North Carolina, in 2008, as a partnership with Duke University. In 2023, New Orleans’ health director, , helped launch a local version of the program.

Avegno was concerned by Louisiana’s particularly grim statistics for maternal and infant health.

The state has some of the highest rates of preterm births, unnecessary cesarean sections, and maternal and infant deaths, according to the . A from the United Health Foundation found that Louisiana was the “least healthy” state for women and children.

“We got to do some real things real differently, unless you like being No. 50 all the time,” Avegno said.

The home visits are free and available to anyone who has just given birth in a New Orleans hospital, no matter their insurance status or income level.

Avegno describes the home visits as going “back to the future,” replicating a practice that was far more common a hundred years ago.

“There is no more critical time and vulnerable time than right at birth and in the few weeks to months following birth,” Avegno said.

The nurses arrive with diaper bags filled with newborn essentials, from diapers to nipple cream. They weigh, measure, and examine the babies, and check in with the mothers about their health and well-being. They offer referrals to other programs across the city.

They ask if the family has enough food, and whether there are guns in the house and how they’re stored, Avegno said.

In Bonfield’s case, the nurse stayed for over two hours. Bonfield especially liked their conversation about how to safely store breastmilk.

“I’ve never felt so well taken care of and listened to,” she said.

Broad Support

Louisiana has struggled a long time with poor maternal and infant health outcomes, but the problem has been complicated by the .

The 2022 law led to risky medical delays and in obstetrical care, and confusion among doctors about what’s allowed in ending dangerous pregnancies or .

Avegno opposes the state’s abortion policies, believing they are harmful to women’s health. But she says that Family Connects offers other ways to preserve and expand care for women. For example, the visiting nurse can check in with the mother about whether she needs help with birth control.

“We can’t give them abortion access,” she said. “That’s not the goal of this program, and that wouldn’t be possible anyway. But we can make sure they’re healthy and understand what their options are for reproductive health care.”

Abortion politics aside, the postpartum home visits seem to have bipartisan support in Louisiana, and state lawmakers want to expand their availability.

Last year, the Republican-dominated legislature requiring private insurance plans to cover the visits.

The new law is another way that Louisiana officials can be “pro-life,” said state , who, as a Republican and an abortion opponent, sponsored the legislation.

“One of the slings used against advocates against abortion is that we’re pro-birth, and not truly pro-life,” Bayham said. “And this bill is proof that we care about the overall well-being of our mothers and our newborns.”

Improving Health and Help for Postpartum Depression

Two years in, there are already promising signs that the program is improving health.

Early data analyzed by researchers at Tulane University showed that families who got the visits were more likely to stick to the recommended schedule of pediatric and postpartum checkups. Moms and babies were also less likely to need hospitalization, and overall health care spending was down among families insured by Medicaid.

Research on Family Connects programs elsewhere has found similar results. In North Carolina, one study showed that three to seven home visits in the year before a baby turned 1.

But the statistic that most excited Avegno related to the program’s role in screening mothers for postpartum depression.

The visiting nurses are helping spot more cases of postpartum depression — earlier — so that new moms can get treatment. About 10% of moms participating in the New Orleans program were eventually diagnosed with postpartum depression, compared with 6% of moms who did not get the visits.

Timely diagnosis is important to prevent depression symptoms from worsening, or leading to more , such as suicidal thoughts, thoughts of harming the baby, or problems bonding with their newborn.

Lizzie Frederick was one of the New Orleans mothers whose postpartum symptoms were caught early by a visiting nurse.

When she was pregnant, she and her husband took all the childbirth and newborn classes they could. They hired a doula to help with the birth. But Frederick still wasn’t prepared for the stresses of the postpartum period, she said.

“I don’t think there are enough classes out there to prepare you for all the different scenarios,” Frederick said.

When her son, James, was born in May, he had trouble breastfeeding. He was sleeping for only 90-minute stretches at night.

When the nurse arrived for the first visit a few weeks later, Frederick was busy trying to feed James. But the nurse reassured her that there was no rush. She could wait.

“I am here to support you and take care of you,” Frederick recalled the nurse saying.

The nurse weighed James, and Frederick was relieved to learn he was gaining weight. But for most of the visit, the nurse focused on Frederick’s needs. She was exhausted, anxious, and had started hearing what she called phantom cries.

The nurse walked her through a mental health questionnaire. Then she recommended that Frederick see a counselor and consider attending group therapy sessions for perinatal women.

Frederick followed up on these suggestions and was eventually diagnosed with postpartum depression.

“I think that I would have felt a lot more alone if I hadn’t had this visit, and struggled in other ways without the resources that the nurse provided,” Frederick said.

Home Visits Save Money

, an assistant professor at Tulane’s School of Public Health, helped interview over 90 families participating in the Family Connects New Orleans program.

“It was overwhelmingly positive experiences,” she said. “This is like a gold-standard public health project, in my opinion.”

To operate, Family Connects costs the city about $1.5 million a year, or $700 per birth, according to Avegno. But the program also has the potential to save money: Research on North Carolina’s program in the program saved $3.17 in health care billing before the child turned 2.

That’s another reason to require the visits statewide, according to state Rep. Bayham.

“The nurses and medical practitioners will be able to monitor potential problems on the front end, so that they could be handled without a trip to the emergency room or something even more drastic,” he said.

Avegno is advocating that the program be included in Louisiana’s Medicaid program, since more than in the state are covered by Medicaid. A recent made the same recommendation.

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Esa es la práctica estándar, según expertos en salud pública y enfermedades infecciosas consultados por Â鶹ŮÓÅ Health News y NPR. El objetivo es evitar que más personas vulnerables se enfermen y recordar al público los beneficios de la vacunación.

Pero este año en Louisiana, no siguieron ese protocolo durante el peor brote de tos ferina en 35 años.

La tos ferina, también conocida como pertussis, es una enfermedad muy contagiosa y prevenible con vacunación que resulta especialmente peligrosa para los bebés más pequeños. Puede causar vómito y dificultad para respirar, y en casos graves puede derivar en neumonía, convulsiones e incluso, aunque rara vez, la muerte.

Madison Flake, residente de pediatría en Baton Rouge, atendió a un bebé que fue hospitalizado durante el brote. El niño, de menos de dos meses, estuvo en cuidados intensivos.

“Tenía episodios de tos muy intensos”, dijo Flake. “Dejaba de respirar durante varios segundos, casi hasta un minuto”.

Los bebés no son elegibles para recibir su primera dosis de la vacuna contra la tos ferina , pero pueden desarrollar inmunidad si la madre se vacuna durante el embarazo.

A finales de enero, dos bebés habían fallecido en ese estado.

Sin embargo, el Departamento de Salud de Louisiana tardó dos meses en publicar un mensaje en redes sociales sugiriendo a la población hablar con sus doctores sobre la vacunación.

La agencia demoró aún más en emitir dirigida a médicos, enviar un comunicado o realizar una conferencia de prensa.

, director ejecutivo de la Asociación Americana de Salud Pública (APHA), dijo que ese retraso no es común.

“Particularmente con enfermedades infantiles, solemos actuar de inmediato”, dijo Benjamin, médico que ha dirigido departamentos de salud en Maryland y Washington, D.C. “Son enfermedades y muertes prevenibles”.

Debido a que las enfermedades infecciosas se propagan de manera exponencial, si las autoridades no alertan al público rápidamente, pierden una ventana de oportunidad clave para evitar más contagios, explicó , profesor en la Universidad de Stanford que ha trabajado en brotes de covid y mpox.

“El tiempo es, quizás, una de las monedas más importantes que se tiene”, agregó.

Prohibida la promoción general de vacunas

Como la inmunidad que ofrece la vacuna contra la tos ferina baja con el tiempo, los casos pueden aumentar o disminuir cíclicamente. Pero en septiembre de 2024, los funcionarios de salud de Louisiana comenzaron a ver un aumento “considerable” de casos, como parte de .

A fines de enero, médicos de un hospital del estado advirtieron a sus colegas que dos bebés habían muerto durante el brote.

El 13 de febrero, el director general de salud del estado, , envió un memo a su personal poniendo fin a la y a los eventos comunitarios de vacunación.

Ese mismo día, pocas horas después de que Robert F. Kennedy Jr., un activista antivacunas, fuera confirmado por el Senado como nuevo secretario del Departamento de Salud y Servicios Humanos de Estados Unidos (HHS), Abraham en el sitio web del departamento de salud estatal.

En el documento, afirmaba que la salud pública se había excedido con sus recomendaciones de vacunación, impulsadas por una “mentalidad colectivista de talla única”. Abraham ha calificado las vacunas contra covid como y ha sido un defensor público de Kennedy.

Cuatro días después, en respuesta a una solicitud del canal WVUE Fox 8 News de Nueva Orleans, el Departamento de Salud de Louisiana confirmó por primera vez por correo electrónico la muerte de dos bebés por tos ferina. WVUE .

Pero el departamento no emitió ninguna alerta, según una revisión de comunicaciones internas y externas hecha por NPR y Â鶹ŮÓÅ Health News.

Durante el mes siguiente, otros dos bebés fueron hospitalizados por tos ferina, de acuerdo con correos electrónicos internos obtenidos mediante una solicitud de acceso público a la información.

En marzo, luego de consultas de NPR y Â鶹ŮÓÅ Health News sobre el aumento de los casos de pertussis, el departamento publicó sus primeros mensajes en redes sociales sobre el brote y ofreció entrevistas a otros medios de comunicación.

Luego, el 1 de mayo —al menos tres meses después de la segunda muerte infantil— el departamento emitió lo que parece ser su primera y hasta ahora única dirigida a médicos. Al día siguiente publicó su y luego realizó una conferencia de prensa sobre la enfermedad, el 14 de mayo.

Para ese entonces, 42 personas habían sido hospitalizadas por tos ferina desde que comenzó el brote. , tres de cada cuatro no estaban al día con sus vacunas contra la enfermedad.

Más de dos tercios de los hospitalizados fueron bebés menores de un año.

Durante el verano, los casos de pertussis siguieron aumentando en el estado. Pero el departamento de salud estatal no volvió a publicar información al respecto.

NPR y Â鶹ŮÓÅ Health News contactaron al departamento para solicitar comentarios el 25 de septiembre. La vocera Emma Herrock no respondió preguntas específicas sobre la falta de comunicación, pero remitió a una publicación del 30 de septiembre en X del director general de salud estatal.

En la publicación, Abraham dijo que el departamento “reportó consistentemente los casos de pertussis y proporcionó orientación para ayudar a los residentes a mantenerse protegidos” en 2025. Aseguró que la vacuna contra la tos ferina es “una de las menos controversiales” y que la recomienda a sus pacientes.

La publicación en X incluyó una gráfica de casos de pertussis por año, pero omitió los datos de 2024 y 2025. También precisó el momento de las muertes infantiles: una a finales de 2024 y otra a principios de 2025.

Un “desastre anunciado” de casos

Louisiana debió haber comenzado a alertar al público pocos días después de la primera muerte infantil, en lugar de esperar meses, señaló Karan, de Stanford.

“Como mínimo”, dijo, “debió haber una promoción intensa del mensaje: ‘Los bebés están en alto riesgo. Se contagian de personas cuya inmunidad ha disminuido. Si no te has vacunado, vacúnate. Si tienes estos síntomas, hazte la prueba’”.

Las muertes por enfermedades prevenibles con vacunas son trágicas, pero también pueden servir como una oportunidad para educar al público sobre los beneficios de vacunarse y así salvar vidas, dijo , ex secretario de salud de Maryland y ahora profesor en la Escuela de Salud Pública Bloomberg de la Universidad Johns Hopkins.

“El riesgo de pertussis siempre está presente, pero cuando hay dos muertes infantiles es una oportunidad para comunicar que se trata de una amenaza real para la salud infantil”, afirmó Sharfstein.

Karan dijo que al no actuar con rapidez, el Departamento de Salud de Louisiana podría haber propiciado un brote más grave.

“Lo que vemos después es un desastre, un brote descomunal, muchas hospitalizaciones”, dijo.

El brote continuó

Hasta el 20 de septiembre, la fecha más reciente con datos disponibles, Louisiana había registrado en 2025, según los Centros para el Control y Prevención de Enfermedades (CDC). Según los datos disponibles desde 1990, el de casos había sido 214, en 2013.

El departamento de salud debería responder de forma agresiva y constante, afirmó , presidente del capítulo de Louisiana de la Academia Americana de Pediatría.

Las autoridades deben asegurarse de que “las personas estén informadas de forma regular y se les recuerde lo que deben hacer”, dijo. “Vacúnense. Si están embarazadas, vacúnense. Y si tienen una enfermedad con tos, consulten al doctor”.

Benjamin, de la Asociación Americana de Salud Pública, dijo que el objetivo permanente de la comunicación en salud pública es prevenir la próxima hospitalización o muerte.

“La conclusión es que no es demasiado tarde”, señaló. “Todavía se puede actuar de forma más agresiva y proactiva para enfrentar la tos ferina”.

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But in Louisiana this year, public health officials appeared to have not followed that playbook during the state’s worst whooping cough outbreak in 35 years.

Whooping cough, also called pertussis, is a highly contagious, vaccine-preventable disease that’s particularly dangerous for the youngest infants. It can cause vomiting and trouble breathing, and serious infections can lead to pneumonia, seizures, and, rarely, death.

Madison Flake, a pediatric resident in Baton Rouge, cared for a baby who was hospitalized during this year’s outbreak. Less than 2 months old, he was sent to the intensive care unit.

“He would have these bouts of very dramatic coughing spells,” Flake said. “He would stop breathing for several seconds to almost a minute.”

Infants are not eligible for their first pertussis vaccine until they are , but they can acquire immunity if the mother is immunized while pregnant.

By late January, two babies had died in Louisiana.

But the Louisiana Department of Health waited two months to send out a social media post suggesting people talk to their doctors about getting vaccinated. The department took even longer to issue a statewide to physicians, send out a press release, or hold a news conference.

That lag is not typical, according to , the executive director of the American Public Health Association.

“Particularly for these childhood diseases, we usually jump all over these,” said Benjamin, a physician who has led health departments in Maryland and Washington, D.C. “These are preventable diseases and preventable deaths.”

Because infectious diseases spread exponentially, if officials don’t alert the public quickly, they lose a key chance to prevent further infections, said , an instructor at Stanford University who has worked on covid and mpox outbreaks.

“Time is perhaps one of the most important currencies that you have,” he added.

General Promotion of Vaccines Banned

Because pertussis vaccine immunity wanes over time, cases can ebb and flow. But in September 2024, Louisiana health officials started seeing a “substantial” increase in whooping cough cases, part of a .

In late January, physicians at one Louisiana hospital warned their colleagues that two infants had died in the outbreak.

On Feb. 13, the state’s surgeon general, , sent a memo to staff and community vaccine events.

He sent that email a few hours after Robert F. Kennedy Jr., an anti-vaccine activist, won Senate confirmation as the new secretary of the U.S. Department of Health and Human Services.

Also that day, Abraham posted a on the state health department’s website. In it, he said public health has overstepped with vaccine recommendations, driven by “a one-size-fits-all, collectivist mentality.” Abraham has called covid vaccines “” and been a vocal supporter of Kennedy.

Four days later, in response to a request from WVUE Fox 8 News in New Orleans, the Louisiana Department of Health in an email confirmed the deaths of two infants from whooping cough for the first time. WVUE on Feb. 20.

But Louisiana’s health department sent out no alerts, according to a review of external and internal communications by NPR and Â鶹ŮÓÅ Health News.

Over the next month, two more infants were hospitalized for whooping cough, according to internal health department emails obtained through a public records request.

In March, after inquiries from NPR and Â鶹ŮÓÅ Health News about the growing number of pertussis cases, the department put out its first social media communications about the outbreak and offered interviews to other journalists.

Then on May 1 — at least three months after the second infant death — the health department issued what appears to be its first and so far only to physicians. It put out its the next day and then held a news conference about pertussis on May 14.

By then, 42 people had been hospitalized for whooping cough since the outbreak began, three-quarters of whom were not up to date on their whooping cough immunizations, .

More than two-thirds of those hospitalized were babies under the age of 1.

Throughout the summer, pertussis cases continued to climb in Louisiana. But there were no further public communications from the state health department.

NPR and Â鶹ŮÓÅ Health News contacted the department for comment on Sept. 25. Emma Herrock, a spokesperson, did not answer specific questions about the lack of communications but referred to a Sept. 30 by the state surgeon general.

In the post, Abraham said the department “consistently reported cases of pertussis and provided guidance to help residents stay protected” in 2025. He called the pertussis vaccine “one of the least controversial” and said he recommends it to his patients.

The X post included a year-by-year graphic of pertussis cases that omitted 2024 and 2025. The post also provided a more specific timeframe for when the infant deaths occurred — one in late 2024 and the other in early 2025.

A ‘Train Wreck’ of Cases

Louisiana should have started warning the public within days of the first infant’s death instead of waiting months, said Stanford’s Karan.

“At minimum,” he said, “it should be like heavy promotion of: ‘Hey, infants are at high risk. They get infected by people who have waning immunity. If you haven’t gotten vaccinated, get vaccinated. If you have these symptoms, get tested.’”

Deaths from a vaccine-preventable illness are tragic, but they can also serve as an opportunity to educate the public about the benefits of vaccines and try to save lives, said , a former Maryland health secretary and now a professor at the Johns Hopkins Bloomberg School of Public Health.

“The risk of pertussis is always there, but when you have two infant deaths it’s a really good opportunity to communicate that this is a real threat to the health of children,” Sharfstein said.

Karan said that by not acting more quickly, the Louisiana Department of Health may have set itself up for a worse outbreak.

“Because then what we see is this train wreck thereafter, of like an insanely large outbreak, a lot of hospitalizations,” he said.

The Outbreak Continued

As of Sept. 20, the most recent date for which data is available, Louisiana had counted in 2025, according to the Centers for Disease Control and Prevention. In data going back to 1990, the was 214 cases, in 2013.

Until the Sept. 30 post on X, the Louisiana Department of Health did not appear to put out any public communications about pertussis over the preceding four months, though hospitalizations continued and case levels surpassed the 2013 levels.

The health department should be responding aggressively and consistently, said , the president of the Louisiana Chapter of the American Academy of Pediatrics.

Health officials should make sure “people are updated on a regular basis and reminded of what needs to be done,” he said. “Get your vaccines. Moms, if you’re pregnant, get vaccinated. And if you have a cough illness, see your doctor.”

Benjamin, with the American Public Health Association, said the ongoing goal of public health communication is to prevent the next hospitalization or death.

“The bottom line is, it’s not too late,” he said. “It’s not too late to be much more aggressive and proactive about dealing with pertussis.”

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“It’s scary. It’s frustrating,” said , co-founder of the Massachusetts Medication Abortion Access Project, a that mails mifepristone and misoprostol pills to patients in states with abortion bans. But, Foster added, “it’s not entirely surprising.”

Ever since the Supreme Court overturned Roe v. Wade in 2022, abortion providers like her had been expecting prosecution or another kind of legal challenge from states with abortion bans, she said.

“It was unclear when those tests would come, and would it be against an individual provider or a practice or organization?” she said. “Would it be a criminal indictment, or would it be a civil lawsuit,” or even an attack on licensure? she wondered. “All of that was kind of unknown, and we’re starting to see some of this play out.”

The indictment also sparked worry among abortion providers like , medical director for . The clinic doesn’t mail pills into states with bans, but it does treat patients who travel from those states to Maine for abortion care.

“It just hit home that this is real, like this could happen to anybody, at any time now, which is scary,” Der Simonian said.

Der Simonian and Foster both know the indicted doctor, Margaret Carpenter.

“I feel for her. I very much support her,” Foster said. “I feel very sad for her that she has to go through all of this.”

On Jan. 31, Carpenter became the first U.S. doctor criminally charged for providing abortion pills across state lines — a medical practice that grew after the U.S. Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision on June 24, 2022, which overturned Roe.

Since Dobbs, have enacted near-total abortion bans, and an additional 10 have outlawed the procedure after a certain point in pregnancy, but before a fetus is viable.

Carpenter was indicted alongside a Louisiana mother who allegedly received the mailed package and gave the pills prescribed by Carpenter to her minor daughter.

The teen wanted to keep the pregnancy and called 911 after taking the pills, according to an NPR and Â鶹ŮÓÅ Health News interview with , the Louisiana local district attorney prosecuting the case. When police responded, they learned about the medication, which carried the prescribing doctor’s name, Clayton said.

On Feb. 11, Louisiana’s Republican governor, , signed an for Carpenter. He later posted arguing she “must face extradition to Louisiana, where she can stand trial and justice will be served.”

New York’s Democratic governor, , countered by releasing her , confirming she was refusing to extradite Carpenter. The charges carry a possible five-year prison sentence.

“Louisiana has changed their laws, but that has no bearing on the laws here in the state of New York,” Hochul said.

Eight states — New York, Maine, California, Colorado, Massachusetts, Rhode Island, Vermont, and Washington — have since 2022 to protect doctors who mail abortion pills out of state, and thereby block or “shield” them from extradition in such cases. But this is the first criminal test of these relatively new “shield laws.”

The telemedicine practice of consulting with remote patients and prescribing them medication abortion via the mail has — and is now playing a critical role in keeping abortion somewhat accessible in states with strict abortion laws, from the Society of Family Planning, a group that supports abortion access.

Doctors who prescribe abortion pills across state lines describe facing a new reality in which the criminal risk is no longer hypothetical. The doctors say that if they stop, tens of thousands of patients would no longer be able to end early pregnancies , under the care of a U.S. physician. But the doctors could end up in the crosshairs of a legal clash over the interstate practice of medicine when two states disagree on whether people have a right to end a pregnancy.

Doctors on Alert but Remain Defiant

Maine Family Planning, a network of clinics across 19 locations, offers abortions, birth control, gender-affirming care, and other services. One patient recently drove over 17 hours from South Carolina, a state with a six-week abortion ban, Der Simonian said.

For Der Simonian, that case illustrates how desperate some of the practice’s patients are for abortion access. It’s why she supported Maine’s 2024 , she said.

Maine Family Planning has discussed whether to start mailing abortion medication to patients in states with bans, but it has decided against it for now, according to Kat Mavengere, a clinic spokesperson.

Reflecting on Carpenter’s indictment, Der Simonian said it underscored the stakes for herself — and her clinic — of providing any abortion care to out-of-state patients. Shield laws were written to protect against the possibility that a state with an abortion ban charges and tries to extradite a doctor who performed a legal, in-person procedure on someone who had traveled there from another state, according to a by the at the UCLA School of Law.

“It is a fearful time to do this line of work in the United States right now,” Der Simonian said. “There will be a next case.” And even though Maine’s shield law protects abortion providers, she said, “you just don’t know what’s going to happen.”

Data shows that in states with total or six-week abortion bans, an average of 7,700 people a month were prescribed and took mifepristone and misoprostol to end their pregnancies by out-of-state doctors practicing in states with shield laws. The data, covering the second quarter of 2024, is part of a estimating the volume and types of abortions in the U.S., conducted by the Society of Family Planning.

Among Louisiana residents, nearly 60% of abortions took place via telemedicine in the second half of 2023 (the most recent period for which estimates are available), giving Louisiana the highest rate of telemedicine abortions among states that passed strict bans after Dobbs, according to the #WeCount survey.

Organizations like the , known as the MAP, are responding to the demand for remote care. The MAP was launched after the Dobbs ruling, with the mission of writing prescriptions for patients in other states.

During 2024, the MAP says, it was mailing abortion medications . In the new year, the monthly average has grown to 3,000 prescriptions a month, said Foster, the group’s co-founder.

The majority of the MAP’s patients — 80% — live in Texas or states in the Southeast, a region blanketed with near-total abortion restrictions, Foster said.

But the recent indictment from Louisiana will not change the MAP’s plans, Foster said. The MAP currently has four staff doctors and is hiring one more.

“I think there will be some providers who will step out of the space, and some new providers will step in. But it has not changed our practice,” Foster said. “It has not changed our intention to continue to practice.”

The MAP’s organizational structure was designed to spread potential liability, Foster said.

“The person who orders the pills is different than the person who prescribes the pills, is different from the person who ships the pills, is different from the person who does the payments,” she explained.

In 22 states and Washington, D.C., Democratic leaders helped establish shield laws or similarly protective executive orders, according to the UCLA School of Law review of shield laws.

The review found that in eight states, the shield law applies to in-person and telemedicine abortions. In the other 14 states plus Washington, D.C., the protections do not explicitly extend to abortion via telemedicine.

Most of the shield laws also apply to civil lawsuits against doctors. Over a month before Louisiana indicted Carpenter, Texas Attorney General Ken Paxton filed a civil suit against her. A Texas judge ruled against Carpenter on Feb. 13, of more than $100,000.

By definition, state shield laws cannot protect doctors when they leave the state. If they move or even travel elsewhere, they lose the first state’s protection and risk arrest in the destination state, and maybe extradition to a third state.

Physicians doing this type of work accept there are parts of the U.S. where they should no longer go, said , a human rights lawyer who helps doctors set up telemedicine practices.

“There’s really a commitment not to visit those banned and restricted states,” said Kay, who worked with Carpenter to help start the .

“We didn’t have anybody going to the Super Bowl or Mardi Gras or anything like that,” Kay said of the doctors who practice abortion telemedicine across state lines.

She said she has talked to other interested doctors who decided against doing it “because they have an elderly parent in Florida, or a college student somewhere, or family in the South.” Any visits, even for a relative’s illness or death, would be too risky.

“I don’t use the word ‘hero’ lightly or toss it around, but it’s a pretty heroic level of providing care,” Kay said.

Governors Clash Over Doctor’s Fate

Carpenter’s case remains unresolved. New York’s rebuff of Louisiana’s extradition request shows the state’s shield law is working as designed, according to and , law professors with expertise in abortion laws.

Louisiana officials, for their part, have pushed back in social media posts and media interviews.

“It is not any different than if she had sent fentanyl here. It’s really not,” Louisiana Attorney General in New Orleans. “She sent drugs that are illegal to send into our state.”

Louisiana’s next step would be challenging New York in federal courts, according to legal experts across the political spectrum.

NPR and Â鶹ŮÓÅ Health News asked Clayton, the Louisiana prosecutor who charged Carpenter, whether Louisiana has plans to do that. Clayton declined to answer.

Case Highlights Fraught New Legal Frontier

A major problem with the new shield laws is that they challenge the basic fabric of U.S. law, which relies on reciprocity between states, including in criminal cases, said , a senior legal fellow with the Heritage Foundation, which supports a .

“This actually tries to undermine another state’s ability to enforce its own laws, and that’s a very grave challenge to this tradition in our country,” Jipping said. “It’s unclear what legal issues, or potentially constitutional issues, it may raise.”

But other legal scholars disagree with Jipping’s interpretation. The U.S. Constitution requires extradition only for those who commit crimes in one state and then flee to another state, said Cohen, a law professor at Drexel University’s .

Telemedicine abortion providers aren’t located in states with abortion bans and have not fled from those states — therefore they aren’t required to be extradited back to those states, Cohen said. If Louisiana tries to take its case to federal court, he said, “they’re going to lose because the Constitution is clear on this.”

“The shield laws certainly do undermine the notion of interstate cooperation, and comity, and respect for the policy choices of each state,” Cohen said, “but that has long been a part of American law and history.”

When states make different policy choices, sometimes they’re willing to give up those policy choices to cooperate with another state, and sometimes they’re not, he said.

The conflicting legal theories will be put to the test if this case goes to federal court, other legal scholars said.

“It probably puts New York and Louisiana in real conflict, potentially a conflict that the Supreme Court is going to have to decide,” said Rebouché, dean of the Temple University .

Rebouché, Cohen, and law professor worked together to draft a proposal for how state shield laws might work. Connecticut passed the first law — though it did not include protections specifically for telemedicine. It was signed by the state’s governor in May 2022, over a month before the Supreme Court overturned Roe, in anticipation of potential future clashes between states over abortion rights.

In some shield-law states, there’s a call to add more protections in response to Carpenter’s indictment.

New York state officials have. On Feb. 3, Hochul signed that allows physicians to name their clinic as the prescriber — instead of using their own names — on abortion medications they mail out of state. The intent is to make it more difficult to indict individual doctors. Der Simonian is pushing for a similar law in Maine.

Samantha Glass, a family medicine physician in New York, has written such prescriptions in a previous job, and plans to find a clinic where she could offer that again. Once a month, she travels to a clinic in Kansas to perform in-person abortions.

Carpenter’s indictment could cause some doctors to stop sending pills to states with bans, Glass said. But she believes abortion should be as accessible as any other health care.

“Someone has to do it. So why wouldn’t it be me?” Glass said. “I just think access to this care is such a lifesaving thing for so many people that I just couldn’t turn my back on it.”

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Mifepristone and misoprostol have many clinical uses, and one use is to take the pills to induce an abortion at up to 10 weeks of gestation.

The bill that moved through the Louisiana Legislature this spring lists both medications as drugs under the state’s , creating penalties of up to for anyone caught with the drugs without a valid prescription. Gov. Jeff Landry, a Republican, into law in May. It takes effect Oct. 1.

The new law is the latest move by anti-abortion advocates trying to control access to abortion medications in states with near-total abortion bans, such as Louisiana. The law is the first of its kind, opening a new front in the state-by-state battle over reproductive medicine.

Republican-controlled states have passed various laws regulating medication abortion in the past, said , an OB-GYN and a reproductive health researcher at the University of California-San Francisco.

But after the Dobbs v. Jackson Women’s Health Organization decision in 2022, in which the Supreme Court ruled there was no constitutional right to an abortion, scrutiny of medication abortions escalated as clinics in certain states shuttered completely or were required to stop offering in-clinic procedures.

“It’s not surprising that states are trying everything they can to try to restrict these drugs,” Grossman said. “But this is certainly a novel approach.”

Before the Louisiana bill passed, more than 250 OB-GYNs and emergency, internal medicine, and other physicians from across the state to the bill’s sponsor, state Sen. , a Republican, arguing the move could threaten women’s health by delaying lifesaving care.

“It’s just really jaw-dropping,” said Nicole Freehill, a New Orleans OB-GYN who signed the letter. “Almost a day doesn’t go by that I don’t utilize one or both of these medications.”

Mifepristone and misoprostol are routinely used to , stop , induce labor, or prepare the cervix for a range of procedures inside the uterus, such as inserting an IUD or taking a biopsy of the uterine lining.

Bill Born From a Family’s Misfortune

The proposal to reschedule the drugs as controlled dangerous substances was introduced as amendments to Pressly’s original bill creating the crime of “coerced criminal abortion” — where someone “knowingly” gives abortion pills to a pregnant woman to cause or attempt to cause an abortion “without her knowledge or consent.”

Pressly’s sister, Catherine Pressly Herring, testified at the hearing on the bill that she had been given abortion drugs by her former husband. Pressly said his sister’s story .

In a statement, Pressly said that he added the new amendments to “control the rampant illegal distribution of abortion-inducing drugs.” He did not respond to requests for comment.

“By placing these drugs on the controlled substance list, we will assist law enforcement in protecting vulnerable women and unborn babies,” Pressly .

Louisiana Right to Life, the state’s most influential anti-abortion group, helped draft the bill. And the group’s , Sarah Zagorski, said that claims that rescheduling the drugs as dangerous could harm women’s health are “fearmongering.”

The real problem, she said, is that mifepristone and misoprostol are too accessible in Louisiana and are being used to induce abortions despite the state’s ban.

“We’ve had pregnancy centers email us with many stories of minors getting access to this medication,” Zagorski said.

Studies have shown in the ordering of abortion pills online in states that have severe restrictions on abortion.

In the Louisiana Legislature committee hearing on the bill, anti-abortion advocates said that physicians would still be allowed to dispense mifepristone and misoprostol for lawful medical care, and that women who give themselves abortions using the medications would be exempted from criminal liability.

“Under this law, or any abortion law, in Louisiana we see the woman as often the second victim,” testified Dorinda Plaisance, a lawyer who works with Louisiana Right to Life. “And so Louisiana has chosen to criminalize abortion providers” rather than women who use the medications for their own abortions.

Move ‘Not Scientifically Based,’ Doctors Say

The U.S. Drug Enforcement Administration and individual states have the power to list drugs as controlled dangerous substances.

State and federal regulations aim to control access to drugs, such as opioids, based on their medical benefit and their potential for abuse, according to Joseph Fontenot, executive director of the , the agency that monitors drugs listed as controlled dangerous substances.

Like other states, Louisiana tracks prescriptions in databases that include the name of the patient, the health provider who wrote the prescription, and the dispensing pharmacy.

Physicians need a special license to prescribe the drugs — in 2023, there were 18,587 physicians in Louisiana, 13,790 of whom had a license to prescribe controlled dangerous substances, according to data from the and the .

“Every state has a prescription drug monitoring program. And they really are designed to identify prescription drug mills that are hawking fentanyl and opioid painkillers,” said , a professor of law and a drug policy expert at Vanderbilt University.

What happened to Pressly’s sister — being tricked into taking mifepristone or misoprostol — is a form of drug abuse, said Zagorski of Louisiana Right to Life, which is why the drugs should be more strictly controlled.

But Fontenot, of the Louisiana Board of Pharmacy, said that under Louisiana’s law, abuse refers to addiction. , a New Orleans emergency physician and the director of the New Orleans Health Department, agrees. “There is no risk of someone getting hooked on misoprostol,” Avegno said.

Under the new law, mifepristone and misoprostol will be added to a list comprised of opioids, depressants, and stimulants. “To classify these medications as a drug of abuse and dependence in the same vein as Xanax, Valium, Darvocet is not only scientifically incorrect, but [a] real concern for limiting access to these drugs,” Avegno said.

Doctors worry that the bill could set a dangerous precedent for state officials who want to restrict access to any drug they consider dangerous or objectionable, regardless of its addictive potential, Avegno said.

Fears Over Delays in Care

In their letter opposing the reclassification, doctors said the “false perception that these are dangerous drugs” could lead to “fear and confusion among patients, doctors, and pharmacists, which delays care and worsens outcomes” in a state with high rates of maternal injury and death.

The increased scrutiny could have a statewide chilling effect and make doctors, pharmacists, and even patients more reluctant to use these drugs, the doctors wrote.

The state database allows any doctor or pharmacist to look up the prescription history of his or her patient. The data is also , which licenses physicians and other providers, and by law enforcement agencies with a warrant.

“Could I be investigated for my use of misoprostol? I don’t know,” said Freehill, the New Orleans OB-GYN.

Pharmacists could become more reluctant to dispense the medications, Freehill said, exacerbating a problem she and other OB-GYNs have since Louisiana banned nearly all abortions. That reluctance could lead to patients miscarrying without timely treatment.

“They could be sitting there bleeding, increasing their risk that they would have a dangerous amount of blood loss” or risking infection, she said.

Before the bill passed, Freehill routinely phoned in every prescription for misoprostol when her patients were miscarrying so she could explain to the pharmacist why she was prescribing it. Once the bill goes into effect in the fall and the drug becomes a controlled dangerous substance, that will no longer be possible because those types of prescriptions must be written on a pad or sent electronically.

In hospitals, the drugs will also . That could potentially cause delays getting the drug when a patient is hemorrhaging after childbirth.

Doctors worry some patients might be afraid to take the medications once they’re listed as dangerous, Avegno said.

In a to the Louisiana physicians who signed the protest letter, Pressly said the doctors whom he’s spoken with feel the bill “will not harm health care for women.”

Criminalizing Support for Abortions

Louisiana’s abortion ban already makes it a crime to provide an abortion, including by giving someone medications used to induce abortion. And a added up to 50 years in prison for mailing mifepristone or misoprostol.

Because the new law explicitly exempts pregnant women, opponents like believe it is meant to isolate those women from others who would help them. Ling, a reproductive rights attorney at , is particularly concerned about the prison penalties, which she believes are intended to frighten and disrupt underground networks of support for patients seeking the pills.

Pregnant patients might worry about ordering online or enlisting a friend to help obtain the pills: “Is my friend who is simply just providing me emotional support going to somehow, you know, be punished for doing that?” Ling said.

Ling added that there’s concern that the law could also be used to target people who aren’t pregnant but who want to order abortion pills online and stock them in case of a future pregnancy. That in states with abortion bans.

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At about six weeks pregnant, Joshua, 30, called a physician group in Baton Rouge. She wanted to make her first prenatal appointment there for around the eight-week mark, as she had in her first pregnancy. But Joshua said the woman on the line told her she was going to have to wait over a month.

“They specifically said, ‘We now no longer see women until they’re at least 12 weeks,'” Joshua recalled. “And I said, ‘Oh, Lord. Is this because of what I think?’ And they said, ‘Yes.'”

Louisiana has a near-total abortion ban, which took effect Aug. 1, that has raised that they could be investigated for treating a miscarriage, since the same treatments are also used for abortion.

Joshua recalled the woman on the phone saying that since the U.S. Supreme Court decision overturned Roe v. Wade, there was what the woman called a gray area in Louisiana’s law. The medical practice was delaying the first prenatal appointment with patients.

Joshua remembered her saying that many women miscarry in the first 12 weeks of pregnancy, and they didn’t want to be liable for an investigation. For anyone convicted of providing an abortion, the law carries stiff penalties of 10 to 15 years in prison, up to $200,000 in fines and the loss of a physician’s license.

Since Louisiana’s ban took effect, some doctors have warned that the law’s language is vague, and that fear and confusion over the law . And fear and confusion are precisely what Joshua and her husband experienced.

During those early weeks of pregnancy, Joshua felt symptoms she hadn’t dealt with in her first pregnancy: mild cramping and spotting. Without access to a doctor, though, Joshua felt she had nowhere to go for answers.

“How in the world can we have a viable health care system for women, especially women of color, when they won’t even see you for 12 weeks?” she said.

Joshua, who works as a community organizer, knew pregnancy can be dangerous, especially for Black women like herself. She also knew about Louisiana’s dismal maternal health statistics: The state has , and Black women are at higher risk than white women, according to reports from the state’s health department.

So Joshua booked an appointment weeks away with one of the few OB-GYNs she could find who was a woman of color. Then, when she was between 10 and 11 weeks pregnant, she started bleeding heavily, passing clots and tissue. She said the pain was worse than when she’d given birth.

Her husband was at work, so Joshua drove herself to the emergency room at Woman’s Hospital in Baton Rouge. There the staff gave her an ultrasound, which they said showed that her fetus had stopped growing, she recalled. It was measuring seven or eight weeks gestation, not 10 or 11 weeks. Her medical records show her pregnancy hormone levels were abnormally low.

She was told her fetus had only a faint heartbeat. Joshua understood she was miscarrying. But hospital staffers wouldn’t definitively confirm it and didn’t explain what treatment options she’d have if she was having a miscarriage.

Joshua said a nurse told her: “‘It appears that you could be having one. But we don’t want to say that’s what it is. So let’s just keep watching it. You can continue to come back. Of course, we’re praying for you.'”

Joshua is Christian. She spends Sunday mornings at church. But she said the comment felt like an insult. “Folks need answers, not prayers. And that’s exactly what I was looking for in that moment,” she said.

The next day, her bleeding and pain were worse. Landon, her husband, was afraid for her life.

By the evening, Joshua was pacing her bathroom floor, bleeding and cramping, when she felt more blood and tissue come out of her body.

“It literally felt like I had almost birthed a child,” she said. “And so I was like, ‘No, I have to go somewhere, like, now.'”

She didn’t want to return to the first ER, so she called her mother and husband and told them to meet her at Baton Rouge General in nearby Prairieville. There, a security guard put her in a wheelchair. Her jeans were soaked through with blood. Staffers gave her another ultrasound, and the technician told her she’d lost a lot of blood.

A doctor came in to talk about the ultrasound results. She told Joshua it looked like a cyst, not a pregnancy, and asked if she was positive she’d been pregnant — a question that made Joshua angry.

Joshua remembers the doctor then said that if she was indeed miscarrying, she should go back home and wait, then follow up with her OB-GYN in two or three days.

Joshua asked the doctor for treatment to alleviate her pain and speed up the process. There are two standard options for managing a confirmed miscarriage, other than letting it pass on its own: a procedure called dilation and curettage, to remove pregnancy tissue; or medication, which can help clear the uterus more quickly. Both of the latter treatments are also used for abortions.

The doctor told her, “‘We’re not going to do that,'” Joshua recalled. “I just remember her saying, ‘We’re not doing that now.'”

The doctor also said she wouldn’t refer Joshua somewhere else for miscarriage treatment, Joshua recalled, or give her discharge papers stating she was having a miscarriage, known in medical terminology as a spontaneous abortion.

“She stated that they’re not going to put anywhere ‘spontaneous abortion’ because that would then flag an investigation on them,” Joshua said.

Landon Joshua said he had the impression that the doctor was afraid to confirm his wife’s miscarriage.

“She would not look me in the eye to tell me what was happening,” Kaitlyn said.

Frustrated and scared, the Joshuas went home.

Both Woman’s Hospital and Baton Rouge General said in statements to NPR that their pregnancy care has not changed since Louisiana’s abortion ban passed. Baton Rouge General said its care of Kaitlyn Joshua was appropriate. NPR contacted the provider whom Joshua originally called for a prenatal appointment, and it denied that it had changed the timing of first appointments.

Both ERs Joshua visited deny that they have changed care because of Louisiana’s ban.

In a statement, Dr. R. Cliff Moore, the chief medical officer and a maternal-fetal medicine specialist at Woman’s Hospital — the first hospital Joshua visited — said bleeding during the first trimester is common and doesn’t necessarily mean a patient is miscarrying. He added that diagnosing a miscarriage “requires complex medical analysis” that can take days or weeks. “Our hearts go out” to those who’ve experienced miscarriages, he added.

Baton Rouge General, the second ER, said it has not changed the way it manages miscarriage or the options provided to patients. In a statement, Dr. Kathleen Varnes, an ER doctor, said that the hospital “sympathizes with the pain and anxiety” Joshua experienced but that it believes her care was “appropriate.” Every patient is different, she said, adding that “there are times when waiting and observing is the right approach, and other times when medication or a procedure may be necessary.”

According to Joshua’s discharge papers from Baton Rouge General, she was suffering from vaginal bleeding, which can, but doesn’t always, lead to miscarriage. But in her medical charts, which Joshua later obtained from the hospital, staff wrote “it appears that she is having a miscarriage,” and diagnosed her as having a “complete or unspecified spontaneous abortion without complication.” Her medical records also note that Joshua’s pregnancy hormone levels, called HCG, had declined from her previous ER visit, when they should have been increasing if her pregnancy was proceeding normally.

After Joshua signed forms allowing the hospital to comment on her care, Baton Rouge General said that because of Joshua’s symptoms, “her discharge papers and treatment plan provided instructions on how to manage bleeding and when to follow up with a physician.”

Other doctors and lawyers in the state are concerned that the abortion ban is affecting some health care decision-making. They point to the fact that even after a state court briefly blocked Louisiana’s ban last summer, Louisiana Attorney General Jeff Landry threatened the medical licenses of physicians, claiming they could still be prosecuted.

In September, at a Louisiana Department of Health meeting, Dr. , the chair of maternal and fetal medicine with Ochsner Health, Louisiana’s largest health system, said some OB-GYN doctors were afraid to provide routine care.

“There has now been such a level of concern created from the attorney general’s office about the threat to them both criminally and civilly and professionally, that many people are not going to provide the care that is needed for patients, whether it’s ectopic pregnancies, miscarriages, ruptured membranes, you know, hemorrhage,” Biggio said. “And we need to figure out a way to be able to provide some clear, unequivocal guidance to providers, or we’re going to see some unintended consequences of all of this.”

The Policy Debate

The author of Louisiana’s abortion ban, Sen. Katrina Jackson, is a Democrat who opposes abortion. She maintains that the law is clear about miscarriages, saying in an emailed statement that “it does not prohibit medical treatment regarding miscarriages.”

communications director for Louisiana Right to Life, which helped draft the ban, said no part of Louisiana’s law requires a physician to delay prenatal care until 12 weeks of pregnancy. And she said the law specifically differentiates miscarriage care from abortion.

“It looks like the fault is not with the law, but with a misinterpretation of the law,” Zagorski said.

Ellie Schilling, a lawyer with , a reproductive justice organization that challenged Louisiana’s law in state court, said that while the law allows for miscarriages to be treated, it is written in legal language that doesn’t translate easily into medicine or necessarily line up with an individual patient’s set of circumstances. And this puts doctors in a very difficult situation.

“They’re trying to interpret specific language and pair it up to specific patients to do some sort of calculation about, you know, have we reached this threshold yet? Or have we not?” she said.

Doctors also must consider whether someone else might later disagree with their decision, she added. “How is somebody else going to interpret that later? How is law enforcement or a prosecutor potentially going to interpret that later?”

She argued that the law needs to be clarified. “It puts providers and patients in a really dangerous situation,” she said. “And to abdicate all responsibility for making the laws, before drafting the laws in a way that will work for physicians on the ground, is just irresponsible.”

The Patient’s Perspective

In the week after Joshua’s last ER visit, the heavy bleeding and piercing pains continued. While mourning the loss of what would have been her new baby, she remained worried about her own health. She feared getting worse and wondered how bad she would need to get to get treatment.

Joshua blames Louisiana’s anti-abortion law for the care she received. “For me to have to navigate so many different channels to get health care should not be happening,” she said. “This has to change. There needs to be clarity within the abortion ban” so that physicians are not confused or afraid to provide care and support.

It took weeks, but Joshua was able to pass the pregnancy at home. If she had been given a choice, she would have chosen care that made the experience faster, less painful, less scary, and less risky, especially as a Black woman.

“This experience has made me see how Black women die. Like, this is how Black women are dying,” she said.

It also has made Kaitlyn and Landon Joshua rethink their plans for more children.

“I love my kid. And so, she constantly makes me want another her. But in this moment, it’s just too dangerous to get pregnant in the state of Louisiana,” Kaitlyn said. “I don’t think it’s worth risking your life for a baby right now.”

This story was produced in partnership with and KHN. It was edited by Carrie Feibel, Jane Greenhalgh, Diane Webber, and Carmel Wroth. Meredith Rizzo and Max Posner handled art direction and design. Photographs by Claire Bangser.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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