A month after the U.S. Supreme Court overturned Roe v. Wade, Texas’ two dozen abortion clinics are slowly coming to terms with a future where their work is virtually outlawed.
Some clinics have already announced that they are shutting down operations and moving to New Mexico and other states that are expected to protect abortion access. Others, including Planned Parenthood, say they will stay and continue to provide other sexual and reproductive health services.
But keeping the doors open will likely come at a high cost for these clinics — financially, politically and psychologically — as they absorb more patients with fewer options.
“It’s really hard to find words in the English language that honor what the experience has been like,” said Dr. Bhavik Kumar, medical director of primary and trans care at Planned Parenthood Gulf Coast in Houston. “It’s just devastation.”
Planned Parenthood clinics in Texas have had to turn away patients in dire situations, according to an open letter provided to The Texas Tribune, including minors and a woman who already had children but had been told by her doctor that she could die if she carried another pregnancy to term.
“People are looking at you and asking you, like, ‘Why can’t you help me?’ ‘Can you make an exception?’” Kumar said. “We hear that all the time, and it just feels so inhumane and unethical … to have to do this over and over again.”
Kumar thought years of navigating abortion restrictions in Texas had prepared him for the overturn of Roe v. Wade. But he wasn’t prepared for the fear that his patients are feeling amid this new legal landscape.
He said he saw a patient last week who was worried about the consequences of even mentioning abortion.
“We’re here in a clinic where we’ve provided abortion care for decades. I’m an abortion-providing doctor, and I talk very openly about abortion,” he said. “But she just had so much fear and apprehension, and was uncertain if she could actually say the words out loud and ask for that help.”
Even if Planned Parenthood can’t offer abortion anymore, it’s committed to staying put and helping Texans access an array of other reproductive health services, including birth control, cancer screenings and testing for sexually transmitted diseases.
Its clinics have been dealing with a surge in demand for long-acting reversible contraception, like IUDs, and information about birth control options including vasectomies, all while expanding their education operations.
But keeping the doors open will mean continuing to contend with a Legislature intent on seeing them shut down. Texas elected officials have spent much of the last decade working to defund Planned Parenthood by removing it from Medicaid and other publicly funded programs.
Even as the state halts abortion services entirely in Texas, Planned Parenthood does not anticipate it stopping those attempts to financially hamstring its work.
“The state has been relentless because of who we are and what we stand for, and that’s unapologetic access to comprehensive sexual reproductive health care, which includes abortion,” Kumar said.
Some clinics plan to relocate
Other Texas clinics are shutting down operations entirely and relocating to “haven states” to continue providing abortions.
Whole Woman’s Health, which started in Texas in 2003 and at one point operated six clinics around the state, has announced plans to relocate to New Mexico.
The group has been slowly pivoting its operations in recent years toward states that protect abortion access, building clinics in Maryland and Virginia and a new location near the airport in Minneapolis. It has invested in a program to help patients travel to these states from Texas.
Now, the organization is closing its remaining four Texas clinics and relocating those operations to an as-yet undisclosed location in New Mexico.
“[Whole Woman’s Health] has served Texans for nearly 20 years, and our love for Texans runs deep,” president and CEO Amy Hagstrom Miller said in a statement. “Even when the courts and the politicians have turned their backs on Texans, we never will.”
Alamo Women’s Reproductive Services, an independent abortion provider, has also announced it will close its San Antonio clinic and a sister facility in Tulsa and relocate to Albuquerque, New Mexico, and Carbondale, Illinois.
New Mexico is Texas’ only direct neighbor that is expected to preserve abortion access, although “neighbor” is a relative term — Las Cruces is more than a 10-hour drive from Dallas or Houston.
The clinics that remain in Texas providing non-abortion care are preparing to serve as the conduit to these out-of-state clinics.
“We understand and deeply empathize with providers who have been forced to close their clinics and move out of state,” said Melaney Linton, president and CEO of Planned Parenthood Gulf Coast, in a statement. “We will continue to work closely with them as we help patients navigate their best options.”
But many Texans will not be able to leave the state, due to finances, child care needs or immigration status.
“Sometimes we hear that it was difficult for them to even come into the clinic that’s closer to home, maybe within 10 miles of where they actually live, let alone having to travel to another state to get that care,” Kumar said. “So it’s very, very scary for folks.”
Hanging on with ultrasounds
For many of the providers who have been on the front lines of contentious legal fights over abortion access in recent years, the overturn of Roe v. Wade was not a surprise. But now that it’s here, they say the reality is worse than they could have imagined.
Most of the patients who come to Houston Women’s Reproductive Services these days already know they want an abortion — and are willing to travel to out of state to get one. Clinic director Kathy Kleinfeld and her staff are in touch with other clinics around the country, helping patients navigate the various legal requirements, wait times and travel logistics that govern abortion access right now.
“It’s very helpful to have someone to talk this through with, who can say, ‘OK, I know this feels overwhelming right now. But have you ever lived in another state? Do you have any friends or family elsewhere?’” she said. “That gets the wheels turning, and if we’re not here to do that, they’re going to have to figure it out on their own.”
For the last month, Houston Women’s has provided only ultrasounds. Kleinfeld said it has seen a steady trickle of patients and identified ectopic pregnancies, false positives and patients who are actively miscarrying.
“In all those circumstances, women would be wasting precious time and money to travel out of state when in fact they may not need the service,” she said. “So it is important to have those ultrasounds in a medical environment where they receive accurate and compassionate care.”
Kleinfeld worries that if that option isn’t available, more people will turn to crisis pregnancy centers. These religiously affiliated nonprofits often offer ultrasounds, but some use coercive and deceptive practices to discourage clients from pursuing abortions.
Kleinfeld said she’s been encouraged by the support her clinic has received, but they’ve scaled back staff and are being realistic about how long they can remain open without their main source of income.
“We’ll do it as long as we can,” she said. “I’m not gonna sell my house and live under the bridge. I’m not going to go that far, but … I think we’re gonna see a lot of creative thinking here and a lot of innovative ideas from some of the brightest people.”
Disclosure: Planned Parenthood has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.
On Friday morning, a nurse at Alamo Women’s Reproductive Services in San Antonio ushered a patient into an exam room. She gave her a gown, told her the doctor would be in shortly, and stepped back out of the room into a changed world.
“I saw the other nurses standing in the hallway,” said Jenny, a nurse who has been with the clinic for five years and asked to be identified only by her first name for fear of being targeted by anti-abortion protesters. “And I just knew.”
In the few minutes she’d been inside the exam room, the U.S. Supreme Court had overturned Roe v. Wade, clearing the way for Texas to fully ban the procedure she had just prepped a patient for.
Jenny and four other staff members stood in the hallway, paralyzed. They had a dozen patients sitting in the lobby awaiting abortions, all seemingly unaware of the seismic shift that had just rocked the reproductive health care world.
Before they could even decide how to proceed, the door to the clinic slammed open and a young woman ran in, yelling about Roe v. Wade and saving babies. They didn’t recognize her but believed she was associated with the anti-abortion protesters who often massed outside the clinic.
The woman quickly fled, leaving the clinic staff alone with a dozen sets of eyes staring back at them from the waiting room chairs.
“Obviously, that wasn’t how we had wanted it to come out,” Jenny said.
While other nurses addressed the elephant in the waiting room, Jenny returned to the patient she had just left.
“I just said, ‘You have to get dressed and come back out to the lobby,’” she said. “I told her, ‘The doctor will explain more … but we can’t even give you a consultation today.’”
The legal status of abortion in Texas was murky in the immediate aftermath of Friday’s ruling. The state has a “trigger law” that automatically bans abortion 30 days after the ruling is certified, a process that could take a month or more.
But in an advisory issued Friday, Texas Attorney General Ken Paxton said that abortion providers could be held criminally liable immediately because the state never repealed the abortion prohibitions that were on the books before Roe v. Wade was decided in 1973.
Rather than risking criminal charges, Texas’ clinics stopped providing abortions Friday.
Andrea Gallegos, executive director of Alamo Women’s Reproductive Services, said she’s hopeful that the clinic’s lawyers may find a way to allow it to resume abortions briefly before the trigger ban goes into effect.
But either way, abortion will soon be banned in the second-largest state in the country. The clinics will close. The staff will relocate or find new jobs. And the people they would have served will melt into the shadows, fleeing over state lines, seeking out illegal abortions or quietly consigning themselves to decades of raising children they never wanted.
Bearing the bad news
The staff at Alamo Women’s Reproductive Services are no strangers to bad news. For years, they’ve had to navigate ever-tightening restrictions that force them to delay care or turn patients away.
But never have they had to deliver so much bad news in such a short period of time. Dr. Alan Braid, who owns the clinic, told the women in the waiting room — and those who had already been admitted to exam rooms — that they were halting all abortions immediately.
Some just got up and left. One woman got upset, angrily demanding that Braid go through with the abortion anyway. She had driven hours to make it to this appointment after her home state of Oklahoma banned all abortions.
“I understand why she’s upset, and she has every right to be upset, but we’re not the enemy here,” Gallegos said. “The only thing we could tell her was this wasn’t because of us, it was because of the Supreme Court.“
One woman was on her fourth visit to the clinic. She’d been too early in the pregnancy for an abortion during the first two appointments, but finally, yesterday, staff were able to detect a pregnancy on the sonogram. But Texas requires clinics to wait 24 hours after a sonogram to perform an abortion, so they sent her home.
She arrived at the clinic Friday morning, not long after the Supreme Court ruled. When staff told her the news, she was bereft — rocking back and forth, wailing, begging for the staff to help her.
“I just told her, you did everything right and we did everything that we could, but unfortunately, our hands are tied today,” clinic director Kristina Hernandez said.
Gallegos said it’s devastating to know just how easily they could have helped that patient.
“Sometimes it’s just a matter of handing somebody a pill, and for the surgical [abortion], it’s less than five minutes,” she said. “It’s fast, it’s easy, it’s safe, it’s done. It’s health care.”
Instead, they had to send her away.
After they cleared the waiting room, the staff turned to the stack of two dozen appointments scheduled for the rest of the day. They distributed the files, took deep breaths, and started dialing.
They explained, again and again: No, you can’t get an abortion here anymore. No, you can’t reschedule. No, you can’t go to another clinic in Texas, or even Oklahoma, or a lot of other states. No, it doesn’t matter if you’re under six weeks. No, not even if you come in right now. No, this isn’t our fault. No, no, no, no.
They offered a list of out-of-state clinics and groups that help fund abortions and travel that they put together when Texas banned abortions after about six weeks of pregnancy. They spent most of the day listening to the busy signals and voicemail boxes of clinics in New Mexico, where abortion will remain legal.
They make this effort because there is little else they can do. But they are well aware that many of their patients struggle to find babysitters for the duration of their appointments, let alone traveling out of state to get abortions.
And even if they can find babysitters, and get time off from work, and safely leave the state, Friday’s ruling is only going to make it harder for low-income Texans to access resources to pay for these journeys. Texas abortion funds have stopped paying for out-of-state travel and abortions until they can better assess the legal implications of their work.
Fear for the future
As the pandemonium of the morning subsided, something far worse settled over the clinic: silence. Staff sat around the check-in desk, filing paperwork and tidying up. Someone ordered pizza.
They listened in to televised press conferences, hoping to glean information about their own fates. They talked about where the fight might go from here, and some of the bigger battles they’ve had to wage over the years. They talked about what this meant for their daughters, and the patients they’d treated over the years, and those they would likely never get the chance to see.
A lot of the staff members have been working for the clinic for years. Hernandez was there with Braid when this location opened in 2015.
“This is my baby,” she said. “This is my life, right? This is what I’m good at. This is what I want to keep doing. I can’t do anything else. I mean, I can, but I don’t want to.”
When Hernandez thinks about all the patients she’s been able to help over the years, it’s overwhelming. She’s had women come up to her in H-E-B, years after she helped with their abortions, and give her hugs before disappearing into the aisles.
On days like this, she thinks a lot about a young woman she spent three hours having a theological discussion with before the woman ultimately decided to have an abortion, and her own sister, who decided not to.
The clinic plans to keep the doors open and the staff employed as long as it can. They’re holding on to hope that they may be able to squeeze in a few more patients before the trigger ban goes into effect.
And they’re still offering follow-up appointments for patients who had abortions recently — perhaps the final patients the clinic will ever get to treat.
A young woman showed up Friday afternoon for her follow-up appointment, with her 3-month-old in tow. She’s a single mom in her early 30s, raising four children already.
When she found out she was pregnant again, she decided she couldn’t responsibly raise another child. She’s already struggling financially, and she was trying to leave her boyfriend, who she said was physically abusive.
“I have to figure out who’s gonna watch my babies on the weekends so I can go to work, and it’s stressful,” she said. “So I’m not gonna bring another baby into this.”
She got the two-drug medication abortion regimen at the clinic earlier this week. It was an easy process, she said, and she was hugely relieved to hear that it had been successful.
But with four kids, if she’d been turned away, she said she wouldn’t have even tried to leave the state or find another way.
“It’s not worth all that effort,” she said. “I would have just kept it.”
Published courtesy of The Texas Tribune, a nonpartisan, nonprofit media organization that informs Texans — and engages with them – about public policy, politics, government and statewide issues.
On June 24, 2022, the U.S. Supreme Court overruled Roe v. Wade, the landmark 1973 decision that established the nationwide right to choose an abortion.
For decades, the rancorous debate about the ruling has often been dominated by politics. Ethics garners less attention, although it lies at the heart of the legal controversy. As a philosopher and bioethicist, I study moral problems in medicine and health policy, including abortion.
Bioethical approaches to abortion often appeal to four principles: respect for patients’ autonomy; nonmaleficence, or “do no harm”; beneficence, or providing beneficial care; and justice. These principles were first developed during the 1970s to guide research involving human subjects. Today, they are essential guides for many doctors and ethicists in challenging medical cases.
Patient autonomy
The ethical principle of autonomy states that patients are entitled to make decisions about their own medical care when able. The American Medical Association’s Code of Medical Ethics recognizes a patient’s right to “receive information and ask questions about recommended treatments” in order to “make well-considered decisions about care.” Respect for autonomy is enshrined in laws governing informed consent, which protects patients’ right to know the medical options available and make an informed voluntary decision.
Some bioethicists regard respect for autonomy as lending firm support to the right to choose abortion, arguing that if a pregnant person wishes to end their pregnancy, the state should not interfere. According to one interpretation of this view, the principle of autonomy means that a person owns their body and should be free to decide what happens in and to it.
Abortion opponents do not necessarily challenge the soundness of respecting people’s autonomy, but may disagree about how to interpret this principle. Some regard a pregnant person as “two patients” – the pregnant person and the fetus.
One way to reconcile these views is to say that as an immature human being becomes “increasingly self-conscious, rational and autonomous it is harmed to an increasing degree,” as philosopher Jeff McMahan writes. In this view, a late-stage fetus has more interest in its future than a fertilized egg, and therefore the later in pregnancy an abortion takes place, the more it may hinder the fetus’s developing interests. In the U.S., where 92.7% of abortions occur at or before 13 weeks’ gestation, a pregnant person’s rights may often outweigh those attributed to the fetus. Later in pregnancy, however, rights attributed to the fetus may assume greater weight. Balancing these competing claims remains contentious.
Nonmaleficence and beneficence
The ethical principle of “do no harm” forbids intentionally harming or injuring a patient. It demands medically competent care that minimizes risks. Nonmaleficence is often paired with a principle of beneficence, a duty to benefit patients. Together, these principles emphasize doing more good than harm.
Although 97% of unsafe abortions occur in developing countries, developed countries that have narrowed abortion access have produced unintended harms. In Poland, for example, doctors fearing prosecution have hesitated to administer cancer treatments during pregnancy or remove a fetus after a pregnant person’s water breaks early in the pregnancy, before the fetus is viable. In the U.S., restrictive abortion laws in some states, like Texas, have complicated care for miscarriages and high-risk pregnancies, putting pregnant people’s lives at risk.
Justice, a final principle of bioethics, requires treating similar cases similarly. If the pregnant person and fetus are moral equals, many argue that it would be unjust to kill the fetus except in self-defense, if the fetus threatens the pregnant person’s life. Others hold that even in self-defense, terminating the fetus’s life is wrong because a fetus is not morally responsible for any threat it poses.
Yet defenders of abortion point out that even if abortion results in the death of an innocent person, that is not its goal. If the ethics of an action is judged by its goals, then abortion might be justified in cases where it realizes an ethical aim, such as saving a woman’s life or protecting a family’s ability to care for their current children. Defenders of abortion also argue that even if the fetus has a right to life, a person does not have a right to everything they need to stay alive. For example, having a right to life does not entail a right to threaten another’s health or life, or ride roughshod over another’s life plans and goals.
Justice also deals with the fair distribution of benefits and burdens. Among wealthy countries, the U.S. has the highest rate of deaths linked to pregnancy and childbirth. Without legal protection for abortion, pregnancy and childbirth for Americans could become even riskier. Studies show that women are more likely to die while pregnant or shortly thereafter in states with the most restrictive abortion policies.
Other marginalized groups, including low-income families, could also be hard hit by abortion restrictions because abortions are expected to get pricier.
Politics aside, abortion raises profound ethical questions that remain unsettled, which courts are left to settle using the blunt instrument of law. In this sense, abortion “begins as a moral argument and ends as a legal argument,” in the words of law and ethics scholar Katherine Watson.
Putting to rest legal controversies surrounding abortion would require reaching moral consensus. Short of that, articulating our own moral views and understanding others’ can bring all sides closer to a principled compromise.
In September, when Texas’ near-total abortion ban took effect, Planned Parenthood clinics in the Lone Star State started offering every patient who walked in information on Senate Bill 8, as well as emergency contraception, condoms and two pregnancy tests. The plan is to distribute 22,000 “empowerment kits” this year.
“We felt it was very important for patients to have as many tools on hand to help them meet this really onerous law,” said Elizabeth Cardwell, lead clinician at Planned Parenthood of Greater Texas, which has 24 clinics across the northern and central regions of the state and provides care to tens of thousands of people annually.
Most of their patients — who tend to be uninsured and have annual household incomes of less than $25,000 — had not known about SB 8 the first several weeks after implementation, said Cardwell. But once they learned about it, patients seemed to rush to get on birth control, she said.
SB 8 allows private citizens, in Texas or elsewhere, to sue anyone who performs an abortion in the state or who “aided or abetted” someone getting an abortion once fetal cardiac activity is detected. This is generally around six weeks, before most people know they’re pregnant. It’s had a chilling effect in Texas, where access to abortion was already limited.
Medical staffs are doubling down on educating patients about birth control. They recognize the strategy isn’t foolproof but are desperate to prevent unintended pregnancies, nearly half of which nationwide end in abortion.
“It’s more important now than it ever has been,” said Cardwell. “I’ve been in abortion care 30-plus years, and my go-to line was ‘You’ve got plenty of time. You don’t have to feel rushed. Talk with your partner. Talk with your family,’” she said. “Now we don’t have that luxury.”
Patients, too, seem to feel a sense of urgency. During September, according to data from Planned Parenthood of Greater Texas, medical staff provided patients with some form of birth control — for example, pill packs, Depo-Provera shots or IUD implant insertions — in more than 3,750 visits, 5% more than in September 2020.
Dr. Jennifer Liedtke, a family physician in West Texas, said she and her nurse practitioners explain SB 8 to every patient who comes to their private practice and saw a 20% increase in requests for long-acting reversible contraceptive methods, known as LARCs, in September.
LARCs, a category that includes intrauterine devices and hormonal implants, have become increasingly appealing because they are 99% effective at preventing pregnancy and last several years. They are also simpler than the pill, which needs to be taken daily, or the vaginal ring, which needs to be changed monthly.
Still, LARCs are not everyone’s preferred method. For example, inserting an IUD can be painful.
A doctor’s office is one of the few opportunities for reliable birth control education. Texas law doesn’t require schools to teach sex education, and if they do, educators must stress abstinence as the preferred birth control method. Some doctors opt to explain abortion access in the state when naming birth control options.
Liedtke is used to having to explain new laws passed by the Texas legislature. “It happens all the time,” she said. But the controversy surrounding SB 8 confuses patients all the more as the law works its way through the court system with differing rulings, one of which briefly blocked the measure. The U.S. Supreme Court heard related arguments Nov. 1.
“People just don’t understand,” said Liedtke. “It was tied up for 48 hours, so they are like, ‘It’s not a law anymore?’ Well, no, technically it is.”
Not all providers are able to talk freely about abortion access. In 2019, the Trump administration barred providers that participate in the federally funded family planning program, Title X, from mentioning abortion care to patients, even if patients themselves raise questions. In early October, the Biden administration reversed that rule. The change will kick in this month. Planned Parenthood can discuss SB 8 in Texas because Texas affiliates do not receive Title X dollars.
Dr. Lindsey Vasquez of Legacy Community Health, the largest federally qualified health center in Texas and a recipient of Title X dollars, said she and other staff members have not discussed abortion or SB 8 because they also must juggle a variety of other priorities. Legacy’s patients are underserved, she said. A majority live at or below the federal poverty level.
Nearly two years into the covid-19 pandemic, “we’re literally maximizing those visits,” Vasquez said. Their jobs go beyond offering reproductive care. “We’re making sure they have food resources, that they have their housing stable,” she said. “We really are trying to make sure that all of their needs are met because we know for these types of populations — patients that we serve — this may be our only moment that we get to meet them.”
Specialized family planning clinics that receive Title X dollars do have proactive conversations about contraceptive methods, according to Every Body Texas, the Title X grantee for the state.
Discussions of long-acting reversible contraception must be handled with sensitivity because these forms of birth control have a questionable history among certain populations, primarily lower-income patients. In the 1990s, lawmakers in several states, including Texas, introduced bills to offer cash assistance recipients financial incentives to get an implant or mandate insertion for people on government benefits, a move seen as reproductive coercion.
“It’s important for a client to get on the contraceptive method of their choice,” said Mimi Garcia, communications director for Every Body Texas. “Some people will just say, ‘Let’s get everyone on IUDs’ or ‘Let’s get everybody on hormonal implants’ because those are the most effective methods. … That’s not something that’s going to work for [every] individual. … Either they don’t agree with it philosophically or they don’t like how it makes their body feel.”
It’s a nuanced subject for providers to broach, so some suggest starting the conversation by asking the patient about their future.
“The best question to ask is ‘When do you want to have another baby?’” said Liedtke. And then if they say, ‘Oh, gosh, I’m not even sure I want to have more kids’ or ‘Five or six years from now,’ then we start talking LARCs. … But if it’s like, ‘Man, I really want to start trying in a year,’ then I don’t talk to them about putting one of those in.”
The Biden administration expected more demand for birth control in Texas, so Health and Human Services Secretary Xavier Becerra announced in mid-September that Every Body Texas would receive additional Title X funding, as would local providers experiencing an influx of clients as a result of SB 8.
But providers said improved access to contraception will not blunt the law’s effects. It will not protect patients who want to get pregnant but ultimately decide on abortion because they receive a diagnosis of a serious complication, their relationship status changes, or they lose financial or social support, said Dr. Elissa Serapio, an OB-GYN in the Rio Grande Valley and a fellow with Physicians for Reproductive Health.
“It’s the very best that we can do,” said Cardwell, of Planned Parenthood of Greater Texas. “There’s no 100% effective method of birth control.”
