The Difficulty of Getting an Abortion in Texas

Can pro-choice groups prove that the state has made it too hard to terminate a pregnancy?
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Lucy Maude Ellis/flickr

AUSTIN, Texas — In October, Susan, a woman who lives in Willacy County in Texas’ southernmost tip, found out she was pregnant. She is married and has three children, and for a few weeks last fall, she couldn’t afford her birth control. Her condition, to her, was not entirely good news.

“I weighed out the pros and cons,” she said. “But I didn't want to have another baby.”

Susan asked her gynecologist about getting an abortion, but the doctor said she didn’t perform the procedure. For women in her area, there was only one place to go: Reproductive Services of Harlingen, where Dr. Lester Minto has been providing abortions since 1990. She made an appointment, sat anxiously in the packed waiting room, and got it over with quickly, she said.

By the time she came back for a follow-up visit two weeks later, Minto was no longer offering abortions. In fact, the entire Rio Grande Valley—an area with 275,000 women of reproductive age—is now without a single abortion provider.

What happened in the interim was the implementation of one of the provisions of House Bill 2, a state law that pro-choice activists called one of the harshest anti-abortion measures in the nation. It prohibited abortion after 20 weeks, added restrictions to medicated abortions, and mandated that abortion providers have hospital-admitting privileges at clinics within 30 miles of where they practice.

Starting in September of this year, it will also require all abortion clinics to conform to the standards of ambulatory surgical centers, which include specifications on everything from the spacing of the hand-sanitizer dispensers to the flooring of the janitor’s closet.

In a state where a person can drive for hours without encountering much more than cattle and brush, just 27 percent of Texas’s 630 hospitals are located in rural areas. Of the 34 abortion clinics that were open in the state in October 2013, 12 closed in November because their doctors weren’t able to secure admitting privileges. (Three of them have since reopened to at least partial capacity). Of those 25 clinics, only three are currently licensed surgical centers that are staffed by a doctor with admitting privileges.

Now, women who live in Willacy County must drive 120 miles to Corpus Christi, where the nearest physician with admitting privileges struggles to keep up with a torrent of new patients. Starting in September, they will have to drive 250 miles, to San Antonio, to visit the nearest abortion clinic that’s also a surgical center. And because a 2011 Texas law required women to first get an ultrasound, then wait 24 hours before getting an abortion, they would likely have to stay overnight.

“I know I'm a good mother and I provide for my children, but I see a lot of kids who aren't wanted, and I think it's going to be even worse now with this law,” Susan said. “I remember it cost me $1,000 just to give birth to my last child. And the abortion was $550.”

The new law has been embroiled in a bitter legal war since its passage last summer—a vote that itself was famously filibustered for 13 hours by the pink-sneaker-clad state Senator Wendy Davis. In October, a panel of judges at the Fifth Circuit Court of Appeals in New Orleans said the law requiring doctors to have admitting privileges can take effect while the case works its way through the system. The court acknowledged that the provision “may increase the cost of accessing an abortion provider and decrease the number of physicians available to perform abortions,” but said the state’s goals were ultimately aligned with the public interest.

Last week, a coalition of abortion providers argued before the Fifth Circuit Court of appeals that Texas’ expansive terrain—and the capriciousness of hospitals’ decisions—means not every abortion doctor will be granted admitting privileges, and desperate women will suffer as a result. They say that more than 22,000 women would be left without any meaningful access to abortions.

Throughout the legal back-and-forth, the state has maintained a persuasive counter-argument: Abortions would still be available in the state, after all, and the pro-choice groups so far haven’t been able to offer proof that specific women would be hurt by the new restrictions. “Aggregate information from providers,” they said, doesn’t constitute demonstrating an “undue burden” on women’s abortion rights, as would be required for the law to be unconstitutional.

I discovered a similar problem when reporting on reproductive laws in Texas. Though countless abortion clinics and providers made themselves available to me, they could not put me in touch with a single woman who has so far been affected by the new law. Even Susan, though she squeaked in just before the deadline, was ultimately able to terminate her pregnancy. When I asked roughly a dozen pro-choice groups for examples of patients who had suffered under the law, they responded either that nobody wanted to come forward out of privacy concerns, or that it’s hard to know when someone isn’t able to do something. Without standing in the living rooms of newly pregnant women as they attempt to make appointments or scrounge for gas money in order to trek to far-away clinics, it’s impossible to determine when an obstructed abortion results in an unplanned birth.

"Susan" is a pseudonym—she asked to remain anonymous because, as she told me, “I would be judged for my decision.” In a place where few women want their names associated with the “a” word, long drives and overnight stays are powerful deterrents. The question for the courts is, do they make for an “undue burden?”

***

An abortion clinic exam room in Austin. (Olga Khazan)

HB2 is in good company: More state abortion restrictions were passed between 2011 and 2013 than in the entire previous decade, from 2001 to 2010, according to the Guttmacher Institute, a pro-choice nonprofit.

The story of Texas’s own abortion-limiting thrust begins in 2011, with a law that required women to have an ultrasound 24 hours before an abortion and to hear both the fetus’ heartbeat and a description of its body.

Writing in the Texas Observer, Carolyn Jones recalled her doctor describing her own sonogram: “Here I see a well-developed diaphragm, and here I see four healthy chambers of the heart…,” he said, as Jones sobbed.

A friend of mine recently went to one of the few clinics in Dallas where an OB-GYN still has admitting privileges. After her sonogram, the doctor read a required script on the health dangers of having an abortion, which included scientifically disputed information on the procedure’s negative psychological consequences and its link to breast cancer.

“You know this is all b.s., right?” my friend said the doctor told her. “It’s just that I have to tell you this.”

Women who live in remote towns sometimes stay overnight near their clinics to avoid making two trips. Local abortion funds, which normally help subsidize the costs of the procedures themselves, have started raising money to cover gas and hotel expenses, as well.

If the goal of the sonogram law was to reduce the number of pregnancies that were terminated, it was effective.

“When the sonogram law went into effect, we saw a drop-off in patients,” said Fatimah Gifford, the director of public relations at Whole Woman’s Health, a clinic in Austin that provides abortions. “That extra day is a hurdle. They don’t like to come in twice.”

A study conducted by the University of Texas and the University of Alabama at Birmingham found that the waiting period and ultrasound requirements had caused abortions in the state to decline by 10 to 15 percent, a difference of roughly 8,000 procedures. Women had to wait an average of 3.7 days between their initial visit and the day of the procedure, mostly because of scheduling difficulties. They traveled an average of 84 miles round-trip for the procedure, and they incurred $146 in expenses in travel expenses, childcare and lost wages.

***

Whole Woman's Health in Austin. (Olga Khazan)

Whole Woman’s Health is situated in a squat, nondescript building off a busy Austin freeway. Inside, it’s a maze of purple walls emblazoned with inspirational quotes from prominent women. In one waiting room, Aretha Franklin says, “The brother that gets me is going to get one hell of a woman,” in all caps.

Patients first meet with a counselor to make sure they want to proceed. This isn’t part of the law, it’s just an extra step the clinic takes, “because we don’t want a woman to ever regret having an abortion,” Gifford said.

They’re then escorted to the exam rooms, which are outfitted with beds and equipment that are similar to a hospital’s. But the rooms are only about a third the size of an exam room that an ambulatory surgical center would have, Gifford tells me, and that’s why the clinic may soon close. The building’s hallways, too, are too narrow—HB2 requires them to be eight feet wide.

Gifford said it would take $2 million to renovate the building into compliance with the law, a sum the company can’t afford because their profit margins hover near one percent, she said.

Part of the rationale for the new law, according to its proponents, is to make it easier to administer emergency medical intervention in case something goes wrong. But nationally, less than 0.3 percent of all abortion patients experience complications that require hospitalization, according to the Guttmacher Institute.

"I've been absolutely terrified every moment of my life
and I've never let it keep me from doing a
single thing I wanted to do. -- Georgia O'Keeffe" (Olga Khazan)

Abortions are an outpatient procedure. After it’s done, patients at Whole Woman’s Health are taken to yet another magenta room, this one lined with La-Z-Boy chairs, where they’re given snacks and checked on by clinicians. After 30 minutes, they leave. Pro-choice advocates here say that not only is there no incision with an abortion, but similar procedures, such as vasectomies and oral surgeries, are commonly performed in run-of-the-mill doctors’ offices.

The law’s backers, though, say any risk of harm during an abortion is unacceptable.

“An abortion and vasectomy are two different things,” said Lucy Nashed, a press officer for Texas Governor Rick Perry, who supports the law. “An abortion is a beating heart. The notion that it's the same as a minor surgical procedure is completely false. Whether you have few patients that need to be rushed to emergency care or a million, every patient should have a reasonable expectation that the staff can handle any emergency.”

Nashed points out that several women and providers have testified before the state Senate that they experienced complications during an abortion.

In their Fifth Circuit appeal, the state argued that the admitting privileges requirement would keep abortion doctors from “abandoning” their patients at emergency rooms in cases where complications did arise, and that it acts as “another layer of protection for patient safety.” The court found that even if the restriction does make abortions more costly—but not impossible—to obtain, it’s within the state’s rights to impose it.

Pro-choice activists, meanwhile, say the burden arises from the sheer number of clinics that will close because the hospitals are too far away or won’t accept their providers' applications for privileges. During testimony this summer, University of Texas researchers said that as a result, women from five rural areas of the state would have to drive 16 hours in two round trips to get the procedure.

The Planned Parenthood in Waco, which is two hours from both Austin and Dallas, stopped providing abortions in October because its doctor was not able to gain privileges at a local hospital. When women now call the Waco clinic to schedule an appointment, the clinic staff refers them to the nearest facility that does meet the new regulations, usually a 90- to 100-mile drive away.

Of the six Whole Woman’s Health clinics in Texas, four shut down after HB2 went into effect, but one has since re-opened to partial capacity. Several abortion providers told me that local hospitals’ religious affiliations might be a factor in the abortion doctors’ difficulties in gaining admitting privileges. But in its ruling, the Fifth Circuit Court said that “under both state and federal law, hospitals are prohibited from discriminating against physicians who perform abortions in determining if admitting privileges will be extended.”

Whole Woman’s Health CEO Amy Hagstrom Miller said women are now coming from “all over” the state to get abortions at her clinic. She thinks the newest regulations will have downstream effects in which “women who need abortions aren't going to get them.”

Medicaid pays for 57 percent of all births in Texas. After the state cut $73 million from family planning budgets in 2011, the Texas Health and Human Services Commission projected that between 2014 and 2015, poor women who lost access to birth control would deliver an estimated 23,760 more babies than they otherwise would have, costing taxpayers as much as $273 million.

But the state’s Medicaid program does not cover abortions, and Miller thinks the consequences of the most recent law will be even more profound.

“Women of means will travel, or they'll leave Texas and go elsewhere. But for a huge percentage of the population, you'll see a bunch of people having children they didn't want and didn't intend to have,” she said.

She also worries about would-be patients taking pills in an attempt to induce a miscarriage.

“I’m concerned about self-abortion,” she said. “Women aren't changing their minds. You make them look at the ultrasound; it doesn't change their mind. It's insulting and patronizing, and they get mad about it, but it doesn't change their mind.”

***

As the case has moved through the courts, the law’s supporters have trumpeted the importance of women’s safety.

“This is just an effort to put in common-sense safety guidelines,” Nashed said. “The patient should have an expectation that the clinic is safe and clean and that they know how to handle any emergency.”

Opponents, meanwhile, think it’s part of a larger political maneuver staged by Perry and his Republican allies, including state Attorney General Greg Abbott, who is running for governor this year against Davis, the filibustering senator.

“Perry’s personal political ambition is what, to me, has been driving most of this,” Planned Parenthood President Cecile Richards told me in a phone interview. “He is trying to position himself to run for president and curry favor with the most extreme parts of the Republican Party.”

She points to the fact that GOP notables like Rick Santorum and Mike Huckabee both held rallies in Austin in the lead-up to the bill’s passage. Huckabee was joined at his event by TLC reality stars Michelle and Jim Bob Duggar, whose show 19 Kids and Counting documents the adventures of their teeming household.

Screenshot: YouTube

"In our nation, there is a baby holocaust taking place where doctors and nurses are being paid to take the lives of innocent unborn children," Michelle Duggar said in her speech. 

At a separate rally last year, Perry said, "The ideal world is one without abortion. Until then, we will continue to pass laws to ensure that they are rare as possible.”

Lester Minto, Susan’s doctor in South Texas, said he no longer practices because a nearby hospital would not grant him privileges. He said some women in his area are now crossing the border to purchase Misoprostol, an abortifacient, in Mexican markets, and that he now sees “six to eight” women a week who have taken the drug and experienced complications.

“It causes the uterus to begin to contract and forces the uterus to expel the contents,” he told me by phone. “Oftentimes it works, but a good many times it doesn't work. What you'll have is a partial miscarriage or incomplete miscarriage. The uterus still has products of conception in it, but no viable fetus.”

Susan said many of her neighbors in south Texas can’t travel north to the nearest abortion clinics because their visas only allow them to work and live within the Rio Grande Valley.

“I don't even know what to do if I were to get pregnant right now,” she said. “If it were to happen to my daughter, I would get a loan and take her wherever I had to. I would know she was too young.”

 
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Olga Khazan is an associate editor at The Atlantic, where she covers health.

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