Vox: Getting an abortion in “the most pro-life state in America”

SHREVEPORT, Louisiana — The first patients arrive around 10 am.

They wear boots and coats against the December cold, but there’s coffee inside to help them warm up. Christmas figurines — a Santa holding a tree, a quaint house covered in snow — give the place a homey feel. In the waiting room, Friends plays on the TV.

Even before they sit down, though, patients are confronted with reminders that this place is under threat. A sign on the door reads “internal and external security surveillance: 24 hours a day.” Another, nearby, asks patients not to speak to protesters. Then there is theominous poster on the waiting room wall: “The coastline of Louisiana is not eroding nearly as fast as a woman’s right to determine her own outcome.”

This is Hope Medical Group for Women, one of the last abortion clinics in Louisiana, which was recently ranked “the most pro-life state in America.”

Once patients are here, the first step is an ultrasound, required under Louisiana law for each patient seeking an abortion. A technician is also required to display the ultrasound image on a screen, describe in detail what it depicts (“including limbs if they are present and viewable”), and offer a printout of the image. There is also a 23-point consent form patients must review and sign, which states that “the heartbeat of the unborn child is required to be made audible to me,” although patients can decline to listen.

After the ultrasound comes a visit to a doctor, who is required to offer patients a packet from the Louisiana Department of Health titled “Women’s Right to Know.” In the two dozen or so pages, they’ll find a warning that patients with a family history of breast cancer should seek medical advice before getting an abortion (studies have shown no link between abortion and breast cancer). A section titled “emotional side of an abortion” states that “some women have reported serious psychological effects after their abortion.” (A recent study found that five years after an abortion, 84 percent of patients had positive feelings about the decision or no feelings at all.)

Then, before they can actually get an abortion, patients have to wait.

Like many states, Louisiana requires a 24-hour waiting period between the ultrasound and the procedure. For patients who live in Shreveport, that could mean an extra bus trip home and back. But the clinic routinely draws patients from 200 miles away in any direction.

“We get Mississippi, Texas, Arkansas,” assistant clinic administrator Stephannie Chaffee tells me during my December visit. “We get from Oklahoma.”

Clinics have been closing across the South and Midwest for a decade now, and for many people in the region, Hope is the best option — even if it’s a three-hour drive. The majority of patients at Hope live at or below the poverty line, and many don’t own cars. So they wait until they can borrow a car or get a ride.

Some patients end up having to barter with friends, Merritt Rebouche, director of patient advocacy at Hope and a board member with the Abortion Care Network, tells me: “If you watch my kids and drive me to this appointment, then I’ll watch your kids for the next three weeks.”

If it’s too far to drive back between the ultrasound and the abortion, some patients stay in hotels in the area. Nicole Jordan, an ultrasound technician at the clinic, tells me she’s driven several patients to hotels herself. But at a minimum of around $30 a night, hotels may be out of reach for someone about to spend hundreds of dollars on an abortion — especially in a state where the minimum wage is just $7.25 an hour.

This is what it’s like to get an abortion in Louisiana right now: It’s legal, but getting one is an enormous undertaking, requiring patients to travel hundreds of miles, spend hundreds of dollars, and sometimes be away from their families for days at a time. And this year, it might get a lot harder.

In March, the Supreme Court will hear oral arguments in June Medical Services v. Russo (formerly June Medical Services v. Gee), a challenge to a Louisiana law requiring abortion providers to have admitting privileges at a local hospital. If the state wins and the law goes into effect, two of Louisiana’s three clinics could close — including Hope.

Abortion opponents — and more than 200 Republican members of Congress — are urging the Court to uphold the Louisiana law, arguing that it’s necessary for patients to get the best care. “The bill that the Supreme Court will hear is a women’s health piece of legislation,” its sponsor, Louisiana state Sen. Katrina Jackson, tells me.

But abortion rights groups around the country say that upholding the law could be the beginning of the end of legal abortion in America — at least for the Americans most likely to seek the procedure.

If Hope closes, patients who would ordinarily come to this clinic in the northwest corner of Louisiana would likely have to travel to New Orleans, more than 300 miles away in the southernmost part of the state. The other option would be to cross state lines — but if the Court upholds Louisiana’s law, other states in the region are likely to pass more restrictions, and their clinics could shut down, too.

“Louisiana is very much the canary in the coal mine, and we will see a decline that starts there and spreads to other states,” T.J. Tu, senior counsel for US litigation with the Center for Reproductive Rights, which is representing Hope in the case, tells me.

In the past year, six states, including Louisiana, have passed near-total bans on abortion. But all those bans have been blocked in court. And what makes getting an abortion today so difficult — and could make it even more difficult in future — isn’t a sweeping ban. It’s distance, time, money, the challenge of getting a ride, taking a day off work, and finding someone to care for the children that most abortion seekers already have.

Those barriers are especially high for patients who are low-income — the majority of people who seek abortion in America. And if the state of Louisiana wins its case this year, the barriers could get a lot higher.

A visit to Hope is a reminder that in many parts of the country, all that stands between pregnant people and the end of Roe v. Wade is a handful of clinics — most of them small, isolated, and racing to keep up with an increasing number of restrictions that, staff say, have nothing to do with patient care. And with each new requirement from the state, Hope clinic administrator Kathaleen Pittman tells me, “it’s the patients that pay the price.”

One of the biggest barriers to abortion in Louisiana is just getting to the clinic in the first place

Louisiana laws end up affecting patients at Hope in ways that might be surprising to outsiders.

For example, during my visit, a patient asks Katie Caldwell, a staff patient advocate at the clinic, about getting an IUD, one of several highly effective, long-acting contraceptive methods that have been credited with reducing the rate of abortions nationwide in recent years. But Hope doesn’t perform IUD insertions — federal and Louisiana laws banning Medicaid coverage for most abortions make it hard for abortion clinics to provide other medical services, because Medicaid won’t pay for them. However, the clinic can give prescriptions for birth control pills, patches, or the NuvaRing. So the patient gets a prescription for the patch before she leaves Caldwell’s office.

She also gets an appointment for the following week to get mifepristone, the first drug in a medication abortion regimen. Under Food and Drug Administration regulations, the drug has to be dispensed in a doctor’s office or other health care center, not a pharmacy. The second drug, misoprostol, can be obtained at a pharmacy, but Caldwell warns the patient to get any prescriptions from Hope filled before she leaves Shreveport.

“We send people to area pharmacies that we have an idea will be hospitable to them filling their prescriptions, but with each pharmacist change, that could change,” Caldwell tells me later.

The reason stems from a Louisiana law that allows health care providers, including pharmacists, to refuse any health care service that violates their “sincerely held religious belief or moral conviction.”

“What that looks like for us is pharmacies refusing to fill patient prescriptions because they have our location’s name on there, or our physician’s name on there,” Caldwell says.

But it’s not just misoprostol. Pharmacists have refused to fill birth control and PrEP HIV prophylaxis medication. Caldwell has also heard of primary care doctors refusing to care for patients after they find out they’ve had abortions.

If a pharmacy does deny the patient while she’s still in Shreveport, at least Hope clinic staff can help her find another pharmacy that might provide the medication before she begins the drive home.

If she drives, that is. Chaffee, the assistant clinic administrator, estimates that around 15 percent of patients who come to Hope don’t have a car.

Public transportation in the state, meanwhile, is “quite limited,” Steffani Bangel, the executive director of the New Orleans Abortion Fund, says. There’s a bus system in Shreveport, but many of Hope’s patients come from rural areas of Louisiana or surrounding states, Chaffee says. “Some of them don’t even have bus stations in their town.”

Most patients end up needing a partner or a friend to drive them. “A lot of times, that’s what hinders them from getting here in a timely fashion,” Chaffee says. “They just don’t have a ride or anyone that will take them.”

And getting a ride to Shreveport is only half the battle. Patients have to make at least two visits to the clinic, 24 hours apart. That means they need a place to stay and a way to get there, and a way to pay for all of that.

A patient’s first visit to Hope costs $50, including the ultrasound. For the next visit, if the patient chooses a medication abortion, the cost is $550. A surgical abortion in the first 12 weeks of pregnancy costs the same as the medication, but later procedures are more expensive. Hope does abortions for patients who are up to 16.5 weeks pregnant. After that, they have to go to one of the other clinics in the state or drive across state lines, since Louisiana law bans abortion after 20 weeks.

In most cases, the cost of the procedure isn’t covered by insurance. In addition to the federal restrictions on Medicaid, Louisiana also bans health care plans on the state’s Affordable Care Act exchanges from covering abortion. That leaves most patients at Hope, 70 to 85 percent of whom live at or below the federal poverty line, to come up with the money out of pocket.

Because this is a common setback,staff at Hope canhelp patients get financial assistance to pay for the procedure. On any given day, 75 to 90 percent of the clinic’s patients get some form of financial assistance, Chaffee tells me. The New Orleans Abortion Fund, for example, has helped more than 1,500 patients around the state since it was established in 2012. The fund paid an average of about $350 per patient last year. “Of course the need far exceeds our capacity, but we’re really proud to say that our capacity is growing,” Bangel says.

Still, money remains an obstacle for a lot of patients. People often know they’re pregnant but can’t make it to Hope before the 16.5-week deadline; Chaffee says it happens “all the time.” About half the time, money is the reason. The other half, it’s transportation.

More than half of Hope patients already have children at home, Pittman tells me. They may need to pay for child care — in a state with a serious shortage of affordable care for kids. Patients may also have to take time off work and lose wages as a result. “These costs add up tremendously and quickly,” Bangel says.

One study conducted in 2014 found that for more than half of patients who got abortions at a variety of clinics around the country, total out-of-pocket costs — including the procedure and travel — were more than a third of their monthly income.

All of this is further complicated by the stigma around abortion. For another medical procedure, patients might be able to borrow money from friends or family. But “if you’re unable to talk about the care that you’re seeking with the people in your community, you’re unable to pull together resources,” says Elizabeth Gelvin, client services program coordinator at the New Orleans Abortion Fund.

Aidi Kansas, who got an abortion in Louisiana in the early 1990s, remembers the stigma well. “I grew up in New Orleans with a very Catholic Latino family,” she tells me, “and so there was a lot of shame attached to female sexuality.”

When she decided to get an abortion, she only told her boyfriend and her best friend what was happening — not her mother or her sister, even though she and her sister are only 11 months apart. “It’s crazy that I didn’t feel that I could turn to her,” she says, “but I just felt at the time that being a sexually active 19-year-old carried a lot of shame for me.”

Stigma was also a factor for Kimberly O’Brien, who was living in Louisiana with her husband and daughter when she became pregnant in 2011. It was a much-wanted pregnancy, she tells me, but at about 20 weeks, doctors discovered multiple severe abnormalities in the fetus.

At the time, O’Brien only knew of one abortion clinic in her area. She’d driven by it and seen the protesters in the parking lot: “There was a woman with a shopping cart with baby dolls in it,” she says.

“No way in hell am I doing that,” she says she thought, especially because she was “already super upset” at having to end a wanted pregnancy. Instead, she and her husband ended up driving to Texas, where a doctor started her abortion procedure — only to be told that the hospital no longer allowed abortions past 20 weeks unless the pregnant patient’s life was in danger.

O’Brien had to go, mid-procedure, to a clinic next door. “They basically had me put on some sweatpants, I’m hooked up to the IV of fluids already, get in a wheelchair, roll across the street,” where a doctor injected a drug to stop the fetal heart, she says. Then she was sent back to the hospital to finish dilating her cervix and emptying her uterus.

“It felt so frustrating and just so insane,” O’Brien says. But she also knew she was fortunate, because “I have so many resources that so many other women do not have.

“I have a husband that can take off work, I have parents that can watch my child, we have health insurance, we have a car that we can pay to put gas in, we can pay to get a hotel room for a couple of nights,” she says. “It was very eye-opening to me that what a pain in the ass it was to me would have been tenfold for so many other women.”

Today’s abortion laws in Louisiana have a decades-long history

The obstacles that O’Brien and others have faced in Louisiana are part of a nationwide story. Abortion started to become a partisan issue in the 1970s, when Republicans began using opposition to the procedure as a way to appeal to Catholic voters and other social conservatives. States had begun liberalizing their abortion laws in the 1960s, and in 1972, strategists for Richard Nixon’s presidential campaign used anti-abortion messages “to present Nixon to all Americans as a cultural conservative who stood for the preservation of traditional roles and values,” Linda Greenhouse and Reva B. Siegel write in their book Before Roe v. Wade.

Nixon won in 1972, but the following year, the Supreme Court in Roe v. Wade made legal a nationwide right to abortion. Anti-abortion groups, some of which had already been established in the years of loosening state laws, began looking for ways to restrict the procedure within the limits the Court had just set. Meanwhile, Republicans revisited Nixon’s strategy, using abortion to attract socially conservative voters in the South away from the Democratic Party.

Whether because of that strategy or as part of a larger party realignment or both, Republican and Democratic voters began to move apart on the issue of abortion, and in 2018, while 46 percent of Democrats thought abortion should be legal under any circumstances, only 11 percent of Republicans thought so. Essentially, over the past three decades, people who strongly oppose abortion have become a crucial Republican voting bloc, with Republican lawmakers backing ever-stricter regulations on the procedure in an effort to appeal to them.

Those efforts got a significant boost in 2010 when Republicans gained majorities in state legislatures across the country. After that, abortion restrictions began passing at a faster clip than ever before — more than 80 passed in 2011 alone.

Many of the laws passed after 2010 were restrictions on abortion clinic operations that abortion rights supporters argued were aimed at shutting down clinics. They certainly had that effect — the South and the Midwest, where Republicans had legislative majorities, lost 83 clinics between 2011 and 2017.

Then in 2016, abortion opponents won another victory with the election of President Trump. As a candidate, Trump had promised to nominate Supreme Court justices who would overturn Roe v. Wade. Many believe he’s made good on his word. After his appointment of Justices Neil Gorsuch and Brett Kavanaugh, many advocates on both sides of the abortion issue believe conservatives on the Court have the votes to, if not get rid of Roe completely, then at least weaken it to the point of uselessness.

And their opportunity could come from Louisiana.

The Hope clinic sits at the center of a Supreme Court case that could dismantle Roe v. Wade

The state is unusual in that Democratic politicians, not just Republicans, have opposed abortion there, too. Gov. John Bel Edwards, a Democrat, signed the state’s “heartbeat” bill last year. And as Alexandra Seghers, director of education at the group Louisiana Right to Life, tells me, “our Louisiana legislature is very bipartisan in their pro-life efforts.”

Over the years, those efforts have led to some of the most stringent abortion restrictions in the country. “Louisiana has truly become one of the test kitchens of anti-choice politics,” Bangel says. “What I always say to folks is, if there is a restriction that’s going to be introduced somewhere, it’s either been introduced in Louisiana first or they’ll introduce it here next year.”

In 2014, the state passed a law requiring doctors who perform abortions to have admitting privileges at a local hospital. Jackson, the Democratic state senator who introduced the bill when she was a member of the Louisiana House of Representatives, describes it as “a women’s health issue.” Without it, she tells me, “there was no continuity of care” because if patients had emergency complications, “the physician couldn’t call ahead and get them admitted to the hospital.”

Abortion rights advocates, however, counter that patients can always get care at a hospital, whether or not the doctor who performed their abortion has admitting privileges there. Meanwhile, they point out that it can be very difficult for abortion providers to get privileges — often, paradoxically, because so few of their patients are ever admitted to hospitals (fewer than 0.25 percent of patients have major complications after an abortion, according to one 2014 study). The result has been that in states with admitting privileges laws, clinics are forced to close.

But abortion providers also challenged these laws in court, arguing that they violated Americans’ rights under Roe. In 2016, a challenge to an admitting privileges law in Texas made it all the way to the Supreme Court, which struck down the law, finding that it did not offer a medical benefit to patients that was “sufficient to justify the burdens upon access” it imposed.

In 2014, Hope challenged the admitting privileges law in Louisiana, and the measure has been blocked while it works its way through the courts. In March, the Supreme Court will hear the case. However, the Court looks very different from how it did in 2016 — with the addition of Trump-appointed Justices Gorsuch and Kavanaugh, many believe the Court will reverse its 2016 decision and uphold the Louisiana law.

If the law goes into effect, Hope may be forced to close. One of the physicians there has admitting privileges, Hope’s administrator tells me. But “he has said all along, if he is the last remaining physician, he cannot handle it by himself,” Pittman says. He has been targeted by abortion opponents for many years, she explains. “And the fewer clinics we have, the [bigger] increase in targeting we see.”

While the clinic would not “close overnight” if the law went into effect — “we would honor our commitments,” Pittman says — she doesn’t know how long they could hang on. It’s not entirely clear what would happen with the other two clinics in the state. But a district court in the case found that if the 2014 law were enforced, “the one remaining clinic would be the clinic in New Orleans,” Tu, the Center for Reproductive Rights attorney, says.

New Orleans is a five-hour drive from Shreveport, much of it across rural areas of the state. Traveling there would add more than 600 miles, round-trip, for many patients coming from the north or west.

And the change would leave one clinic responsible for an enormous number of patients — 8,000 to 10,000 abortions are performed in Louisiana every year, Pittman says.

“Folks will probably have a harder time scheduling appointments,” Bangel says, leading to later and more expensive procedures. At “every level, it’s going to become more difficult for folks,” she says.

And those difficulties will disproportionately affect low-income people and people of color, many say. “As a woman of color, it upsets me because I know that white women are not going to suffer for this as much as women of color,” Aidi Kansas says, adding that when she was able to get her abortion, “it was because my white boyfriend had the money.”

Ultimately, if the Supreme Court upholds the admitting privileges law, “what that means is that almost all patients in Louisiana will have nowhere to go,” Tu says.

Going to a neighboring state is unlikely to help much, either.

After Texas passed its admitting privileges law in 2013, more than half of the state’s clinics shut down. After that, Hope saw an increase in patients from Texas “that’s never dropped back down,” even after the law was overturned, Pittman says. If Hope closes, those Texas patients will have to find somewhere else to go, too.

Their journeys will also be complicated by the fact that, depending on what the Supreme Court decides, other states may ramp up their efforts to pass restrictions on clinics.

In the wake of the 2016 case, many states put the brakes on admitting privileges laws. But if the Court upholds the Louisiana law, “what you’ll see is a number of states dust off these unconstitutional admitting privileges laws and try to enact them again,” Tu says.

Moreover, he says, the decision could pave the way for “a whole new generation of targeted regulations of abortion providers” beyond just admitting privileges requirements.

Today, nearly 90 percent of counties in the US have no abortion clinic, and with every new type of clinic restriction, the number of clinics declines further, Tu says. Nationwide, the impact of a decision in favor of the Louisiana law would be “potentially devastating.”

If Hope closes, people who want to end pregnancies will be left with few options

Louisiana isn’t just a difficult place to end a pregnancy; it’s also a hard — and sometimes dangerous — place to give birth and raise a child.

The state had the second-highest maternal mortality rate in the country in 2019, at 44.8 maternal deaths per 100,000 births. The rate is even higher for black women in the state, with 72.6 deaths per 100,000.

When it comes to helping people care for children, the state also struggles. “There’s not really a social safety net here,” Rebouche, the director of patient advocacy, says. Only about 12 percent of Temporary Assistance for Needy Families funding — meant to help low-income families with basic needs — goes directly to families in the state, she says.

Some of it actually goes to crisis pregnancy centers, controversial facilities for pregnant people that have an anti-abortion message, Rebouche says. Under a program established in 2003 — and since adopted in other states — the centers and other anti-abortion groups can get state money to offer “abortion alternative services,” as Sarah Moore reported last year at Facing South. In recent years, the program has received more than $1 million annually.

The anti-abortion centers do provide resources for pregnant people in need, from diapers, wipes, and baby clothes to referrals to social workers, says Seghers of Louisiana Right to Life. “If pro-life people are going to say that abortion is wrong and that these women shouldn’t have to choose abortion, we agree that they should be able to follow through and help these women,” Seghers says. “You can’t just say, ‘You can’t do that,’ and then leave them be.”

But anti-abortion centers can also give patients misinformation about pregnancy and abortion, Rebouche says, like falsely claiming that abortion is highly dangerous. “They can literally lie to you,” she says. One 2017 study of the websites of crisis pregnancy centers in Georgia found that 41 percent contained misinformation about the physical or mental health risks of abortion.

If Hope and other clinics in Louisiana close, some people who want an abortion simply won’t be able to get one and will end up carrying their pregnancies to term. Such a situation can have a severe impact on pregnant people and their families: Research has shown that people who want an abortion but can’t get one are more financially insecure than people who are able to terminate their pregnancies, and may have more difficulty bonding with their children. Being denied an abortion is also associated with short-term health risks, like anxiety, and longer-term ones, like higher rates of chronic headaches and migraines compared with people who are able to get the procedure.

And in the absence of clinics, others will try to terminate their pregnancies outside the medical system, some staffers at Hope say.

Already, “we’re seeing more patients that are trying to self-manage,” inducing abortion themselves with medication or herbs purchased online or elsewhere, Caldwell says. A lot of patients will probably turn to the internet, she says.

Contrary to the pre-Roe narrative of people using coat hangers to induce their own abortions, many reproductive health advocates say that self-managing an abortion can be a safe option, at least from a medical perspective. While medication ordered online may not have been through FDA testing to establish potency and lack of contamination, one recent study of abortion pills ordered online found that most contained enough of the necessary medication to be effective.

But people who self-manage abortions can face legal risks. While Louisiana isn’t one of the five states that explicitly ban the practice of self-managing an abortion, other laws could still be used to criminalize the practice.

Abortion rights advocates are studying “ways that the legislature might try to enact some policies that actually do go so far as to punish people with criminal enforcement for self-managing their own abortion,” Michelle Erenberg, executive director of the reproductive health group Lift Louisiana, tells Vox. “This is the real nightmare scenario.”

Some at Hope mention other disturbing consequences if the clinic shuts down.

“I’m thinking the worst,” Jordan, the ultrasound technician, tells me when I ask what patients would do. “I would hate for women to go back in time,” with situations like “babies in dumpsters,” she says.

For Jordan, one thing is clear: Shutting down Hope won’t shut down abortion.

“Us as women,” she says, “if we need something done, we’re going to find a way to get it done.”