‘Only a few days to work with’: a south Texas abortion clinic strains under SB8’s tight deadline

Originally published by the 19th

Karla S knew she was pregnant almost right away. She could tell by the smells: “Everything was rancid,” Karla said.

She texted her boyfriend, who bought her a test that she took that same night. When the result was positive, she didn’t know what to do.

“It made me very nervous,” said Karla, whose full name has been withheld for privacy. “But it also made me very determined. I was not in any type of way prepared to have a child. I had to be very sure of what I was going to do.”

Karla, 23, was on birth control – she hadn’t been trying to conceive. For two weeks, she sat with the decision of whether to have the baby, trying to picture herself with a child. It didn’t click. She wants to have children someday, but she wants to finish college first.

So she made an appointment at Whole Woman’s Health in McAllen, Texas, the only abortion clinic serving the Rio Grande Valley, which spans about 4,250 square miles and includes a large portion of the state’s border with Mexico. It was a little over two weeks after Senate Bill 8, the new Texas law banning abortion after six weeks, went into effect.

Even before SB8, Texans were facing an uphill battle when it came to access. The burden is especially acute in the Valley, a remote part of the state which is one of the poorest areas not just in the state of Texas, but in the entire country.

The McAllen clinic is Texas’s only abortion provider south of San Antonio, close to 250 miles away. It draws people from all over the region – which is home to almost 1.4 million people, predominantly Latinx – many traveling close to 200 miles each way for an appointment. Every doctor who performs abortions here travels from somewhere else – Austin or Houston or California – and the clinic’s appointment schedule depends in large part on when they are able to practice.

While clinics in Oklahoma, Kansas and New Mexico are all reporting surges in Texas-based patients, it’s particularly difficult to make the journey from the Valley. The closest out-of-state option from McAllen is in Mexico City, at least two hours on a plane, or close to 600 miles by car. It’s a journey that simply isn’t feasible for many people who come to Whole Woman’s Health.

Now that getting an abortion is nearly impossible under the best of circumstances, what happens if something goes wrong? That’s what Karla, a lifelong resident of the Valley, had to figure out.

Karla lives one city over from McAllen, in Mission. She went to Whole Woman’s Health for the first time on 17 September, and was still under the six-week gestational limit. Texas requires anyone seeking an abortion to wait 24 hours after their initial consultation, so the next day, on Friday, 18 September, she went back and was given the set of pills that would induce an abortion: one to take in the clinic, and the other at home.

After 24 hours, nothing had happened.

Karla didn’t bleed or experience cramps or any of the symptoms indicating the abortion had worked. The following Monday, the soonest she could get an appointment, she went to the McAllen clinic and took more pills. Still, nothing happened. Tuesday, she came in one more time, hoping to get a surgical abortion instead. She knew she was running out of time.

“I’m hoping this will work,” she told the 19th that day through tears. “I was already at five weeks. I don’t want to get closer to six, or even seven.”

At Whole Woman’s Health, a network of abortion clinics, the procedure and necessary appointments in Texas cost at least $800 – far more than what it costs in many other states – and abortions in Texas are rarely covered by health insurance.

There are financial resources available that, in theory, would be even better equipped now to offer support. The Frontera Fund, which helps people in the Valley pay for abortions and associated travel, was overwhelmed with donations after the Texas law took effect. But requests for aid have fallen sharply, said Zaena Zamora, the fund’s executive director.

Before SB8 went into effect, three to five people would call each day to request help paying for an abortion, she said. Now if they get one call it’s a busy day.

Zamora believes that’s a byproduct of people being unable to book appointments in the state. And for many, she said, leaving to get an abortion elsewhere isn’t possible. They don’t have time off from work. They can’t risk forgoing the wages.

Most of the callers Frontera Fund does get are parents, so going out of state means bringing their kids with them or finding childcare. Abortion remains stigmatized, and it’s hard to explain where someone is going, and why they might have to leave the state for a few days. And anyone traveling north of McAllen will face immigration checkpoints – a deterrent in particular for people who are undocumented. About 136,000 undocumented people live in the Valley’s two largest counties, according to the Migration Policy Institute.

That means that, for many, there is no point in asking for help to pay for out-of-state travel – they can’t go anywhere.

“I can’t make up for lost wages. I can’t find a nanny or someone to take care of your children for you. I can’t call your boss and ask for your time off,” Zamora said. “And people from the Valley – some of us never leave the Valley. We’re a very close, tight-knit community, and some people never leave here.”

In that way, Karla is one of the lucky ones. Traveling to get an abortion would pose a substantial hardship, to be sure. It would drain her savings, but it would be doable.

Right now, she works as a cashier at a grocery store. But she had been feeling sick recently, and that, combined with the time off she sought to recover from her first attempt at an abortion, meant she hadn’t worked in more than a week. She wasn’t sure she would be put back on the schedule until October – until, the day after her abortion, she received a lucky, unexpected call asking her to come back.

If she had had to travel, her boyfriend would accompany her, helping drive to Mexico, or to a clinic in New Mexico. That would require him missing days of work – forgoing income – to say nothing of the money needed for traveling, for housing and for the abortion itself. Though a fund like Frontera could have helped, nobody had told Karla such organizations existed, or helped her get in touch with one.

“We would definitely struggle. We would have to play catch-up for a while,” she said.

But compared with the alternative? There’s no question, she said.

“I can be broke now, or I can be broke the next 18 years of my life.”

When Karla went in for her appointment, she found she had been able to expel the embryo, even without any visible bleeding. The abortion pills had worked after all.

In the days before SB8 took effect, calls to the McAllen’s Whole Woman’s Health clinic surged – one day, there were close to 50 back-to-back, a clinic staffer recalled.

The clinic is open Monday through Saturday, with procedures typically performed on Mondays and Tuesdays and the other days open for follow-ups, counseling and visits from patients seeking medications like the morning-after pill. Before SB8, between 40 and 50 patients would come in on any given service day for a consultation and then, after the 24-hour waiting period, an abortion.

Now, that number has fallen by close to half, said Veronica Hernandez, the clinic director. Maybe 20 to 30 people will come for a consultation. Of those patients, typically half will be able to get an abortion under SB8.

“It’s heartbreaking,” she said. “There are patients you want to help, but you can’t. And they’re emotional, or they start crying, and you want to help, but your hands are tied.”

The decline was visible the week of Monday 20 September, when the 19th visited the clinic. That Monday, Hernandez estimated eight patients came for ultrasounds to see how far along in their pregnancy they were. Only two of them were under the six-week mark, and could, if they wanted to, schedule an abortion for the next day.

That same day, another 23 patients, who believed they were earlier than six weeks, came in for an initial consultation with the doctor, planning to get an abortion the next day, Hernandez said. Of the 23, only about half qualified. The rest were later in their pregnancy than they realized.

Most of the remaining patients came back the next day for an abortion. Those who couldn’t, Hernandez said, either couldn’t find childcare or couldn’t get away from work for the appointment.

The window of eligibility to get an abortion in Texas is infinitesimal. Functionally, pregnant people have about a one-week window in which an abortion is feasible – even smaller than the two-week period experts initially forecast as a best-case scenario.

It has to be late enough in pregnancy that something can show up on an ultrasound, but early enough that the abortion can be done before the six-week deadline. Patients, skittish about the new law, are calling and coming in too early in their pregnancy, undergoing a sonogram that will not show anything, and having to reschedule to return a week later.

Laura M was one of the people able to make it back to the clinic. A 32-year-old teacher and parent to a five-year-old son, Laura took two days off work, and her boyfriend drove her more than an hour both days to the clinic.

When Laura first suspected she was pregnant, her home test came back negative. A week later, on 8 September, she went to her doctor, who did a transvaginal ultrasound. Nothing appeared on the screen.

But the nagging feeling wouldn’t disappear. So on Friday, 17 September, she took one more test. This time, it was positive. The previous test and ultrasound had just been too early in the pregnancy to detect anything.

She made an appointment for a week later – 24 September. But she was worried. She thought she was waiting too long. So she came earlier. On 20 September, she had her initial consultation and ultrasound at Whole Woman’s Health, where she learned she was 5.3 weeks pregnant.

She just made it.

“I had only a few days to work with,” she said on 21 September, from the clinic’s waiting room. “And I know I got really, really lucky.”

Laura’s journey was one of the easier ones. She had the $800 because she had been saving up for a house, but had she not been, she isn’t sure whether the procedure would have been affordable. And in the Valley, an hour-long drive isn’t necessarily so far.

But for other patients, the distances are far greater. Dr Blair Cushing, a California-based OB/GYN and one of the main abortion providers at the clinic, saw another patient that Tuesday morning who had traveled more than 100 miles for an appointment.

Because she lived far away, the patient was eligible to do her initial appointment over the phone the day prior. But she still had to get an ultrasound when she came in.

No embryo appeared on the screen. She was still too early in her pregnancy, and had made the two-hour drive – each way – for nothing.

“Now she’s got to do it all over again with another doctor later this week,” Cushing said. “If she doesn’t come back until next week when I’m here, that’s 10 days from now? Eight days from now? That leaves her open to the possibility she could be too far.”

Cushing worries that the law has wrecked a system that, for many patients in the Valley, was already inaccessible. Even before SB8, coming to the McAllen clinic meant a particularly long journey and an expensive procedure.

“We were already patients’ not even their Plan B – their Plan C,” Cushing said. “My patients are like, ‘I tried emergency contraception and that failed.’ And then, ‘I went to Mexico and took pills, and that failed. And now I’m here.’”

Self-managed abortions are particularly common in the area, in large part because it’s a far cheaper option. Medication abortion pills from the nearby flea markets, or from a pharmacy across the border, might cost $40. A 2018 study found that about a third of McAllen-based respondents knew of somewhere other than a medical establishment where they might find abortion pills.

It’s too early to tell if SB8 is driving more people in the Valley to those self-managed abortions. But evidence suggests it’s a strong possibility, said Kari White, an associate professor at the University of Texas at Austin, and the lead researcher for its Texas Policy Evaluation Project.

In the spring of 2020, Governor Greg Abbott temporarily barred abortion providers from practicing in Texas, citing the emerging Covid-19 crisis and the need to preserve medical supplies. The order only lasted a month, but in that time, the number of Texans who got abortions fell dramatically, compared with previous years.

She anticipates a similar pattern the longer SB8 stays in effect.

“It’s possible, because of what we have observed in some of our prior studies, that people may be able to get medications in Mexico or try to access medications online,” she said.

Through her research, she has interviewed many Texans who buy those pills outside medical settings. Often, she said, they aren’t properly instructed on how to take the medication – putting them at risk of complications, or the abortion simply not working.

“They may not know how many pills to take or in what time period,” she said. “They may get very concerned about how much bleeding they’re having or maybe they didn’t take as many as they needed to, so it’s not effective.”

The greatest stress test has yet to emerge, Hernandez said. September is usually a slower month. But if the Texas law stays in effect throughout the year – if it’s still being enforced come December or January, the busiest time of year for the clinic – she is worried about the implications.

The federal Department of Justice has stepped in, suing the state of Texas over the law, which does not appear to comply with the precedent established by the supreme court’s 1973 Roe v Wade ruling. The DoJ is seeking a temporary injunction to block the law. But the case won’t be heard until 1 October, and a ruling won’t come until after that.

Even if the law is blocked, the state of Texas is likely to appeal to the next court, the conservative fifth circuit court of appeals. The uncertainty means that Whole Woman’s Health hasn’t yet decided if it would start offering abortions after six weeks, even with a favorable ruling.

Hernandez can’t let herself process that reality. It’s too hard to think past tomorrow, and maybe the day after.

“I never expected this to happen,” she said. “It’s just like everything – everything is crumbling down.”

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