Texas’ abortion laws yield substandard care
Since HB2 closed clinics, poor women have resorted to self-induced, unsupervised methods
In 2008, during a study I led documenting the experiences of American women who had attempted to end a pregnancy on their own, I heard many disturbing stories. One of the most jarring was from a 30-year-old woman from Texas I’ll call “Sarah.”
Sarah lived in the Rio Grande Valley, where even seven years ago, abortion access was limited. Since then, it’s gotten worse, with the number of clinics statewide dropping from 41 in 2013 to 18.
These closures are largely due to the restrictive law HB2, which was passed in 2013 and implemented until the U.S. Supreme Court temporarily halted Texas’ enforcement of portions of the law. The law is set to be evaluated by the Supreme Court this term. If it does permanently go into effect, the number of clinics would be further reduced to 10 in a state with 5.4 million women of reproductive age.
The mother of two small children, Sarah became pregnant with an unsupportive partner. She could not afford to pay for an abortion at a clinic, so instead she took pills bought in Mexico.
A week later Sarah still felt pregnant and went to a clinic, where she was told she was too far along for that facility and would have to travel over 250 miles to the next-nearest clinic. With few alternatives, she went to Mexico to get more medication, which eventually worked. But it also caused heavy bleeding that required a blood transfusion, surgery to remove the remaining pregnancy tissue and a weeklong hospitalization.
At the end of the interview with Sarah, we asked whether she would try this again if she were in the same situation. Without missing a beat, she said yes. Sure, if she had money, she would go to a clinic. But in her situation, facing multiple barriers, she would do exactly the same thing.
This is the new face of self-induced abortion — in the U.S. and the world over. It’s rare that women use coat hangers. Now women are more likely to use misoprostol, a very safe and effective medication, to end an early pregnancy without additional intervention.
Sarah experienced one of the rare complications that can occur with the drug. But most women who properly take the recommended dosage early in pregnancy have an uncomplicated abortion — and never have to visit a doctor.
Women who don’t know about misoprostol or can’t easily obtain it report using ineffective methods like herbs, which may delay women from accessing care, or potentially dangerous methods like getting punched in the stomach.
In addition to possible medical risks, there are legal risks to self-induction, as seen in several cases where women have been prosecuted for inducing an abortion on their own, including a recent case in Tennessee.
New research from the Texas Policy Evaluation Project, which I co-lead with colleagues at the University of Texas at Austin, provides further evidence that self-induced abortion is still happening. Over the past year, we interviewed 18 women who recently attempted to self-induce an abortion in Texas.
Almost all of them wanted to go to a clinic, but they faced a variety of barriers, overlaid upon poverty, that pushed them toward trying to end their pregnancies on their own.
For some women, the cost of a clinicbased abortion was too high, while for others making arrangements to travel the long distance to a clinic was too complicated. Some women decided to try to self-induce to avoid the stigma and shame of going to an abortion clinic.
Although these stories indicate that barriers to obtaining abortions at clinics lead some women to attempt self-induction, we don’t yet know whether the practice has become more common since HB2 was passed.
Few women die from unsafe abortions in settings where misoprostol is available, but they continue to face significant risks to obtain the care they need.
In Texas, women are forced to get medications in Mexico, often with unclear instructions about how to use them; many are unsure about what to expect and wonder where they will get help if they have a problem — all to obtain medical care that is ostensibly legal. If the Supreme Court allows the Texas law to go forward, relief may come in the form of a pill. And while this may be the best option for some women, it is not good enough.
Grossman is a co-investigator of the Texas Policy Evaluation Project and professor in the Department of Obstetrics, Gynecolog y and Reproductive Sciences at the University of California, San Francisco, where he is the director of Advancing New Standards in Reproductive Health.