Poland Says No to Pain-Free Childbirth

Anna Wilkowska-Landowska

Poland is struggling with record low numbers of women having children. So why would the Minister of Health suggest that the national health care plan no longer fund anesthetization during delivery?

Here is another curious proposal from the Polish Ministry of Health Director Ewa Kopacz. Not long ago, Kopacz made public her plan to require pregnant Polish women to register their pregnancies (Pregnant
in Poland? Government Considers Tracking You for Illegal Abortion
A week ago the Polish
newspaper "Dziennik"

wrote that the Ministry of Health was not planning to refund anesthetization
during childbirth.  Kopacz, in response to the letter of
the Polish Gynecological Society, which on behalf of women appealed
to the Ministry to refund anesthetization, said that the state budget
cannot afford to ensure free anesthetization during childbirth to all
Polish women. "Childbirth is a pure physiological process and we, women,
were created by nature in such a way as to run certain things in their
natural way, therefore to have childbirth run in its natural way with
no medicine and anesthetization," said the Minister. According to
Kopacz, if anesthetization were provided for free, then hospitals would
have to ensure that the services of anesthesiologists are guaranteed for female
patients to a much broader extent than it is currently. And there are
not enough anesthesiologists in Poland.

"We appeal to the Ministry
of Health not to pull back Polish medicine to the nineteenth century and to
take into account that anesthetization during childbirth has been recognized
as a standard procedure for many years now in the whole Europe," said
Joanna Kluzik-Rostkowska, former Ministry of Labor and Social Policy.

She underlined her disappointment in Kopacz’s words, because these
"difficult words addressed to women" have been expressed by "a
minister, a woman, and a doctor."

"There have been many declarations
stating that we have to do much more in order to make Poles decide more
easily to have children, to encourage Polish women to have more children
and now, what we are hearing is that they have to rely on the forces
of nature," Kluzik-Rostkowska claimed. According to her, Kopacz’s
statement about lack of funds for anesthetization, as well as lack
of anesthesiologists during childbirth, constitute "a sufficient argument
for women to make it more difficult for them to decide about having
a child."

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a discussion following the Ministry’s declaration, advocates suggested that the Minister
should be doing everything possible to ensure an adequate level of medical care,
in order to guarantee that childbirth with anesthetization and with
assistance of anesthesiologists, according to the standards of the twenty-first century, may take place at the hospital. The Minister seems to be forgetting
the European standards she so often refers to when discussing
other aspects of healthcare. In Western European countries, as well
as in Poland’s neighboring countries, childbirth anesthetization
is considered a standard service provided to women. The question becomes, then, why do Polish women have to pay for it? This situation divides the
Polish women into two groups: those who can afford to pay for anesthetization
and those who cannot afford to pay for something to which they are entitled.

Resistance to pain depends inherently on personal features, and
there are women who simply cannot imagine themselves experiencing childbirth in a natural way. That fear can cause negative consequences
to the woman’s physical health and therefore may endanger the security
of a child, say experts of the Polish Gynecological Society. According
to female MPs, the Minister should take all the necessary efforts to make
such a process a safe and non-threatening experience for women and ensure access to anesthetization is refunded from the National Health
Fund for all women in need.

The Ministry of Health prepared
an official response to the article published in "Dziennik." Her response
states that anaesthetization when instructed by a doctor is and will
be financed from public funds. It is for a doctor to decide on the mode
of delivery and potential use of anesthetization. The scope of services,
including procedures used (anesthetization, cesarean section), depend
on the health status of the patient, and the process of her pregnancy
and delivery.

The Ministry also mentions a committee that will prepare health standards on childbirth and related issues. The committee’s purpose
is to draft a legal act describing standards of medical procedures during
pregnancy and delivery. Services resulting from the standards prepared
will be financed from public funds. Completion of the committee’s work is closely
connected with the works of the Polish Gynecological Society experts’
team, acting independently and preparing recommendations related to
medical procedures during childbirth.

The declarations of the Ministry
of Health offer some hope that Poland may develop more
precise and clear standards related to pregnancy and childbirth in particular. Information that Polish women have been given in the last few
weeks have resulted in a state of uncertainty and fear, and those feelings are
least welcome when planning a family or when already pregnant.
It appears that the Polish Ministry of Health easily makes statements
or disseminates information, but unfortunately does not take into consideration
the consequences of these statements or information on the general public,
and women especially. I do hope we will not have a chance to experience
any more "interesting" solutions and the three times rule will not
be applied here.

Analysis Human Rights

Sentenced to 40 Years After a Miscarriage, Maria Teresa Rivera May Have Chance to Go Free

Kathy Bougher

In El Salvador, Maria Teresa Rivera was convicted of aggravated homicide after experiencing an obstetrical emergency. She is scheduled to have a new day in court on May 11, when she will argue that there were judicial errors in her original trial.

Read more of our coverage on the campaign for Las 17, the 17 Salvadoran women imprisoned on abortion-related charges, here.

In November 2011, Maria Teresa Rivera unexpectedly went into labor, giving birth in the latrine of her home. The birth was dangerous and unattended by any medical professionals; the fetus died. Like many women in El Salvador, where abortion is completely illegal, Rivera’s medical crisis led to her being charged with and convicted of aggravated homicide; she was sentenced in 2012 to 40 years in prison.

Rivera’s sentence is the most extreme of “Las 17,” a group of women who have been imprisoned after obstetrical emergencies. Now, she is scheduled to have a new day in court on May 11, when she will argue that there were judicial errors in her original trial. If the judge rules in her favor, she will be freed from prison. Advocates say that her case could influence public sentiment about other similar cases around the country.

With the support of the Agrupación Ciudadana por la Despenalización del Aborto, a Salvadoran feminist organization, Rivera has been fighting her case for several years, as reported earlier in Rewire. Along with the rest of Las 17, she requested a pardon from the Salvadoran government in 2014, but her request was denied.

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“Rivera represents the maximum will of the state to criminalize women in this country,” Morena Herrera, president of the Agrupación, explained in an on-the-ground interview with Rewire. “Her sentence is the longest of any of the women with similar convictions; at 40 years, it is practically a life sentence.”

Fortunate To Be Alive

Maria Teresa Rivera, who shared her story on camera from prison in 2013, was a 28-year-old factory worker in 2011. She was living with her young son and his grandparents, her ex in-laws, in a very modest home in the outskirts of San Salvador. Rivera, the sole provider for the family, supplemented her factory work with house-cleaning in order to pay $13 a month to keep her son in a neighborhood Catholic school and purchase his asthma medication.

One night, according to court documents, Rivera said she awoke with intense thirst. But when she arose from her bed, she felt dizzy and then fainted. When she regained consciousness, she felt a strong urge to defecate and went to the latrine outside the house. As she sat in the latrine, she had intense cramping and “felt as if a little ball fell from her body.” Then she fainted and fell to the ground, where her mother-in-law found her in a pool of blood and called an ambulance to take her to the hospital. No one at the scene—family or paramedics—reported hearing any sounds of a baby, and no one realized she had given birth.

Rivera told doctors, attorneys, and others that did not know she was pregnant. She had been experiencing bleeding during the time of the pregnancy, which she interpreted as her menstrual cycle. Neither she nor any friends, relatives, or co-workers noted any physical changes that would indicate a pregnancy. She had also had two doctor visits for other complaints during those months, and no doctor had diagnosed her pregnancy. According to her own estimations, the last sexual contact she’d had that could have resulted in pregnancy had been six months earlier.

She arrived at the hospital in a severe state of shock from extreme blood loss, fortunate to still be alive. Doctors told her she had given birth and wanted to know where the baby was. Medical personnel contacted police, who went to her home to locate the deceased fetus. Rivera was detained by police at the hospital and has been imprisoned since that time.

Interrogation While Hospitalized

Multiple national and international organizations, including Amnesty International and the Center for Reproductive Rights, along with numerous medical, legal, human rights, and academic experts, have analyzed Rivera’s case in the years since her conviction. Harvard University sociologist Jocelyn Viterna and Salvadoran lawyer Jose Santos Guardado Bautista, for example, used parts of Rivera’s story and court documents in their 2014 analysis of systematic gender discrimination toward Las 17 within the judicial system.

Viterna and Bautista noted, for example, that the only witness testimony the judge considered credible was a supervisor from human resources at the factory where Rivera worked. Contrary to Rivera’s testimony, the supervisor testified that Rivera asked for time off for doctor appointments in January 2011 because she was pregnant. The judge refused to allow testimony from neighbors and friends who stated that they had never seen Rivera show any signs of pregnancy.

“Had Maria Teresa truly reported a pregnancy to her employer in January of 2011, she would have been 11 months pregnant when the birth occurred in November,” Viterna and Bautista observed. “This testimony is nothing short of preposterous. Nevertheless, this is the only witness testimony that the judge deems ‘credible’ in the final sentencing.” 

According to Viterna and Bautista’s report, “The judge admitted that there was no evidence that Maria Teresa had done anything to hurt her baby. The judge also admitted that there was no evidence of any motive for why she would want to kill her baby.” However, he still convicted her of aggravated homicide.

A 2015 resolution from the Salvadoran Attorney General for Human Rights (Procuradoría Para la Defensa de los Derechos Humanos or PDDH in Spanish), which provided a formal opinion on violations of Rivera’s human rights, supports Viterna and Bautista’s findings.

The PDDH resolution observed that Rivera faced a slanted system even before she got to court:

At the First of May Hospital where Rivera was taken, the criminal investigation was prioritized over her right to health. She was subjected to interrogation when she was still in Intensive Care and without legal representation. In addition, the medical personnel did not seek information about her health history; they limited themselves to examining the birth canal, carrying out the extraction of the remaining placenta, and discharging her the following day, without attending to her overall health.

Both the PDDH and Viterna-Bautista reports noted that the judge relied on shoddy, unscientific evidence to convict Rivera. According to court records, the autopsy report for the fetus said its cause of death was “perinatal asphyxia.”

“It is perhaps worth reiterating that there were no signs of trauma on the [fetus], either externally or internally. It is perhaps worth reiterating that, despite the judge’s conclusion that the [fetus] died from suffocating within the latrine, the fetal lungs were clean with no sign of fecal matter or other materials inside them. Rather, the autopsy concluded that the [fetus] died of a medical condition—perinatal asphyxiation—that could have occurred before, during, or after the birth. Clearly, there is no evidence in these documents proving homicide,” Viterna and Bautista wrote. “Perinatal asphyxiation,” they said, “is a medical condition.”

Still, the judge interpreted the autopsy report to mean that Rivera had carried out an intentional criminal act. He also ignored the portion of the autopsy report stating that the umbilical cord could have been separated by its fall into the latrine. As quoted by the PDDH resolution, he wrote:

There is no doubt that the baby was born alive and was full-term and that the detached umbilical cord was cut by the mother …. This judge does not give credibility to what the accused says when she states she did not know she was pregnant …. She knew she was pregnant and that brought with it the obligation to care for and protect this young person she carried in her womb. In this sense, the fact that she went to the latrine, she did it with the intention of violently expelling [it] so that inside the latrine there would be no opportunity to breathe and in that way cause its death and then be able to say it was a [spontaneous] abortion.”

The judge also based his conviction, the PDDH resolution said, on the results of a DNA test showing the fetus was genetically related to Rivera.

“No evidence was introduced to show that Rivera had taken any intentional action to cause the death,” the PDDH resolution concluded.

Convicted by Patriarchy

Rivera’s legal representatives will likely use many of these inconsistencies as evidence for procedural judicial error in court this week. A favorable outcome in her trial can represent a significant step forward for women’s human rights, particularly sexual and reproductive rights in El Salvador. The country’s 1997 absolute ban on abortion, along with a 1998 constitutional modification to declare that life begins at conception, created the social, cultural, and legal environment that has justified courts sending women such as Rivera to prison for documented obstetrical emergencies, not even attempted abortion. According to the global organization Ipas, more than 600 women were incarcerated between 1998 and 2013 under the abortion law.

As the PDDH resolution noted, “in El Salvador, there exists a culture of the promotion of motherhood as the only form of self-realization for women, and the creation of the binomial ‘woman-mother,’ which locates women as instinctive and not rational. This imposes upon women [duties of] sacrifice, abnegation, and the prioritization of children over their own human conditions, behaviors that are not demanded in equal proportions from men.

“Women find themselves with a social expectation to comply with the role ‘woman-mother,’ even in the health system where women should be assured of conditions free of discrimination and obstetric violence,” it continued.

Advocates and researchers have argued that this sexist framework contributed to Rivera’s conviction. As Viterna and Bautista wrote, the trial judge claimed that Rivera “‘decided to carry out her criminal plan within the area of her household, looking for a moment during which there weren’t any other persons around to carry out this homicide,’ as if a woman has complete control over when, where and how her body will give birth.”

The PDDH concluded that “the judge convicted Rivera under subjective criteria with a heavily sexist ideology,” saying that Rivera’s rights to the presumption of innocence were overruled by such an ideology, unsupported by any medical or scientific evidence.

Rivera’s case, along with that of Carmen Guadalupe Vazquez (who was one of Las 17 granted a pardon in 2015 when the Salvadoran Supreme Court recognized judicial errors in her case), is representative of a consistent pattern toward this group of women that the Agrupación has been documenting.

“Correcting these judicial errors is very important, first of all for Rivera and her young son, so that she can go free, but also for all the other women in similar circumstances. It’s also necessary for those who work for justice in this country, particularly women’s reproductive justice, to see that the work has concrete results,” Herrera said.

Herrera hopes that a positive outcome will continue to make visible this pattern of judicial error and “move other cases [of Las 17] forward more rapidly and bring greater justice to the judicial system.”

According to IThe Agrupación is currently representing more than 25 women imprisoned with similar convictions: the original 17, two of whom received pardons, and others who have entered the system more recently.

“Maria Teresa’s story illustrates the systematic ways that women’s rights are violated: the right to health, the right to privacy in one’s life, the right to doctor-patient confidentiality, along with all the judicial procedural rights such as the presumption of innocence,” Herrera said in an interview with Rewire.

“The judicial system in El Salvador is the part of the state that has changed least since the signing of the 1992 peace accords” that ended the Salvadoran civil war, Herrera said. “Not just in how it deals with women, but how little sensitivity it demonstrates overall with regard to human rights.”

Analysis Abortion

Another Choice Lost: HB 2 Targets Most of Texas’ Independent Abortion Providers (Updated)

Andrea Grimes

In a matter of days, five of Texas’ eight legal abortion providers will operate under the Planned Parenthood banner, a special irony in light of state lawmakers’ professed hatred for the provider.

UPDATE, August 29, 2014: Three days before Texas’ HB 2 was set to force all abortion providers to meet the standards of ambulatory surgical center regulations, a federal judge enjoined the law, calling it “unconstitutional because it imposes an undue burden on the right of women throughout Texas to seek a pre-viability abortion.” The State of Texas immediately appealed the ruling to the Fifth Circuit Court of Appeals, which could stay the lower court’s injunction at any time. Until that happens, Texas abortion providers who do not meet ASC standards will be legally allowed to keep their doors open.

Andrea Grimes tours one of Texas’ last remaining abortion clinics, as providers across the state prepare to close their doors in advance of a new law requiring medically unnecessary build-outs to already safe, legal abortion facilities.

September 1, 2014: eight legal abortion facilities are open in Texas, all in the state’s largest metropolitan areas; more than half are Planned Parenthood facilities. The GOP, the party meant to champion the small business owner, has, thanks to the passage of an omnibus bill obliterating access to abortion throughout the state, ensured that the estimated eight million or so Texans of reproductive age who could potentially need abortion care are less likely than ever to receive their comprehensive health services from a small, independent abortion provider.

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Now, rewind to May 2013: more than 40 legal abortion clinics provide services from windswept West Texas to the fertile Rio Grande Valley to the piney woods of East Texas, and Texans who support reproductive rights are told that there has been some “concession” in the ongoing battle over who can provide abortion care in the state.

As the 2013 regular legislative session winds to an end, anti-choice Republicans and their anti-choice Democrat supporters make the promise not to enact new abortion legislation, as long as their pro-choice colleagues don’t get too mouthy.

Anti-choice conservatives agree to attempt to restore some of the $73.4 million in family planning funds they’d cut in 2011, when right-wing lawmakers went on a crusade against Planned Parenthood’s participation in providing publicly funded contraception and cancer screenings to low-income Texans. That could help mitigate the loss of $163 million in savings the state suffered after its decimation of public family planning dollars.

This, according to the Lubbock Avalanche-Journal, represents “rare harmony” between pro-choice Texas Democrats and anti-choice Republicans. The state’s  41 or so legal abortion providers can rest easy until 2015. After all, that big baddie, Planned Parenthood, has supposedly been brought to its knees by funding cuts championed in part by state Sen. Dan Patrick (R-Houston), who is now running for lieutenant governor and touting his achievement:

“[Planned Parenthood is] closing clinics because they make all their money taking the lives of babies,” Patrick claims in a May 2014 debate, repeating the anti-Planned Parenthood battle cry that has, over the past several years, helped him become an anti-choice superstar in the eyes of the state’s conservative base.

And yet, thanks to the efforts of lawmakers like Dan Patrick, Planned Parenthood has rallied donor support to enable the provider’s Texas affiliates to open not one but two new legal, abortion-providing ambulatory surgical centers in Texas as smaller providers are forced to close their doors.

While it’s true that some Planned Parenthood clinics did close after family planning funds were slashed in 2011, and some Planned Parenthood clinics did provide abortion care, none of the Planned Parenthood providers that once received public funds performed abortion care. The majority of the Texas clinics that closed in the wake of funding cuts—more than 70, in total, shut their doors—were non-abortion-providing clinics unaffiliated with Planned Parenthood.

It is as if right-wing lawmakers have deliberately engineered a new reality to fit the fantasy they’d been trying to sell voters for years. In 2011, they claimed that Planned Parenthood was a massive, abortion-providing behemoth dominating the Texas family planning landscape, while in fact, Planned Parenthood provided a variety of family planning services, mostly contraception and cancer screenings, particularly in rural and suburban areas and to tens of thousands of low-income Texans.

In September 2014—just over a year after Texas abortion providers were told they could relax, that they had nothing at all to worry about—more than 30 providers, most of them independent clinics with no Planned Parenthood affiliation, will be forced to close, leaving eight legal abortion providers open in the state.

Why? Because mere weeks after legislators touted their great harmonious compromise on family planning care, conservative lawmakers jammed an omnibus anti-abortion access bill through in a series of special legislative sessions. All that talk about concession went out the window when Gov. Rick Perry opened up the capitol doors to the bill that would become known as HB 2.

That bill, famously filibustered in committee by Texas residents and later on the state senate floor by Wendy Davis, ultimately passed on June 13, 2013. It does four things: severely limits the prescription of medication abortions, bans abortion after 20 weeks, requires abortion-providing doctors to have local hospital admitting privileges, and—in its most restrictive provision—mandates that legal abortion facilities operate as hospital-like ambulatory surgical centers (ASCs). Mainstream medical groups like the American Congress of Obstetricians and Gynecologists and the Texas Medical Association opposed HB 2, calling it medically unnecessary and, in some cases, saying that it could put people who seek legal abortion care at increased risk of complications.

It is HB 2’s final provision, which requires abortion-providing family planning clinics to make medically unnecessary million-dollar modifications to their buildings if they want to continue to provide legal abortion services, that goes into effect September 1, barring intervention from a federal court.

That means that in a matter of days, five of Texas’ eight legal abortion providers will operate under the Planned Parenthood banner, a special irony in light of state lawmakers’ professed hatred for the provider.

“Mom and pop” abortion facilities, as independent abortion providers occasionally referred to their businesses in interviews with Rewire, don’t have the mass brand recognition and donor base that Planned Parenthood enjoys. As a result, state lawmakers who worked themselves into a froth over the nationwide family planning provider three years ago have created a situation in which Texans are more likely than ever to have no other option but to go to Planned Parenthood for legal abortion care.

From a safety perspective, that’s not a problem: Legal abortion is a tremendously safe and common outpatient procedure, whether it is provided in a Planned Parenthood facility or an independently owned clinic. One in three women, trans*, or queer people who can become pregnant will have an abortion in their lifetime. Legal, induced abortion is fourteen times safer than childbirth.

The difference is that where once Texans could experience a kind of choice within the choice, calling various abortion clinics to compare pricing, or location, for example, HB 2’s restrictions more or less force abortion-seeking Texans to go to the nearest legal provider, or pay to drive, take a bus, or fly hundreds of miles to the next closest ambulatory surgical center.

Of course, those with means could always travel out of state to their provider of choice, and those without means may continue to explore illegal, less effective, and potentially less safe options for ending their pregnancies—something that was already not unheard-of in places like the Rio Grande Valley, where border pharmacists sell abortion-inducing ulcer medication, and herbal alleged-abortifacients are also available.

But for those who can and will seek legal abortion care in Texas, cost and location could have been just some of the variables, back when at least some Texans had the ability to choose the doctor who would provide their abortion: different abortion providers offer a variety of counseling processes, have different rules for allowing partners or friends to accompany patients through their procedures, and some provide aftercare with a personal touch.

And while regulations like those in HB 2 are not unique to Texas, no other state’s lawmakers have been able to so successfully pass so many TRAP (targeted regulation of abortion provider) provisions, affecting so many people, all at once.

Texas abortion providers of all stripes have, over the past year, struggled to comply with HB 2. Some, like Planned Parenthood, have been able to rally enough angry supporters to raise money—potentially millions of dollars—to build new facilities that comply with HB 2’s medically unnecessary requirements.

Indeed, in a summer 2014 statement praising “generous support” from donors, Planned Parenthood of Greater Texas’ Ken Lambrecht announced the coming opening of a new abortion-providing ASC in Dallas, and the launch of a patient assistance fund to help Texans travel to Dallas for care.

“Planned Parenthood is incredibly grateful to donors and supporters who have made generous contributions,” said Lambrecht, “and continue to invest in Planned Parenthood’s commitment to our communities.”

Smaller clinic groups and individual providers, however, have not been so fortunate.

Amy Hagstrom Miller, whose Whole Woman’s Health organization once ran five clinics in Texas, testified in federal court in August that she has struggled to obtain bank loans for building new million-dollar facilities and has been turned away from lease agreements with existing ASCs whose owners are leery of dealing with an influx of anti-choice protesters on their sidewalks, or whose facility leases include specific anti-abortion (and anti-vasectomy, and anti-tubal ligation) covenants. Whole Woman’s now has just two locations in Texas: a licensed abortion facility in Fort Worth that must stop providing abortion care on September 1, and an ambulatory surgical center and licensed abortion facility in one complex in San Antonio.

The ultimate result—apart from the drastically diminished availability of legal abortion care in Texas—has been to force providers to, perhaps unduly, focus on compliance with a law that at least one Texas lawmaker has admitted was expressly intended to close clinics, rather than on the positive patient experience many have spent years, even decades, building.

“In our quest to comply with HB 2,” Hagstrom Miller wondered aloud in an interview with Rewire before she closed her East Texas and Rio Grande Valley clinics last spring, “What does it do to the patients?”

A More Medicalized, Anxiety-Inducing Experience

In San Antonio, Whole Woman’s corporate vice president Andrea Ferrigno took me on a tour of their two-facility space: a small, purple-tinted clinic that feels like a cozy gynecologist’s office, and a fluorescent-lit surgical center with two icy operating rooms.

In the first facility—where Whole Woman’s used to provide legal abortion care but which they now use for state-mandated ultrasounds and pre-abortion counseling—each room is named for a famous woman from history or fiction: Gloria, Rigoberta, even Wonder Woman. “Mood lighting,” as Ferrigno described it, seeps out from light-diffusing lamps.

The Whole Woman's San Antonio licensed abortion clinic recovery room features recliners and hot tea, for a "living-room" style feel, according to Andrea Ferrigno. The ASC recovery room, in contrast, features stretchers and pre-packaged snacks.

The Whole Woman’s San Antonio licensed abortion clinic recovery room features recliners and hot tea, for a “living-room” style feel, according to Andrea Ferrigno. The ASC recovery room, in contrast, features stretchers and pre-packaged snacks.

In these rooms, the Whole Woman’s staff counsels patients through a process that, Ferrigno says, everyone understands and experiences differently. In years past, patients had been able to keep on much of their own clothing during abortion procedures performed in cozy exam rooms with inspirational quotes written on the walls.

They would then walk themselves down a short hallway to a sunny room filled with cushy recliners and fuzzy fleece blankets, where Whole Woman’s served a special herbal tea developed especially for their group in Austin. Patients’ partners, friends, mothers, sisters, or other supporters could join them in the recovery room for a short sojourn.

But now that they’re performing procedures in the ASC—a facility that Hagstrom Miller acquired so that she could provide legal abortion care after 16 weeks, as previously required by Texas law before the coming requirements of HB 2 would shift all legal abortion care into ASCs, regardless of the gestation of pregnancy—the word “anxiety” seems to come up more often, said Ferrigno.

Operating rooms at the Whole Woman's ASC in San Antonio change almost nothing about how a legal abortion procedure is performed, medically speaking, but the bright lights and increased staff members often have an anxiety-inducing effect on patients.

Operating rooms at the Whole Woman’s ASC in San Antonio change almost nothing about how a legal abortion procedure is performed, medically speaking, but the bright lights and increased staff members often have an anxiety-inducing effect on patients.

In the ASC, regulations don’t allow patients to walk on their own from the operating room to recovery. They must constantly be trailed by staffers who dress and undress them. They are lifted from the operating table to a stretcher, said Ferrigno, like something you might see on ER. They’re counseled behind curtains rather than closed doors.

“It’s about the perception and feeling for the patients,” explained Ferrigno. “It’s about not being trusted to get dressed on their own.”

In recovery, when everyone’s wearing hospital gowns and laying on hospital-style stretchers, it’s more difficult to invite partners and friends to join patients after their procedures. There’s no herbal tea, no feeling of relaxing in a friend’s living room. Everything feels more medical, more sterile, more intimidating.

Unnecessarily so, said Ferrigno.

“In terms of their physical experience, the actual performance of the procedure, it doesn’t change,” she said. The early trimester abortion procedures that could have once been performed in the smaller clinic are just as safe in either location, even with the mild or medium sedation that some patients prefer.

“But it does change the perception and the experience of the woman,” said Ferrigno. Being in a hospital-like room, said Ferrigno, has a kind of psychosomatic effect on some patients. They’ll ask staff questions, said Ferrigno, like, “‘Is it more dangerous now? Will there be more pain?’”

The answer to those concerns, said Ferrigno, is a resounding “no.”

It is as if the state of Texas seems hell-bent on ensuring that people who seek abortion care here jump through as many hoops, and feel as much anxiety and stigma, as possible.

Stigma and anxiety are two things that abortion providers, especially small and independent abortion providers, have been working to combat since the procedure became legal more than 40 years ago.

Independent Providers: Pioneers In Abortion Care

“Right from the beginning, independent abortion providers were established specifically to serve the women in their communities,” explained Charlotte Taft, the executive director of the Abortion Care Network, a coalition of smaller providers operating around the country. “Many of them have served those women for over 40 years.”

Whereas Planned Parenthood focused predominantly on family planning care, said Taft, outpatient abortion providers focused specifically on pregnancy terminations, and “pioneered the entire concept of informed consent.”

Taft, a founding member of a group that became known as the “November Gang,” after its foundation in November 1989, has been working in abortion care for decades. In the 1980s, she began developing a counseling process tailored to women who wanted a more emotion-centered approach to working through their feelings about their abortion procedures.

Many independent clinics have taken on models of counseling similar to what Taft developed.

“We wanted to make sure that this was not just a health care process that you sign on the bottom line and then you get whisked away and you don’t know what’s going on,” said Taft.

And while not every patient needs or wants that kind of counseling process, its availability can make all the difference to those who do. Taft praised Whole Woman’s in particular as a place where multiple kinds of emotional needs could be met under one roof.

A Whole Woman's staffer privately counsels every patient who receives services at their center, covering options that range from abortion, to adoption to parenting. After their private consultation, patients are invited to bring partners, friends or relatives who will support them through their decision-making process into the counseling room to discuss their process.

A Whole Woman’s staffer privately counsels every patient who receives services at their center, covering options that range from abortion, to adoption to parenting. After their private consultation, patients are invited to bring partners, friends or relatives who will support them through their decision-making process into the counseling room to discuss their process.

“Whole Woman’s, just the name they chose, they chose to talk about treating the whole woman,” said Taft. “That idea, and how that is manifest in that clinic, is in every single part of their decor. The sayings on the wall—every single part of that not only is designed to support women and their families but the staff who work there.”

Taft lamented the idea that Texans might now have no ability to seek out that abortion provider with a “philosophy” that feels right for them.

“The safety of abortion is not the issue,” she said. “The difference is going to be the atmosphere of the place, how you feel, and what philosophy they’re coming from.”

It’s important to note that not all independent providers have been committed to or offer this same model of care, and many larger corporate providers—like Planned Parenthood—do extensive counseling with patients who need it. One reproductive health-care researcher Rewire spoke to was careful to observe that both the “best and the worst” of abortion care models have been represented in the independent sector.

But in Texas, HB 2 has forced all legal abortion providers, regardless of any larger corporate affiliation, to move to a highly medicalized, potentially anxiety-inducing model that dictates not just where abortions are performed, but how many patients feel may about their procedures.

And patients themselves, who may or may not have ever been aware that they had a choice between, say, a Planned Parenthood or a Whole Woman’s-type establishment, are today less likely than ever to be able to have access to the type of legal abortion care—with attendant counseling and personalization—that is right for them.

Losing a Choice Within the Choice

A close friend of mine here in Austin has often spoken highly of her experience getting an abortion at a Planned Parenthood in the northeast years ago. “My doula was great,” she told me. “The insurance was easy.”

But with the increased media attention around HB 2, she said she’s now aware—when she wouldn’t have been previously—of the wide variety of abortion care models that could have been available to her, and which will not necessarily be available to her should she ever need abortion care again.

“Now knowing that there are some options,” she said, would prompt her to “do some research” on different providers.

The catch is that as of Monday, there will be just one legal abortion provider open in Austin—a Planned Parenthood surgical center. And whether smaller providers will be able to compete with corporate facilities after HB 2 goes into full effect remains to be seen.

While some reproductive health-care providers that Rewire spoke to for this story expressed frustration over Planned Parenthood opening new facilities in cities where independent ASCs already exist—a potential threat to the sustainability of independent providers with less name recognition and a smaller capacity—the reality is that while Planned Parenthood is more than capable of raising a great deal of money for new facilities, its doctors have the same difficulties obtaining hospital admitting privileges in deeply conservative areas that independent provider doctors have encountered.

That’s why, according to Planned Parenthood South Texas’ Mara Posada, the affiliate decided to work on opening a new ASC in San Antonio, rather than in Rio Grande Valley, where there are no legal abortion providers whatsoever.

“Expanding abortion services to new areas such as the Rio Grande Valley is something we will consider in the future,” Posada told Rewire via email. “Before even discussing this possibility, we would need to find a solution to the admitting privileges difficulty that led to the closures of two abortion providers in the Valley,” she said, referencing the McAllen Whole Woman’s facility and a Harlingen abortion provider that closed after doctors there could find no local hospital willing to sponsor them for admitting privileges.

Posada continued: “Building a building doesn’t solve everything.”

Even with a reduced post-HB 2 abortion rate in Texas, around 60,000 abortion procedures are performed annually, and only the best-funded, best-equipped, best-supported providers may be able to keep up with the increased patient load that will soon be shared among a handful of legal abortion facilities in major cities.

My friend and I talked about what we might do if either of us needed a legal abortion. She worried that there might be angry protesters outside the clinic in Austin, and talked about flying to New York City or Seattle, where she might be able to stay with friends and sidestep a 24-hour waiting period.

Would the abortion provider we could access take our health insurance? If not, could we get more affordable procedures in Houston or Dallas—but would that cost be offset by the price of a hotel room or gas? And we—white women living in a major metropolitan area—are the most fortunate ones, to even be able to consider having our conversation in the first place.

I thought of the warmth I’d experienced when visiting Whole Woman’s clinics in McAllen, Beaumont, and Austin to do interviews or take photographs for a story. I imagined myself driving to San Antonio, staying overnight to fulfill the 24-hour waiting period between a state-mandated ultrasound and a procedure.

I imagined myself walking by the protesters I’ve already encountered on the street outside the Whole Woman’s San Antonio, the protesters who screamed and yelled at me, assuring me they could “help” me, even when I told them I wasn’t pregnant—after which, a moment of levity: “They’ve got birth control in there!” one warned me ominously.

But there is nothing funny about what is to come, as low-income Texans, especially Texans of color and trans* and queer folks who already experience difficulty accessing high-quality, comprehensive reproductive health care, struggle to travel hundreds of miles to the state’s remaining legal abortion providers. Dozens of clinics across Texas, in Corpus Christi, Harlingen, McAllen, Killeen, Waco, Midland, Lubbock, Odessa, College Station, and Beaumont have already closed. In a few days, the remaining non-ambulatory surgical centers in El Paso, Fort Worth, Dallas, Houston, and Austin will be forced to stop providing legal abortion care.

On September 1, an estimated 1.3 million Texans will live farther than 100 miles from a county with a legal abortion provider. Then, when there are eight legal abortion providers serving eight million or so potentially pregnancy-capable Texans, those of us who have the means to travel, and who can obtain appointments at overloaded clinics, who can afford child care for our existing children and buy bus tickets or gas cards, will relinquish a choice within a choice, and simply attempt to go where we must.


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