The Supreme Court agreed to review Whole Woman's Health v. Cole - its first abortion case in nearly a decade - just days before a new study revealed that between 100,000 and 240,000 Texans have attempted to terminate their own pregnancies without medical help. The Texas Policy Evaluation Project study underscores exactly what is at stake when the Supreme Court rules in June 2016.
"I didn't have any money to go to San Antonio or Corpus. Like I was just dirt broke. I was poor."
If the court decides to allow the omnibus anti-abortion law HB2 to take full effect (i.e., rules against Whole Woman's Health), the state of Texas would have at most 10 abortion clinics remaining - nine fewer than at present and 32 fewer than when HB2 was passed in 2013. Such an outcome would only exacerbate the situation documented in the Texas report, titled "Texas women's experiences attempting self-induced abortion in the face of dwindling options," which found that most of the hundreds of thousands of Texans who attempted self-induction cited challenges in accessing a clinic setting as the reason for attempting abortion at home rather than seeking medical support. Numerous international studies have found negligible changes in abortion rate when the procedure is made nearly or entirely illegal, supporting the hypothesis that the self-induction rate would rise if the Supreme Court upholds HB2.
"This is the latest body of evidence demonstrating the negative implications of laws like HB2 that pretend to protect women but in reality place them, and particularly women of color and economically disadvantaged women, at significant risk," said Dr. Daniel Grossman, a co-investigator with the Texas Policy Evaluation Project and professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco. "As clinic-based care becomes harder to access in Texas, we can expect more women to feel that they have no other option and take matters into their own hands."
Dwindling Access to Abortion
The study found that the populations most familiar with self-induced abortion methods are those most acutely affected by recent clinic closures - rural communities, poor people, immigrants, undocumented people and people of color - leading researchers to anticipate increases in self-induced abortions should clinic-based care become even harder to access. International studies support the hypothesis that reduced access to clinics will only lead to rising rates of self-induced abortion. Because of an existing lack of access, residents of areas near the Texas-Mexico border in the Rio Grande Valley are at particular risk should further legal restrictions reduce access to clinic-based care.
"These restrictions were designed by politicians to make abortion harder to get."
Almost all the women interviewed for the study either contacted a clinic or considered doing so during their abortion process, but they cited poverty-related obstacles as insurmountable barriers to accessing these clinics. Among those who found themselves facing those exact barriers is a 24-year-old woman from the Lower Rio Grande Valley.
"I didn't have any money to go to San Antonio or Corpus," the woman told researchers. "I didn't even have any money to get across town. Like I was just dirt broke. I was poor."
Should the Supreme Court uphold HB2, the distance to the nearest clinic for many in Texas will increase dramatically. Both the 300-mile stretch from the tip of Texas in the Valley to San Antonio and the 500-mile stretch between San Antonio and the New Mexico border would be left without a single clinic. With patients already describing the distance to a clinic in combination with the cost of the procedure as putting clinic-based abortion care out of reach, additional clinic closures would be devastating.
Disproportionate Effects on Latina Patients
Closures do not impact all communities equally, and communities of color are often hit hardest. Jessica González-Rojas, executive director of the National Latina Institute for Reproductive Health, points out that Latinas are disproportionately affected by dwindling access.
"These restrictions were designed by politicians to make abortion harder to get. While this politically motivated attack threatens all Texas women, it's particularly harmful for the 40 percent of Texas women who are Latina," González-Rojas said. "We're already suffering from recent clinic closures and funding cuts throughout the state. Latinas are twice as likely to experience unintended pregnancies as non-Latina white women and are more likely to be of reproductive age. We already face too many barriers to getting the health care we need."
These barriers include not just a reduction in clinics that provide abortion, but also a 66 percent cut in funding for family planning resulting in an increase in unintended pregnancies. Altogether, the hostile climate for reproductive health care leaves many with the impression that even fewer clinics are available than currently remain open.
"I was like, I've just got to get it done now. And I just said, 'well, there's only like what - I think there's less than ten clinics in all of Texas now and they're going to be busy,'" a 26-year-old Corpus Christi woman told researchers. "So when I call to make the appointment, you know, I couldn't - I think the earliest they saw me was like a month from when I called because they're so busy, you know."
The clinic she called was 150 miles away, so she attempted to self-induce using an herbal remedy. When she was unsuccessful, she had to make the costly trip.
A handful of women whom researchers spoke to used herbs, teas or vitamins - all unsuccessfully. Others found ways to get misoprostol (also known by the brand name Cytotec), one of the two drugs commonly used in a prescribed medication abortion protocol.
As inducing a miscarriage is illegal (in every state), those attempting to self-induce face potential prosecution.
Dr. Grossman explained in a November 17 press call that though some of the women had successfully self-induced using misoprostol, there are health risks based on the patient's specific medical history, how far along they are and whether they are able to obtain accurate dosage information. As inducing a miscarriage is illegal (in every state, not just Texas), those attempting to self-induce by any means also face potential prosecution. Even if the risks could be mitigated, patients who would prefer to see a doctor or nurse practitioner shouldn't be expected to handle terminating a pregnancy on their own.
"It's certainly not ideal that women are doing this on their own when they don't want to do this on their own, and they really want access to clinic-based care," Grossman said. "From a human rights perspective, women should be able to have access to the highest possibly quality of health care, and this is not the best quality health care if they don't have accurate information about what the dose is of the medication, how to use an evidenced-based regimen."
Amy Hagstrom Miller, president and CEO of Whole Woman's Health, echoed Grossman's assessment: "I think it's important to point out that abortion is legal in this country. And so every woman deserves to have access to whatever method for terminating her pregnancy safely she might choose in her local community."
While those interviewed for the study who utilized misoprostol to self-induce were successful, having some patients safely terminate on their own hardly means that a reduction in access to clinic-based care is not causing harm.
"Sometimes we get to this least common denominator ... as though somehow because she was able to figure out outside the medical system how to get the medication that she needs and didn't bleed to death, we're somehow supposed to say that that's adequate," Hagstrom Miller said. "And I think it's tremendously disrespectful to every woman who deserves the same access to safe care and to have choices in her care. Not to be forced to choose a method of abortion that she may not have wanted to choose in the first place."
As politicians and leaders in the anti-abortion movement continue to claim that laws like HB2 are for the health and safety of women, advocates are looking to the Supreme Court as a last resort for restoring some of the health-care access in their state.
"We are hopeful that when the Supreme Court reviews these deceptive and devastating laws, which fall hardest on Latinas and immigrant women, they will see what we already know. These laws have nothing to do with protecting women, and everything to do with creating coercive and nearly impossible-to-navigate hurdles for those who seek abortion," González-Rojas said.
Beyond the Border
Border communities are certainly not the only ones affected by abortion restrictions like HB2. Throughout Texas, people seeking abortions have experienced challenges from reduced access and are at risk of increased self-induction rates following the June decision on Whole Woman's Health v. Cole.
"We speak with North Texans every day who have been negatively affected by HB2," said Kamyon Conner, a Texas Equal Access Fund intake director and board member. "They are being forced to schedule their procedures a month or so out because of the high demand that has been placed on the remaining clinics. Many have had to travel to other states for abortion services, causing them to incur undue stress, expense and time away from work and family."
Those fighting HB2 on the ground in Texas are aware that the law passed in their state will ultimately affect more than the 5.4 million women of reproductive age within its borders.
"I hope that the court will carefully consider the impact of these laws on all Texans and recognize them for the unnecessary and damaging restrictions that they are," Conner said. "This would mean not only a win for Texans seeking abortion access but also a win for abortion access and reproductive health care nationwide,"
Indeed, because of the record number of abortion restrictions passed around the country since 2011 - 287 as of this summer, according to the Guttmacher Institute - the court's decision will echo beyond the borders of the Lone Star State.
"If these regulations are allowed to stand, others like them will inevitably follow, threatening to drag our country back to the perilous days before Roe [v. Wade] and endangering women's lives," said Nancy Northup, president and CEO of the Center for Reproductive Rights. "We are counting on the US Supreme Court to overturn these deceptive laws and reject the underhanded tactics of legislators who care more about political gamesmanship than the health, well-being and constitutional rights of women in their state."
As Slate court reporter Dahlia Lithwick wrote in October as the session started, the outcome of the Supreme Court case is anyone's guess.
"In each of these reproductive rights cases, all eyes will be on Justice Kennedy: If the Kennedy who voted to uphold Roe v. Wade in 1992's Planned Parenthood v. Casey decision shows up, the right to choose will live another day," Lithwick wrote. "If he decides to fret about maternal regrets as he did in 2007's Gonzales v. Carhart, abortion rights for women in many states will all but evaporate."