Health

Texas anti-abortion law forces women to make tough choices

On Jan. 6, an appeals court will hear a challenge to the measure, which has led clinics to close

Reproductive Services of Harlingen, one of two abortion clinics in the Rio Grande Valley, had to stop providing abortions after the new law went into effect last year
Lindsay Beyerstein

When Hannah Roe Beck, a 21-year-old student at the University of Texas at San Antonio, volunteers for the Lilith Fund hotline, she has $1,080 per shift to allocate as she sees fit. A nonprofit organization that provides cash assistance for women seeking abortions in South Texas, the Lilith Fund is typically able to fund only about a third of the women who call for help. So every shift involves difficult choices. Beck usually allocates about $75 to each caller she can help; she could give up to $200, but that's very rare. She gets roughly 25 calls per six-hour shift, and she has to turn down some women.

They call her in tears, begging for help. She has brainstormed with clients about which possessions they might pawn. She takes calls from the couch in the living room of her student apartment, surrounded by college bric-a-brac, including stenciled street art and a classical bust that her roommate has incongruously dressed up in a snowboarding cap. Beck's new to the hotline, but she already has ways of coping with the pressure. "I've got a blanket that looks like the Texas flag, and sometimes I cover myself in that if I need some security," she says.

But recent changes in Texas' abortion laws are making Beck's life — and the lives of the women calling the help line — much more difficult. Texas' sweeping new abortion measure, which passed in July and went into effect Oct. 31, led at least 12 abortion clinics to stop providing abortions and other clinics to scale back their services. (At least three have since reopened). The law requires that all physicians who perform abortions have admitting privileges to hospitals within 30 miles of their clinics, and many have already been turned down. Planned Parenthood is challenging the law. The 5th U.S. Circuit Court of Appeals is scheduled to hear the challenge on Jan. 6, and the case is expected to eventually end up before the Supreme Court.

In theory, Roe v. Wade established every American woman's constitutional right to an abortion. In South Texas' Lower Rio Grande Valley, however, women seeking abortions can get them only if they have the time and money to travel hundreds of miles.

Chipping away at Roe v. Wade

Whole Women's Health of McAllen, Texas, has stopped providing abortions since the new measure
Whole Women's Health of McAllen, Texas, had to stop providing abortions because its doctors lacked admitting privileges at local hospitals
Lindsay Beyerstein

The Lower Rio Grande Valley is a fertile floodplain nearly the size of Connecticut on the southernmost tip of Texas and home to a Latino-majority population of 1.3 million. Dubbed the Texas tropics by guidebooks, the Valley is a paradise for bird-watchers and citrus growers — and one of the poorest regions in the country. Its four counties are among the 100 poorest in the United States. Starr County is the third-poorest in the nation, with an annual per capita income of just $7,609; per capita incomes in the other three Valley counties hover around $10,000. An estimated 350,000 Valley residents live in "colonias," rural slums along the U.S.-Mexico border that often lack basic amenities such as paved roads, running water and streetlights. Nearly 40 percent of Hidalgo County residents rely on food stamps.

There were 2,634 abortions, the vast majority performed at clinics, in the Lower Rio Grande Valley in 2011, the last year for which data are available. Demographers estimate that the new law will cause more than 22,000 Texas women to forgo abortions in 2014.

The region is a microcosm of the abortion-rights battles playing out around the nation. Since 2010, anti-abortion activists have stepped up their efforts to restrict abortion access by imposing medically unnecessary regulations on abortion providers. Bills requiring abortion providers to have admitting privileges at local hospitals were introduced in nine states this year and were enacted in four: Alabama, Wisconsin and North Dakota, in addition to Texas. So far, courts in Alabama, Wisconsin and North Dakota have blocked their laws from going into effect, pending court challenges, but the 5th Circuit ruled that Texas' law could go into effect while Planned Parenthood challenges it in court.

According to Roe v. Wade, states may not pass laws preventing women from terminating a pregnancy in the first trimester, and states may pass laws restricting abortion in the second trimester only for the sake of the mother's health.

But the Supreme Court's 1992 ruling in Planned Parenthood v. Casey set new standards. While states could not impose an "undue burden" on a woman seeking to end any pregnancy before the fetus is viable, a 24-hour waiting period, parental consent for minors and "informed consent" were not considered undue burdens. "Informed consent" laws may require abortion seekers to view color photographs of aborted fetuses or to listen to a prepared script linking abortion to breast cancer and suicide — which is not supported by medical literature.

Consequently, over the years, anti-abortion activists have fought to restrict the procedure piecemeal through state-level legislation that makes it more difficult to get an abortion without technically making it illegal.

The anti-abortion legal group Americans United for Life says that several years of "aggressive legislative action" have transformed Texas into one of the most abortion-unfriendly states in the country. In 2000, Texas imposed a parental-notification requirement for minors. Since 2004, Texas has required that abortions after 16 weeks be performed in ambulatory surgical centers, which offer hospital-grade operating rooms suitable for gastric-bypass surgery or back surgery outside a hospital. (Abortion has complication rates comparable to wisdom tooth extraction and other procedures that are routinely performed in medical offices and clinics. Fewer than 0.05 percent result in complications serious enough to require hospitalization.)

Two years later, the state tightened the maternal-health exemption for third-trimester abortions and switched from parental notification for minors to parental consent. In 2011 the state imposed mandatory ultrasounds and a 24-hour waiting period between the scan and the procedure. This July, Gov. Rick Perry signed into law the sweeping House Bill 2, which requires that all abortion providers have admitting privileges at a local hospital, mandates an outdated protocol for medication abortions and bans all abortions after 20 weeks. The law also requires that all abortions be performed in outpatient surgery clinics, but that requirement doesn’t take effect until October 2014.

The legal challenge brought by Planned Parenthood and a coalition of Texas abortion providers focuses on two requirements that came into effect first: local admitting privileges and medication abortions. U.S. District Judge Lee Yeakel ruled that the admitting-privileges requirement lacked any medical justification and granted an injunction to hold that requirement in abeyance until Planned Parenthood's lawsuit could be decided. However, on Oct. 31, a three-judge panel from the 5th Circuit overruled Yeakel and brought H.B. 2's admitting privileges provision into effect immediately. Planned Parenthood asked the Supreme Court to block the law until the 5th Circuit could hear the case this month, but on Nov. 19 the Supreme Court refused to put H.B. 2 on hold while the conservative 5th Circuit makes up its mind.

The Valley used to have two abortion providers — Whole Woman's Health McAllen (WWHM) and Reproductive Services of Harlingen — but now it has none that currently offer abortions, because their doctors lack admitting privileges. (Emergency rooms are required to provide the same care to all patients, regardless of whether their doctors have admitting privileges there. While the doctors at WWHM are applying for privileges at local hospitals, Reproductive Services of Harlingen's physician has already been turned down by all the hospitals in his area.) Even if Planned Parenthood wins its lawsuit, abortions will still have to be performed in ambulatory surgical centers by this time next year, which means that neither clinic can continue to operate in its current facility.

Medication abortions

WWHM is the only abortion clinic in this border city of 134,000. Right now, according to WWHM's Fatimah Gifford, if a woman in the Rio Grande Valley needs an abortion, she has to travel 240 miles north to San Antonio. Though Texas' standard 24-hour waiting period is waived for women who live more than 100 miles from the nearest clinic, that allowance applies only to surgical abortions. To reach San Antonio via Highway 281, a woman has to pass through the Falfurrias border checkpoint, where the Texas Border Patrol will likely grill her about her immigration status, a daunting prospect for an undocumented woman seeking abortion care. Gifford says most of her undocumented patients won't risk the trip.

A woman seeking a medication abortion must make three trips to San Antonio. A medication abortion, also known as a pill abortion, uses two drugs to induce a miscarriage in the first trimester. Under the new law, the first trip is for the ultrasound, consultation and the first pill, then she must return to the clinic 48 hours later for her second pill. Doctors who offer pill abortions in other states routinely give patients the second dose of pills to take home, but Texas law doesn’t allow it. Finally, she has to go back to the clinic 14 days later for a follow-up visit so that the same doctor can check to make sure that the drugs worked. Many abortion providers travel to clinics across the state or the country, which makes it difficult to ensure that the same doctor will be available for all three steps.

Planned Parenthood argued in court that this provision makes it so difficult for women to obtain abortions that it is equivalent to a ban, which has serious implications for the rights and health of women with existing conditions that make drug-induced abortion the only safe option.

Some women resort to self-induced medication abortions with the ulcer drug misoprostol, widely used in Latin America to terminate early pregnancies. Though it is available only by prescription in the United States, misoprostol can easily be purchased at pharmacies across the border in Mexico or at flea markets in the Valley. WWHM saw about one failed misoprostol self-induced abortion a day.

Andrea Ferrigno, WWHM's vice president, said that if a woman arrives at the clinic after taking the pills for weeks and is still bleeding, doctors will typically complete the abortion if she's still pregnant or clean out any residual tissue, as they would for a spontaneous miscarriage. Misoprostol is 85 percent effective, if administered properly, which suggests that many more women self-terminate and don’t need further medical attention.

Beck, the student volunteer, knows the clock is ticking for her callers. Abortion gets significantly more expensive as a pregnancy progresses. Often, by the time women can cobble together the money to cover the cost of an early abortion, the price has gone up. Providers call it chasing the fee. The very earliest abortions start at $400. "When you're at 18 to 24 weeks, you could easily be looking at $3,500," Beck says — a figure that doesn’t even count time off work, travel expenses, child care or any of the other ancillary costs of an abortion.

If a caller lives in the Lower Rio Grande Valley and needs an abortion after 17 weeks, she will have to compete for one of the limited number of slots in San Antonio, drive 300 miles to Houston or go out of state.

I hope our politicians are made aware of how many girls are self-aborting in the Rio Grande Valley. This law is backfiring.

Lester Minto

Reproductive Services of Harlingen

Dr. Lester Minto, who runs an abortion clinic in South Texas, says he has been complying with the law but doesn't rule out whatever it takes to help women
Dr. Lester Minto, who runs an abortion clinic in South Texas, says he has been complying with the law but doesn't rule out doing whatever it takes to help women
Lindsay Beyerstein

Reproductive Services of Harlingen, in the Valley's Cameron County, is a one-story building set back from the street by a large and immaculately manicured lawn. The entrance to the parking lot is flanked by palm trees. When it was still providing abortions, back in October, the waiting room looked like a family doctor’s office: no frills but homey, with plenty of inspirational posters about the nature of success and the importance of condoms. The recovery area resembled a suburban living room, with a handful of colorful pleather recliners, neatly folded electric blankets, art on the walls and a pot of yellow artificial flowers.

Reproductive Services has been in Harlingen since 1973, just after Roe v. Wade. The clinic looks its age, but everything is spotless. Its owner, Dr. Lester Minto, a lanky bald man with an almost military bearing, has been running it almost since the beginning.

"A buddy of mine, a gynecologist, asked me to help him out. Ultimately, he ran away with my nurse. Left me holding this bag," Minto says, smiling. "I've been here ever since."

The protesters had just left for the day. "They're always waving their Bibles at me," he said. He says he has received plenty of death threats over the years, which he dutifully reports to the Harlingen Police Department. He carries a .45 pistol, wears a bulletproof vest and keeps the FBI and a federal marshal on speed dial.

A self-proclaimed redneck, the doctor lives on a ranch outside Austin and raises macaws and other large parrots in his spare time. A sticker on his office wall at the clinic reads, "Trust women." He says he sometimes clashes with his neighbors because they watch too much Fox News and don’t believe in global warming. He doesn't let other people's opinions bother him, though. "I'm a f--- you kinda guy," he says.

Minto says that earlier that day, he asked one of his patients what she would do if she got pregnant again after his clinic closed. In that case, she told him, she'd have to resort to something illegal.

When asked in October what he planned to do after he stopped providing abortions, he laughed and said, "Who said I'm not going to do abortions? You said that. I didn't say that. There's other names you can call it." Minto has been complying with the law since it went into effect, but he’s leaving his options open. Whatever it takes, he says, to keep helping women.

Legally, he says, he can't tell women where to get misoprostol, but he doesn't have to. The pills work about two-thirds of the time, he says, and the remaining third must have outpatient surgery to complete the miscarriage. Minto estimated that by mid-December, he had seen about 200 women since the law went into effect and that roughly 100 of them returned to have him complete their abortions.

"I hope our politicians are made aware of how many girls are self-aborting in the Rio Grande Valley," Minto says. "This law is backfiring."

Funding for some of the reporting for this piece was provided by the Investigative Fund of the Nation Institute.  

 

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