In an action that appears to be increasingly commonplace, a Florida hospital has threatened to force a pregnant patient to undergo cesarean surgery against her will, or to report her to child welfare authorities for attempting to exercise her right to make the medical decisions she deems best for herself and her family.

Jennifer Goodall of Coral Gables was informed in a July 10 letter from the chief financial officer of Bayfront Health Port Charlotte that because she decided to attempt vaginal delivery before agreeing to cesarean surgery in her fourth pregnancy, her prenatal care providers intended to report her to the Department of Children and Family Services, seek a court order to perform surgery, and perform cesarean surgery on her “with or without [her] consent” if she came to the hospital.

A complaint on behalf of Goodall was filed in federal court last week by National Advocates for Pregnant Women (NAPW) and Florida attorney Patricia E. Kahn, seeking a temporary restraining order to prevent the hospital from carrying out its threats. Federal District Judge John E. Steele denied the request, stating in part that Goodall has no “right to compel a physician or medical facility to perform a medical procedure in the manner she wishes against their best medical judgment.”

Goodall is now 41 weeks pregnant and has told her lawyers she is terrified to enter a hospital. Given this and the weight of medical evidence in Goodall’s favor regarding the safety of the delivery she wanted to have, it is unclear whether the hospital or the courts are considering “best medical judgment” and in whose interest they are acting.

Goodall delivered her three other children via c-section and now desires to undergo what is commonly known as vaginal birth after cesarean (VBAC). In decades past, VBAC was a common choice for women who had previously had c-sections, rising from roughly 5 percent of all deliveries after a cesarean in 1985 to roughly 28 percent by 1996. The rate of VBAC deliveries started to fall in the late ’90s, according to the American Congress of Obstetricians and Gynecologists, reaching 8.5 percent in 2006 due in part to “restrictions that some hospitals and insurers placed” on the procedure. In tandem with what some have noted as pressure on women to undergo cesareans, the rate of cesarean delivery overall in the United States simultaneously increased dramatically over the past four decades, from 5 percent to over 31 percent in 2007.

Medical and public health bodies have long criticized the high rate of cesarean sections in the United States. The World Health Organization points out that at the current rate of 30 percent of all deliveries, cesarean sections in the United States far exceed what should normally be between 5 to 10 percent of all deliveries. ACOG agrees. “The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns,” ACOG President Richard N. Waldman said in a statement. “[ACOG’s] VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate.”

“The risks associated with a vaginal delivery are lower than the risks associated with a C-section overall, as long as you can deliver the baby at a facility equipped to handle a C-section in case of emergency,” Roger W. Harms, an obstetrician at the Mayo Clinic in Rochester, Minnesota, and medical editor-in-chief of MayoClinic.com, said in a statement. And the recovery time is faster. Undergoing a cesarean surgery for the fourth time carries a 1 in 8 chance of major complications. In short, VBAC deliveries are safer for both the pregnant person and the fetus and lead to fewer complications.

These facts did not escape Goodall, who said in a statement released by NAPW:

My decision to allow labor to proceed before consenting to a surgical intervention is based on years of research, careful consideration of the risks to me and my baby, and my family’s needs. All I want is to be able to go to the hospital when I’m in labor and have my medical decisions respected – and my decision is to proceed with a trial of labor and not have cesarean surgery unless some medical complication arises that makes cesarean surgery necessary for my or my baby’s health. Instead of respecting my wishes like they would for any other patient, my health care providers have made me fear for my safety and custody of my children. The people who are supposed to be caring for me and my baby have put me into an even more dangerous situation. I know I’m not the only one to go through this; I’m speaking out because pregnant women deserve better.

“I would definitely consent to surgery if there were any indication during labor that it is necessary,” Goodall added. “I am trying to make the decision that will be safest for both me and my baby, and give me the greatest chance at being able to heal quickly after my child is born so I can care for my newborn and my three other children.”

NAPW staff attorney Farah Diaz-Tello expressed disappointment in Judge Steele’s ruling. “The process of labor and delivery isn’t a procedure; our client is the one trying to avoid a compelled medical procedure. Deciding whether and when to consent to surgery is a constitutionally protected right,” she said in a statement. Diaz-Tello explained that every appellate court to rule on this issue on a full record has held that pregnant women retain their constitutional rights, including rights to medical decision-making and bodily integrity. “No woman should fear that because she’s pregnant, she can be threatened, coerced, or deprived of her constitutional rights,” she said.

But this is exactly what happened to Rinat Dray in Staten Island and to at least six other women in Florida, according to NAPW. “Florida is particularly bad for people giving birth,” Diaz-Tello told Rewire in an email. “We know of at least a half dozen other women who have had court orders or threats of legal action this against them, but the certainty with which hospitals have made these threats makes us think there are more we don’t know of.”

According to declarations of medical experts filed with the lawsuit, the hospital’s actions violate medical ethics. In a statement to NAPW, Mary Faith Marshall, director of the Center for Biomedical Ethics & Humanities at the University of Virginia School of Medicine, called the hospital’s actions “troubling.”

“Given the clear statements from ACOG’s Committee on Ethics and other professional groups that coerced or court-ordered medical procedures are not ethically justified, it is stunning that a hospital would threaten such an action,” she said.

Diaz-Tello acknowledged the hospital’s concerns about malpractice liability, but noted that there is no legal or ethical authority that supports managing liability concerns by forcibly performing unwanted surgery. “The Florida Supreme Court has said health care providers are protected from liability when they respect and follow the decisions of a competent and informed patient to delay or refuse a proposed treatment, even when there are risks involved,” she said in the NAPW statement. “Ms. Goodall has explicitly and carefully documented her informed decision to proceed with a trial of labor; there is no justification for forcing her, or any person, to have unwanted surgery to protect a hospital’s bottom line.”

Read more of our coverage of Whole Woman’s Health v. Hellerstedt here.

Reproductive health physicians are nervously awaiting the Supreme Court’s decision in Whole Woman’s Health v. Hellerstedt this week. Rightly so: the outcome of this case will dramatically affect the ability to access safe, legal abortions in Texas, and could extend to other states with restrictions that are similar to HB 2, the law at the heart of the case.

But we also recognize that even if we are able to celebrate a favorable outcome in the case, the battle for reproductive health will continue in dozens of states across the country.

The two provisions of HB 2 before the Court are presented by supporters as improvements to abortion safety and protective of women. But the reality is quite contrary to this. For one thing, abortion is already one of the safest medical procedures; women do not need to be “protected” by politicians.

For another, the requirements imposed by the law—mandating that abortion providers have admitting privileges at a local hospital and forcing abortion facilities to meet ambulatory surgical center (ASC) standards—do not directly or indirectly have a positive affect on the care provided before, during, or after abortion.

In practice, these targeted regulation of abortion providers (TRAP) requirements only restrict access to abortion. Few clinics have the resources needed to make the costly (and medically unnecessary) updates needed for ASC standards, and physicians can be refused hospital admitting privileges for a wide range of reasons unrelated to the quality of care that they provide.

Instead of improving care, TRAP law restrictions cause clinics to close, and prevent qualified, trained, experienced, dedicated health professionals from providing abortions to patients who need them. Fewer abortion providers means that some will have to wait much longer for their abortions, delaying care until later in pregnancy when the risk of complications—although still small—is increased.

TRAP laws also make abortion completely inaccessible for some women. The reasons can be complicated, involving factors such as geographical limitations, prohibitive cost of travel, and inability to obtain child care or take additional time off work. Regardless of the cause, the result is the same: Abortion restrictions force some women to carry their pregnancies to term, actually exposing them to greater risks associated with pregnancy and childbirth.

Not surprisingly, these laws disproportionately affect low-income women, only heightening the disparities that they already face day-to-day.

Even as our eyes are turned toward the Supreme Court, we must remember that Texans are not the only ones facing restrictions on their ability to access abortion care. Similar TRAP laws have been passed in other states, and in some cases, their implementation will depend on the outcome of Whole Woman’s Health. In addition, lawmakers have adopted a variety of creative approaches to limit abortion access.

In Indiana, state legislators passed a bill that would ban abortion for specific reasons; that law is awaiting judicial review. In Utah, a new law forces doctors to provide anesthesia to the fetus in an abortion performed after 20 weeks, despite there being no medical method for doing so and despite robust evidence that at that stage in development, a fetus does not feel pain. In Kansas and Oklahoma, state lawmakers banned physicians from using the preferred procedure for second-trimester abortion, subjecting women to less-than-standard methods; despite these laws currently being enjoined, five other states have followed suit.

None of these attacks are grounded in medicine, none of them are supported by the American College of Obstetricians and Gynecologists (ACOG) or the American Medical Association, and unfortunately, none of them would be struck down by a favorable decision from the Supreme Court. Even if access is restored in parts of Texas, advocates cannot rest on our laurels.

OB-GYNs do not have to be abortion providers in order to see the significant effect that an unintended pregnancy can have on overall health and well-being. We do not have to provide abortions ourselves in order to recognize that access to abortion is essential for the patients whom we provide care for every day.

As an OB-GYN and the president of ACOG, I remain hopeful and optimistic that we will see access to abortion restored and protected nationwide. But I urge reproductive health advocates to remain vigilant as state politicians continue to strip away access to care.

Korianne Gamble was six months pregnant in November 2014 when she arrived at the Bristol County Sheriff’s Office Women’s Center, a jail in North Dartmouth, Massachusetts. Six months prior, the state had passed “An Act to Prevent Shackling and Promote Safe Pregnancies for Female Inmates.”

According to the new law, the jail should have been prohibited from using any type of restraint on Gamble during labor, and using of leg and waist restraints on her during and immediately after her pregnancy. It also guaranteed her minimum standards of pregnancy care and required—as with everyone incarcerated while in their second or third trimesters—that she be transported in the jail’s vehicles with seat belts whenever she was taken to court, medical appointments, or anywhere outside the jail.

But that wasn’t the case for Gamble. Instead, she says, when it came time for her to give birth, she was left to labor in a cell for eight hours before finally being handcuffed, placed in the back of a police cruiser without a seatbelt, and driven to a hospital, where she was shackled to the bed with a leg iron after delivering.

According to a new report, Gamble isn’t alone. Advocates have been monitoring pregnancy-related care since the law’s passage. After obtaining and analyzing the policies of the state’s prison and jail system, they found that no facility has policies that are fully compliant with the 2014 law. They issued their findings in a new report, Breaking Promises: Violations of the Massachusetts Pregnancy Standards and Anti-Shackling Law—co-authored by Marianne Bullock of the Prison Birth Project, Lauren Petit of Prisoners’ Legal Services of Massachusetts, and Rachel Roth, a reproductive-justice expert.

In addition to analyzing policies, they spoke with women who were pregnant while in custody and learned that women continue to be handcuffed during labor, restrained to the bed postpartum, and placed in full restraints—including leg irons and waist chains—after giving birth.

“The promise to respect the human rights of pregnant women in prison and jail has been broken,” the report’s authors concluded.

Medical experts, including the American Congress of Obstetricians and Gynecologists, the American Medical Association and the American College of Nurse-Midwives, have all agreed that shackling during pregnancy is unnecessary, inhumane, and dangerous. Shackling increases the risk of falling and injury to both mother and fetus while also preventing medical staff from assessing and assisting during labor and delivery. In 2014, both the Massachusetts legislature and then-Gov. Deval Patrick (D) agreed, passing the law against it.

“The Massachusetts law is part of a national trend and is one of the most comprehensive in protecting pregnant and postpartum women from the risks of restraints,” said Roth in an interview with Rewire. “However, like most other states, the Massachusetts law doesn’t have any oversight built in. This report clearly shows the need for staff training and enforcement so that women who are incarcerated will be treated the way the legislature intended.”

Gamble learned all of this firsthand. In the month before her arrest, Gamble had undergone a cervical cerclage, in which a doctor temporarily stitches up the cervix to prevent premature labor. She had weekly visits to a gynecologist to monitor the development of her fetus. The cerclage was scheduled to be removed at 37 weeks. But then she was arrested and sent to jail.

Gamble told jail medical staff that hers was a high-risk pregnancy, that she had had a cerclage, and that her first child had been born six weeks prematurely. Still, she says she waited two months before seeing an obstetrician.

As her due date drew closer, the doctor, concerned about the lack of amniotic fluid, scheduled Gamble for an induction on Feb. 19, 2015. But, she says, jail staff cancelled her induction without telling her why.

That same evening, around 5 p.m., Gamble went into labor. Jail staff took her to the medical unit. There, according to Gamble, the jail’s nurses took her blood pressure and did a quick exam, but did not send her to the hospital. “They [the nurses] thought I was ‘acting up’ because my induction was canceled,” she told Rewire.

She was placed in a see-through cell where, as the hours progressed, her labor pains grew worse. “I kept calling to get the [correctional officers] to get the nurse,” Gamble recalled. By the time a nurse came, Gamble was bleeding. “The nurse made me pull down my pants to show her the blood—in front of a male [correctional officer]!” Gamble stated. Still, she says, no one called for an ambulance or made arrangements to drive her to the hospital.

At 1:45 in the morning, over eight hours after she first went into labor, the jail’s captain learned that Gamble was in labor. “[He] must have heard all the commotion, and he called to find out what was going on,” she said. He ordered his staff to call an ambulance and bring her to the hospital.

But instead of calling an ambulance, Gamble says jail staff handcuffed her, placed her in the back of a police cruiser without a seatbelt—in violation of the law—and drove her to Charlton Memorial Hospital. “My body was already starting to push the baby out,” she said. She recalled that the officers driving the car worried that they would have to pull over and she would give birth by the side of the road.

Gamble made it to the hospital, but just barely. Nine minutes after arriving, she gave birth: “I didn’t even make it to Labor and Delivery,” she remembered.

But her ordeal wasn’t over. Gamble’s mother, who had contacted Prisoners’ Legal Services and Prison Birth Project weeks earlier, knew that the law prohibited postpartum restraints. So did Gamble, who had received a packet in jail outlining the law and her rights from Prisoners’ Legal Services. When an officer approached her bed with a leg iron and chain, she told him that, by law, she should not be restrained and asked him to call the jail to confirm. He called, then told her that she was indeed supposed to be shackled. Gamble says she spent the night with her left leg shackled to the bed.

When the female officer working the morning shift arrived, she was outraged. “Why is she shackled to the bed?” Gamble recalled the officer demanding. “Every day in roll call they go over the fact that a pregnant woman is not to be shackled to anything after having a baby.” The officer removed the restraint, allowing Gamble to move around.

According to advocates, it’s not unusual for staff at the same jail to have different understandings of the law. For Gamble, that meant that when the shift changed, so did her ability to move. When the morning shift was over, she says, the next officer once again shackled Gamble’s leg to the bed. “I was so tired, I just went along with it,” Gamble recounted.

Two days after she had given birth, it was time for Gamble to return to the jail. Despite Massachusetts’ prohibition on leg and waist restraints for women postpartum, Gamble says she was fully shackled. That meant handcuffs around her wrists, leg irons around her ankles, a chain around her waist,g and a black box that pulled her handcuffs tightly to the waist chain. That was how she endured the 20-minute drive back to the jail.

Gamble’s jail records do not discuss restraints. According to Petit, who reviewed the records, that’s not unusual. “Because correctional officers don’t see it as out of the ordinary to [shackle], they do not record it,” she explained. “It’s not so much a misapplication of the extraordinary circumstances requirement as failure to apply it at all, whether because they don’t know or they intentionally ignore it.”

While Bristol County Sheriff’s Office Women’s Center’s policies ban shackling during labor, they currently do not prohibit restraints during postpartum recovery in the hospital or on the drive back to the jail. They also do not ban leg and waist restraints during pregnancy. Jonathan Darling, the public information officer for the Bristol County Sheriff’s Office, told Rewire that the jail is currently reviewing and updating policies to reflect the 2014 law. Meanwhile, administrators provide updates and new information about policy and law changes at its daily roll call. For staff not present during roll call, the jail makes these updates, including hospital details, available on its east post. (Roll call announcements are not available to the public.)

“Part of the problem is the difference in interpretation between us and the jurisdictions, particularly in postpartum coverage,” explained Petit to Rewire. Massachusetts has 14 county jails, but only four (and the state prison at Framingham) hold women awaiting trial. As Breaking Promises noted: “Whether or not counties incarcerate women in their jails, every county sheriff is, at minimum, responsible for driving women who were arrested in their county to court and medical appointments. Because of this responsibility, they are all required to have a written policy that spells out how employees should comply with the 2014 law’s restrictions on the use of restraints.”

Four jurisdictions, including the state Department of Correction, have policies that expressly prohibit leg and waist restraints during the postpartum period, but limit that postpartum period to the time before a woman is taken from the hospital back to the jail or prison, rather than the medical standard of six weeks following birth. Jails in 11 other counties, however, have written policies that violate the prohibition on leg and waist shackles during pregnancy, and the postpartum prohibition on restraints when being driven back to the jail or prison.

Even institutions with policies that correctly reflected the law in this regard sometimes failed to follow them: Advocates found that in some counties, women reported being restrained to the bed after giving birth in conflict with the jail’s own policies.

“When the nurse left, the officer stood up and said that since I was not confirmed to be in ‘active labor,’ she would need to restrain me and that she was sorry, but those were the rules,” one woman reported, even though the law prohibits restraining women in any stage of labor.

But shackling pregnant women during and after labor is only one part of the law that falls short. The law requires that pregnant women be provided with regular prenatal and postpartum medical care, including periodic monitoring and evaluation; a diet with the nutrients necessary to maintain a healthy pregnancy; written information about prenatal nutrition; appropriate clothing; and a postpartum screening for depression. Long waits before transporting women in labor to the hospital are another recurring complaint. So are routinely being given meals without fruits and vegetables, not receiving a postpartum obstetrician visit, and waiting long stretches for postpartum care.

That was also the case with Gamble. It was the middle of the night one week after her son’s birth when Gamble felt as if a rock was coming through her brain. That was all she remembered. One hour later, she woke to find herself back at the hospital, this time in the Critical Care Unit, where staff told her she had suffered a seizure. She later learned that her cellmate, a certified nursing assistant, immediately got help when Gamble’s seizure began. (The cell doors at the jail are not locked.)

Hospital staff told her that she had preeclampsia, a pregnancy complication characterized by high blood pressure. Postpartum preeclampsia is rare, but can occur when a woman has high blood pressure and excess protein in her urine soon after childbirth. She was prescribed medications for preeclampsia; she never had another seizure, but continued to suffer multiple headaches each day.

Dr. Carolyn Sufrin is an assistant professor of gynecology and obstetrics at Johns Hopkins Medicine. She has also provided pregnancy-related care for women at the San Francisco County Jail. “Preeclampsia is a leading cause of maternal mortality,” she told Rewire. Delayed preeclampsia, or postpartum preeclampsia, which develops within one to two weeks after labor and delivery, is a very rare condition. The patient suffering seizures as a result of the postpartum preeclampsia is even more rare.

Postpartum preeclampsia not only needs to be treated immediately, Sufrin said, but follow-up care within a week at most is urgent. If no follow-up is provided, the patient risks having uncontrolled high blood pressure, stroke, and heart failure. Another risk, though much rarer, is the development of abnormal kidney functions.

While Sufrin has never had to treat postpartum preeclampsia in a jail setting, she stated that “the protocol if someone needs obstetrical follow-up, is to give them that follow-up. Follow through. Have continuity with the hospital. Follow their instructions.”

But that didn’t happen for Gamble, who was scheduled for a two-week follow-up visit. She says she was not brought to that appointment. It was only two months later that she finally saw a doctor, shortly before she was paroled.

As they gathered stories like Gamble’s and information for their report, advocates with the Prison Birth Project and Prisoners’ Legal Services of Massachusetts met with Rep. Kay Khan (D-Newton), to bring her attention to the lack of compliance by both county jails and the state prison system. In June 2015, Khan introduced An Act to Ensure Compliance With the Anti-Shackling Law for Pregnant Incarcerated Women (Bill H 3679) to address the concerns raised by both organizations.

The act defines the postpartum period in which a woman cannot be restrained as six weeks. It also requires annual staff trainings about the law and that, if restraints are used, that the jail or prison administration report it to the Secretary of Public Safety and Security within 48 hours. To monitor compliance, the act also includes the requirement that an annual report about all use of restraints be made to the legislature; the report will be public record. Like other statutes and bills across the country, the act does not have specific penalties for noncompliance.

In December 2015, Gamble’s son was 9 months old and Gamble had been out of jail for several months. Nonetheless, both Gamble and her mother drove to Boston to testify at a Public Safety Committee hearing, urging them to pass the bill. “I am angered, appalled, and saddened that they shackled her,” Gamble’s mother told legislators. “What my daughter faced is cruel and unusual punishment. It endangered my daughter’s life, as well as her baby.”

Since then, both the Public Safety Committee and Health Care Financing Committee approved the bill. It is now before the House Committee for Bills in the Third Reading, which means it is now at the stage where it can be taken up by the House for a vote.

Though she has left the jail behind, Gamble wants to ensure that the law is followed. “Because of the pain I went through, I don’t ever want anyone to go through what I did,” she explained to Rewire. “Even though you’re in jail and you’re being punished, you still have rights. You’re a human being.”