Everything changed on the day of the Dobbs decision, June 24. By the end of that Friday, a three-year-old law had been triggered into effect, a so-called ‘‘heartbeat bill’’ that made it a felony to terminate a pregnancy after a fetal heartbeat has been detected. A heartbeat can generally be detected at around six gestational weeks, before many women know they are pregnant; previously abortions were permitted, with restrictions, until 22 weeks. All of a sudden, most of the termination procedures scheduled a week earlier by the Cleveland Clinic were now crimes. Only three exceptions allowed for abortions after the new cutoff: to prevent the mother’s death; to forestall a ‘‘serious risk of the substantial and irreversible impairment of a major bodily function of the pregnant woman’’; and to respond to ectopic pregnancies, in which a fertilized egg implants itself outside the uterus.

The uncertainties about how to interpret and deliver care in response to those exceptions meant the Cleveland Clinic personnel had to continue doing their jobs in unclear legal circumstances. How do you know if a mother’s life is at risk? How do you predict, then prove, that the mother faces potentially irreversible bodily damage? ‘‘As physicians, we literally take an oath to take care of patients,’’ says Dr. Stacey Ehrenberg, who specializes in high-risk pregnancies at the Cleveland Clinic. ‘‘And we now have our hands tied.’’

Once the heartbeat bill became law, routine procedures for treating miscarriage — which is how at least one in 10 pregnancies ends — could be considered abortions. The most effective drugs used in cases of miscarriage, mifepristone and misoprostol, are the same ones used to induce abortion by medication; the surgical evacuation of the uterus is another procedure used with miscarriages that is also an abortion method. The new law means that most patients admitted to the Cleveland Clinic Emergency Department while miscarrying are supposed to wait for 24 hours before receiving treatment — treatment given earlier than that could be considered an illegal abortion. Dr. Ashley Brant, an OB/GYN at the Cleveland Clinic, says that they had a core group of physicians providing abortion care who were well versed in what had been the law. But the new law, she says, ‘‘opens up the floodgates of who might be providing this kind of care.’’ A doctor in the emergency room accustomed to treating miscarriages with certain procedures, for example, could now potentially be breaking the law. That risk threatens to affect medical care. Ohio had been changing the parameters of reproductive care since 2012. Doctors are required to ask patients who want and qualify for an abortion if they would like to hear the fetal heartbeat; doctors and other medical providers, including pharmacists, are allowed to withhold medical care based on their moral, religious or ethical beliefs; doctors are required to send an official record to the state health department for every patient who receives a qualified abortion. And every patient who elects to have an abortion must be offered a 21-page booklet titled ‘‘Fetal Development & Family Planning.’’ Those changes happened over the course of many years. The heartbeat bill took effect so quickly that even powerful institutions like the Cleveland Clinic were caught off guard. ‘‘I have lived in a restrictive state for almost my entire career and lived through legislative changes along the way that have restricted access, but not to this sweeping extent,’’ says Dr. Justin Lappen, who is the head of maternal fetal medicine at Cleveland Clinic.

Lappen, Brant and a lawyer for the clinic held an emergency meeting the Monday after the Supreme Court’s decision, in order to convey medical and legal guidance to the more than 600 doctors, nurses and administrators who attend- ed remotely. ‘‘Everyone was really emotional and upset that this was actually happening,’’ Dr. Amanda Kalan, a specialist in maternal fetal medicine, says.‘‘The people making the laws are not doctors, and they don’t understand the implications of all of these laws.’’

Elizabeth Whitmarsh, the communications director for Ohio Right to Life, which lobbied for the heartbeat bill, denies that the bill itself is responsible for any adverse ramifications. ‘‘The only thing that is not legal in Ohio now is the murder of a child,’’ she says, when asked about the bill’s repercussions. The Ohio state representative Adam Holmes, along with Congressman Steve Chabot and former Gov. John Kasich, did not respond to requests for comment.

On July 11, two and a half weeks after the Dobbs decision, an Ohio representative named Gary Click introduced a two-sentence ‘‘personhood’’ bill that would further limit abortion. The bill is meant to ‘‘protect the constitutional rights, of all unborn human individuals from the moment of conception,’’ unless the life of the mother is endangered. At the moment, Lappen says, ‘‘We have some patients who at five or six weeks may still be able to have abortion care if there’s not a heartbeat detected.’’ But if this bill becomes law, he adds, ‘‘then there really would be virtually no abortion care left on the table in Ohio.’’

Dr. Maeve Hopkins, an OB/GYN who specializes in high-risk pregnancy at the Cleveland Clinic, grew up outside Cleveland and returned to the city after working in Pennsylvania and North Carolina. She now questions her move home. ‘‘I don’t know an OB/GYN in Ohio who isn’t think- ing about leaving,’’ she says. U.S. News & World Report currently ranks Cleveland Clinic’s obstetrics and gynecology care as the fourth-best in the nation, but Dr. Tristi Muir, the chairwoman of the OB/GYN and Women’s Health Institute there, points out that this status — and, even more important, the quality of women’s health care available to Ohioans — has become vulnerable: ‘‘Doctors may not come to our state to practice or to train.’’

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